NCM 109 LECTURE

Chapter 1 - Obesity
❑If a young person's body mass index (BMI) is above the 85th percentile, they are
deemed overweight, and obese if their BMI is above the 95th percentile.
❑These definitions take into account the age and gender of the infant or adolescent
(Anderson & Butcher, 2006).

Physiological problems that go along with obesity includes:

❑Hypertension
❑Diabetes
❑Sleep apnea
❑Increased risk for cardiovascular disease
❑lowered self-esteem and social development caused by teasing and bullying

Assessment
❑Comprehensive individual and family history
❑Physical assessment
❑Laboratory data
❑Height, weight, and body mass index (BMI) should all be measured and plotted on
the CDC's charts.

Diagnosis
❑Obesity is described as having an excess of fat in relation to lean body mass.
❑Obesity is described as a child's weight being higher than that which is considered
appropriate for his or her height (BMI above the 95th percentile).

Nursing Care
❑In order to begin preventive teaching efforts, a vital role for the nurse is to assess
the following:
❑Risk factors and early onset of obesity (family history,
❑Sedentary lifestyle
❑Availability of safe nutritional resources
❑Health teaching on improving children’s and adolescent’s activity level

NCM 109 LECTURE 1

 ❑Encourage parents to keep a close eye on their children's diet and activity levels,
particularly when they are engaged in passive entertainment (computer, television,
or video games).

❑Dieting is not suggested to young people

❑Focus should be on healthy eating and exercise

Eating Disorders
❑ Anorexia Nervosa an eating disorder characterized by a refusal to maintain a
minimally normal body weight and by severe weight loss in the absence of obvious
physical causes.
❑Bulimia (from the Greek meaning “ox hunger”) refers to an eating disorder
characterized by repeated episodes of binge eating followed by inappropriate
compensatory behaviours such as self-induced vomiting; misuse of laxatives,
diuretics or other medications, fasting or excessive exercise.

Diagnosis
•The diagnosis of anorexia nervosa or bulimia can be challenging and based on both
physical and emotional signs and symptoms.
•Adolescents with this disorder are below their ideal body weight and are often
preoccupied with food.

Nursing Care
❑Correct electrolyte imbalance
❑Once the child’s physical health has been stabilized the child is admitted to a
psychological unit or directed to outpatient psychological care
❑May be given anti-depressant and anti-psychotic drugs
❑Along with physical and mental care, adolescents with bulimia nervosa may need
dental care for repair of dental erosion and cavities that result from vomiting.

Substance Abuse
❑Is the misuse of an addictive substance that changes the user’s mental state.
❑As adolescents search for identity and independence, they are susceptible to
many pressures from society and their peers. They may experiment with substances
that may be habit forming or addictive and ultimately will harm them.
❑Tobacco, alcohol and controlled illicit drugs – commonly used addictive substances
❑Consumption is influenced by peers and some instances adults in their family are
hooked to those kinds of vices.

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 Note:
The children at greatest risk of becoming substance abusers are those who:
▪ Have families in which alcohol or drug abuse is or has been present
▪ Suffer from abuse, neglect, loss, or have no close relationships as a result of a
dysfunctional family
▪ Have behavior problems, such as aggressiveness, or are excessively rebellious
▪ Are slow learners or have learning disabilities or attention deficit disorder
▪ Have problems with depression and low self-esteem

Prevention:
▪ Education in the early school years
▪ Information-dissemination about how to cope with problems without using drugs
▪ However, educational programs have lesser impact if the child comes from a home
where alcohol or other drugs are used by family members

Suicide
▪ The turmoil that adolescents experience while searching for self-esteem and self-
confidence can cause stress that may lead to depression and suicide and conduct
disorders.
▪ Suicide is one of the leading causes of death in children 10-19 years of age, falling
just short of the death rate for homicide.
▪ Adolescent males commit suicide four times more often than girls.
▪ Girls attempt suicide 5 times more often than boys do.
▪ Boys use more violent means of committing suicide than girls and are successful
more often.

The following are some of the reasons for committing suicide:

Difficulty establishing independence
▪ Identity crisis
▪ Lack of intimate relationships
▪ Breakdown in family communication
▪ A sense of alienation
▪ A conflict that interferes with problem solving.

Note:
▪ Don’t ignore behaviors or statements of hopelessness in children and teenagers.
▪ Make an effort to ensure the child’s safety until counselling and treatment

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 resources are in place

Warning Signs in Children’s Behavior

✓ Previous suicide attempt
✓ Thoughts of wishing to kill self
✓ Plans for self-destructive acts
✓ Feeling “down in the dumps”
✓ Withdrawal from social activities
✓ Loss of pleasure in daily activities
✓ Change in activity—increase or decrease
✓ Poor concentration
✓ Complaints of headaches, upset stomach, joint pains, frequent colds
✓ Change in eating or sleeping patterns
✓ Strong feelings of guilt, inadequacy, hopelessness
✓ Preoccupation with thoughts of people dying, getting sick, or being injured
✓ Substance abuse
✓ Violence, truancy, stealing, or lying
Changes in Child’s Interpersonal Relationships
✓ Conflicts with peers
✓ Loss of boyfriend or girlfriend
✓ School problems—behavioral or academic
✓ Feelings of great frustration, being misunderstood, or not being part of the group
✓ Lack of positive support from family, peers, or other
✓ Earlier suicide of family member, friend, or classmate
✓ Separations, deaths, births, moves, or serious illnesses in the family

Chapter 2 - INTUSSUSCEPTION
Kinakain yung isang part ng intestine nung kabilang intestine

naging case ay yung intestine pumasok sa isang intestine, sausage like shape
na pwedeng makapa sa abdomen

Intussusception is a condition in which a segment of intestine invaginates or

telescopes into the adjoining intestinal lumen, causing bowel obstruction.

It occurs most commonly at the juncture of the ileum and the colon, although it
can appear elsewhere in the intestinal tract.

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 The invagination is from above downward, the upper portion slipping over the
lower portion pulling the mesentery along with it.

STATISTIC
According to RN Pedia, a wide geographic variation in the incidence of
intussusception among countries and cities within countries make determining a
true prevalence of the disease difficult.

Its estimated incidence is approximately 1 case per 2000 live births.

In Great Britain, incidence varies from 1.6-4 cases per 1000 live births.

Overall, the male-to-female ratio is approximately 3:1.

With advancing age, gender difference becomes marked; in patients older than 4
years, the male-to-female ratio is 8:1.

Two-thirds of children with intussusception are younger than 1 year; most

commonly, intussusception occurs in infants aged 5-10 months.

Intussusception is the most common cause of intestinal obstruction in patients

aged 5 months to 3 years.

Intussusception can account for as many as 25% of abdominal surgical

emergencies in children younger than 5 years, exceeding the incidence of
appendicitis.

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 PATHOPHYSIOLOGY
The pathophysiology of intussusception is not well establish.

It is thought to be caused by an imbalance in longitudinal stresses along the

intestinal wall.

As a result of an imbalance in the forces of the intestinal wall, an area of the

intestine invaginates into the lumen of the adjacent bowel.

The invaginating portion of the intestine (ie, the intussusceptum) completely

“telescopes” into the receiving portion of the intestine (ie, the intussuscipiens);
this process continues and more proximal areas follow, allowing the
intussusceptum to proceed along the lumen of the intussuscipiens.

If the intussusceptum's mesentery is slack and advancement is rapid, the

intussusceptum can move to the distal colon or sigmoid and even prolapse out
the anus.

The mesentery of the intussusceptum invaginates with the intestine, resulting in

the basic pathophysiologic process of any intestinal obstruction.

COMPLICATIONS
If intussusception isn’t treated quickly, it can lead to potentially life threatening
situations, such as:

dehydration

intestinal obstruction

a tear, or hole, in the wall of the intestine

an infection in the lining of the abdominal cavity (peritonitis)

shock

Sepsis

PREVENTION
Intussusception cannot be prevented

MEDICAL MANAGEMENT
Intravenous Fluid- Start Intravenous fluid reuscitation and nasogastric
decompression to children Immediately.

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 Therapeutic Enema- In order to prevent surgery, doctors may perform a
therapeutic enema. It uses air or contrast material solution to create pressure to
the intestine.

Surgical Reduction- If non-operative reduction fails or there is apparent

perforation, the newborn should be referred for surgical therapy right once; the
chance of intussusception recurrence following operative reduction is less than
5%.

Laparoscopy- A surgical diagnostic method used to check the organs inside the
stomach. It is a low-risk, minimally invasive technique that involves only minor
incisions. It also lets your doctor to look inside your body in real time without
having to create big incisions.

NURSING INTERVENTION
Intravenous fluids- Administer IV fluids as ordered; if the patient is in shock, give
blood or plasma as ordered.

Decompression- A nasogastric tube is inserted to decompress the bowel.

Monitor I&O- Replace volume lost as ordered, and monitor the intake and output
accordingly.

Education- Educate the family caregivers on what happens during

intussusception and about the surgery, and answer questions to reduce the
anxiety.

Chapter 3 - Failure to thrive

What is Failure to thrive?
Failure to thrive is a unique syndrome in which an infant falls below the 5th
percentile for weight and height on a standard growth chart or is falling in
percentiles on a growth chart. This condition can be divided into two categories:
syndromes that can be explained because of organic causes (cardiac disease;
celiac disease, and cerebral palsy).

Another one is syndromes that occur because of a disturbance in the parent-

child relationship, resulting in maternal role insufficiency (a non-organic cause).
Sometimes both physical and emotional factors play a role in failure to thrive
(Stephens et al., 2008)

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 Statistics
Prevalence Rate of FFT

Under 2 year olds- 1-10%

Primary care setting (US)- 5-10%

Hospital setting (US)- 3-5%

Pediatric hospital admissions (Ph) - 1-5%

Stunting rate in the Philippines

6-11 month olds- 15.5%

One-year olds- 36.6%

Stunting rate Globally

Under 5 year olds- 26%

Pathophysiology
Nutritional intake does not support normal growth and development. This can be
because of

Inadequate calorie intake;

Malabsorption (calories are going into the gut but not making it into the
blood/body); and/or

Increased metabolic demand

Complications
A child with FTT is at risk for problems such as:

Short height

Behavior problems

Developmental delay

Long-term complications, including:

learning disabilities

emotional problems

restricted growth

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 Secondary sexual characteristics

developmental delay

Prevention
Promotion of exclusive breast-feeding for early infancy

Community effort

Encouraging parenting education courses

Early detection of FTT and Intervention

Prevention of low birthweight

Neonatal screening for treatable metabolic disorders

Management
Ensure adequate nutrition

Nurture the child

Support and encourage the parents

Nutritional counseling to the family

Ensure evaluation and follow-up

Chapter 4 - SUDDEN INFANT DEATH

SYNDROME
According to (Burnett, 2018) SIDS is defined as the sudden, unexpected death
of an infant less than 1 year of age that cannot be explained despite a thorough
investigation, including a complete autopsy, examination of the death scene, and
review of the clinical and social history.

SIDS should not be used as an emergency department diagnosis. It is more

accurate to use “Sudden Unexpected Infant Death” if there is no external
evidence of injury to the infant and no scene information to suggest another
cause of death. To confirm the diagnosis of SIDS, a complete forensic autopsy
needs to be performed, using information gathered from the scene investigation,
interview of caregivers and review of medical and social history

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 Statistics
SIDS is the leading cause of death among infants aged 1–12 months, and is the
third leading cause overall of infant mortality in the United States. The rate of
SIDS occurrence is 0.5/1000 births in the US; there are racial and ethnic
disparities (African American and Native American children have twice the
average risk of SIDS). SIDS may occur in infants and children younger than 16
months of age, but the peak incidence is between 2 and 4 months of age.
Although the overall rate of SIDS in the United States has declined by more than
50% since 1990, rates for non-Hispanic black and American Indian/Alaska
Native infants remain disproportionately higher than the rest of the US
population (Burnett, 2018).

