CHILD Nursing Care of the HighRisk Newborn to Maturity   I.


I. PREMATURITY > preterm birth refers to the birth of a baby of less than 37 weeks gestational age. >Premature birth, commonly used as a synonym for preterm birth, refers to the birth of a premature infant. Øweight is less than 2,500 g( 5 lb 8 oz) at birth Ø Ø

HIGH RISK PREGNANT WOMEN > less than 18, more than 35 > undergone previous induced abortions > deficient in vitamins and minerals > low BMI Ødiabetes and hypertension

CAUSES > low socioeconomic level > Poor nutritional status > Lack of prenatal care > Multiple pregnancy > Previous Early birth > Race ( nonwhites have higher incidence of prematurity that whites) > Cigarette smoking ØAge of the mother ( highest incidence is is mothers younger than age 20)

> Order of birth ( early termination is highest in first pregnancies and in those beyond the fourth pregnancy ) > Closely spaced pregnancies > Abnormalities of the mother's reproductive system, such as intrauterine septum > Infections ( especially urinary tract infection) > Obstetric complications, such as premature rupture of membranes or prematue separation of the placenta > Early induction of labor ØElective cesarean birth

ASSESSMENT > appears small and underdeveloped > head is disproportionately large ( 3 cm or more greater than chest size) > skin is generally unusually ruddy because the infant has little subcutaneous fat beneath it > veins are easily noticeable > high degree of acrocyanosis may be present Ø24-36 weeks Ø

> Lanugo is usually extensive > Both anterior and posterior fonatanelles are small > there are few or no creases on the soles of the feet > eyes appear small > myopia ( nearsightedness ) because of lack of eye globe depth. > cartilage of the ear is immature and allows pinna to fall forward > ears appear large in relation to the head > if below 33 weeks, sucking, swallowing and deep tendon reflexes. Ørarely cries



Meconium stain

POTENTIAL COMPLICATIONS ANEMIA PREMATURITY > anemia normochromic and normocytic ( normal cells, just few in numbers) > decrease reticulocyte count > pale, lethargic and anorectic Øimmaturity of hematopoietic system combined with destruction of RBC due to low levels of vit. E. Ø

KERNICTERUS > destruction of brain cells by invasion of indirect bilirubin > this invasion results from the high concentrations of indirect bilirubin in the blood from excessive breakdown of red blood cells. Øjaundice ( tx.phototherapy or exchange transfusion can be started to prevent excessively high indirect bilirubin levels) Ø

Care of Newborn in Jaundice - Phototherapy o Is the exposure of the NB to high intensity light. o Maybe used alone or in conjunction w/ exchange transfusion to reduce serum bilirubin levels. o Decreases serum bilirubin levels by changing bilirubin from the non-water soluble form to water-soluble by products that can be excreted.  Exchange Transfusion o Is the withdrawal and replacement of newborn’s blood with donor blood.

Patent ductus arteriosus (PDA) is a congenital heart defect wherein a neonate's ductus arteriosus fails to close after birth. Symptoms are uncommon but in the first year of life include increased work of breathing and poor weight gain. With age, the PDA may lead to congestive heart failure if left uncorrected.

PERSISTENT PATENT DUCTUS ARTERIOSUS > pulmonary artery hypertension, which may interfere with closure of the ductus arteriosus Tx: Adm. IV ( to avoid increasing blood pressure) Adm. Indomethacin ( to close the patent ductus arteriosus) and Ibuprofen S/E: Oliguria (U/O monitoring)

Etiology A patent ductus arteriosus can be idiopathic (i.e. without an identifiable cause), or secondary to another condition. Some common contributing factors in humans include: - Premature infants Congenital rubella syndrome Chromosomal abnormalities such as Down Syndrome

Normal ductus arteriosus closure - In the developing fetus, the ductus arteriosus ( DA ) is the vascular connection between the pulmonary artery and the aortic arch that allows most of the blood from the right ventricle to bypass the fetus' fluid - filled compressed lungs. - During fetal development , this shunt protects the right ventricle from pumping against the high resistance in the lungs , which can lead to right ventricular failure if the DA closes in - utero . - When the newborn takes its first breath , the lungs open and pulmonary vascular resistance decreases . After birth , the lungs release bradykinin to constrict the smooth muscle wall of the DA and reduce bloodflow through the DA as it narrows and completely closes , usually within the first few weeks of life .

In most newborns with a patent ductus arteriosus the blood flow is reversed from that of in utero flow , ie . the blood flow is from the higher pressure aorta to the now lower pressure pulmonary arteries . In normal newborns , the DA is substantially closed within 12 - 24 hours after birth , and is completely sealed after three weeks . The primary stimulus for the closure of the ductus is the increase in neonatal blood oxygen content . Withdrawal from maternal circulating maternal prostaglandins also contributes to ductal closure . The residual scar tissue from the fibrotic remnants of DA , called the ligamentum arteriosum, remains in the normal adult

Patent ductus arteriosus -Patent ductus arteriosus , or PDA, is a heart condition that is normal but reverses soon after birth. -In a persistent PDA, there is an irregular transmission of blood between two of the most important arteries in close proximity to the heart. -Although the ductus arteriosus normally seals off within a few days, in PDA, the newborn's ductus arteriosus does not close but remains patent. -PDA is common in neonates with persistent respiratory problems such as hypoxia, and has a high occurrence in premature children. In hypoxic newborns, too little oxygen reaches the lungs to produce sufficient levels of bradykinin and subsequent closing of the DA. -Premature children are more likely to be hypoxic and thus have PDA because of their underdeveloped heart and lungs.

