CARE OF CHILD AT RISK
hospitalization.
OR WITH PROBLEMS
(ACUTE & CHRONIC)
I. CARE OF
HOSPITALIZED
CHILD
3 FOCUS IN CARING FOR A
HOSPITALIZED CHILD
1. Alleviating the anxieties of
children
• Apprehensive and frightened
when they anticipate or
experience pain.
• Use pain-free of topical
anesthetics.
• Use sedatives to prevent and
moderate pain environment.
• For neonates use oral glucose
pacifiers.
• Use procedural (description of the
treatment and sequence of steps)
and sensory information (how
they might feel).
2. Major factors to support coping
during illness and hospitalization.
• Inner strengths, talents, and
attributes of the child ability to
cope in situations with assistance
of adult.
• External determinants
• Expertise of the nurse:
understanding verbal and non-
verbal behavior of the ill child.
• Discerning the meaning intended
• Responding skillfully and
accurately.
• Support of families
• Relationship between nurses
and families
• Climate of pediatric unit as
supportive environment: feelings
of safety and security.
• Play as therapeutic in facilitating
coping: active life progress,
attractive, well – equipped
playroom.
• school room must provide
opportunities for children to
engage in play activities and
learning designed to avert
untoward effects of
• Provide information - Encourage
emotional expression.
• Establish trusting relationships.
• Teach coping strategies
(thorough tour): use of puppets,
medical play, children's literature,
audiovisual media.
II. PAIN MANAGEMENT
IN CHILDREN
Pain in children is not only a hurting
sensation, but it can also be a confusing
one because a child does not anticipate the
pain, does not have words to explain how it
feels, and cannot always understand its
cause.
PAIN PHYSIOLOGY:
1. Nociceptors: free nerve endings
w/ specific receptors found in
tissue throughout the body.
Four reasons:
• reduced oxygen in
tissues from
impaired circulation
• pressure on tissue
• external injury
• overstretching of
body cavities with
fluid or air.
2. Pain Receptor: a sensory
neuron that responds to
damaging or potentially damaging
stimuli by sending “possible
threat” signals to the spinal cord
and the brain.
Pain impulses stimulated by
the neurotransmitters
conducted by:
1. A-alpha and A-beta fibers:
large fibers that are myelinated,
conduct the response at a rapid
rate transmits sharp, well
localized pain.
2. A-delta nerve: fibers that are
smaller and conduct at a slower
rate like light pressure and
vibration.
3. C-nerve - fibers-slowly
conducting un-myelinated axons
that transmit diffuse, dull,
burning, and chronic pain.

PAIN IMPULSES:

- join central nervous system

(CNS) fibers in the dorsal horn
of the spinal cord
- -projected upward to the
brain, where they will be
perceived as pain

This is called the Gate Control Theory which

pain impulses travel and interpreted in the
body.

PAIN ASSESSMENT:
A. Pain interview and History
(PQRST):

P = Presence of pain “Are you hurting

today?
Q - Quality “What words describe your
pain?” (i.e. sharp, burning, tingling)
CLASSIFICATION OF PAIN
R – Radiation or location “Where is
your pain? Or “Does it shoot or radiate
1. Acute Pain – sharp pain
anywhere else?”
2. Chronic Pain – pain that lasts
S – Severity ”Give me a number
for a prolonged period (often
between 0-10 for your pain”
defined as 6 months)
T - Timing ”How long have you had this
3. Cutaneous pain – arises
pain?” or “How long does it last when
from superficial structures
the pain comes?”
such as the skin and mucous
membrane.
B. Assessment Measures
4. Somatic Pain – originates
from deep body
1. Objective Measures - used by
5. Visceral pain – involves
observer to score client behavior
sensations that arise from
or physiologic parameters
internal organs
associated w/ painful response,
6. Referred pain – is pain that is
HR, BP, and self-reporting
perceived at a site distant
instruments.
from its point of origin.
2. Subjective (Self – Rating)
Measures: when children
MECHANISM/FLOW OF PAIN
measure the pain themselves.
Pain Impulse
PAIN MANAGEMENT:

1. Nonpharmacologic: distraction,
Stimulated noxious stimuli (mechanical, preparation, relaxation,
chemical, thermal) electrical activity, cutaneous stimulation, self-
transduction, transmission exercises, hypnosis
2. Pharmacologic: Analgesics-
NSAIDS, Local or regional
Moves along peripheral - sensory
anesthesia
nerves, spinal column and brain
 III. NEWBORN
EXAMINATION
LBW Infants: Less than 2,500
grams or less at birth regardless
of gestational age
1. SGA: small for gestational age –
have intrauterine growth
retardation (IUGR)
2. SFD : small for date-birth weight
fall below 10% percentile on
intrauterine growth charts
3. AGA: appropriate in weight for
gestational age
4. LGA : large for gestational age –
weight above 90% on intrauterine
growth chart
GESTATIONAL AGE
➢ Premature (preterm) infants:
regardless of birth weight are
those delivered before 37 weeks
from 1st day of LMP.
➢ Full term infants: those born
between 37- and 42- weeks
gestation.
➢ Postmature infants: those born
after a prolonged gestation (after
42nd weeks) regardless of birth
weight.
GESTATIONAL AGE-RELATED
PROBLEMS
1. PRETERM INFANT
(Prematurity) - A preterm
infant is traditionally defined
as a live-born infant born
before week 37 of gestation.
Another criterion used is a
weight of less than 2500 g (5
lbs. 8 oz)
- Preterm neonate is at risk for
complications because the
organ systems are immature.
- The degree of complications
depends on gestational age.
CAUSES
➢ Multiple pregnancy
➢ Adolescent pregnancy
➢ Lack of prenatal care
➢ Substance abuse
➢ Smoking
➢ Previous preterm delivery
➢ High, unexplained alpha
fetoprotein level in 2nd trimester
➢ Abnormalities of the uterus
➢ Cervical incompetence
➢ Premature rupture of membranes
➢ Placenta previa
➢ Pregnancy Induced Hypertension
(PIH)
Note: It may be necessary to deliver a
neonate prematurely if evidence of a
maternal complication exists.
HIGHER RISK WITH YOUNGER
GESTATIONAL AGE
Clinical Manifestations
Respiratory Manifestations:
• Tachypnea
• Grunting
• Nasal Flaring
• Cyanosis
• Decreased Oxygen Saturation
• Decreased Oxygen Levels
• Abnormal Arterial Blood gas
(ABG) values
Cardiovascular Manifestations:
• Poor Tissue Perfusion
• Hypotension
• Patent Ductus arteriosus
Gastrointestinal manifestations:
• Feeding intolerance
• Gastric reflux
• Vomiting
• Gastric residuals
Altered fluid status
• Fluid excess
• Fluid deficit
Fluid excess
• Edema
• Congestive heart failure
Fluid deficit
• Tachycardia
• Poor skin turgor
• Decreased urine output
• Abnormal Electrolyte
• Decreased blood pressure
 IATROGENIC ANEMIA • Serum calcium
• lowered hematocrit and • Serum bilirubin
hemoglobin count resulting • Euglobulin lysis time
from large or frequent removal • CBC
of blood samples
MEDICAL MANAGEMENT