Base on the report of (DOH, 2014), SIDS is the 8th on 10 leading cause of Infant
Mortality during 1999 having a percentage of 1.2% in every 1000 live births and
counted 298 cases that time

Pathophysiology
As explained by (Raab, 2021), The cause of SIDS is unknown, although it is
most likely due to dysfunction of neural cardiorespiratory control mechanisms.
The dysfunction may be intermittent or transient, and multiple mechanisms are
probably involved Factors that may be involved are the infant having a poor
sleep arousal mechanism, an inability to detect elevated CO2 levels in the blood,
or a cardiac channelopathy that affects heart rhythm.

Risk Factors
Fetal Factors

Brain Abnormalities

Low Birth Weight

Respiratory Infection

Prematurity

Secondhand smoke

Sleep environmental factor

Sleeping on the stomach or the side

Sleeping on the soft surface

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 Sleeping with parents

Maternal Factors

· Younger than 20 in age

· Smoking

· Drug use

· Inadequate prenatal care

Complication
According to (Smith, 2017), The association between SIDS and complications in
other pregnancies appears to be mediated partly by maternal risk factors and by
recurrence of prematurity and low birth weight. This fact could partly explain the
tendency for SIDS to recur in families

Prevention
Recommendations regarding the infant’s sleep position and bedtime environment
have been with a view to preventing SIDS

According to (Burnett, 2018) suggested measures for preventing SIDS include the
following:

Start prenatal care early; schedule frequent well-baby checkups, and ensure that
immunizations are current

Avoid cigarettes, alcohol, and other drugs while pregnant; in particular, avoid
exposing the baby to cigarette smoke

If possible, breastfeed the baby

Burp the baby during and after feedings, especially before putting the baby to
sleep

Place the baby on a firm, flat mattress in a safety-approved crib; avoid pillows,
blankets, sheepskins, foam pads, or water beds

Do not restrain the baby during sleep

Consider using a fan in the infant’s room to improve ventilation

Management
The effects of SIDS on caregivers and families are devastating.

NCM 109 LECTURE 11

 Grief is coupled with guilt, even though SIDS cannot be predicted; disbelief, hostility,
and anger are common reactions.

Allow expression of feelings.

Appropriate referrals.

Encourage use of community resources

Monitoring subsequent infants

Chapter 5 - INFANTILE COLIC

Colic occurs when a normally healthy baby cries or fusses excessively for no
apparent reason. It's characterized as crying for more than 3 hours a day at least
3 days per week for more than 3 weeks. There are times when there is nothing
you can do to stop your infant from crying. Managing colic can be stressful for
new parents who are already exhausted or stressed.

PREVALENCE
Colic is thought to affect 20% of all infants worldwide. The syndrome normally
appears in the
second or third week of life, peaks around six weeks, and resolves between 12
and sixteen weeks. Colic is characterized by inconsolable sobbing, impatience,
and shouting for no apparent reason.

WHAT CAUSES COLIC?

The underlying cause is unknown.

The following are some of the possible contributory elements that have been
investigated:

Inadequately developed digestive system

An imbalance of good bacteria in the digestive tract

Food intolerances or allergies

Infrequent burping, overfeeding, or underfeeding

Migraine in its early stages in childhood

Anxiety or stress in the family

NCM 109 LECTURE 12

 COMPLICATIONS
Colic does not cause short-term or long-term medical problems for a child.

Colic is a source of stress for parents. There is a link between colic and the
following issues with parent well-being, according to research:

Mothers are more likely to have postpartum depression.

Early cessation of breast-feeding

Feelings of guilt, exhaustion, helplessness or anger

PREVENTION AND MANAGEMENT

Soothing strategies

Using a pacifier

Taking your infant for a car ride or on a walk in a stroller

Walking around with or rocking your baby

Swaddling your baby in a blanket

Giving your baby a warm bath

Rubbing your infant's tummy or placing your baby on the tummy for a back
rub

Playing an audio of heartbeats or quiet, soothing sounds

Providing white noise by running a white noise machine, a vacuum cleaner

or clothes drier in a nearby room

Dimming the lights and limiting other visual stimulation

Feeding practices

Changes in food habits may also offer some assistance. Burp regularly
during and after feedings and bottle-feed your infant in an upright position. A
curved bottle will aid upright feeding, while a collapsible bag bottle will limit
air intake.

Trial changes in diet

Formula changes

Maternal diet

Parent Self-care

NCM 109 LECTURE 13

 Take a break

Use the crib for short breaks

Express your feelings

Don’t judge yourself

Take care of your health

Remember that it is temporary

Have a rescue plan

Chapter 6 - HIRSCHSPRUNG'S DISEASE

Hirschsprung’s disease (HD), also known as congenital aganglionic megacolon
disease, is a congenital disease in which ganglionic cells fail to develop in the
large intestine. This commonly presents as delayed or failed passage of
meconium around birth.

STATISTICS
Occurs in 1 in 5000 live births and is more common in boys than girls.

NCM 109 LECTURE 14

 Children with other medical conditions, such as Down syndrome, are at a higher
risk of having Hirschsprung disease.

PATHOPYSIOLOGY
Migration failure of neural crestcells

Absence of the parasympathetic ganglion cells

Absence of peristalsis in the aganglionic colon

Functional obstruction

COMPLICATION
Serious intestinal infection called enterocolitis

soiling, or when a child has accidental bowel movements in their underwear

megacolon, or severe constipation and swelling of the intestine

malnutrition, or when a child doesn’t get enough vitamins, minerals, and other
nutrients to grow and be healthy

perforation, or a hole in the wall of the intestine, which is more common in

newborns than in older children

PREVENTION
According to the Trusted medical advice from the American Academy of Family
Physicians (familydoctors.org), you cannot prevent or avoid it. However, parents who
have the disease can unknowingly pass it on to their children.

MANAGEMENT
Ostomy surgery and Pull-through procedure

NCM 109 LECTURE 15

 A temporary colostomy is performed to decompress the bowel and divert the
fecal contents,

When the bowel regains normal tone, after approximately 3 to 4 months , a

rectal pull-through procedure is performed in which all aganglionic bowel is
removed and the normal bowel is reconnected to the anus.

NCM 109 LECTURE 16

 After surgery, it is still important to establish protocol in diet and activity to
promote a healthy digestive system during recovery and throughout life for those
effected by HD.

For infants, this includes formulas to relieve constipation, increased fluids and
laxatives as directed by a physician.

For young children through adults, including high-fiber foods and physical activity
will promote regular bowel movements.

Chapter 7 - IMPERFORATE ANUS

Imperforate anus, also known as anorectal malformation, occurs when the anal
orifice and rectum do not form properly. It is a congenital condition, meaning it exists
before the infant is born, and it stops the newborn from passing feces normally. An
imperforate anus infant may have an anal aperture that is:
● Too small for stool to pass
● In the wrong location
● Completely missing, causing stool to pass into the pelvic area, vagina, or bladder
instead

NCM 109 LECTURE 17

 Statistic
● Imperforate anus is a relatively common anomaly, with an incidence of 1 : 1500 to
1 : 5000 in newborns. Cases of isolated imperforate anus exist, but most commonly
this condition is found as one among a wide spectrum of other anomalies.
● In the philippines the case of imperforate anus (698/8,686 or 8%) is over 698
newborns out of 8,686 or 8%

Pathophysiology
● Ventral urogenital external opening forms first; dorsal anal membrane opens later
● Anal development

NCM 109 LECTURE 18

 Fusion of the anal tubercles and an external invagination (proctoderm) which
deepens toward the rectum but separated from it by an anal membrane

Anal membrane should desintegrate by 8 th week

There are known risk factors that predispose a person to have a child with
imperforate anus

A genetic linkage is sometimes present

Complication
Failure to diagnose this condition early may result in newborn developing
dehydration, vomiting, aspiration, and sepsis. Surgical site infection wound
dehiscence, and urinary tract infection can accompany most abdominal surgeries.
Postsurgical complications specific to surgical repair of ARMs include recurrent or
persistent fistula, anal stenosis, stricture of other reconstructed structures, and rectal
prolapse. The complexity of malformations and associated anomalies (e.g., vertebral
anomalies) usually determine long-term results. Those with significant vertebral
anomalies, spinal cord tethering, or complex ARMs may be disabled for the rest of
their lives.

Prevention
Imperforate anus is a condition that causes when a baby is still developing within the
womb. While there is no way to avoid imperforate anus, there are surgical
treatments that can be used to address it.

Management
A child with an intermediate or high imperforate anus may need many surgeries.
This is done to rebuild or move the anus. If your child has a complicated defect, he
or she might first need a colostomy. In this surgery, part of the large intestine is
connected to the outside of your child's body.

Chapter 8 - CLEFT PALATE

What is Cleft Palate?
A cleft palate is an opening or split in the roof of the mouththat occurs when the
tissue doesn't fuse together during development in the womb. A cleft palate

NCM 109 LECTURE 19

 often includes a split (cleft) in the upper lip (cleft lip) but can occur without
affecting the lip.

Cleft lip and cleft palate are among the most common birth defects. They most
commonly occur as isolated birth defects but are also associated with many
inherited genetic conditions or syndromes.

Having a baby born with a cleft can be upsetting, but cleft lip and cleft palate can
be corrected. In most babies, a series of surgeries can restore normal function
and achieve a more normal appearance with minimal scarring.

How Many Babies are Born with Cleft Lip/Cleft

Palate? (STATISTICS IN UNITED STATES ALONE)
About 1 in every 1,600 babies is born with cleft lip with cleft palate in the United
States.

About 1 in every 1,700 babies is born with cleft palate in the United States.

About 1 in every 2,800 babies is born with cleft lip without cleft palate in the
United States.

It occurs more frequently in infants of Asian, American, and Indian descents followed
by white infants. Lowest incidents in black infants.

PATHOPHYSIOLOGY
In Embryology facial morphogenesis, neural crest cells migrate into the facial
region, where they form the skeletal and connective tissue and all dental tissues
except the enamel. Vascular endothelium and muscle are of mesodermal origin.

The upper lip is derived from medial nasal and maxillary processes. Failure of
merging between the medial nasal and maxillary processes at 5 weeks'
gestation, on one or both sides, results in CL.

CL usually occurs at the junction between the central and lateral parts of the
upper lip on either side. The cleft may affect only the upper lip, or it may extend
more deeply into the maxilla and the primary palate. (Cleft of the primary palate
includes CL and cleft of the alveolus.)

If the fusion of palatal shelves is impaired also, the CL is accompanied by CP,

forming the CLP abnormality.

NCM 109 LECTURE 20

 CP is a partial or total lack of fusion of palatal shelves. It can occur in the
following ways:

Defective growth of palatal shelves

Failure of the shelves to attain a horizontal position

Lack of contact between shelves

Rupture after fusion of shelves

The secondary palate develops from the right and left palatal processes. Fusion
of palatal shelves begins at 8 weeks' gestation and continues usually until 12
weeks' gestation. One hypothesis is that a threshold is noted beyond which
delayed movement of palatal shelves does not allow closure to take place, and
this results in a CP.

COMPLICATIONS
Children with cleft lip with or without cleft palate face a variety of challenges,
depending on the type and severity of the cleft.

Difficulty feeding. One of the most immediate concerns after birth is feeding.
While most babies with cleft lip can breast-feed, a cleft palate may make sucking
difficult.

Ear infections and hearing loss. Babies with cleft palate are especially at risk
of developing middle ear fluid and hearing loss.

Dental problems. If the cleft extends through the upper gum, tooth development
may be affected.

Speech difficulties. Because the palate is used in forming sounds, the

development of normal speech can be affected by a cleft palate. Speech may
sound too nasal.

Challenges of coping with a medical condition. Children with clefts may face
social,
emotional and behavioral problems due to differences in appearance and the
stress of intensive medical care.