-A patent ductus arteriosus allows a portion of the oxygenated blood from the left heart to flow back to the lungs by flowing from the aorta (which has higher pressure) to the pulmonary artery. -If this shunt is substantial, the neonate becomes short of breath: the additional fluid returning to the lungs increases lung pressure to the point that the neonate has greater difficulty inflating the lungs. -This uses more calories than normal and often interferes with feeding in infancy. This condition, as a constellation of findings, is called congestive heart failure. -In some cases, such as in transposition of the great vessels (the pulmonary artery and the aorta), a PDA may need to remain open. In this cardiovascular condition, the PDA is the only way that oxygenated blood can mix with deoxygenated blood. In these cases, prostaglandins are used to keep the patent ductus arteriosus open.

Signs and symptoms While some cases of PDA are asymptomatic, common symptoms include: tachycardia respiratory problems shortness of breath continuous machine-like murmur enlarged heart Left subclavicular thrill Bounding pulse Widened pulse pressure Patients typically present in good health, with normal respirations and heart rate. If the ductus is moderate or large, widened pulse pressure and bounding peripheral pulses are frequently present, reflecting increased left ventricular stroke volume and diastolic runoff of blood into the initially lower-resistance pulmonary vascular bed. Prominent suprasternal and carotid pulsations may be noted secondary to increased left ventricular stroke volume. Poor growth

Diagnosis PDA is usually diagnosed using noninvasive techniques. Echocardiography, in which sound waves are used to capture the motion of the heart, and associated Doppler studies are the primary methods of detecting PDA. Electrocardiography (ECG), in which electrodes are used to record the electrical activity of the heart, is not particularly helpful as there are no specific rhythms or ECG patterns which can be used to detect PDA. A chest X-ray may be taken, which reveals the overall size of neonate's heart (as a reflection of the combined mass of the cardiac chambers) and the appearance of the blood flow to the lungs. A small PDA most often shows a normal sized heart and normal blood flow to the lungs. A large PDA generally shows an enlarged cardiac silhouette and increased blood flow to the lungs.

Robert E. Gross. Because Prostaglandin E-2 is responsible for keeping the ductus patent, inhibitors of prostaglandin synthesis such as Indomethacin have been used to help close a PDA. This is an especially viable alternative for premature infants. In certain cases it may be beneficial to the neonate to prevent closure of the ductus arteriosus. For example, in transposition of the great vessels, a PDA may prolong the newborn's life until surgical correction is possible. The ductus arteriosus can be induced to remain open by administering prostaglandin analogs such as alprostadil or misoprostol (prostaglandin E1 analogs). More recently, PDAs can be closed by percutaneous interventional method. Via the femoral vein or femoral artery, a platinum coil can be deployed via a catheter, which induces thrombosis (coil embolization). Alternatively, a PDA occluder device (AGA Medical), composed of nitinol mesh, is deployed from the pulmonary artery through the PDA. The larger skirt of the device sits on the aortic side while the ampulla of the device hugs the walls of the PDA, with care taken to avoid occlusion of the pulmonary arterial lumen by the device. These methods permit closure without open heart surgery.

PERIVENTRICULAR/INTRAVENTRICULAR HEMORRHAGE -lesions of the CNS specifically affect infants born prematurely and result in long-term disability. This chapter reviews one of the important CNS lesions, periventricular hemorrhage–intraventricular hemorrhage (PVH-IVH), which involves the periventricular white matter (motor tracts) and is associated with long-term disability

> bleeding into the tissue surrounding ventricles > fragile capillaries and immature cerebral vascular development > when there is rapid change in cerebral blood pressure, such as with hypoxia, Intravenous infusion, ventilation or pneumothorax, capillaries rupture. > brain anoxia distal to the rupture > hydrocephalus may occur from bleeding into the aqueduct of Sylvius with resulting clotting and obstruction of the awueduct. Dx. Cranial ultrasound

II. POSTMATURITY > Postmaturity is when a baby has not yet been born after 42 weeks of gestation. >Post-term, postmaturity, prolonged pregnancy, and post-dates pregnancy all refer to post-mature birth. >Post-mature births do not have any harmful effects on the mother, but the fetus, however, can begin to suffer from malnutrition. After the 42nd week of gestation, the placenta, which supplies the baby with nutrients and oxygen from the mother, starts aging and will eventually fail. If the fetus passes fecal matter, which is not typical until after birth, and the child breathes it in, then the baby could become sick with pneumonia. Doctors have the choice to induce labor once the pregnancy reaches two weeks beyond the normal 40 week gestation period.

CAUSES The causes of post-term births is unknown. But post-mature births are more likely when the mother has experienced a previous post-mature birth. -Due dates are easily miscalculated when the mother is unsure of her last menstrual period. -When there is a miscalculation, the baby could be delivered before or after the expected due date. -Most post-mature pregnancies are because the mother is not certain of her last period, so in reality the baby is not technically post-mature.

SYSMPTOMS Different babies will show different symptoms of postmaturity. The most common symptoms are : > dry skin, cracked, almost leather-like skin from lack of fluid, and absence of vernix. > overgrown nails > creases on the baby's palms and soles of their feet, minimal fat, > a lot of hair on their head, (hirsutism) > brown, green, or yellow discoloration of their skin. > dehydrated > meconium stained > difficulty establishing respirations > hypolglycemia > low subcuataneous fat > polycythemia Øelevated hematocrit

MECONIUM-first stool of the newborn

COMPLICATIONS >placental deterioration. > towards the end of pregnancy calcium is deposited on the walls of blood vessels and proteins are deposited on the surface of the placenta, which changes the placenta. > This limits the blood flow through the placenta and ultimately leads to placental insufficiency and the baby is no longer properly nourished. Induced labor is strongly encouraged if this happens. >Post-term babies may be larger than a "normal" baby, thus increasing the length of labor. The labor is increased because the baby's head is too big to pass through the mother's pelvis. This is called cephalopelvic disproportion. Caesarean sections are encouraged if this happens. >When post-mature babies are larger than average forceps or vacuum delivery may be used to resolve the difficulties at the delivery time. Difficulty in delivering the shoulders, shoulder dystocia, becomes an increased risk.