PREMATURE NEONATES
• Cared for by a specially trained
staff in the neonatal intensive
care unit (NICU)
• Top priority is supporting the
cardiac and respiratory systems
• Providing thermoregulation
• Starting IV
• Gavage nutrition

IATROGENIC ANEMIA
• tachycardia
• pallor
• decreased blood pressure
• increasing oxygen
requirements
• apnea

OTHER RISK FACTORS: NURSING MANAGEMENT

• Infection • Assess heart sounds for
• Hypoglycemia presence of murmurs
• Hyperglycemia • Assess apical pulse
• Ineffective Temperature • Assess perfusion
Control (inability to maintain • Monitor vital signs
core body temp) • Provide adequate fluids and
electrolytes and nutrition.
NEUROMUSCULAR SYSTEM • Maintain a neutral thermal
• Decreased suck and swallow environment.
reflex • Prevent infection.
• Hypotonia • Assess for readiness for selected
• Altered state transition interventions.
• Provide stimulation when
HYPERBILIRUBINEMIA appropriate to infant state and
• Rapid destruction of red blood readiness.
cells • Encourage flexion in the supine
• Jaundice position by using blanket rolls.
• Lethargy • Provide the newborn with body
• ERNICTERUS - the deposition of boundaries through swaddling or
unconjugated bilirubin in the brain using blanket rolls against the
cells and is associated with newborn’s body and feet
mental retardation • Promote parent- newborn
attachment.
DIAGNOSTIC TESTS: • Initiate phototherapy as required.

• Chest X-ray NOTE:

• ABG Analysis Nursing interventions for the premature
• Head ultrasound neonate should focus on maintaining an
• Echocardiography environment like the intrauterine
environment
• Eye examination- retinal
specialist
• Serum Glucose
COMPLICATIONS: Treatment of Patent Ductus
Arteriosus
• fluid regulation
• respiratory support
• administration of indomethacin
• surgical ligation (if the neonate
doesn’t respond to other
therapies)

NECROTIZING ENTEROCOLITIS
(NEC)

RESPIRATORY DISTRESS • an inflammatory disease of the GI

SYNDROME (RDS) mucosa
• occurs in neonates whose GI
• Leading cause of morbidity and tract has suffered vascular
mortality among premature compromise
neonates. • bowel wall swells and breaks
• Lungs lack surfactant, which down
prevents alveolar collapse at the
end of respiration.
• Treatment involves administration
of surfactant, oxygen
administration, and mechanical
ventilation

RETINOPATHY OF PREMATURITY
ROP)

• Disease caused by abnormal

growth of retinal blood vessels.
• Prematurity may cause abnormal
vessels to grow.
• Supplemental oxygen is also
thought to contribute to this
growth.
• ROP can cause mild to severe
eye and vision problems.
• Treatment may involve laser
surgery or cryotherapy

PATENT DUCTUS ATERIOSUS

The ductus arteriosus reopens after

birth due to lowered oxygen tension
associated with respiratory Treatment:
impairment. • discontinuation of enteral
feedings
• nasogastric suction
• administration of IV
• antibiotics
• administration of parenteral
fluid
• surgery
BRONCHOPULMONARY DYSPLASIA Treatment:
(BPD) • Theophylline
• also called chronic lung disease • Caffeine
• lungs may be less compliant • Provide gentle sensory
because of the damage caused stimulation: stroking face,
by prematurity, infection, or chest, groin; apnea due to
mechanical ventilation. anemia: management is blood
transfusion

II. GESTATIONAL AGE-RELATED

PROBLEMS

1. POSTMATURE INFANT - After

42 weeks in the uterus the infant
is at special risk because a
placenta appears to only function
effectively for 40 weeks (placental
insufficiency)

• After 40 weeks, the

placenta lose its
ability to carry
nutrients effectively
to the fetus, the
fetus may die or
develop post-term
syndrome/complicat
Treatment: ions.
supplying oxygen
maintaining good nutrition, If the placenta continues to function well
preventing respiratory illness • Fetus will continue
to grow, resulting to
an LGA infant who
APNEA OF PREMATURITY may manifest
problems:
• common phenomenon in o birth trauma
• the premature neonate o hypoglycemi
• occurs due to neurologic and a
chemical respiratory control If placental function decreases
mechanisms that are immature • fetus may not
• number of apneic spells tends to receive adequate
increase the younger the nutrition
gestational age of the neonate • fetus will utilize its
subcutaneous fat
stores for energy
• Wasting of
subcutaneous fat
occurs, resulting in
fetal dysmaturity
syndrome.