UPDATES IN PREVENTION AND MANAGEMENT

MANAGEMENT OF CLEFTS

Team Approach

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 Surgical Management of Clefts

Primary Correction

Lip Surgery by 3 months

Palatal lip surgery by 6-18 months

Secondary Correction

Pharyngeal Flap

25% of cases

Improves velopharyngeal competence

Done between 6-12 year of age.

Dental Management

Issues related to chewing and speech

Orthodontics

Prosthodontist

Obturators

Audiological Management

Middle ear disease

Chronic otitis media

Persistent conductive hearing loss

Psychosocial Management

Facial Differences

Speech Difference

Self-Esteem

PREVENTION
After a baby is born with a cleft, parents are understandably concerned about the
possibility of having another child with the same condition. While many cases of cleft
lip and cleft palate can't be prevented, consider these steps to increase your
understanding or lower your risk:

NCM 109 LECTURE 22

 Consider genetic counseling. If you have a family history of cleft lip and cleft
palate, tell your doctor before you become pregnant. Your doctor may refer you
to a genetic counselor who can help determine your risk of having children with
cleft lip and cleft palate.

Take prenatal vitamins. If you're planning to get pregnant soon, ask your doctor if
you should take prenatal vitamins.

Don't use tobacco or alcohol. Use of alcohol or tobacco during pregnancy

increases the risk of having a baby with a birth defect.

Chapter 9 - Otitis Media & Meningitis

Otitis media is inflammation in the middle ear caused by bacterial and viral
infection.

Otitis media can occur as a result of a cold, sore throat, or respiratory infection.

The condition is most common in children ages between 3 months and 3 years.

According to the Lucile Packard Foundation for Children’s Health, otitis media
occur in 80 percent of children by the time they reach age 3.

NCM 109 LECTURE 23

 Acute Otitis Media (AOM)
Fluid and mucus is trapped in the ear

NCM 109 LECTURE 24

 Swelling

Redness

Otitis media with effusion (OME)

Fluid (effusion) and mucus continue to accumulate after initial infection subsides

Fullness

Hearing loss

Chronic otitis media with effusion (COME)

Fluid remains for a prolonged period even if there is no infection

Hearing loss

Difficulty fighting new infection

Pathophysiology
What causes Otitis Media

malfunction of the eustachian tube

prevents normal drainage of fluid

causes build up of fluid behind the eardrum

no fluid drainage gives opportunity for bacteria and viruses to grow ergo infection

Complication
Permanent hearing loss

Problems with speech and language development

Infection in other parts of the head

NCM 109 LECTURE 25

 Prevention
Breastfeed your baby

Bottle Feed your baby in an upright angle

Wash your hands

Don’t Smoke

Immunizations

Management
Medical Management

Antibiotic

Analgesic

Antihistamine

Nursing Management

Health teaching

NCM 109 LECTURE 26

 Surgical Management

Myringotomy or tympanostomy

What is Meningitis?
Meningitis is an inflammation of the tissues that cover the brain and spinal cord. The
inflammation sometimes affects the brain itself. With early diagnosis and proper
treatment, a child with meningitis has a reasonable chance of a good recovery,
though some forms of bacterial meningitis develop rapidly and have a high risk of
complications.

NCM 109 LECTURE 27

 Statistics
Out of 1,000 live births, about 0.1 to 0.4 neonates (a baby less than 28 days old)
get meningitis, estimates a 2017 review

Before there was a pneumococcal vaccine, 10 out of 100,000 babies under 1

year got pneumococcal meningitis, reports the Centers for Disease Control and
Prevention (CDC).

From 2002 through 2007, when the vaccine was routinely used, only about 8 out
of 100,000 babies age 1 to 23 months got any type of bacterial meningitis,

NCM 109 LECTURE 28

 estimates a 2011 article.

Pathophysiology
Bacteria, viruses, or a fungus can cause meningitis in a baby.

Viral meningitis has long been the most common cause of meningitis.

During the first 28 days of life, bacterial meningitis is most often caused by
bacteria called Group B Streptococcus, Gram-negative bacilli, and Listeria
monocytogenes.

Fungal meningitis is very rare because it usually only affects people with a weak
immune system.

Complications
There can be serious complications if meningitis goes untreated or if treatment is
delayed. These complications may include:

seizures

brain damage

hearing loss

hydrocephalus, or fluid buildup and brain swelling.

myocarditis, or inflammation of the heart if the infection reaches it

kidney failure

death

Prevention
vaccines against viruses that can lead to meningitis

follow general precautions

using routine infection precautions

Management
intravenous (IV) antiviral medication

antibiotics

NCM 109 LECTURE 29

 intravenous (IV) antifungal medication

Chapter 10 - Hydrocephalus
Hydrocephalus is the buildup of fluid in the cavities (ventricles) deep within the
brain. The excess fluid increases the size of the ventricles and puts pressure on
the brain.

Hydrocephalus may be present at birth (congenital) or may develop over time

as a result of injury or disease (acquired).

Causes usually are genetic factors and how the fetus develops.

1. Obstruction

2. Poor absorption.

3. Overproduction

CSF is produced by the choroid plexus of the ventricles of the brain, and
absorbed in the arachnoid granulations.

Normal CSF production

0.2-0.35 mL/min

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NCM 109 LECTURE 31
 Statistics
Global Statistics

One out of every 770 babies will develop hydrocephalus

Normal pressure hydrocephalus is estimated to affect about 5 per 100,000

people, with rates increasing with age

Warf et al. estimated an annual incidence of more than 225,000 new cases of
infant hydrocephalus, the majority likely resulting from neonatal or childhood
CNS infection.

Local Statistics

Dr. Manuel Cacdac said that “about one out of 1,000 poor children suffer from
hydrocephalus in the Philippines. ”

1. Primary hydrocephalus

1. Communicating type of hydrocephalus

can be due to poor absorption of the CSF by the arachnoid villi.

And also due to the fact that overproduction of CSF

2. Non-communicating type of hydrocephalus

It interferes or blocks normal CSF circulation from the ventricles to the

subarachnoid space.

2. Secondary hydrocephalus

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 It is a much less common form of hydrocephalus.

It is defined as compensatory increases of CSF due to loss of neural tissue

without being associated with increases in intracranial pressure

S/SX are influenced by:

Patient's Age

Cause

Location of obstruction

Duration

Infantile Risk Factors

Birth weight <1500 g

Prematurity (gestational age ≤30 weeks)

Maternal diabetes

Low socioeconomic status

Male sex

Race/ethnicity (the risk is decreased in Asians)

Clinical Manifestation
Infants

Head enlargement

Poor feeding

Irritability

Reduced activity

Projectile Vomiting

High-pitched cry

Bulging of the anterior fontanelles.

Setting sun sign

Children & Adults Complications

Slowing of mental capacity

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 Headache

Neck pain - Tonsilar herniation

Vomiting

Blurred vision Papilledema

Double vision = 6th nerve palsy

Drowsiness

Limb spasticity & difficulty in walking - Stretching of pyramidal & periventricular

tracked

Assessment and Diagnostics Findings

Computed tomography (CT) scanning.

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 used to assess the size of ventricles and other structures.

Magnetic resonance imaging (MRI).

used to assess for Chiari malformation or cerebellar or periaqueductal tumors.

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 Ultrasonography through anterior fontanelle in infants.

This study assesses for subependymal and intraventricular hemorrhage to follow

infants for possible progressive hydrocephalus.

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 Radionuclide cisternography (in NPH)

To assess the prognosis with regard to possible shunting—however, due to its

poor sensitivity in predicting shunt response when the ventricular to total
intracranial activity (V/T) ratio is less than 32%, this test is no longer commonly
used.

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 MRI cine

To measure CSF stroke volume (SV) in the cerebral aqueduct; however, such
measurements don’t appear to be useful in predicting response to shunting.

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 Diffusion tensor imaging (DTI).

To detect differences in fractional anisotropy and mean diffusivity of the brain

parenchyma surrounding the ventricles; allows recognition of microstructural
changes in periventricular white matter region that may be too subtle on
conventional MRI

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 Skull radiography.

To detect erosion of sella turcica, or “beaten copper cranium” (or “beaten silver
cranium”)—the latter can also be seen in craniosynostosis; (after shunt insertion)
to confirm correct positioning of installed hardware.

Pharmacologic Therapy
Diuretics.

Acetazolamide (ACZ) and furosemide (FUR) treat posthemorrhagic

hydrocephalus in neonates;

decrease secretion of CSF at the level of the choroid plexus.

Anticonvulsants.

Helps to interfere impulse transmission of cerebral cortex and prevent seizures.

Antibiotics.

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 Culture and sensitivity dependent for shunt infections such as septicemia,
ventriculitis, meningitis, or given as a prophylactic treatment.

Surgical Management
Surgery. Surgical treatment is the preferred therapeutic option in patients with
hydrocephalus.

Ventriculoperitoneal (VP) shunt. A ventriculoperitoneal (VP) shunt is a medical

device that relieves pressure on the brain caused by fluid accumulation.

Ventriculoatrial (VA) shunt. Ventriculoatrial shunt placement enables cerebrospinal

fluid (CSF) to flow from the cerebral ventricular system to the atrium of the heart.

Lumboperitoneal shunt.

Only used for communicating hydrocephalus, CSF fistula, or pseudotumor

cerebri).

Torkildsen shunt (rarely)

Effective only in acquired obstructive hydrocephalus.

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 Ventriculopleural shunt (second-line therapy).

Used if other shunt types contraindicated.

Nursing Management
Assess the following:

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 Head circumference.

Neurologic and vital signs.

Check the fontanelles.

Monitor increase in intracranial pressure.

History taking.

Interventions:

Preventing injury.

Maintaining skin integrity.

Preventing infection.

Maintaining growth and development.

Reducing family anxiety via patient education

Chapter 11 - SPINA BIFIDA

Accoding to CDC, Spina bifida is a condition that affects the spine and is usually
apparent at birth. It is a type of neural tube defect (NTD)

Spina bifida can happen anywhere along the spine if the neural tube does not
close all the way. When the neural tube doesn’t close all the way, the backbone
that protects the spinal cord doesn’t form and close as it should. This often
results in damage to the spinal cord and nerves.

Spina bifida might cause physical and intellectual disabilities that range from
mild to severe. The severity depends on:

The size and location of the opening in the spine.

Whether part of the spinal cord and nerves are affected

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 Data and Statistics
Each year, about 1,427 babies are born with spina bifida, or 1 in every 2,758
births. [Read article summaryexternalicon]

Hispanic women have the highest rate of having a child affected by spina bifida,
when compared with non-Hispanic white and non-Hispanic black women. Data
from 12 state- based birth defects tracking programs were used to estimate the
total number of pregnancies affected by spina bifida compared to the total
number of live births (also called the prevalence of spina bifida) for each

Hispanic: 3.80 per 10,000 live births

Non-Hispanic black or African-American: 2.73 per 10,000 live births

Non-Hispanic white: 3.09 per 10,000 live births

Pathophysiology
Neural tube defects are the result of a teratogenic process that causes failed
closure and abnormal differentiation of the embryonic neural tube. Neural tube
defects occur between the 17th and 30th day of gestation, at a time when the
mother may not be aware that she is pregnant and the fetus is estimated to be
about the size of a grain of rice.

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 In the fetal development, the ectoderm (the outer later of the fertilized egg) starts
to form a ridge that soon develops a neural tube (spinal cord, the bain, and the
meninges), and when spina bifida happens that process did not properly close.
This results in the defect of Vertebral Arches to the failure of mesoderm to
organize over the region of defect.

MYELOMENINGOCELE

Is the most serious type of spina bifida.

A sac of fluid comes through an opening in the baby’s back. Part of the spinal
cord and nerves in this sac are damaged.

Causes moderate to severe disabilities, such as problems affecting how the

person goes to the bathroom, loss of feeling in the person’s legs or feet, and not
being able to move the legs.