METHODS OF MONITORING POST-MATURE BABIES Once a baby is diagnosed post-mature, it needs to be monitored to make sure its health is being maintained. a. Fetal movement recording >Regular movements of the baby is the best sign indicating that it is still in good health. The mother should keep a "kick-chart" to record the movements of her baby. Less than 10 movements in 12 hours is not a good sign and a doctor should be contacted. If there is a reduction in the number of movements it could indicate placental deterioration.

b. Electronic fetal monitoring >Electronic fetal monitoring uses a cardiograph to check the baby's heartbeat and is typically monitored over a 30-minute period. If the heartbeat proves to be normal the doctor will not usually suggest induced labor. c. Ultrasound scan >An ultrasound scan evaluates the amount of amniotic fluid around the baby. If the placenta is deteriorating, then the amount of fluid will be low and induced labor is highly recommended.

d. Biophysical profile >A biophysical profile checks for the baby's heart rate, muscle tone, movement, breathing, and the amount of amniotic fluid surrounding the baby. e. Doppler flow study >Doppler flow study is a type of ultrasound that measures the amount of blood flowing in and out of the placenta.

B. PROBLEMS RELATED TO GESTATIONAL AGE I. SMALL-FOR-GESTATIONAL AGE (SGA) DEFINITION > Birth weight below the 10th percentile on an intrauterine growth curve for that age. > may be born preterm ( before week 38 of gestation), term or post-term ØSGA are small for age because they have experienced intrauterine growth restriction (IUGR) or failed to grow at the expected rate in utero. Ø

CAUSES > lack of adequate nutrition > early pregnancy (an adolescent has her own nutritional and growth needs, and these, when coupled with the increased nutritional needs of pregnancy, can affect a growing fetus. > placental anomaly ( either the placenta did not obtain sufficient nutrients from the uterine arteries or it was inefficient at transporting nutrients to the fetus. > placental damage ( partial placental separation with bleeding) > pregnancy-induced hypertension (severe DM) Øsmokers and uses narcotics Ø

ASSESSMENT Prenatal Assessment through... > Sonogram > Nonstress test > Placental grading > Amniotic fluid amount ØUltrasound

Assessment for the infant... APPEARANCE > below average weight, length, head circumference > small liver (difficulty regulating glucose, protein and bilirubin levels after birth) > poor skin turgor > large head and the rest of the body is small > separated skull sutures > hair is dull and lusterless > abdomen sunken > dry cord and stained yellow > birth asphyxia Øless able to control temperature

LABORATORY FINDINGS > High hematocritlevels ( less than normal amounts of plasma in proportion to red blood cells are represent due to lack of fluid in utero) > Increase RBC ( polycythemia)- due to a state of anoxia during intrauterine life, increases blood viscosity, a condition that puts extra work on the infant's heart because it is more difficult to effectively circulate this thick blood. > Acrocyanosis ( blueness of the hands and feet) Øhypoglycemia ( decreased blood glucose, or level below 40 mg/dL)

NURSING INTERVENTIONS > prepare for resuscitation Øa careful control of environment Ø

II. LARGE-FOR-GESTATIONAL-AGE INFANT DEFINITION > a.k.a. macrosomia > birth weight is above the 90th percentile on an intrauterine growth chart for the gestational age CAUSES > overproduction of growth hormone in utero > happens most often to infants of mothers with diabetes mellitus and obese > multiparous > Beckwith syndrome ( a rare condition charaterized by overgrowth) Øomphalacele ( congenital anomalies)

ASSESSMENT > woman's uterus is unusually large for the date of pregnancy > growing abnormally in a rapid rate ( sonogram) > placenta's ability to sustain the large fetus during labor (non-stress test) Ølung maturity maybe assessed by amniocentesis Ø

ASSESSMENT FOR THE INFANT > immature reflexes > extensive bruising or a birth injury such as broken clavicle or Erb-Duchene paralysis from trauma to the cervical nerves if he or she was born vaginally > prominent caput succedaneum, cephalhematoma or molding > hyperbilirubinemia > polycythemia ØHypoglycemia Ø

IMPORTANT ASSESSMENT CRITERIA FOR A LARGE-FOR-GESTATIONAL-AGE INFANT ASSESSMENT > skin color for ecchymosis, jaundice, and erythema RATIONALE > bruising occurs with vaginal birth; jaundice may occur from breakdown of ecchymotic collections of blood, polycythemia causes ruddiness of skin.

> Motion of extremities on spontaneous > clavicle or cervical nerve injuries may movement and in response to a Moro's reflex occur due to problem of birth of wider-thanto detect clavicle fracture 9crepitus or normal shoulders swelling may then be palpated at the fracture site) or Erb's palsy due to edema of the cervical nerve plexus > Asymmetry of the anterior chest or unilateral lack of movement to detect diaphragmatic paralysis from edema of the phrenic nerve > Eyes for evidence of unresponsive or dilated pupils; vomiting, bulging fontanelles, and a high-pitched cry suggestive of increased intracranial pressure > this cervical nerve may be stretched by birth of wide shoulders

> Compression of 3rd , 4th , and 6th cranial nerves by increased pressure limits eye response; other signs of increased intracranial pressure may occur.

> Activities such as jitteriness, lethargy, and > seizures may be caused by increased uncoordinated eye movements that suggest intracranial pressure; hypoglycemia seizures seizure activity in newborns often produce only vague symptoms.