3 STAGES OF FETAL
DYSMATURITY

Stage 1
• Chronic placental
insufficiency
• Dry, cracked, peeling,
loose, and wrinkled skin
• Malnourished appearance
Stage 2– Acute Placental Insufficiency
• All Features Of Stage 1
• Meconium Staining
• Perinatal Depression
• A non-stress test or complete
biophysical profile – determine if
the placenta functions adequately
NURSING MANAGEMENT:

Stage 3– Subacute placental 1. Manage meconium aspiration

insufficiency
• Findings of stage 1 and 2
• Green staining of skin, nails,
cord, and placental membrane
• A higher risk of fetal intrapartum
or neonatal death
• The newborn is at increased risk
for developing complications
related to compromised
uteroplacental perfusion and
hypoxia (e.g., meconium
aspiration MAS)
• Chronic intrauterine hypoxia
causes increased fetal
erythropoietin and red blood cell
production resulting in
polycythemia.
• Post – term infants are
susceptible to hypoglycemia
because of the rapid use of
glycogen stores.
ASSESSMENT FINDINGS:
• long, thin newborn with wasted
appearance
• parchment-like skin
• meconium-stained skin, nails,
and umbilical cord.
• Fingernails are long
• Lanugo is absent
• Meconium aspiration syndrome is
manifested by:
o Fetal Hypoxia
o Blue or pale skin
o Low HR
o Weak muscle tone
o Weak Cry/ No Cry
o Difficulty breathing
• Meconium staining of amniotic
fluid
• Respiratory distress at delivery
• Meconium-stained vocal cords
syndrome
o Suction mouth and nares
while the head is on
perineum
o Suction before the first
breath to prevent
meconium aspiration
o Once the infant is dry and
on the warmer, intubate
with direct tracheal
suctioning
o Perform chest
physiotherapy with
suctioning to remove
excess meconium
secretions
o Provide oxygen and
respiratory support
2. Obtain serial blood glucose
measurements
3. Provide early feeding to prevent
hypoglycemia, if not
contraindicated by respiratory
status.
4. Maintain skin integrity.
o Keep the skin integrity
o Avoid the use of powders,
creams, and lotions.
o Avoid the use of tape

DIAGNOSTIC FINDINGS:

• Hematocrit may be elevated due

to polycythemia and dehydration
– lowers the circulation plasma
level
• Sonogram measures the
biparietal diameter
 IV. GESTATIONAL WEIGHT –
RELATED PROBLEMS
1. Small for Gestational
Age
o An SGA infant is one whose
length, weight, and head
circumference are below the 10th
percentile of the normal variation
for gestational age as determined
by neonatal examination
o May be preterm, term or post-
term
ETIOLOGY:
1. Maternal conditions associated
with SGA babies include:
o Hypertension (chronic or
pregnancy- induced)
o Cardiac, pulmonary, or renal
disease
o Diabetes mellitus
o Poor nutrition
o Use of alcohol, tobacco or drugs
o Age
o Multiple gestation
o Placental insufficiency
1. Fetal conditions associated with
SGA infants include:
o Normal genetically small infant
o Chromosomal abnormality
o Malformations
o Congenital infection, especially
rubella and cytomegalovirus
2. The effect of these factors upon
the fetus is dependent on the
stage of fetal development
Early gestation is a time of rapid cell
proliferation. normal size cells, but
they are fewer in number.
o Infants are symmetrical (their
heads and bodies grew
proportionately) but their organs
are smaller.
o Usually, these infants have a poor
prognosis and may never catch
up.
Later in gestation, growth of the fetus
results from an increase in cell size.
o Organs with a normal number of
cells that are smaller in size and
causes asymmetric growth.
o They have appropriate-sized
heads and body lengths, but their
weight and organ sizes are
decreased.
o These infants usually have a
better prognosis since they have
an adequate number of cells.
o Their growth catches up if they
are provided with good nutrition
postnatally
ASSESSMENT FINDINGS:
o Soft tissue wasting
o Loose, dry, and scaling skin
o Perinatal asphyxia (due to a small
placenta that is less efficient in
gas exchange)
o Deprivation of oxygen
Asphyxia - Deprivation of oxygen:
o low HR
o no or weak breathing
o poor muscle tone
o amniotic fluid is stained with
meconium
o Respiratory distress, and
central nervous system (CNS)
aberrations (if the infant has
polycythemia – volume
percentage of RBC is
elevated)
o Congenital anomalies
(occurring in as many as 35%
LABARATORY/ DIAGNOSTIC TEST
FINDINGS:
• Glucose testing will reveal
decreased glycogen stores,
which increases the potential for
hypothermia and hypoglycemia.
• Hematocrit level may be
increased (65%), which indicates
polycythemia as a result of
chronic fetal hypoxia.
 o Use isolation precautions
when congenital infections
NURSING MANAGEMENT: are suspected