MENINGOCELE

With meningocele, a sac of fluid comes through an opening in the baby’s back.
But, the spinal cord is not in this sac. There is usually little or no nerve damage.
This type of spina bifida can cause minor disabilities.

Least common type of Spina Bifida

SPINA BIFIDA OCCULTA

Is the mildest type of spina bifida.

It is sometimes called “hidden” spina bifida. With it, there is a small gap in the
spine, but no opening or sac on the back. The spinal cord and the nerves usually
are normal.

Many times, spina bifida occulta is not discovered until late childhood or
adulthood. This type of spina bifida usually does not cause any disabilities

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 COMPLICATIONS
Traumatic birth and difficult delivery of the baby

Frequent urinary tract infections

Fluid buildup on the brain (hydrocephalus)

Loss of bowel or bladder control

Brain infection (meningitis)

Permanent weakness or paralysis of legs

PREVENTION
Even though there is no known cause, experts believe spina bifida can be avoided
with some simple measures to follow:

Folic acid, a water-soluble B vitamin often found in leafy green vegetables, plays
an important role in the prevention of spina bifida. During childbearing years,
women should take a vitamin with 400 mcg (0.4 mg) folic acid every day. Some
studies suggest that if women take this dosage of folic acid the incidence of
spina bifida could be reduced by up to 75%.

Tell your healthcare provider if you are taking any prescription and over-the-
counter drugs, herbal and dietary supplements and vitamins.

Treat any fevers immediately with store brand acetaminophen or its brand name
Tylenol®.

Avoid using hot tubs or saunas that overheat your body.

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 If you have diabetes or are obese, be sure to do your best to keep these
conditions under control while you’re pregnant.

MANAGEMENT
Surgery, physiotherapy and medication are used to treat some of the effects of spina
bifida and may be needed throughout a patient's life to prevent and manage certain
complications. Children with spina bifida, especially those who experienced
hydrocephalus, sometimes have learning problems. These learning disorders
generally involve difficulty with:

Paying attention.

Expressing or understanding language.

Organizing.

Sequencing.

Comprehending math and reading.

Chapter 12 - Trisomy 21
What is Trisomy 21?
Down syndrome is a genetic disorder caused when abnormal cell division results
in an extra full or partial copy of chromosome 21. This extra genetic material
causes the developmental changes and physical features of Down syndrome.

Down syndrome varies in severity among individuals, causing lifelong intellectual

disability and developmental delays. It's the most common genetic chromosomal
disorder and cause of learning disabilities in children. It also commonly causes
other medical abnormalities, including heart and gastrointestinal disorders

In recent years, Down syndrome has become more common, and children with
Down syndrome are living longer. Read below for recent statistics on Down
syndrome in the United States.

Down syndrome continues to be the most common chromosomal disorder. Each

year, about 6,000 babies are born with Down syndrome, which is about 1 in
every 700 babies born.

Older mothers are more likely to have a baby affected by Down syndrome than
younger mothers. In other words, the prevalence of Down syndrome increases

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 as the mother’s age increases. Prevalence is an estimate of how often a
condition occurs among a certain group of people. To estimate the prevalence of
Down syndrome, the number of pregnancies affected by Down syndrome is
compared to the total number of live births

Pathophysiology
Trisomy 21. About 95 percent of the time, Down syndrome is caused by trisomy 21
— the person has three copies of chroamosome 21, instead of the usual two copies,
in all cells. This is caused by abnormal cell division during the development of the
sperm cell or the egg cell.

Complications
People with Down syndrome can have a variety of complications, some of which
become more prominent as they get older. These complications can include:
Heart defects Spinal problems
Gastrointestinal (GI) defects Leukemia
Immune disorders Dementia
Sleep apnea Other problems:
Obesity

Prevention
There's no way to prevent Down syndrome. If you're at high risk of having a child
with Down syndrome or you already have one child with Down syndrome, you
may want to consult a genetic counselor before becoming pregnant.

A genetic counselor can help you understand your chances of having a child
with Down syndrome. He or she can also explain the prenatal tests that are
available and help explain the pros and cons of testing.

Treatment
Early intervention for infants and children with Down syndrome can make a major
difference in improving their quality of life. Because each child with Down syndrome
is unique, treatment will depend on individual needs. Also, different stages of life
may require different services
If your child has Down syndrome, you'll likely rely on a team of specialists that can
provide medical care and help him or her develop skills as fully as

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 possible.Depending on your child's particular needs, your team may include some of
these experts:

Team care

Primary care pediatrician to coordinate and provide routine childhood care

Pediatric cardiologist

Pediatric gastroenterologist

Pediatric endocrinologist

Developmental pediatrician

Pediatric neurologist

Pediatric ear, nose and throat (ENT) specialist

Pediatric eye doctor (ophthalmologist)

Team care

Pediatric eye doctor (ophthalmologist)

Audiologist

Speech pathologist

Physical therapist

Occupational therapist

Nursing Interventions
Provide adequate nutrition

Frequent consultations are a must.

Assess understanding of Down syndrome.

Provide emotional support and motivation.

Chapter 13 - Autism and ADHD

Autism spectrum disorder (ASD) is a set of developmental differences that
affect the way people communicate, behave, and interact with others.

ADHD stands for attention deficit hyperactivity disorder. It is a medical

condition. A person with ADHD has differences in brain development and brain

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 activity that affect attention, the ability to sit still, and self-control. ADHD can
affect a child at school, at home, and in friendships

Signs
Autism

Declining eye contact

Little pointing or gesturing

Limited or no response to their name

Reduced emotion in facial expression

Delayed language or speech

Regression

ADHD

Inattentive

Hyperactive

Impulsive

Statistics of Autism
In 2021, the CDC reported that approximately 1 in 44 children in the U.S. is
diagnosed with an autism spectrum disorder (ASD), according to 2018 data.

1 in 27 boys identified with autism

1 in 116 girls identified with autism

Boys are four times more likely to be diagnosed with autism than girls.

Most children were still being diagnosed after age 4, though autism can be
reliably diagnosed as early as age 2.

31% of children with ASD have an intellectual disability (intelligence

quotient [IQ] <70), 25% are in the borderline range (IQ 71–85), and 44%
have IQ scores in the average to above average range (i.e., IQ >85).

Autism affects all ethnic and socioeconomic groups.

Minority groups tend to be diagnosed later and less often.

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 Statistics of ADHD
Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common
mental disorders among children, affecting an estimated 3 to 5 percent of the
population aged 0 to 14 years in the Philippines

The estimated number of children ever diagnosed with ADHD, according to a

national 2016 parent survey, is 6.1 million (9.4%). This number includes:

388,000 children aged 2–5 years

2.4 million children aged 6–11 years

3.3 million children aged 12–17 years

Boys are more likely to be diagnosed with ADHD than girls (12.9% compared to
5.6%).

Pathophysiology of Autism
Autism spectrum disorder has no single known cause. Given the complexity of
the disorder, and the fact that symptoms and severity vary, there are probably
many causes.

Several genes have been implicated in the pathogenesis of ASD, most of them
are involved in neuronal synaptogenesis. A number of environmental factors and
associated conditions such as gastrointestinal (GI) abnormalities and immune
imbalance have been linked to the pathophysiology of ASD.

Pathophysiology of ADHD
The exact pathophysiology of Attention Deficit Hyperactivity Disorder (ADHD) is not
clear. Several mechanisms have been proposed as factors associated with the
condition such as:

1. Neurotransmitters. Dopamine and Noradrenaline have been suggested as

key players in the pathophysiology of ADHD.

2. Brain structure. The frontal and prefrontal regions of the brain, as well as
possibly the parietal lobe and cerebellum, are thought to be associated
with ADHD.

3. Cognitive function. ADHD is also linked to some neurophysiological

deficits and abnormalities in cognitive function. These deficits may usually
be seen in the resting brain but the Default-Mode-Network (DMN) activity

NCM 109 LECTURE 51

 may be involved, which is key in the region of the brain used to process
tasks. As a result, affected individuals are likely to have difficulty in
regulating and maintaining attention.

Complications
Autism
Problems with social interactions, communication and behavior can lead to:

Problems in school and with successful learning

Employment problems

Inability to live independently

Social isolation

Victimization and being bullied

ADHD

Often struggle in the classroom

Tend to have more accidents and injuries of all kinds

Tend to have poor self-esteem

More likely to have trouble interacting with and being accepted by peers and
adults

Increased risk of alcohol and drug abuse and other delinquent behavior

Prevention
Autism

Cannot be prevented

Early Diagnosis

ADHD

Cannot be prevented

Promoting good brain health

Taking prenatal vitamins

Eating nutritious foods

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 Management
Autism

Cognitive Behavioral Therapy

Social Skills Training (SST)

Sensory Integration Therapy

Occupational Therapy

Speech Therapy

Medications

ADHD

Medications (stimulants or non-stimulants

Skills training

Counseling

Behavioral therapy

Health Problems Common in Adolescent

Chapter 1 - Bone Tumors

Bone tumors can affect any bone in the body and develop in any part of the bone —
from the surface to the center of the bone, called the bone marrow. A growing bone
tumor — even a benign (not cancerous) tumor — destroys healthy tissue and
weakens bone, making it more vulnerable to fracture.

When a bone tumor is malignant (cancerous), it is either a primary bone cancer or a

secondary bone cancer.

A primary bone cancer actually begins in bone

A secondary bone cancer begins somewhere else in the body and then
metastasizes or spreads to bone. Secondary bone cancer is also called
metastatic bone disease.

Osteosarcoma: Most Common Bone Tumor in

Adolescents

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 Osteosarcoma is the most common type of bone cancer, and accounts for about 3%
of cancers that happen in children. Although other types of cancer can eventually
spread to parts of the skeleton, osteosarcoma is one of the few that actually begin in
bones and sometimes spread (or metastasize) elsewhere, usually to the lungs or
other bones.

Osteosarcoma usually develops from osteoblasts (the cells that make growing
bone), it most commonly affects teens who are having a growth spurt. Boys are more
likely to have osteosarcoma than girls, and most cases of osteosarcoma involve the
knee.

Types and subtypes of osteosarcoma

There are 2 types of osteosarcoma.

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 Central tumor, also called a medullary tumor

Surface tumor, also called a peripheral tumor

Each type of osteosarcoma has different subtypes. The type and subtype of
osteosarcoma is determined by looking at the tumor cells through a microscope.
Subtypes of medullary osteosarcoma include:

Conventional central osteosarcoma, such as osteoblastic, chondroblastic,

fibroblastic, and mixed types

Telangiectatic osteosarcoma

Intraosseous well-differentiated or low-grade central osteosarcoma

Small cell osteosarcoma

Subtypes of peripheral osteosarcoma include:

Parosteal well-differentiated or low-grade osteosarcoma, also called juxtacortical

osteosarcoma

Periosteal osteosarcoma that is low grade to intermediate grade

High-grade surface osteosarcoma

Statistics
This year, an estimated 1,000 people of all ages in the United States will be
diagnosed with osteosarcoma. About half of these cases will occur in children
and teens.

Osteosarcoma makes up 2% of all cancers in children ages 0 to 14 and 3% of all

cancers in teens ages 15 to 19.

It is most often diagnosed between the ages of 10 and 30, with most of these
diagnoses occurring in teens.

The overall 5-year survival rate for children ages 0 to 14 with osteosarcoma is
68%.

For teens ages 15 to 19, the 5-year survival rate is also 68%.

Pathophysiology
Osteosarcoma begins when a healthy bone cell develops changes in its DNA. A
cell's DNA contains the instructions that tell a cell what to do. The changes tell the

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 cell to start making new bone when it isn't needed. The result is a mass (tumor) of
poorly formed bone cells that can invade and destroy healthy body tissue

Complications
Osteosarcoma and its treatment can lead to complications including:

Bone fractures

Wound infection and slow healing

Problems with a donor bone graft or prosthesis

Chemotherapy side effects such as anemia, bleeding, kidney or liver damage,

hearing loss, and a higher risk of other cancers

Treatment & Management

Surgery

surgery is the removal of the tumor and some surrounding tissue during an
operation. An orthopedic oncologist is a doctor who specializes in surgery when
cancer affects the bone.