ACUTE CONDITIONS OF THE NEONATE SUCH AS: A.RESPIRATORY DISTRESS SYNDROME > formerly termed hyaline membrane disease > hyaline –line (fibrous) membrane formed from an exudate of an infant's blood that begins to the line the terminal bronchioles, alveolar ducts and alveoli. > this membrane prevents exchange of oxygen and carbon dioxide at the alveolar-capiallrymembrane. Ømost often occurs in preterm infants, infants of diabetic mothers, infants born by cesarean birth, or those who for any reason have decreased blood perfusion of the lungs, such as occurs with meconium aspiration. Ø

CAUSE > Low level or absence of surfactant the phospholipid that normally lines the alveoli and reduces surface tension on expiration to keep the alveoli from collapsing on expiration. ASSESSMENT > difficulty initiating respiration at birth. > low body temperature > nasal flaring > Sternal and subcostal retractions > tachypnea ( more than 60 respiration per minute) ØCyanotic mucous membranes Ø

As distress increases, an infant may exhibit: > seesaw respirations ( on inspiration, the anterior chest wall retracts and the abdomen protrudes; on expiration, the sternum rises) > heart failure , evidenced by decreased urine output and edema of the extremities > pale gray skin > periods of apnea > Bradycardia ØPneumothorax

Diagnostic findings > made on the clinical signs of grunting, cyanosis in room air, tachypnea, nasal flaring, retractions, and shock. > chest x-ray will reveal a diffuse pattern of radiopaque areas that look like grou D glass ( haziness). > blood gas studies ( taken from umbilical vessel catheter) will reveal respiratory acidosis ØCultures of blood, cerebrospinal fluid and skin

THERAPEUTIC MANAGEMENT 1. SURFACTANT REPLACEMENT, sprayed into the lungs by a syringe or catheter by an endotracheal tube at birth while an infant is first positioned with the head held upright and then tilted downward. > it is important an infant's airway not be suctioned for as long a period as possible after administration of surfactant to avoid suctioning the drug away. > an infant who is receiving surfactant and then is placed on a ventilator needs close observation because during lung expansion can improve rapidly Øanticipate the need to adjust ventilator settings to prevent excessive lung pressure. Ø Ø

2. OXYGEN ADMINISTRATION > to maintain correct Po2 and pH levels. > continuous positive airway pressure (CPAP) or assisted ventilation with positive endexpiratory pressure (PEEP) will exert pressure on the alveoli at the end of expiration and keep the alveoli from collapsing. 3. VENTILATION > inspiratory/expiratory ratio (I/E ratio) 2:1 > these are pressurepcycled to control the force with which air is delivered

4. Muscle Relaxant Administration > Pancuronium ( Pavulon) can be administered intravenously to the point of abolishing spontaneous respiratory action. > antidote: Atropine and Prostigmin 5. Extracorporeal Membrane Oxygenation (ECMO) > blood is removed from the baby by gravity using a venous catheter advanced into the right atrium of the heart. > the blood circulates from the catheter to the ECMO machine, where it is oxygenated and rewarmed. > it is then returned to an infant's aortic arch by a catheter advanced through the carotid artery. > ECMO is typically used for 4 to 7 days. > potential complications, intracranial hemorrhage ( possibly from the anticoagulation therapy necessary to prevent thromboembolism. ØConstant nursing care is required for a child receiving ECMO to ensure that the child's blood volume remains adequate, bleeding does not occur, and adequate oxygen is being supplied to body tissues.

. Liquid Ventilation > involves use of perfluorocarbons, substances used in industry to assess for leakage in pipes. > when oxygen is bubbled through it , perfluorocarbonspick up and carry the oxygen with them. > when perfluorocarbons are introduced into the lungs that inflate poorly because they are deficient in surfactant, or in lungs damaged by trauma or disease, the weight of the fluid, which is heavy compared with air, helps to distend the lungs. > as the liquid moves into the lung, oxygen is carried along with it, as the liquid spreads over all lung surfaces, an exchange of oxygen occurs Øthe administration of liquid ventilation can also be used to deliver surfactant to a newborn's lungs. Ø

7. AMDINISTRATION OF NITRIC OXIDE > causes pulmonary vasodilation, which can be helpful to increase blood flow to the alveoli when persistent pulmonary hypertension is present 8. SUPPORTIVE CARE > an infant with RDS must be kept warm because cooling increases acidosis in all newborns, and for the newborn with RDS it may increase to lethal levels > Keeping an infant warm also reduces the metabolic oxygen demand Øprovide hydration and nutrition with intravenous fluid, glucose, or gavagefeeding because the respiratory effort makes an infant too exhausted to suck Ø

B. MECONIUM ASPIRATION SYNDROME > meconium is present in the fetal bowel as early as 10 weeks' gestation. > an infant with hypoxia in utero experiences a vagal reflex relaxation of the rectal sphincter, which releases meconiuminto the amniotic fluid. > Babies born breech may expel meconium into the amniotic fluid from pressure on the buttocks. > appearance of the fluid at birth is green to greenish black from the staining. > meconiumstaining occurs in approximately 10%-12% of all pregnancies > an infant may aspirate meconium either in utero or with first breath after birth. > meconiumcan cause severe respiratory distress in three ways: a. it causes inflammation of bronchioles because it is a foreign substance; b. it can block small bronchioles by mechanical plugging c. it can cause a decrease in surfactant production through lung cell trauma. Øhypoxemia, carbon dioxide retention, and intrapulmonary and extrapulmonary shunting occur. A SECONDARY INFECTION of injured tissue may lead to pneumonia. Ø

ASSESSMENT > hypoxia > low APGAR score > tachypnea > cyanosis > barrel chest > blood gas ( poor gas exchange) Ødecreased Po2 and an increased Pco2 Ø