1. Provide adequate fluid and 7. Provide education and emotional

electrolytes and nutrition. support.
o High calorie formula for o Explain the possible
feeding (more than 20 causes of intrauterine
calories per ounce) to growth retardation. -
promote steady weight Inform parents of the
gain infant’s goal weight for
o 15 to 30 grams per day discharge.
o If the infant is breast o Provide instruction on
feeding, add human milk managing the infant at
fortifier to expressed home.
breast milk. o Explain how to prepare a
2. Decrease metabolic demands higher calorie formula or
when possible. breast feeding.
o Provide small frequent o Explain the importance of
feedings. follow-up with a
o Provide gavage feedings if developmental specialist
the infant does not have a who will screen for
steady weight gain. milestone achievements.
o Provide a neutral thermal
environment. 2.LARGE FOR GESTATIONAL
3. Prevent hypoglycemia
o Monitor glucose screening. AGE
o Provide early feedings
o Provide frequent feedings A LGA newborn is one weighs more
(every 2 to 3 hours) than 4,000 g, is above the 90th
o Administer IV glucose if percentile
blood sugar does not
normalize with oral
feedings.
4. Maintain a neutral thermal
environment.
5. Monitor serum hematocrit
(normal is 45% to 65%)
o If an initial high hematocrit
was obtained by heelstick
capillary sample,a follow-
up sample should be done
by venipuncture.
o Observe for signs,
symptoms, and
complications of
polycythemia Ruddy PATHOPHYSIOLOGY:
appearance;
▪ Cyanosis Infants who are large for gestational age
▪ Lethargy have been subjected to an
▪ Jitteriness overproduction of growth hormone in
(unable to utero. This most frequently happens with
relax) infants of diabetic mothers who are
Seizures poorly controlled. It may also occur in
▪ Jaundice multiparous pregnancies because with
6. Assess the prenatal history for each pregnancy babies tend to grow
possible toxoplasmosis, rubella, larger.
cytomegalovirus, and herpes
simplex infections during
pregnancy.
o Assess maternal and
infant antibody titers.
CLINICAL MANIFESTATIONS:
o Complications associated with
maternal diabetes
o Birth injuries due to
disproportionate size of newborn
to birth passageway
NURSING MANAGEMENT:
1. If IDM, observe for potential
complication
2. Monitor for, and manage, birth
injuries and complications of birth
injuries.
o Clavicle fracture
BIRTH INJURIES
1. Intracranial Hemorrhage -
trauma or anoxia congenital
vascular anomaly or hemorrhagic
problem.
Causes: trauma, CPD, prolonged
labor, precipitate delivery, breech
presentation, mechanical
interference.
ASSESSMENT:
• cyanosis, pallor, apnea, difficult
respiration, irregular breathing
without other signs of respiratory
distress
• lethargy, somnolence with absent
or diminished Moro reflex, poor
response to stimuli, exaggerated
reflex, tremors, convulsions,
tensed or bulging fontanels
DIAGNOSTICS MANAGEMENT:
Diagnostics:
• UTZ, CT scan , Hemotocrit
determination
• small dose of vit K, BT, sedative,
subdural tap (to remove collection
of fluid and reduce ICP
Nursing Management:
• provide warmth and rest: place in
incubator
• infant’s head elevated, measure
head circumference daily
• feed with care: gavage if can’t
tolerate IVF
FACIAL NERVE INJURY
• Assess for symmetry of mouth
while crying.
• Wrinkles are deeper on the
unaffected side.
• The paralyzed side is smooth
with a swollen appearance.
• The nasolabial fold is absent.
• If the eye is affected, protect it
with patches and artificial tears.
MANAGEMENT:
• X-ray studies of the shoulder and
upper arm to rule out bony injury
• Examination of the chest to rule
out phrenic nerve injury
• Delay of passive movement to
maintain range of motion of the
affected joints until the nerve
edema resolves (7 to 10 days)
• Splints may be useful to prevent
wrist and digit contractures on the
affected side
ERB-DUCHENNE PALSY AND
KLUMPKE PARALYSIS
• Erb-Duchenne palsy.- paralysis of
the arm caused injury to the trunk
(C5-C6)
• Assess for adduction of the
affected arm with internal rotation
and elbow extension.
• The Moro reflex is absent on the
affected side.
• The grasp reflex is intact.
• Klumpke paralysis.
• Assess for absent grasp on the
affected side.
• The hand appears claw-shaped.
PHRENIC NERVE PALSY
• Assess for respiratory
• distress with diminished
• breath sounds.
• X-ray usually shows
• Elevation of the diaphragm •on
the affected side.
SKULL FRACTURE
Assess for soft-tissue swelling over
fracture site, visible indentation in scalp,
cephalhematoma, positive skull x-ray,
and CNS signs with intracranial
hemorrhage (e.g., lethargy, seizures,
apnea, and hypotonia).
V. ACUTE
CONDITIONS OF
THE NEONATES
RESPIRATORY DISTRESS
SYNDROME
• Formerly termed hyaline
membrane disease
• Most often occurs in preterm
infants, infants of diabetic
mothers, infants born by CS birth,
or those who for any reason have
decreased blood perfusion of the
lungs
PATHOPHYSIOLOGY:
• High pressure is required to fill
the lungs with air for the 1st time
and overcome the pressure of
lung fluid
• Deficient surfactant → alveoli
collapse with each expiration →
takes forceful inspiration to inflate
them → with deficient surfactant,
areas of hypoinflation occur and
pulmonary resistance is
increased → blood then shunts
through the foramen ovale and
the ductus arteriosus as it did
during fetal life → lungs are
poorly perfused, thus affecting
gas exchange → alveoli is no
longer adequate to sustain life
without ventilator support.
 expiration, or there is an
inspiratory/expiratory ratio of 1:2
- Limiting fluid intake may help
decrease pulmonary
congestion
- Indomethacin may be used to
cause closure of the patent
ductus arteriosus, thus
making ventilation more
efficient

Increase distress: PREVENTION:

• Seesaw respirations (on
inspiration, the anterior chest wall Dating a pregnancy by sonogram or the
retracts and the abdomen lecithin/sphingomyelin ratio of amniotic
protrudes, on expiration the fluid is an important way to be certain
sternum rises) that an infant born by CS or induced is
• Heart failure evidenced by mature enough the RDS is not apt to
decreased urine output and occur.
edema of the extremities
• Pale gray skin color
• Periods of apnea
• Bradycardia
• Diagnosis of RDS is made on the
clinical signs of grunting,
cyanosis in room air, tachypnea,
nasal flaring, retractions, and
shock

DIAGNOSTIC TEST FINDINGS:

1. Chest x-ray film will reveal a

diffuse pattern of radiopaque MECONIUM ASPIRATION
areas that look like ground glass SYNDROME
2. Blood gas studies will reveal
respiratory acidosis
3. Grp B beta hemolytic ,
streptococcal infection may mimic
RDS. This infection is so severe
in newborns that the insult to the
lungs is intense enough to stop
surfactant production. Cultures of
blood, CSF, skin may be done to
rule out this condition

MEDICAL MANAGEMENT:

A. Surfactant replacement and rescue

– synthetic surfactant is sprayed into the
lungs by a syringe or catheter through
endotracheal tube at birth while the
infant is positioned with the head upright
and then tilted downward

B. Oxygen administration – is Pathophysiology:

necessary to correct oxygen . A possible
complication of oxygen therapy in the 1. Risk factors for meconium
very immature or very ill infant is aspiration syndrome include: •o
retinopathy of prematurity. Maternal diabetes
o Maternal hypertension
C. Ventilation – normally, on a o Difficult delivery
ventilator, inspiration is shorter than o Fetal distress
 o Intrauterine hypoxia SUDDEN INFANT DEATH
o Advanced gestational age SYNDROME
(greater than 40 weeks)
o Poor intrauterine growth
2. Meconium can cause severe
respiratory distress in three ways:
o It can bring inflammation of
bronchioles because it is a
foreign substance
o can block small
bronchioles by mechanical
plugging
o It can cause a decrease in
surfactant production
through lung cell trauma
PATHOPHYSIOLOGY:
ASSESSMENT FINDINGS:
• Sudden unexplained death in
1. Obvious presence of meconium infancy
in the amniotic fluid (dark • Usually during sleep
greenish staining or streaking of • Usually related to immature CNS
the amniotic fluid)
o Skin with greenish stain CAUSE IS UNKNOWN
o Limp appearance at birth
o Cyanosis
o Difficulty respirations at birth
o Apgar score is apt to be low
o Tachypnea, retractions, apnea
o Increased RR
o Chest retractions (barrel Chest)
Hypothermia

DIAGNOSTIC FINDINGS:

o Blood gases will reveal a poor RECOMMENDATIONS:

gas exchange evidenced by
decreased oxygen and increase
carbon dioxide levels; acidosis
o Chest x-ray will show patches or
streaks of meconium in the lung,
with spaces of hyperaeration
(honeycomb effect). The
diaphragm will be pushed
downward
• Supine sleeping position
• Use of firm sleep surface
• Room sharing without bed
sharing
• Routine immunization
• Breastfeeding
• Consideration of using pacifier

TREATMENT:

• Suctioning before the first breath

• Respiratory assistance with
mechanical ventilation
• Neutral thermal environment
• Surfactant
• Antibiotic
• Monitoring of Vital signs, lung • Parents must be counselled at
status, respiratory rate and the time of the infant’s death and
character periodically
• Autopsy result must be given to
parents as soon as they are
available
WARNING SIGNS: CLINICAL MANIFESTATIONS:

• Fast breathing (more than sixty • Jaundice all over

breaths in one minute), although
keep in mind that babies normally
breathe more rapidly than adults
• Retractions (sucking in the
muscles between the ribs with
each breath, so that her ribs stick
out)
• Flaring of her nose
• Grunting while breathing
• Persistent blue skin coloring
HYPERBILIRUBINEMIA
Two types of bilirubin
1. Direct (conjugated)
• water-soluble
• easier for the body to eliminate
• yellow discoloration of the sclera
• Lethargy
• Dark amber concentrated urine
• Poor feeding
• Dark stool
COMPLICATIONS:
Kernicterus
Bilirubin is deposited in the brain
causing destruction of brain cells
Causes permanent impaired
neurological function

2. Indirect (unconjugated)
• fat-soluble; easily cross the
blood-brain barrier
• hard for the body to eliminate

PHYSIOLOGIC JAUNDICE:

• Jaundice begins within the first 24

hours of life
• Usually related to hemolytic
disease of the
• newborn
• Rh incompatibility
• ABO incompatibility
• Other Causes:
infection,polycythemia,biliary
atresia

PREDISPOSING FACTORS:
• Prematurity
• Cephalhematoma- is a
MANAGEMENT:
hemorrhage,collection of blood
between the skull and periosteum
•Early and frequent feedings to stimulate
peristalsis
ASSESSMENT:
•Exchange transfusion Phototherapy
Assessment includes blanching of the
•Photo-oxidation by the use of artificial
skin specifically forehead and cheeks
blue light in order to convert bilirubin into
an excretable form).

NURSING RESPONSIBILITIES IN
PHOTOTHERAPY CARE:

• Monitor Intake and output every 8

hours
• Weigh infant daily
• Increase fluid intake
• Monitor skin and provide skin
care
• Monitor bilirubin levels
NEONATAL SEPSIS/ SEPSIS
NEONATARUM
TYPES:
Early Onset
✓Begins within 24 hours
✓More rapid progression
✓Often causes pneumonia or meningitis
Late Onset
✓ Develops after 48 hrs to 1st week of
life
✓ Usually involve CNS
ETIOLOGY;
• Group B streptococci(GBS) and
Escherichia Coli(E. Coli)
• Staphylococcus epidermidis,
Staphylococcus Aureus,
• Haemophilus influenza
• Candida albicans - common
cause of nosocomial infections of
hospitalized low birth
weight(LBW) infants
• Vertical Infection
• Horizontal Infection
PREDISPOSING FACTORS:
• Prolonged rupture of membranes
• Long, difficult labor
• Resuscitation and other invasive
procedures
• Maternal infection
• Vaginosis – most common cause
of neonatal sepsis
• Aspiration of amniotic fluid
• bacteria, virus, fungus,
Escherichia coli
ASSESSMENT FINDINGS:
• Hypotonia, Lethargy
• Temperature instability
• Feeding intolerance (poor
sucking vomiting, hyperglycemia,
hypoglycemia)
• Mottling, pallor, cyanosis
• Respiratory distress (nasal
flaring, retractions, grunting)
• Tachycardia, Tachypnea(Initially
which is followed by periods of
apnea and bradycardia)
• Hypotension
• Abdominal distension and
diarrhea
THERAPEUTIC MANAGEMENT:
• Culture of the blood, urine, skin
lesions, CSF
• Blood analysis
• Lumbar puncture to rule out
meningitis
• Gastric aspiration
• Antibiotic administration
(Ampicillin, Gentamicin)
• Neutral thermal environment
• Vital signs frequently
• Collect specimens to identify
causative organism
• Chest radiograph
NURSING MANAGEMENT:
• Identify infants at risk
• Emphasize hand washing
• Use of medical asepsis
• On time medications
administration
• Maintain fluid balance and hourly
urine output
• Monitor vital signs
• Observe for complications
• Gavage feeding PRN
• Parental support
NURSING DIAGNOSIS:
• Impaired gas exchange
• Ineffective thermoregulation
• Risk for imbalanced nutrition, less
than body requirements
• Risk for deficient fluid volume
• Risk for infection
• Risk for impaired parenting
 • Appear within 1 – 3 days of getting
infected
NURSING CARE OF A • Symptoms last 1 week to 10 days or
longer
CHILD WITH UPPER
RESPIRATORY
GROUP AT RISK
PROBLEM • Babies and children have higher risk
for colds
• School children are especially at risk
I. NASOPHARYNGITIS due to easy spread of the virus
• Being in close contact with someone
infected
• Any group situation where one or
more people have colds: office, gym,
sports events, party, crowded places
• People with weakened immune
system