Limb-sparing surgery is used most often. Sometimes, the operation that results
in the most useful and strongest limb is different from the one that gives the most
normal appearance.

Occasionally, doctors will need to remove a limb to ensure that the entire tumor
has been eliminated this is called amputation.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the
cancer cells from growing, dividing, and making more cells. Chemotherapy is
given by a pediatric oncologist or medical oncologist, a doctor who specializes in
treating cancer with medication.

Systemic chemotherapy is given through the bloodstream to reach tumor cells

throughout the body. Common ways to give chemotherapy include an
intravenous (IV) tube placed into a vein using a needle or in a pill that is
swallowed (orally).

The chemotherapy used in osteosarcoma is typically given through an IV. Most

children with osteosarcoma have a small box placed under the skin with a tube
that goes into a large vein.This device, often called an infusaport or port-a-cath,

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 allows direct access to veins to deliver chemotherapy. A small operation is
needed to place the device.

Radiotherapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy

cancer cells. A doctor who specializes in giving radiation therapy to treat cancer
is called a radiation oncologist.

When used, radiation treatment for osteosarcoma is usually external-beam

radiation therapy. This is radiation therapy given from a machine outside the
body. A radiation therapy regimen, or schedule, usually consists of a specific
number of treatments given over a set period of time.

If treatment does not work

Although treatment is successful for many children with cancer, sometimes it is

not. If a child’s cancer cannot be cured or controlled, this is called advanced or
terminal cancer.

This diagnosis is stressful, and particularly when involving a child, adolescent, or

young adult, advanced cancer is difficult to discuss.

However, it is important to have open and honest conversations with your child’s
health care team to express your family’s feelings, preferences, and concerns.
The health care team has special skills, experience, and knowledge to support
patients and their families and is there to help.

Chapter 2 - FEBRILE SEIZURES

A FEBRILE SEIZURE IS A SEIZURE IN YOUR CHILD THAT’S CAUSED BY
A FEVER. THESE TYPES OF SEIZURES ARE AGE-SPECIFIC, HAPPENING IN
INFANTS AS YOUNG AS 6 MONTHS AND CHILDREN UP TO 5 YEARS OLD.
FEBRILE SEIZURES MOST COMMONLY OCCUR BETWEEN 12 AND 18
MONTHS OF AGE. THEY’RE USUALLY HARMLESS, AND MOST DON’T HAVE A
LASTING EFFECT.

TYPES OF FEBRILE SEIZURE

SIMPLE FEBRILE SEIZURES

AFFECTS BOTH SIDES OF YOUR CHILD’S BODY IS “GENERALIZED” (AS

OPPOSED TO FOCAL SEIZURES, WHICH ONLY AFFECT ONE SIDE OF
THEIR BODY).

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 LAST FEWER THAN 15 MINUTES.

DON’T HAPPEN MORE THAN ONCE WITHIN 24 HOURS.

COMPLEX FEBRILE SEIZURES

COMPLEX FEBRILE SEIZURES ARE LESS COMMON, ACCOUNTING FOR TWO

OUT OF 10 CASES. A COMPLEX FEBRILE SEIZURE IS ANY SEIZURE THAT
HAS ONE OR MORE OF THE FOLLOWING FEATURES:

THE SEIZURE LASTS LONGER THAN 15 MINUTES

YOUR CHILD ONLY HAS SYMPTOMS IN ONE PART OF THEIR BODY (THIS
IS KNOWN AS A PARTIAL OR FOCAL SEIZURE)

YOUR CHILD HAS ANOTHER SEIZURE WITHIN 24 HOURS OF THE FIRST

SEIZURE, OR DURING THE SAME PERIOD OF ILLNESS

YOUR CHILD DOESN'T FULLY RECOVER FROM THE SEIZURE WITHIN ONE
HOUR

STATISTICS
FEBRILE SEIZURES OCCUR IN 3 OR 4 OUT OF EVERY 100 CHILDREN
BETWEEN SIX MONTHS AND FIVE YEARS OF AGE, BUT MOST OFTEN
AROUND TWELVE TO IN THE UNITED STATES AND WESTERN EUROPE,
THEY OCCUR IN 2% TO 4% OF ALL CHILDREN.

IN JAPAN, HOWEVER, 9% TO 10% OF ALL CHILDREN EXPERIENCE AT

LEAST ONE FEBRILE SEIZURE.

RATES AS HIGH AS 14% HAVE BEEN REPORTED FROM THE MARIANA

ISLANDS IN GUAM.

NINETY PERCENT OF SEIZURES OCCUR WITHIN THE FIRST 3 YEARS OF

LIFE, 4% BEFORE 6 MONTHS, AND 6% AFTER AGE 3 YEARS.

APPROXIMATELY 50% APPEAR DURING THE SECOND YEAR OF LIFE,

WITH A PEAK INCIDENCE BETWEEN AGE 18 AND 24 MONTHS.

PATHOPHYSIOLOGY
INFECTION

THE FEVERS THAT TRIGGER FEBRILE SEIZURES ARE USUALLY CAUSED BY

A VIRAL INFECTION, AND LESS COMMONLY BY A BACTERIAL INFECTION.
THE FLU (INFLUENZA) VIRUS AND THE VIRUS THAT CAUSES ROSEOLA,

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 WHICH OFTEN ARE ACCOMPANIED BY HIGH FEVERS, APPEAR TO BE MOST
FREQUENTLY ASSOCIATED WITH FEBRILE SEIZURES.

POST-VACCINATION SEIZURES

THE RISK OF FEBRILE SEIZURES MAY INCREASE AFTER SOME CHILDHOOD

VACCINATIONS. THESE INCLUDE THE DIPHTHERIA, TETANUS AND
PERTUSSIS VACCINE AND THE MEASLES-MUMPS-RUBELLA VACCINE. A
CHILD CAN DEVELOP A LOW-GRADE FEVER AFTER A VACCINATION.

RISK FACTORS
RISK FACTORS:

GENETIC PREDISPOSITION

VIRAL INFECTION (E.G., HHV-6, INFLUENZA

HIGHFEVER (> 40°C (104°F))

COMPLICATION
ACUTE COMPLICATION

HYPOXIA

HYPOGLYCEMIA

HYPERPYREXIA

ASPIRATION PNEUMONIA

STATUS EPILEPTICUS

CHRONIC COMPLICATIONS

RECURRENCE FURTHER FEBRILE SEIZURES

EPILEPSY

MANAGEMENT
FOR THE GENERAL MANAGEMENT:

AIRWAY – BREATHING – CIRCULATION

OXYGEN BY MASK

MONITORING – GCS, VITALS, SAO2

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 SEIZURE MANAGEMENT:

IV DIAZEPAM OR IV MIDAZOLAM

IV LEVETIRACETAM IF NEEDED

FEVER MANAGEMENT:

IV PARACETAMOL

SPONGING WITH WATER

Chapter 3 - DIABETES MELLITUS

Diabetes mellitus is taken from the Greek word diabetes, meaning siphon - to
pass through and the Latin word mellitus meaning sweet.

Diabetes mellitus (DM) is a disease of inadequate control of blood levels of

glucose.

Diabetes mellitus is a disorder in which the body does not produce enough or
respond normally to insulin, causing blood sugar (glucose) levels to be
abnormally high. Urination and thirst are increased, and people may lose weight
even if they are not trying to.

Several categories of Diabetes Mellitus

Type 1 diabetes - once known as juvenile diabetes or insulin-dependent diabetes, is
a chronic condition in which the pancreas produces little or no insulin

Family History

Genetics

Geography

Age

Type 2 diabetes - involves a more insidious onset where an imbalance between

insulin levels and insulin sensitivity causes a functional deficit of insulin. Insulin
resistance is multifactorial but commonly develops from obesity and aging.
Maturity- onset diabetes of the young (MODY) - is a heterogeneous disorder
identified by non-insulin-dependent diabetes diagnosed at a young age (usually
under 25 years).

Gestational diabetes - is essentially diabetes that manifests during pregnancy.

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 Statistic
The number of people with diabetes rose from 108 million in 1980 to 422 million
in 2014. Prevalence has been rising more rapidly in low- and middle-income
countries than in high-income countries

In 2014, 8.5% of adults aged 18 years and older had diabetes. In 2019, diabetes
was the direct cause of 1.5 million deaths and 48% of all deaths due to diabetes
occurred before the age of 70 years.

Diabetes is a major cause of blindness, kidney failure, heart attacks, stroke and
lower limb amputation.

Between 2000 and 2016, there was a 5% increase in premature mortality rates
(i.e. before the age of 70) from diabetes. In high-income countries the premature
mortality rate due to diabetes decreased from 2000 to 2010 but then increased
in 2010-2016. In lower-middle-income countries, the premature mortality rate
due to diabetes increased across both periods

Pathophysiology
A patient with DM has the potential for hyperglycemia. The pathology of DM can
be unclear since several factors can often contribute to the disease.
Hyperglycemia alone can impair pancreatic beta-cell function and contributes to
impaired insulin secretion. Consequentially, there is a vicious cycle of
hyperglycemia leading to an impaired metabolic state. Blood glucose levels
above 180 mg/dL are often considered hyperglycemic in this context, though
because of the variety of mechanisms, there is no clear cutoff point.

Patients experience osmotic diuresis due to saturation of the glucose

transporters in the nephron at higher blood glucose levels. Although the effect is
variable, serum glucose levels above 250 mg/dL are likely to cause symptoms of
polyuria and polydipsia.

Insulin resistance is attributable to excess fatty acids and proinflammatory

cytokines, which leads to impaired glucose transport and increases fat
breakdown. Since there is an inadequate response or production of insulin, the
body responds by inappropriately increasing glucagon, thus further contributing
to hyperglycemia.

While insulin resistance is a component of Type 2 Diabetes Mellitus, the full

extent of the disease results when the patient has inadequate production of
insulin to compensate for their insulin resistance.

NCM 109 LECTURE 61

 Chronic hyperglycemia also causes nonenzymatic glycation of proteins and
lipids. The extent of this is measurable via the glycation hemoglobin (HbA1c)
test. Glycation leads to damage in small blood vessels in the retina, kidney, and
peripheral nerves. Higher glucose levels hasten the process.

This damage leads to the classic diabetic complications of diabetic retinopathy,

nephropathy, and neuropathy and the preventable outcomes of blindness,
dialysis, and amputation, respectively

Risk factors of type 1

Family History - Your risk increases if a parent or sibling has type 1 diabetes.

Environmental Factors - Circumstances such as exposure to a viral illness likely

play some role in type 1 diabetes.

Geography - Certain countries, such as Finland and Sweden, have higher rates of
type 1 diabetes.

Risk factors of type 2

Weight

Inactivity

Family history.

Race or ethnicity.

Age

Gestational diabetes

Polycystic ovary syndrome

High blood pressure

Abnormal

Cholesterol and triglyceride levels.

Risk factors for gestational diabetes

Weight

Age

Family or personal history

NCM 109 LECTURE 62

 Race or ethnicity

Complications
Acute Complications
i. Diabetes Ketoacidosis
ii. Hypoglycemia
iii. Diabetic non-ketoic
hyperosmolar
coma

Chronic Complications

a. Microvascular
i. Retinopathy
ii. Nephropathy
iii. Neuropathy
iv. Diabetic foot
v. Dermopathy
b) Macrovascular
i. Cerebrovascular
ii. Cardiovascular
iii. Peripheral vascular disease

PREVENTION
1. Cut sugar and refined Carbs from the diet.