Nursing/ Therapeutic Management > Amniotransfusion can be used to dilute the amount of meconium in amniotic fluid and reduce the risk of aspiration > CESARIAN BIRTH, after deeply meconium-stained amniotic fluid becomes evident during labor. > suctioning using bulb syringe or catheter while at the perineum to prevent meconium aspiration > intubation > do not administer oxygen under pressure ( bag and mask) until an infant has been intubated and suctioned, so that the pressure of the oxygen does not drive small plugs of meconium farther down into the lungs, worsening the irritation and obstruction. > observe for signs of heart failure ( increase heart rate or respiratory distress) > maintain temperature-neutral environment to prevent increasing the metabolic oxygen demands. > Chest physiotherapy with clapping and vibration maybe helpful to encourage removal of remnants of meconium from the lungs. ØECMO is maintained to ensure adequate oxygenation Ø Ø Ø

C. SUDDEN INFANT DEATH SYNDROME (SIDS) > is a sudden unexplained death in infancy > it tends to occur at a higher-than-usual rate in infants of adolescents mothers, infants of closely spaced pregnancies, underweight and preterm infants. > also prone to SIDS are infants with bronchopulmonary dysplasia, twins. > Native American Infants, Alaskan native infants, economically disadvantaged black infants, and infants of narcotic-dependent mothers. > the peak age of incidence is 2-4 months of age

OTHER POSSIBLE CONTRIBUTING FACTORS •Viral respiratory or botulism infection •Pulmonary edema •Brain stem abnormalities •Neurotransmitter deficiencies •Heart rate abnormalities •Distorted familial breathing patterns •Decreased arousal responses •Possible lack of surfactant in alveoli •Sleeping prone (respiratory muscles are restricted)   NURSING MANAGEMENT Counselling

D. SEPSIS DEFINITION - is a blood infection that occurs in an infant younger than 90 days old - early onset sepsis is seen in the first week of life - late onset sepsis occurs between 8 and 9 days CAUSES - number of different bacteria (E. coli) - preterm delivery - rupture of membranes that last longer than 24 hours - infection of the placenta and amniotic fluid

Signs and symptoms - body temp. changes - breathing problems - diarrhea - low blood sugar - reduced movements - reduced sucking - seizure - slow HR - swollen belly area - vomiting - jaundice Lab Test: - Blood and culture - CBC Treatment - antibiotics

E. HYPERBILIRUBINEMIA - yellowish of the skin, appears about 50% of all newborns as a result of the breakdown of fetal RBC - total serum bilirubin level above 5 mg/dl pigment in the skin and mucus membranes - the inc. bilirubin cause the infant's skin and whites of the eyes to look yellow CAUSES - abnormal blood cell shapes - blood type incopatibilies *ABO incompatibility ( mother has type O blood baby does not) * Rh incompatibility ( mother is Rh negative, baby is not) - cephalhematoma or other birth injury - high levels of RBC ( polycythemia) - infection - premature - transfusions

ASSESSMENT - skin and sclera of the eyes appear noticeably yellow - infants with extensive bruising - jaundice first on the head next to the rest of the body Signs and Symptoms - yellow of the skin ( best seen right after gently pressing a finger onto the skin) - the color sometimes begins on the face and then moves down to the chest, belly area, legs, soles of the feet. - sometimes, infants with significant jaundice have extreme tiredness and poor feeding

EXAM (Tests) - newborns should be examined for jaundice at least every 8-12 hours for the first day of life - skin or blood test ( jaundice in the first 24 hours) - CBC TREATMENT - usually not necessary - keep the baby well hydrated with breast milk/formula ( frequent feeding encourage frequent bowel movements, which helps remove bilirubin through the stools ) - Phototherapy - helps to breakdown bilirubin in the skin - infant is placed naked under artificial light - eyes are protected from light - breastfeeding be continued if possible - Exchange transfusion ( baby's blood is replaced with fresh blood)(severe cases) - jaundice is an emergency if the baby has fever or is not feeding well

INTUSSUSCEPTION •is the invagination of one of the portion of the intestine into another •this disorder generally occurs in the second half of the first year of life •this condition is a surgical emergency, reduction of this intussusception must be done promptly by either instillation of solution (or air) or surgery before necrosis of the invaginated portion of the bowel occurs
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•Assessment: -Sudden drawing up of legs and crying as if they are in severe pain, they may vomit -Approximately 15 minutes oIntense abdominal pain strikes again oVomitus will begin to contain bile -After approximately 12 hours oBlood appears in the stool “currant jelly” oAbdomen becomes distended -If necrosis has occurred oElevated temperature oPeritoneal irritation oIncreased WBC oRapid pulse o

•Diagnostic procedure: sonogram •Therapeutic management: -Surgery: to straighten the invaginated portion and reduction by the installation of water-soluble solution barium enema or air

FAILURE TO THRIVE (Reactive Attachment Disorder) •is a unique syndrome in which an infant falls below the 5th percentile for weight and height on standard growth chart. •Two categories: -Syndromes with organic cause: such as organic disease -Syndromes with non-organic cause: disturbance in parent-child relationship -

•Assessment: -On physical examination, these infants usually demonstrate some typical characteristics, such as the following: oLethargy with poor muscle tone, a loss of subcutaneous fat or skin breakdown oLack of resistance to the examiner’s manipulation, unlike the response of the average infant oRocking on all forms excessively, as if seeking stimulation, if emotionally deprived oPossibly greater reluctance to reach for toys or initiate human contact than is demonstrated by the average infant

oStaring hungrily at people who approach them as if they are starved for human contact (some health care personnel have an uneasy feeling when caring for these infants because their eye contact is so intense) oLittle cuddling or conforming to being held by the second month of life oAchievements of developmental milestones in prone position by the third or fourth month because the child spends so much time alone oMarkedly delayed or absent speech because of the lack of interaction oDiminished or non-existent crying
o o o

•Therapeutic Management: -Ensure adequate nutrition -Nurture the child -Support and encourage the parents -Ensure evaluation and follow-up

COLIC •is a paroxysmal abdominal pain that generally occurs in infants under three months of age •Assessment: -An infant cries loudly and pulls the legs up against the abdomen -Infant’s face becomes red and flushed -The fists clench -Abdomen becomes tense -If offered a bottle, the infant’s sucks vigorously for a few minutes as if starred, then stop as another wave of intestinal pain occurs.