DIAGNOSING VIRAL
NASOPHARYNGITIS
• Doctor will ask questions about the
symptoms
• physical examination (nose, throat,
and ears)
• swab test
• Known as “cold” • swollen lymph node
• It is an upper respiratory infection or • recurrence of nasopharyngitis –
rhinitis” referral to ENT specialist
• swelling of the nasal passages and
the back of the throat TREATMENT
CAUSES: Focus: Treating Symptoms (Virus cannot
Bacteria or virus can be spread through tiny be treated with antibiotics)
air droplets through:
• Symptoms gradually improves in
o sneezing
o coughing few days
o blowing of the nose • Rest periods
o talking • Drink plenty of fluids
o by touching a contaminated object • Over-the-counter remedies to
such as doorknobs, toys, phones relieve pain and help lessen the
etc. symptoms
o by touching the eyes nose or mouth
Over-the-counter medications:
Bacteria and virus can rapidly spread in any
group setting:
• Zinc supplements – taken at the
o Office first sign of symptoms
o classroom • Cough suppressants – severe
o daycare centers cough Robitussin, Zicam, Delsym
o any institutions or Codeine
o Rhinovirus is the most common • Nasal spray – fluticasone
cold-causing virus which is highly propionate (Flonase)
contagious. • Antiviral for influenza
• Vapor rub - Vicks VapoRub
SYMPTOMS OF VIRAL
NASOPHARYNGITIS: • Saline nasal spray
• runny or stuffy nose • Decongestants -
• sneezing pseudoephedrine (Sudafed)
• coughing • Lozenges – soothe the throat
• sore or scratchy throat • NSAIDS – aspirin, ibuprofen
• watery or itchy eyes (Advil, Motrin)
• headache • Mucus thinners – guaifenesin
• tiredness (Mucinex)
• body aches
• low fever
• post-nasal drip
ALTERNATIVE TREATMENT
• Use a humidifier or vaporizer, or
breathe in steam from hot water
or a shower, to help relieve
congestion.
• Eat chicken soup.
• Dissolve 1⁄2 teaspoon of salt in
warm water and gargle it. This
can help relieve the pain from a
sore throat.
• Add honey to warm water to help
soothe a sore throat. Don’t give
honey to children under 1 year
old.
• Don’t smoke or avoid
secondhand smoke.
II. TONSILITIS
• An inflammation of the tonsils
• Two oval-shaped pads of tissue
at the back of the throat — one
tonsil on each side.
SIGNS & SYMPTOMS
• Swollen tonsils
• Sore throat
• Difficulty swallowing
• Tender lymph nodes on the sides
of the neck
CAUSES
• Most cases of tonsillitis are
caused by infection with a
common virus,
• Bacterial infections also cause
tonsillitis
• VIRUSES
• BACTERIA (STREPTOCOCCUS
PYOGENES) - group A
streptococcus - bacterium that
causes strep throat
• other strain of streptococcus and
other bacteria also cause tonsilitis
WHAT IS A TONSIL?
• The first line of defense of the
immune system against bacteria
and viruses
• This function makes the tonsils
particularly vulnerable to infection
and inflammation
• The function of the tonsil’s
immune system declines after
puberty — accounts for the rare
cases of tonsillitis in adults.
TREATMENT
• Appropriate treatment depends
on the cause
• Prompt and accurate diagnosis is
important
• Removal of tonsils applies for
frequent recurrence of tonsilitis or
doesn’t respond to other common
treatments and causes serious
complications
RISK FACTORS
Young age
• Tonsillitis most often affects
children
• Tonsillitis caused by bacteria is
most common in ages 5 to 15.
Frequent exposure to germs
• School-age children are in close
contact with their peers and
frequently exposed to viruses or
bacteria that can cause tonsillitis
• Commonly affects children
between preschool ages and the
mid-teenage years.
SYMPTOMS:
• Red, swollen tonsils
• White or yellow coating or
patches on the tonsils
• Sore throat
• Difficult or painful swallowing
• Fever
• Enlarged, tender glands (lymph
nodes) in the neck
• A scratchy, muffled or throaty
voice
• Bad breath
• Stomachache
• Neck pain or stiff neck
• Headache
In young children who are unable to
describe how they feel, signs of tonsillitis
may include:
• Drooling
• Difficult or painful swallowing
• Refusal to eat
• Unusual fussiness
Call the Doctor if child is experiencing:
• A sore throat with fever
• A sore throat that doesn't go
away within 24 to 48 hours
• Painful or difficult swallowing
• Extreme weakness, fatigue or
fussiness
Get immediate care if the child has any
of these signs:
• Difficulty breathing
• Extreme difficulty of swallowing
• Excessive drooling
COMPLICATIONS:
Frequent or ongoing (chronic) tonsillitis
can cause complications such as:
• Disrupted breathing during sleep
(obstructive sleep apnea)
• Infection that spreads deep into
surrounding tissue (tonsillar
cellulitis)
• Infection that results in a
collection of pus behind a tonsil
(peritonsillar abscess)
STREP INFECTION:
If group A streptococcus or another