2. Work Out Regularly.

3. Drink water as primary beverage.

4. Lose weight if overweight or obese.

5. Quit smoking.

6. Follow a Very-Low-Carb Diet.

7. Avoid sedentary behaviors.

8. Optimize vitamin D levels.

9. Minimize intake of processed foods

MANAGEMENT

NCM 109 LECTURE 63

 Assessment:
History: symptoms of diabetes, results of blood glucose monitoring, dietary pattern,
pharmacologic and exercise regimen, patient’s lifestyle.
Blood pressure examination while sitting and standing to detect orthostatic changes.
Body mass index and visual acuity of the patient.
Physical examination of foot, skin, mouth and nervous system.

Laboratory examinations:

Urine tests

Blood sugar (random and fasting)

Oral glucose tolerance test

1. Fluid volume deficit related to dehydration as evidenced by dry lips and

poor skin elasticity.

2. Anxiety related to fear of inability to manage treatment process as evidenced by

facial expression.

3. Increased thirst related to high blood sugar has evidenced by patient’s

verbalization.

4. Knowledge deficit related to treatment and self care needs as evidenced by

development of preventable complication i.e. diabetic foot.

5. Impaired physical mobility related to wound in foot as evidenced by inability

to move.

6. Risk for infection related to delayed wound healing.

Chapter 4 - PEDICULOSIS
Pediculosis is an infestation of the hairy parts of the body or clothing with the eggs,
larvae or adults of lice. The crawling stages of this insect feed on human blood,
which can result in severe itching. Head lice are usually located on the scalp, crab
lice in the pubic area and body lice along seams of clothing.

Three species of lice infest humans:

Pediculus humanus var. capitis (head lice),

Pediculus humanus var. corporis (body lice)

and Phthirus pubis (pubic lice, also known as crab lice).

NCM 109 LECTURE 64

 STATISTICS:
In the Philippines, the burden of disease is high at 54.7% in a population of
primary school children with female predilection (66.5% versus 42.3% in males).

An estimated 6 million to 12 million infestations occur each year in the United

States among children 3 to 11 years of age.

Prevalence varied from 0.7% to 59% and was higher in girls and women. Of the
29 studies, 24 involved schoolchildren; the other studies involved refugee
children, child laborers, the general population, street children, jail inmates, and
children accompanying their mothers in prison.

Pathophysiology
Head to head contact: hats, combs, bedding

Lice crawl-do not fly or jump

Eggs(nits) attach to hair shaft with water insoluble glue usually in the auricular or
occipital areas of the head

Nymphs emerge in 7-10 days; lifespan=30 days

Brown in color, size of sesame seed

Complications
Bacterial infections

Extremely itchy scalp

Hyper sensibility

Sores

It can also result in dry, hyperpigmented, thickly encrusted, scaly skin with
residual scarring.

Prevention
The following are steps that can be taken to help prevent and control the spread of
head lice:

Avoid head-to-head (hair-to-hair) contact during play and other activities at

home, school, and elsewhere (sports activities, playground, slumber parties,
camp).

NCM 109 LECTURE 65

 Do not share clothing such as hats, scarves, coats, sports uniforms, hair ribbons,
or barrettes.Do not share combs, brushes, or towels.

Disinfest combs and brushes used by an infested person by soaking them in hot
water (at least 130°F) for 5–10 minutes

Do not lie on beds, couches, pillows, carpets, or stuffed animals that have
recently been in contact with an infested person.

Machine wash and dry clothing, bed linens, and other items that an infested
person wore or used during the 2 days before treatment using the hot water
(130°F) laundry cycle and the high heat drying cycle. Clothing and items that are
not washable can be dry-cleaned OR sealed in a plastic bag and stored for 2
weeks.

Vacuum the floor and furniture, particularly where the infested person sat or lay.

Management
To eliminate pediculosis, both motile adult lice and all of the eggs must be killed
through physical removal using a nit comb and chemical treatment.

Lindane-based shampoos are not recommended for infants, young children,

pregnant women, lactating women, the elderly, persons with HIV or seizure
disorders, persons who have very irritated skin or sores where the lidane will be
applied and persons who weigh less than 110 pounds. Retreatment after 7 to 10
days is often recommended to ensure that no eggs have survived.

Put oil and use nit comb.

Use permethrin or pyrethrins cream /shampoo.

Nursing Care plan

• Administer medicated head lice lotions or creams as prescribed. To kill head lice
and their nits or eggs. Educate the patient and carer about proper hair and scalp
hygiene through washing them with warm water daily and practicing wet-combing

Chapter 5 - RHEUMATIC FEVER

Rheumatic fever is an inflammatory disease that can develop when strep throat or
scarlet fever isn't properly treated. Strep throat is caused by an infection with
streptococcus bacteria.

NCM 109 LECTURE 66

 An auto-immune response to group A streptococcus (GAS) infection of upper
respiratory tract.

Recurrences of rheumatic fever are likely in the absence of preventative

measures and may cause further cardiac valve and muscle damage, leading to
heart failure, strokes and premature death.

When the inflammation leads to permanent damage of the valve the individual has
rheumatic heart disease (RHD).

Etiopathogenesis
(ARF) is a delayed non suppurative sequel of pharyngeal infection with group A
beta hemolytic streptococcus (GABHS).

The bacteria is very rich in M-protein

This type of protein is antigenic

Epidemiology

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 Ages 5-15 yrs are most susceptible

Rare <3 yrs

Girls>boys

Common in 3rd world countries

Environmental factors-- over crowding, poor sanitation, poverty,

Incidence more during fall ,winter & early spring

Pathogenesis
Antibodies produced against the streptoccocal antigens cause inflammation in
the endocardium,myocardium and pericardium, as well as the joints and
skin.

Acute rheumatic fever usually affects children(5-15) or people in area of

poverty and crowded.

Clinical Finding: Major Manifestations

Migratory Polyarthitis

It involves a series of painful joints, followed by another series of painful joints.

This form of arthritis rarely causes permanent joint deformity.

Pancarditis
Inflammation of all three layers of the heart tissue

Endocarditis

The acute stage of inflammation tere is roughening and chronic stage there is
thickening of the surface lining

Myocarditis

Inflamed area in the myocardial tissue called Aschoff bodies

Most common cause of death

Pericarditis
Cause pain and friction rub

Subcutaneous Nodules

There are 0.5-2cm i diameter, round, firm, freely mobile and painless
nodules.

NCM 109 LECTURE 68

 Erythema marginatum

Occur mainly on the trunk and proximal extremities.

They are small, firm and painless.

Sydenham’s chorea:

A rapid movement in the face and arm

Artralgia : there is pain on joint movement without evidence of swelling or heat.

Other diagnostic method:

Blood test

1. C -reactive protein (CRP)

2. Antistreptolysin O titre (ASOT)

3. Erythrocyte sedimentation rate (ESR)

Electrocardiograph (ECG)

1. PR prolongation is seen in 25% of cases of ARF.

Echo-cardiography

Treatment
Use anti-inflammatory medications

Use antibiotics

Ensure to have plenty of bed rest

Anti-inflammatory:

aspirin

Chorea

Providing a calm environment

Carbamazepine or sodium valproate

Prevention
Primary prevention:

NCM 109 LECTURE 69

 by adequate antibiotic therapy of group A streptococcal upper respiratory tract
(URT) infections to prevent an initial attack of acute RF.

Secondary prevention:

Penicillin

Prognosis
Rheumatic fever can recur whenever the individual experience new GABH
infection, if not on

prophylactic medicines.

Good prognosis for older age group & if no carditis during the initial attack

Bad prognosis for younger children & those with carditis with valve lesions

Discussion Summary
Acute Rheumatic Fever is an auto-immune response to group A streptococcus
(GAS) infection of the upper respiratory tract. Antibodies produced against the
streptococcal antigens cause inflammation in the endocardium, myocardium and
pericardium, as well as the joints and skin.

Diagnosis is clinical and relies on Jones Criteria, anti-inflammatory medications to

relieve symptoms. Use antibiotics to get rid any remaining streptococcus bacteria in
the body of a child.

Chapter 6 - IMPETIGO
Impetigo is a superficial skin infection that is seen most commonly in children
and is transmitted easily from person to person (CDC,2020)

Reddish sores ( face, nose, mouth, hands and feet). Over about a week, the
sores burst and develop honey-colored crusts.

Caused by a bacteria; group A Streptococcus and Staphylococcus aureus.

Bullous, non- bullous & ecthyma Impetigo

2 ways of initial infection can occur:

Primary impetigo- bacteria invades the skin through a cut , insect bite, or other
injury

NCM 109 LECTURE 70

 Secondary impetigo- bacteria invades the skin because the skin barrier has
been disrupted by another skin infection, such as scabies or eczema.

NCM 109 LECTURE 71

NCM 109 LECTURE 72
 STATISTICS
In the United States, impetigo is more common in the summer.1 The World Health
Organization estimates that 111 million children in the developing world have
streptococcal impetigo at any one time.4 Higher rates of impetigo are found in
crowded and impoverished settings, in warm and humid conditions, and among
populations with poor hygiene.

Epidemiology
The bullous form most frequently affects neonates and accounts for
approximately 10% of all cases of impetigo

Based on data from studies published since 2000 from low and low-middle
income countries, we estimate the global population of children suffering from
impetigo at any one time to be in excess of 162 million, predominantly in tropical,
resource-poor contexts. Impetigo is an under-recognised disease and in
conjunction with scabies, comprises a major childhood dermatological condition
with potential lifelong consequences if untreated.

Pathophysiology
Bullous impetigo is caused by staphylococci producing exfoliative toxins that
contain serine proteases acting on desmoglein , a structurally critical peptide
bond in a molecule that holds epidermal cells together. This process allows
Staphylococcus aureus to spread under the stratum corneum in the space
formed by the toxin, causing the epidermis to split just below the stratum
granulosum. Large blisters then form in the epidermis with neutrophil .

In bullous impetigo, the bullae rupture quickly, causing superficial erosion and a
yellow crust.

Non-bullous impetigo, Streptococcus typically produces a thick-walled pustule

with an erythematous base. Histology of non-bullous established lesions shows
a thick surface crust composed of serum and neutrophils in various stages of
breakdown with parakeratotic material

Complication
Impetigo typically isn't dangerous. And the sores in mild forms of the infection
generally heal without scarring.

NCM 109 LECTURE 73

 Rarely, complications of impetigo include:

Cellulitis. This potentially life-threatening infection affects the tissues underlying

the skin and eventually may spread to the lymph nodes and bloodstream.

Kidney problems. One of the types of bacteria that cause impetigo can also
damage the kidneys.

Scarring. The sores associated with ecthyma can leave scars.

Signs and Symptoms

Pruritus(severe itching)

Other systemic signs of infection

Weakness

Fever

Diarrhea

Non bullous impetigo manifests initially as small, fluid filled vesicles

In the bullous form of impetigo, the lesions begin as vesicles and turn into bullae
containing clear yellow fluid.

IS IMPETIGO CONTAGIOUS?
Impetigo is contagious, mostly from direct contact with someone who has it.

Can be transmitted through:

Towels

Toys

clothing

household items

Diagnosis:
Doctors generally diagnose impetigo by looking at the distinctive sores.

Sometimes culture test are done

complete blood count because leukocytosis is common.

NCM 109 LECTURE 74

 Treatment
Mild cases can be handled by:

gentle cleansing, removing crusts, and applying the prescription-strength

antibiotic ointment mupirocin ( Bactroban).

More severe or widespread cases:

may require oral antibiotic medication for impetigo

antimicrobial treatment such as cellulitis

Antibiotic as indicated by the doctor

Penicillinase resistant penicillins

Cephalexin

benzathine penicillin

Care of the impetigo

Wash the sores (lesions) with an antibacterial or antiseptic soap every eight to
12 hours, soaking off visible crust.

After each wash, pat the lesions dry. Use a clean towel each time.

Apply a waterproof occlusive dressing to stop further spread of the infection.