•cause: unclear •it may occur in susceptible infants from overfeeding or from swallowing too much air while feeding •formula-fed babies are more likely to have colic than breast-feed babies •Management: •Determine the baby’s feeding pattern •Try placing a hot water on the infant’s stomach for comfort but this should be discouraged •Changing formula bottles to the type with disposable bags that collapse as baby sucks may help minimize the amount of air swallowed.
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TRISOMY 21 (DOWN SYNDROME) •The most frequently occurring chromosomal abnormality •Occurs in about 1 in 800 line births •It occurs most frequently in the pregnancies of women who are older than 35 years of age •Paternal age older than 55 years old •
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•Assessment: -The nose is broad and flat -Eyelids have an extra fold of tissue at the inner canthus and the palpebral fissure tends to slant laterally upward -Iris of the eye may have white specks in it (Brushfield spots) -Tongue may protrude from the mouth -Back of the head is flat, neck is short and extra pad of fats at the base of the head causes the skin to be so loose in can be lifted up (like a puppy’s skin) -Ears may be low-set -Muscle-tone is poor, giving the baby a rug doll appearance -Fingers are short and clench and little finger is often curved inward -Wide space between the first and second toes and between the first and second fingers -The palm of the hand shows a peculiar crease (Simian line) which is a single horizontal palmar crease rather than the normal three creases in the palmar -IQ is 50-70

CLEFT LIP AND PALATE CLEFT LIP •the fusion of the maxillary and median nasal process fails to occur in varying degrees, causing this disorders to range from small notch in the upper lip to total separation of the lip and facial structure up into the floor of the nose with even the upper teeth and gingival absent •more prevalent among boys and girls •it occurs at a rate of approximately 1 in every 700 livebirths •occurs as a familial tendency or most likely occurs from the transmission of multiple genes • •
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CLEFT PALATE •an opening of the palate, is usually on the midline and may involve the anterior hand palate, the posterior soft palate or both •it tends to occur more frequently in girls than in boys •the incidence is approximately 1 in every 1,000 births •Assessment: -Cleft lip oMaybe detected by a sonogram while the infant is in the utero -Cleft palate oCan be determined by depressing newborn’s tongue with a tongue blade oThis reveals the total palate and the extent of cleft palate oMust be assessed for other congenital anomalies o

•therapeutic management: -Cleft lip is discovered in the utero oFetal surgery can repair the condition but the procedure is not usuaaly attempted -Cleft lip discovered during birth oRepaired surgically shortly after birth oSometimes at the time of the initial hospital stay or between 2-10 weeks of age oEarly repair also helps infants experience the pleasure of sucking as soon as possible -Cleft palate oIt’s repair is usually postponed until a child is 618 months old to allow the anatomic change in the palate contour that occur during the first year of life to take place oRepairs made before this change maybe ineffective and may have to be repeated o

IMPERFORATE ANUS •is stricture of the anus •this disorder can be relatively minor, requiring just surgical incision of the persistent membrane or much more severe, involving sections of the bowel that are many inclus apart with no anus •occurs approximately in 1 in 5,000 live births •more commonly in boys than in girls •may occur as an additional complication of spinal cord disorder, because both the external and anal canal and the spinal cord arise from the same germ layer

Assessment: •No anus is present •A membrane filled with black meconium can be seen protruding from the anus •A “wink reflex” (touching the skin near the rectum should make it contract) will not be present if sensory nerve endings in the rectum are not intact •Inability to insert a rubber catheter into the rectum •No stool will be passed •Abdominal distention is evident •Diagnostic procedure: X-ray •Therapeutic management: •Simple anastomosis of the separated bowel segment • • •

HIRSCHPRUNG’S DISEASE (AGANGLIONIC MEGACOLON) •absence of the ganglionic innervation to the muscle of a section of the bowel •The absence of nerve cells means there is no peristaltic waves in this section to move fecal material through that segment of the intestine •This results to the chronic constipation or ribbon-like stools (stools passing through such a small, narrow segment look-like ribbons) •It occurs more often in males than in females •It is caused by an abnormal gene in chromosome 10. (incidence 1:5,000 LB)

•Assessment: •Fail to pass meconium by 24 hours of age •Increased abdominal distention •Definitive diagnosis: biopsy of the affected segment to show the lack of innervation or by anorectal manometry •Therapeutic management: •Repair of aganglionic megacolon involves dissection and removal of the affected section with anastomosis of the intestine •The condition is treated generally in newborn by two-stage surgery: -Temporary colostomy -Bowel repair at 12-18 months of age -

Neural Tube Disorder Spina Bifida -Latina for “ divided spine” - the most often used as a collective term for all spinal cord disorders, but there are well defined degrees of spina bifida involvement and not all neural tube disorder involve the spinal cord - all these disorders, however occur because of fusion of the posterior surface of the embryo in the intrauterine life - may occur as a polygenic inheritance pattern, but poor nutrition, especially a diet deficient in folic acid – pregnant are advised to ingest 0.4 mg. of folic acid daily - risk of bearing a child with neural tube defect once is 1 in 20 - maternal serum essay or amniocentesis of alfa-fetoprotein(AFP) to determine if such a defect is present in a pregnancy ( levels will be abnormally increased if there is an open spinal lesion) -sonogram is also helpful to determine the presence of the disorder -