strain of streptococcal bacterial tonsilitis
isn't treated or if antibiotic treatment is
incomplete, the child has an increased
risk of rare disorders such as:
• Rheumatic fever, a serious
inflammatory condition that can
affect the heart, joints, nervous
system and skin
• Complications of scarlet fever, a
streptococcal infection
characterized by a prominent
rash
• Inflammation of the kidney
(poststreptococcal
glomerulonephritis)
Poststreptococcal reactive
arthritis, a condition that causes
inflammation of the joints
PREVENTION:
The germs that cause viral and bacterial
tonsillitis are contagious. Therefore, the
best prevention is to practice good
hygiene. Teach children to:
• Wash his or her hands thoroughly
and frequently, especially after
using the toilet and before eating
• Avoid sharing food, drinking
glasses, water bottles or utensils
• Replace his or her toothbrush
after being diagnosed with
tonsillitis
Prevention of spreading infection to
others:
• Keep the child at home when he
or she is ill
• Ask the doctor when it's all right
for the child to return to school
• Teach the child to cough or
sneeze into a tissue or, when
necessary, into his or her elbow
• Teach the child to wash his or her
hands after sneezing or coughing
 III. EPISTAXIS
Nosebleeds (also called
epistaxis) can occur easily
because of the location of
the nose and the close-to-
the-surface location of
blood vessels in the lining
of the nose
CAUSES:
Common causes of nosebleeds:
HOW TO STOP A NOSEBLEED?
• Dry air caused by hot, low-humid
climate or heated indoor
• Nose rubbing or picking.
• Colds (upper respiratory
infections) and sinusitis,
especially episodes that cause
repeated sneezing, coughing and
nose blowing.
• Blowing the nose with force.
• Inserting an object into the nose.
• Injury to the nose and/or face.
• Allergic and non-allergic rhinitis
(inflammation of the nasal lining).
• High altitudes. The air is thinner
(lack of oxygen) and drier as the
altitude increases.
• Blood-thinning drugs (aspirin,
NSAIDS, warfarin, and others).
• Cocaine and other drugs inhaled
through the nose.
• Chemical irritants (chemicals in
cleaning supplies, chemical
fumes at the workplace, other
strong odors).
• Deviated septum (an abnormal
shape of the wall that separates
the two sides of the nose).
• Frequent use of nasal sprays and
medications to treat itchy, runny
or stuffy nose – antihistamines
and decongestants can dry out
the nasal membranes.
1. Relax.
2. Sit upright and lean body and
head slightly forward. This will
keep the blood from running
down the throat, which can cause
nausea, vomiting, and diarrhea.
3. Do NOT lay flat or put the head
between legs.
4. Breathe through the mouth.
5. Use a tissue or damp washcloth
to catch the blood.
6. Use thumb and index finger to
pinch together the soft part of the
nose.
7. Pinch the soft part of the nose
against the hard bony ridge that
forms the bridge of the nose.
Squeezing at or above the bony
part of the nose will not put
pressure where it can help stop
the bleeding.
 8. Use thumb and index finger to
pinch together the soft part of the IV. SINUSITIS
nose.
9. Pinch the soft part of the nose
against the hard bony ridge that
forms the bridge of the nose.
Squeezing at or above the bony
part of the nose will not put
pressure where it can help stop
the bleeding
10. Keep pinching the nose
continuously for at least 5
minutes (timed by clock) before
checking if the bleeding has
stopped. If it is still bleeds,
continue squeezing the nose for
another 10 minutes.
11. Apply an ice pack to the bridge of
• An inflammation or swelling of the
the nose to further help constrict
tissue lining the sinuses.
blood vessels (which will slow the
bleeding) and provide comfort • Healthy sinuses are filled with air
(not a necessary step) but when being blocked and filled
with fluid, germs can grow and
12. Spray an over-the-counter cause an infection.
decongestant spray, such as
oxymetazoline (Afrin®, Dristan®, CAUSES:
Neo-Synephrine®, Vicks Sinex®,
others) into the bleeding side of • The common cold
the nose and apply pressure to • Allergic rhinitis - swelling of the
the nose as described above. lining of the nose caused by
allergens
WARNING: These topical decongestant • Nasal polyps - small growths in
sprays should not be used over a long the lining of the nose
period of time. Doing so can actually • A deviated septum, which is a
cause an increase in the chance of a shift in the nasal cavity
nosebleed.
For children:
13. After the bleeding stops, DO NOT • Allergies
bend over, strain and/or lift • Illnesses from other kids at
anything heavy. DO NOT blow or daycare or school
rub the nose for several days. • Pacifiers
• Bottle drinking while lying on the
back
• Smoke in the environment