See your doctor if the sores spread and get worse despite treatment, or if the
child becomes unwell with fever.

Change the child’s linen daily while the infection is present.

How to Avoid Spreading of Impetigo

Hand washing frequently and dry it completely

A child with impetigo should be kept home from school or day care until
appropriate treatment has begun

Cut your child’s fingernails short

Avoid scratching or touching the sores

Keep affected areas of skin clean and covered to minimise the chance of
spreading the infection.

Always wash your hands with soap before and after touching sores or scabs.

NCM 109 LECTURE 75

 Encourage children to use their own towel and face cloth. No sharing.

Wash the child’s linen, towels and clothes in hot water. Wash all household linen
in hot water while the infection is present.

Dispose of used dressings promptly and thoroughly.

Chapter 7 - (RHEUMATIC ATHRITIS) /

JUVENILE RHEUMATOID ARTHRITIS
Juvenile rheumatoid arthritis (JRA), often referred to by doctors as Juvenile
Idiopathic arthritis (JIA). Is antype of arthritis that causes joint inflammation
andnstiffness for more than six weeks in a child aged 16 or younger.

JRA is an autoimmune disorder, means that the body mistakenly identifies some
of its own cells and tissues as foreign.

3 Major Types of JIA

Oligoarticular JIA (arthritis in four joints or less)

Polyarticular JIA (arthritis in five or more joints)

Systemic JIA (arthritis plus fever, rash and large lymph nodes)

Statistics
Globally, approximately 3 million children and young adults are estimated to suffer
from JIA. The global prevalence of JIA has been estimated to range from 3.8 to
400/100,000 with an incidence of 1.6 to 23/100,000 ; Girls were consistently found to
be at a higher risk than boys.

In Philippines, a study were conducted by Pediatric Rheumatology of the University

of Santo Tomas Hospital (USTH) from 2009 to 2019. 127 patients with SJIA or
Systemic Juvenile Idiopathic Arthritis, 88 (61%) of them developed persistently
active disease. 36 (41%) were diagnosed after five weeks. Only 33 (41%) received
biological agents.

PATHOPHYSIOLOGY
Initiation of the JIA pathophysiological cascade includes abnormal activation of
T-cells, B-cells, natural killer (NK) cells, dendritic cells (DC), macrophages and

NCM 109 LECTURE 76

 neutrophils and the production of pro-inflammatory mediators that cause joint
destruction and systemic complication.

In juvenile rheumatoid arthritis, the immune system may recognize normal cells
and tissues as the invaders and launches attack on those healthy cells and
tissues causing autoimmune disease.

T-cells and B-cells are two types of white blood cells involved in rheumatoid
arthritis. The T-cells release cytokines (chemicals that play a role in the
inflammatory response) and cause the B cells to release antibodies (immune
proteins) which causes inflammation.

Signs and Symptoms

Pain or achiness in more than one joint

Stiffness in more than one joint that lasts longer than 30 minutes

Swelling in more than one joint

Symmetrical joint involvement

A general feeling of being unwell

Low-grade fever

Appetite loss

Weight loss

Weakness

Joint deformity

Loss of function and mobility

Unsteadiness when walking

Diagnosis
Blood tests

Some of the most common blood tests for suspected cases include:

Erythrocyte sedimentation rate (ESR).

C-reactive protein.

Antinuclear antibody.

NCM 109 LECTURE 77

 Rheumatoid factor.

Cyclic citrullinated peptide (CCP).

Imaging scans

X-rays or magnetic resonance imaging may be taken to exclude other conditions,

such as fractures, tumors, infection or congenital defects.

COMPLICATIONS
There are several complications of JIA which may or may not affect the child,
depending on the type of JIA they have, how severe it is, and how well it is
managed.

GROWTH PROBLEMS

Inflammation of JIA can affect how the body grows. Inflammation causes an
increase in blood flow to the growth plates resulting to more rapid growth of the
bones in the affected joints. In some cases, the inflammation can cause the
growth plate to fuse or close earlier than it was supposed to.

JOINT CONTRACTURES

Inflammation causes pressure and pain around the affected joints. Sometimes,
children will keep the inflamed joint in the most comfortable position which is
usually bent. As a result the joint becomes stuck in a bent position.

MUSCLE WEAKNESS AND MUSCLE LOSS

When a joint is swollen, stiff, and painful to move, it is natural for a child to
reduce their activities. However, doing this can make their muscle weaker when
muscles are not used regularly, they will become smaller.

OSTEOPOROSIS

Is when the bones become thin and weak; easy to fracture. Not staying active
and not getting enough calcium which helps to make the bone strong and
healthy.

EYE PROBLEMS

In addition to joint problems, JIA may cause problems with the eyes including
uveitis, glaucoma, or cataracts.

MEDICATION

NCM 109 LECTURE 78

 The medications used to help children with juvenile idiopathic arthritis are chosen to
decrease pain, improve function and minimize potential joint damage.

Typical medications include:

Nonsteroidal anti-inflammatory drugs (NSAIDs).

Disease-modifying antirheumatic drugs (DMARDs).

Biologic agents.

Corticosteroids.

Therapies

Surgery

TREATMENT
New treatments, interventions and tests as a means to prevent, detect, treat or
manage this condition.

Lifestyle and home remedies

Caregivers can help children learn self-care techniques that help limit the effects
of juvenile idiopathic arthritis. Techniques include:

Getting regular exercise.

Applying cold or heat.

Eating well.

Coping and support

Family members can play critical roles in helping children cope with their
condition.

Chapter 8 - Scabies
Scabies is a skin infection caused by the human itch mite (Sarcoptes scabiei var.
hominis) that burrows into the upper skin layer and lays its eggs there.

This parasitic skin infestation is primarily transmitted via direct, prolonged skin-
to-skin contact.

Scabies is a disease that affects people of all ethnicities and social groups
worldwide. It can spread quickly in crowded places where close human-to-
human contact is frequent.

NCM 109 LECTURE 79

 Crusted (Norwegian) Scabies a severe form of scabies that can occur in
immunocompromised individuals.

Statistics
Approximately 300 million cases of scabies are reported worldwide each year.

One study found that the infestation rate for scabies was highest among children
aged 10-12 years old.

The disease was more commonly evident in boys (50%) than in girls (16%).

An estimated 200 million people worldwide suffer from scabies at any one time.

Up to 10% of children in resource-poor areas are affected by scabies.

Pathophysiology
The fertilized female mite tunnels into the superficial skin layer and forms a
burrow where she lays her eggs and deposits scybala (feces)

After two months, the adult female dies on site.

The larvae become adult mites three weeks later, maintaining the infestation
cycle.

The excretions of the mites and their decomposing bodies contain antigens
which cause an immunological response presenting as severe pruritus and
excoriations.

Complications
The intense itching of scabies leads to scratching which can lead to skin sores. The
sores sometimes become infected with bacteria on the skin, such as Staphylococcus
aureus or beta-hemolytic streptococci. Sometimes the bacterial skin infection can
lead to an inflammation of the kidneys called post-streptococcal glomerulonephritis.

Treatment
Ointments, creams, and lotions

Pramoxine lotion

Steroid Creams

Medications:

NCM 109 LECTURE 80

 Antihistamines (Benadryl)Antibiotics

Ivermectin (Stromectol) for severe or widespread scabies

Sulfur (soap, ointment, shampoo, or liquid)

NOTE: OTC scabies treatment must be FDA approved.

Natural Treatments:

Tea tree oil

Aloe Vera

Capsaicin cream

Essential Oils

Prevention
Avoiding direct skin-to-skin contact with someone who has scabies is the best way to
prevent contracting the disease. It's also preferable to avoid wearing or sleeping in
scabies-infected clothing or bedding.

Nursing Interventions
Prevent infection.

Wash hands and teach the patient to wash hands before contact with patients
and between procedures with the patient.

Encourage fluid intake of 2,000 to 3,000 mL of water per day, unless

contraindicated.

Teach the patient, family, and caregivers, the purpose and proper technique for
maintaining isolation.

If infection occurs, teach the patient to take antibiotics as prescribed. Instruct

patient to take the full course of antibiotics even if symptoms improve or
disappear.

Restore skin integrity.

Monitor status of skin around the wound.

Monitor patient’s skincare practices, noting the type of soap or other cleansing
agents used, the temperature of the water, and frequency of skin cleansing. Tell

NCM 109 LECTURE 81

 the patient to avoid rubbing and scratching; provide gloves or clip the nails if
necessary.

Instruct patient, significant others, and family in the proper care of the wound
including handwashing, wound cleansing, dressing changes, and application of
topical medications).

Relieve pain.

Acknowledge reports of pain immediately; provide rest periods to promote relief,

sleep, and relaxation; provide analgesics as ordered, evaluate the effectiveness
and inspect for any signs and symptoms of adverse effects; and determine the
appropriate pain relief method.

Chapter 9 - Scoliosis
Adolescent idiopathic scoliosis is an abnormal curvature of the spine that
appears in late childhood or adolescence. Instead of growing straight, the spine
develops a side-to-side curvature, usually in an elongated “S” or “C” shape; the
bones of the spine are also slightly twisted or rotated.

The term scoliosis is derived from the Greek word skolios (“twisted”) and refers
to a sideward (right or left) curve in the spine.

Two forms of scoliosis

Structural - Involves rotated and malformed vertebrae

Functional(postural) - Poor posture muscle spasm caused by trauma

unequal length of legs.

Idiopathic - Idiopathic is the most common type of scoliosis. This means that
the cause is unknown or that there is no single factor that contributes to the
development of the disease.

Congenital - Congenital forms of scoliosis result from a spinal defect present

at birth. This is usually detected at a much earlier age than idiopathic forms
of scoliosis.

Neuromuscular - Neuromuscular scoliosis is spinal curvature that develops

because of some kind of another disease.

Statistics

NCM 109 LECTURE 82

 470-5200 Scoliosis is the most common spinal deformity. The prevalence of
scoliosis is approximately 470-5200 per 100,000 individuals worldwide.

Symptoms
Uneven shoulders

One shoulder blade that appears more prominent than the other

Uneven waist

One hip higher than the other

One side of the rib cage jutting forward

A prominence on one side of the back when bending forward

Causes
Doctors don’t know what causes the most common type of scoliosis — although
it appears to
involve hereditary factors, because the disorder sometimes runs in families. Less
common types of scoliosis may be caused by:

Certain neuromuscular conditions, such as cerebral palsy or muscular

dystrophy

Birth defects affecting the development of the bones of the spine

Previous surgery on the chest wall as a baby

Injuries to or infections of the spine

Spinal cord abnormalities

Pathophysiology
Most cases of structural scoliosis are idiopathic; a few are caused by
congenital deformities or infection. Most of the curves in the spine develop
during the first year of life, and strong correlation has been found between
the nursing posture of the infant and development of the curve. It is less
common in the United States than in Europe, where babies are nursed in the
supine position. Infants have a natural tendency to turn toward the right side,
and because of plasticity of the infant’s axial skeleton, this can lead to
development of plagiocephaly, bat ear on the right side, and curvature of the
spine toward the left side.

NCM 109 LECTURE 83

 PREVENTION
While scoliosis is often easier to treat when it is diagnosed early, scoliosis
prevention is not possible. Even activities like practicing good posture, exercising
and doing yoga or Pilates cannot prevent scoliosis. The only type that may be
prevented is adult scoliosis caused by osteoporosis.

Complications
Breathing Problems - In severe scoliosis, the rib cage may press against the
lungs, making it more difficult to breathe.

Back Problems - People who had scoliosis as children may be more likely to
have chronic back pain as adults, especially if their abnormal curves are
large and untreated.

Appearance - As scoliosis worsens, it can cause more noticeable changes

— including uneven hips and shoulders, prominent ribs, and a shift of the
waist and trunk to the side.

Risk Factors
Age - Signs and symptoms typically begin in adolescence.