Types of defects Anencephaly - absence of the cerebral hemispheres - occurs when the upper end of the neural tube fails to close in early intrauterine life- revealed by an elevated level of AFP in maternal serum or on amniocentesis and confirmed by sonogram - infants may have difficulty in labor because the underdeveloped head does not engage the cervix well- many such infants present in breech position -children cannot survive with this disorder because they have no cerebral function- respiratory and cardiac centers are located in the intact medulla however, may survive for a number of days after birth. -

when condition is discovered prenatally parents are offered the option of abortion - an ethical problem has arises in a number of instances, when parents aware that the child cannot survive, elect to carry the infant to term so the organs can be used for transplant. Nurses need to think through their feelings about caring for such infants, because it can be difficult to give care to a child who will most likely die or who has been born only to help others live.

Microcephaly - a disorder in which brain growth is so low that it falls more than 3 standard deviations below normal on growth charts - the cause might be a defect in brain development associated with an intrauterine infection such rubella, cytomegalovirus or toxoplasmosis - may also be the result from severe malnutrition or anoxia in early infancy - prognosis for a normal life is guarded and depends on the extent of restriction of brain growth and on the cause. - generally, intent is cognitively challenged because of the lack of functioning brain tissue. -the microcephaly must be differentiated from craniosynostosis ( normal brain growth but premative fusion of the cranial sutures)have abnormally closed fontanelles and often show bulging ( bossing of the forehead and signs of increased intracranial pressure) – with surgery, can be relieved a brain growth will be normal. -

Spina Bitida Occulta - occurs when the laminae of the vertebrate fail to fuse - occurs most commonly at the fifth lumbar or first sacral level but may occur at any point along the spinal canal. - the disorder may be noticeable as a dimpling at the point of poor fusion; abnormal tufts of hair may be present -simple spina bifida occulta is a benign defect; it occurs as frequently as in one of every four children. The term “ spina bifida “, is often used wrongly to denote all spinal cord anomalies. Because of this wrong usage, parents, when told of this, may interpret this as their child has an extremely serious disorder. Help clarify the degree of defect for them. -

Meningocele - if the meninges covering the spinal cord herniate through unformed vertebrae - The anomaly appears as a protruding mass, usually approximately the size of an orange, at the center of the back. -generally occurs in the lumber region, although it might be present anywhere along the spinal canal- the protrusion may be covered by a layer of skin or only the clear durameter -

Myelomeningocele - the spinal cord and the meninges protude through the vertebrae defect the same as with meningocele- the difference is that the spinal cord ends at the point of the defect, so motor and sensory function is absent beyond this point. - this results in lower motor neuron damage, the child will have flaccidity and lack of sensation of the lower extremeties and loss of bowel and bladder control - infant's legs are ay and he or she does not move them; urine and stool continually dribble because of lack of sphincter control - talipes (clubfoot) disorders and development hip dysplasia. - hydrocephalus accompanies myelomeningocele in as many as 80% of infants due to the lack of a subarachnoid membrane for CSF absorption; -the higher the myclomeningocele occurs on the cord, the more likely hydrocephalus will accompany it. It is generally, difficult to tell from visual appearance whether the disorder is myelomeningocele or the simpler meningocele. A CT or sonographic scan or MRI will reveal this. -

Encephalocele - is a cranial meningocele or mylomeningocele - defect occurs most often in the occipital area of the skull but may occur as a nasal or nasopharyngeal defect. - are covered fully by the skin, but they may be open or covered only by the dura. - transillumination of the sac will reveal solid substances or fluid in the sac. -CT, MRI or sonography will reveal the size of the skull defect. -

Assessment: - Neural tube may be discovered during the intrauterine life by sonography, fetoscopy, amniocentesis( discovery of increased AFP in amniotic fluid) or analysis of AFP in maternal serum - when infants are detected as having meningocele or mylomeningocele, they may be born by cesarean birth to avoid pressure and injury to the spinal cord - Observe and record whether an infant born with a neural tube disorder has spontaneous movement of the lower extremeties to assess lower motor function. - Assess the nature and pattern of voiding and defecation- a normal infant appears to be “always'' wet from voiding but actually voids in amounts of approximately 30 ml. and then is dry for 2 to 3 hours before voiding again. •an infant without sphincter control voids continually •Observing these features (voiding & defecating) aids in differentiating between meningocele and myclomeningocele.
>Differentiation can be further established by sonography or MRI

Therapeutic Management - Children with spina bifida occulta need no immediate surgery - Some children may eventually need surgery to prevent vertebral deterioration due to the unbalanced spinal column. - treatment for a meningocele, myclomenigoceleor enphalocele involves surgery- to replace the contents that replaceable and to close the skin defect to prevent infection by an exposed meninges. - The child with myclomeningocele will continue to have paralysis of the lower extremeties and loss of bowel and bladder function after surgery because the absent lower cord cannot be replaced. -In the past, surgery for neutral tube disorders was done only after the infant had survived the newborn period.