TYPES OF SINUSITIS:

1. Acute sinusitis usually starts

with cold-like symptoms such as
a runny, stuffy nose and facial
pain. It may start suddenly and
last 2-4 weeks.
2. Subacute sinusitis usually lasts
4 to 12 weeks.
3. Chronic sinusitis symptoms last
12 weeks or longer.
4. Recurrent sinusitis happens
several times a year.
SYMPTOMS OF ACUTE SINUSITIS:
• Facial pain or pressure
• "Stuffed-up" nose
• Runny nose
• Loss of smell
• Cough or congestion
• Thick green, or yellow nasal
discharge
SYMPTOMS OF CHRONIC SINUSITIS:
You may have these symptoms for 12
weeks or more:
• A feeling of congestion or fullness
in the face
• A nasal obstruction or nasal
blockage
• Pus in the nasal cavity
• Fever
• Runny nose or discolored
postnasal drainage
• May also have headaches, bad
breath, and tooth pain and fatigue
V. LARYNGITIS
• An inflammation of the voice box
(larynx) from overuse, irritation or
infection
• Swelling of vocal cords
• Distortion of the sound produced
by air passing
• Hoarseness
• Undetectable in some cases
• Acute or short-lived
• Chronic or long-lasting
• Most cases – triggered by a
temporary viral infection (not
serious)
• Persistent hoarseness signals a
more serious underlying medical
condition
LARYNX
• vocal cords
• 2 folds of mucous membrane
• covering muscle
• Cartilage
• Vocal cords open and close
smoothly forming sounds by
movement and vibration
CAUSES
1. Acute laryngitis
Most cases are temporary and improve
after the underlying cause gets better.
• Viral infections similar to those
that cause a cold
• Vocal strain, caused by yelling or
overusing your voice
• Bacterial infections, although
these are less common
2. Chronic laryngitis
• Lasts longer than 3 weeks
• Causes vocal cord strain and
injuries
• Causes growths like polyps and
nodules
• Inhaled irritants, such as
chemical fumes, allergens or
smoke
• Acid reflux, also called
gastroesophageal reflux disease
(GERD)
• Chronic sinusitis
• Excessive alcohol use
• Habitual overuse of your voice
(singers or cheerleaders)
• Smoking
3. Less common causes of
Chronic Laryngitis:
• Bacterial infections
• Fungal infections
• Infections with certain parasites
 4. Chronic Hoarseness: VI. CROUP
• Cancer
• Vocal cord paralysis – may result
from nerve injury due to surgery
• Injury to the chest or neck
• Bowing of the vocal cords
• Nerve disorders and other health
conditions

RISK FACTORS

• Having a respiratory infection

(cold, bronchitis or sinusitis)
• Exposure to irritating substances
(smoking, excessive drinking of
Croup is a viral condition that causes
alcohol, stomach acid, inhalation
swelling around the vocal cords.
of chemicals)
• Overusing of voice (too much
CAUSES:
speaking, too loud speaking,
• Parainfluenza viruses (the
shouting or singing)
common cold).
SYMPTOMS: • Adenovirus (another group of
common cold viruses)
• hoarseness
• Respiratory Syncytial Virus
• weak voice
(RSV), the most common germ
• loss of voice
affecting young children, and
• tickling sensation and rawness in
measles.
your throat
• Allergies exposure to inhaled
• sore throat irritants, or bacterial infections.
• dry throat (considered to be rare)
• dry cough
SYMPTOMS:
SEEK IMMEDIATE MEDICAL • cold symptoms like sneezing and
ATTENTION IF CHILD: runny nose
• Makes noisy, high-pitched • fever
breathing sounds when inhaling • barking cough
(stridor)
• heavy breathing
• Drools more than usual
• hoarse voice
• Has trouble swallowing
• Has difficulty breathing TREATMENT:
• Has a fever • Cool mist humidifiers (mild cases)
• Symptoms may indicate croup – • Severe cases:
inflammation of the larynx and the • Steroid medications- open your
airway just beneath it. child’s airways, allowing easier
• Can also indicate epiglottitis – breathing
inflammation of the tissue that • Oxygen - to help your child get
acts as a lid (epiglottis) to cover enough oxygen
the windpipe (trachea) which can
• Antibiotic - bacterial infection
be life threatening
• Rehydrate with IVF
PREVENTION:
• Avoid smoking and stay away
from secondhand smoke.
• Limit alcohol and caffeine.
• Drink plenty of water.
• Keep spicy foods out of your diet.
• Include a variety of healthy foods
in your diet.
• Avoid clearing your throat.
• Avoid upper respiratory
infections.
 VII. EPIGLOTTIS
Epiglottitis is characterized by
inflammation and swelling of your
epiglottis. It’s a potentially life
threatening illness.
CAUSES:
• Bacterial infection – Haemophilus
Influenzae type b, also known as
Hib
• Other bacterial strains that can
cause epiglottitis include
Streptococcus A, B, or C and
Streptococcus pneumoniae.
Streptococcus A is the type of
bacteria that can also cause strep
throat. Streptococcus
pneumoniae is a common cause
of bacterial pneumonia.
Other causes of this condition
include:
• smoking crack cocaine
• inhaling chemicals and chemical
burns
• swallowing a foreign object
• burning your throat from steam or
other sources of heat
• experiencing throat injury from
trauma, such as a stabbing or
gunshot wound
RISK FACTORS:
• AGE- Children younger than 12
months of age are at a higher risk
for developing epiglottitis
• SEX- Males are more likely to
develop epiglottitis than females
• ENVIRONMENT - heavily
populated environments such as
schools or child care centers
• WEAK IMMUNE SYSTEM - Poor
immune function makes it easier
for epiglottitis to develop
The symptoms of epiglottitis that are
common in children include:
• a high fever
• lessened symptoms when leaning
forward or sitting upright
• sore throat
• a hoarse voice
• drooling
• difficulty swallowing
• painful swallowing
• restlessness
• breathing through their mouth
DIAGNOSTIC PROCEDURES
• Physical observations and a
medical history
• X-rays of your throat and chest to
view the severity of the
inflammation and infection
• Throat and blood cultures to
determine the cause of infection,
such as bacteria or a virus
• Throat examination using a fiber
optic tube
TREATMENT
• Monitoring your oxygen levels
with a pulse oximetry device and
protecting your airway
• Intravenous fluids for nutrition
and hydration until you’re able to
swallow again
• Antibiotics to treat a known or
suspected bacterial infection
• Anti-inflammatory medication,
such as corticosteroids, to reduce
the swelling in your throat
TREATMENT: SEVERE CASES
• A tracheostomy is a minor
surgical procedure where a small
incision is made between the
tracheal rings. Then a breathing
tube is placed directly through
your neck and into your windpipe,
bypassing your epiglottis. This
allows exchange of oxygen and
prevents respiratory failure.
• A last resort cricothyroidotomy is
where an incision or a needle is
inserted into your trachea just
below the Adam’s apple.