Sex - Although both boys and girls develop mild scoliosis at about the same
rate, girls
have a much higher risk of the curve worsening and requiring treatment.

Family history - Scoliosis can run in families, but most children with scoliosis
don’t have a family history of the disease.

Treatment
Surgery - Severe scoliosis typically progresses with time, so your doctor
might suggest scoliosis surgery to help straighten the curve and prevent it
from getting worse.

Surgical options include:

Spinal fusion

Expanding rod

Vertebral body tethering

NCM 109 LECTURE 84

 Braces - If your child’s bones are still growing and he or she has moderate
scoliosis, your doctor may recommend a brace. Wearing a brace won’t cure
scoliosis or reverse the curve, but it usually prevents the curve from getting
worse.

FACTS AND MYTHS

Scoliosis is extremely painful

Scoliosis is only occurs during adolescence

Having children is difficult with scoliosis

Scoliosis is caused by heavy backpacks

Sports are Dangerous

You Can Prevent Scoliosis

Chapter 10 - Amenorrhea
Amenorrhea is when you aren’t getting your periods even though you’ve been
through puberty,
aren’t pregnant, and haven’t gone through menopause. It is the absence of
menstruation, often
defined as missing one or more menstrual periods.

Amenorrhea Types

Primary Amenorrhea - This when young women have not had their first
period by the age of 15.

NCM 109 LECTURE 85

 Secondary Amenorrhea - This when you have had normal menstrual cycles,
but they stop 3 or more months.

Statistics
Amenorrhea is not life-threatening, but the loss of the menstrual cycle has been
associated with a high risk of hip and wrist fractures. In the US, amenorrhea affects
about 1% of women. Recent studies indicate that childhood obesity may contribute
to the early onset of menarche.

Pathophysiology
Normally, the hypothalamus generates pulses of gonadotropin-releasing
hormone (GnRH).

GnRH stimulates the pituitary to produce gonadotropins (follicle-stimulating

hormone [FSH] and luteinizing hormone [LH] Theidealized cyclic changes in
pituitarygonadotropins, estradiol, progesterone and uterine endometrium during
the normal menstrual cycle), which are released into the bloodstream.

Gonadotropins stimulate the ovaries to produce estrogen (mainly estradiol),

androgens (mainly testosterone), and progesterone.

Complications
● Infertility and problems with pregnancy
● Psychological stress
● Osteoporosis and Cardiovascular disease
● Pelvic pain

How to Prevent Amenorrhea?

There are few measures you can take at home to help regulate your periods:
● Eat a balanced diet
● Get regular exercise to maintain healthy weight
● Manage and reduce your stress
● Be aware of your cycle
● Get regular and adequate sleep
● Take birth control as prescribed

Management and Treatment

NCM 109 LECTURE 86

 If your period stopped because of menopause or pregnancy, your provider will not
need to treat it. In other cases, your treatment will depend on the cause and may
include:
https://my.clevelandclinic.org/health/diseases/3924-amenorrhea

● Losing weight through dieting and exercise (if excess weight is the cause).
● Gaining weight through an individualized diet plan (if extreme weight loss is the
cause).
● Stress management techniques.
● Changing exercise levels.

● Hormonal treatment (medication), as prescribed by your healthcare provider.

○ Estrogen therapy
● Calcium and Vitamin D supplements (as prescribed)
● Surgery (in rare cases).

Chapter 11 - Dysmenorrhea
Medical term for painful menstrual periods which are caused by uterine contractions.

Two Types of Dysmenorrhea

Primary dysmenorrhea refers to recurrent pain

Secondary dysmenorrhea results from reproductive system disorders

Statistics
The worldwide prevalence of of dysmenorrhea has ranged from 15.8% to 91.5%,
with higher rates reported in adolescent populations. As many as 90% of women in
the Philippines say they have ever had period pain and dysmenorrhea is not a
hindrance to do their work while 89% say that period pain has affected their ability to
work.

Pathophysiology
Prostaglandin - More intense uterine contraction - Primary Dysmenorrhea

Secondary Dysmenorrhea - Gynecologic Conditions - Endometriosis, Adenomyosis,

Fibroids, Pelvic Inflammatory Disease, Cervical Stenosis

Complications

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 Primary Dysmenorrhea

Menstrual cramps don't cause other medical complications, but they can
interfere with school, work and social activities.

Secondary Dysmenorrhea

Fibroid - anemia and difficulties in pregnancy

Endometriosis - fertility problems

Pelvic Inflammatory Disease - chronic pelvic pain, infertility, increase risk of

ectopic pregnancy

Adenomyosis - Hypermenorrhea (heavy menstrual bleeding)

Cervical stenosis - infertility and chronic pain

Prevention
Both primary and secondary dysmenorrhea cannot be prevented but symptoms may
be reduced.

Primary Dysmenorrhea

● Talk to your doctor about taking anti-inflammatory medication one to two days
before your period is scheduled to begin to ward off symptoms of primary
dysmenorrhea.
● Get plenty of rest
● Avoid or quit smoking
● Have a normal BMI (18.5-24.9)

Secondary Dysmenorrhea

● Avoiding exposure to sexually transmitted diseases and having good hygiene may
prevent certain underlying conditions, like infections.
● Have a regular check up.

Management
Primary Dysmenorrhea

● Drink more water

● Eat anti inflammatory foods
● Reach for decaf
● Applying heat, such as a hot water bottle, to the abdomen
● Relaxation techniques

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 Secondary Dysmenorrhea

● Fibroids - If fibroids are causing your pain, the first step may be to try NSAIDs, a
birth control method, or GnRH agonists. If these do not work, a treatment called
uterine artery embolization (UAE) may be recommended.
● Endometriosis - NSAID, Hormone Therapy such as Hormonal contraceptives,
Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists, Progestin
therapy, and Aromatase inhibitors. Conservative surgery and Hysterectomy with
removal of the ovaries can also be a treatment.

● Adenomyosis - NSAIDs, hormone medication, and hysterectomy.

● Pelvic Inflammatory Disease - Antibiotics, treatment for your partner, temporary

abstinence.

● Cervical stenosis - widening of the cervix by inserting small, lubricated metal rods
(dilators) then inserting large dilators.

Chapter 12 - SEXUALLY TRANSMITTED

DISEASE
A.K.A sexually transmitted infections (STIs)

a recognizable disease state that has developed from an infection that are
passed to another through sexual contact.

Cause by bacteria, viruses, and parasites

May pass from person to person in blood, semen, or vaginal and other bodily
fluids.

can be transmitted nonsexual (during pregnancy or childbirth, or through blood

transfusions or shared needles)

STATISTICS
A CDC analysis provides the clearest picture to date of STIs in the United
States. CDC estimates indicate about 20 percent of the U.S. population –
approximately one in five people in the U.S. – had an STI on any given day in
2018, and STIs acquired that year will cost the American healthcare system
nearly $16 billion in healthcare costs alone.

The analysis included eight common STIs: chlamydia, gonorrhea, hepatitis B

virus (HBV), herpes simplex virus type 2 (HSV-2), human immunodeficiency

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 virus (HIV), human papillomavirus (HPV), syphilis, and trichomoniasis.
Chlamydia, trichomoniasis, genital herpes, and HPV accounted for 98% of all
prevalent STIs and 93% of all new STIs in 2018.

WHO: Each year there are estimated 374 million new infections with 1 of 4 STIs:
chlamydia, gonorrhea, syphilis and trichomoniasis.

PATHOPHYSIOLOGY
Sexually transmitted diseases (STDs) are transmitted via the mucous
membranes of the vagina, penis, urethra or rectum, during sexual contact
with an infected individual. Transmission can also occur via membranes
of the throat, respiratory tract, mouth and eyes.

The mucous membranes are thinner than skin and allow microbes to
cross them into the body. In addition, minor breaks in the skin and
mucous membranes due to abrasions or cuts further increase the risk of
infection. The microbes are often present in fluids secreted from the
penis, vagina, saliva, feces, urine and sweat. Sometimes, only a small
amount of the microbes can lead to transmission of an STD.

Any sexual contact including oral sex and deep kissing can lead to the
transmission of certain infections, although the concentration of the
microbes is often lower in saliva than in the genital fluids. Non-sexual
contact such as hugging and shaking hands is not usually responsible for
transmitting infection.

COMPLICATIONS
Pelvic pain

Pregnancy complications

Eye inflammation

Arthritis

Pelvic inflammatory disease

Infertility

Heart disease

Certain cancers, such as HPV-associated cervical and rectal cancers

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 CLINICAL PREVENTION GUIDANCE
Prevention and control of STIs are based on the following five major strategies (5):

1. Accurate risk assessment, education and counseling of persons at risk regarding

ways to avoid STIs through changes in sexual behaviors and use of
recommended prevention services

2. Pre-exposure vaccination for vaccine-preventable STIs

3. Identification of persons with an asymptomatic infection and persons with

symptoms associated with an STI

4. Effective diagnosis, treatment, counseling, and follow-up of persons who are

infected with an STI

5. Evaluation, treatment, and counseling of sex partners of persons who are

infected with an STI

Chapter 13 - ACCIDENT
(TRAUMA/INJURY)
One in every twelve pregnancies is complicated by trauma, and it is the biggest
nonobstetric cause of death among pregnant women. Motor vehicle accidents,
assaults, falls, and intimate partner violence are the most common causes of
traumatic injuries. Minor injuries account for nine out of ten traumatic injuries during
pregnancy, but they account for 60 to 70% of fetal losses following trauma.

Minor and major trauma injuries are distinguished. Minor trauma, by definition, does
not involve the abdomen, rapid compression, deceleration, or shearing forces, and
the patient does not complain of pain, vaginal bleeding, fluid loss, or decreased fetal
movement.

ASSESSMENT
Minor incidents, such as car accidents and mild blunt abdominal trauma, are the
most
common pregnancy-related traumas. In these cases, clinical judgment is required
regarding the extent of maternal and fetal assessment. However, because minor
trauma
can cause fetal injury or death, fetal monitoring recommendations for pregnant
women

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 who have experienced minor trauma are similar to those for women who have
experienced
major trauma. In patients who have experienced IPV, an assessment for depression
and
suicidality should be combined with an assessment for immediate safety.
The primary assessment in major trauma should focus on airway, breathing, and
circulation. Following the completion of the primary assessment, a secondary
assessment
should include obstetric and nonobstetric injuries, as well as fetal well-being.

A placental abruption may appear soon after the injury. Fetal monitoring
should begin as soon as the patient is stabilized in women who have
experienced trauma at more than 20 weeks’ gestation. Tocodynamometry
should be used to monitor the patient for at least four hours.

For placental abruption, ultrasonography has a low sensitivity but a high

specificity. Regardless of Rh status, the Kleihauer-Betke test should be
performed after major trauma to determine the extent of fetomaternal
hemorrhage.

MANAGEMENT
MINOR TRAUMA
Minor trauma management consists of treating lacerations or
fractures, discussing appropriate analgesics, counseling about the
signs and symptoms of abruption, and ensuring appropriate
follow-up. If tetanus toxoid, reduced diphtheria toxoid, and
acellular pertussis (Tdap) vaccine have not been given during the
current pregnancy, tetanus toxoid should be given. Appropriate
referrals to community-based advocacy groups should be made
for individuals who have experienced IPV, and a plan should be
developed to ensure the safety of the patient and other vulnerable
people living in the household.
MAJOR TRAUMA

Patients who have suffered major trauma should be

transported as soon as possible to a hospital that has the
resources to perform a timely trauma evaluation.
Because placental abruption has been reported to occur
up to 24 hours after trauma, tocodynamometry

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 monitoring should be continued for at least 24 hours if at
least six uterine contractions have occurred or if there are
nonreassuring fetal heart rate patterns, vaginal bleeding,
significant uterine tenderness, serious maternal injury, or
a positive Kleihauer-Betke test result. If none of these
findings are found, the patient may be sent home with
precautions.

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