Currently, it is done as soon as after as possible ( usually within 24 to 48 hours ) so infection through the exposed meninges does not occur- parents need to be cautioned that the surgery is not without risk and that brain defects accompanying on encephalocele may limit the child's cognitive potential -The loss of meninges by surgery may limit the rate of absorption of CSF- this may lead to build up in amount in hydrocephalus . -Parents need a great deal of support to care for a child with myclomeningocele because their child has multiple challenges. Referral to a community support group can be helpful. -

Nursing Diognosis: Risk for infection r/t rupture or invasion of the neural tube. Outcome identification : Child will not develop an infection before surgery. Outcome evaluation : the neural tube sac remains intact, the child's auxillary temperature remains below 98.6 degree F ( 37 degree C )

Nervous System Developmental Disorders Hydrocephalus – Is an excess of cerebrospinal fluid (CSF) in the ventricles and the subarachnoid spaces of the brain . •In the infant whose cranial sutures are not firmly knitted, this excess fluid causes enlargement of the head . •communicating hydrocephalus - if fluid passes between the ventricles and the spinal cord. •Obstructive hydrocephalus or intraventricular hydrocephalus – if there is a block to such passage of fluid. •Classification : Congenital – occurs at birth Acquired – from the incident later in life *Congenital Hydrocephalus – Cause is unknown, material infection such as toxoplasmosis may be factor . •Excess of CSF in the new born can result from 1 of 3 main reasons •

.) Overproduction of fluid by a choroid plexus in the first or second ventricles(rare) • 2.) Obstruction of passage of fluid in the narrow aqueduct of sylvius (the most frequent cause) • 3.) Interference with the absorption of the fluid from the subarachnoid space if a portion of a subarachnoid space is removed. •Over production is most frequently caused by a tumor in the choroid plexus •Obstruction generally occur as a congenital atresia, usually along the narrow aqueduct of Sylvius leading to the 3rd ventricle. Other common sites include the foramine of Magendie and Luschka, the openings that allow fluid to leave the 4th ventricle – in an older child, infections such as meningitis or encephalitis may leave adhesions that lead to obstruction- hemorrhage from trauma or a growing tumor also may obstruct the passage of CSF – an Arnold-Chiari disorder (elongation of the lower brain stem and displacement of the 4th ventricles into the upper cervical canal) is yet another cause. •Interference with absorption can occur if a portion of the subarachnoid membrane is removed or after extensive sub-arachnoid hemorrhage when portions of the membrane absorption surface become obscured.

• •
• •

Assessment : •When an obstruction is present : *excessive fluid accumulates and dilates the system above the point of obstruction •If atresia is in the aqueduct of sylvius *the 1st ,2nd and 3rd ventricles will dilate •symptoms may develop rapidly or slowly ,depending on the extent of atresia •Infants show symptoms of increase intracranial pressure (ICP) such as : * decrease pulse and respirations * increase temperature and BP * hyperactive reflexes * strabismus * optic atrophy * either irritable or lethargic * fail to thrive •typical shrill, high-pitched cry

•treatment is most effective when the disorder is recognized early , because ICP becomes so acute that brain tissue is damaged and motor or mental deterioration results, even the best shunting procedure cannot replace or repair damage to the brain cells. Assisting with detection of hydrocephalus is an important role for the nurses in ambulatory child health settings – all children under 2 years old should have their head circumference recorded and plotted on an appropriate growth chart with health care visits, so a child whose head is growing abnormally can be detected.

•Measure the head circumference of all infants within an hour of birth and again before discharge from the health care facility to establish a baseline •Older children who have suffered head trauma is severe enough to be seen in a medical facility should have their head circumference noted at the time of the accident; if other symptoms of ICP appear, head circumference can be added meaningfully to store of information available concerning to the child's condition •
• •

•Note any asymmetry that is occurring, because this may suggest the point of obstruction, Ex.Skull that is enlarging anteriorly with shallow posterior fossa , suggests that the obstruction is in the aqueduct or 3rd ventricle •Infant's motor function becomes impaired as the head enlarges because of both neurologic impairment and atrophy caused by the inability to move such as heavy head •Can be demonstrated by a sonogram , computed tomograhy and magnetic resonance imaging •a skull x-ray film will reveal the separating sutures and thinning of the skull bones •Transillumination ( holding a bright light such as flashlight or a specialized light ( a Chun gun) against the skull with the child in a darkened room) will reveal a skull filled with fluid rather than solid brain. •If the hydrocephalus is a non-communicating type, dye inserted into a ventricle through the anterior fontanelle will not appear in CSF obtain from a lumbar puncture

Therapeutic Management •The treatment of hydrocephalus depends on its cause and extent. •If it caused by overproduction of fluid, acetazolamide(Diamox) may be ordered to promote the excretion of fluid. •Destruction of a portion of the choroid plexus maybe attempted by ventricular endoscopy, or if a tumor in that area is responsible for the over production of fluid, removal of the tumor should provide a solution.

•Hydrocephalus is usually caused by obstruction , so the treatment usually involves laser surgery to re-open the rate of flow or by passing the point of absorption by shunting the fluid to another point of absorption. * A shunting procedure involves threading a polyethylene catheter under the skin from the ventricles to the peritoneum. Fluid drains and is absorbed across the peritoneal membrane and into the body circulation. This type of shunt has to be replaced as the child grows and it becomes too short and become obstructed. •The ultimate prognosis for infants with hydrocephalus depends on whether brain damaged occurred before shunting or surgery and if a shunt is in place, whether the parents are able to recognize when it needs replacing to reduce the possibility of increased ICP. • •

Nursing Diagnosis: •Risk for ineffective cerebral tissue perfusion related to ICP. Outcome Identification: •Child will remain free of signs of ICP during childhood. Outcome Evaluation: •Child shows no increased temperature and blood pressure, or decreased pulse rate, decreased respiratory rate or decreased level of consciousness; PERLA (Pupil Equally Reactive to Light Accommodation), muscle strength equal a strong bilaterally; head circumference is maintained at age appropriate level. •After a shunt is inserted, the infant's bed is usually left Flat or raised only about 30 degrees so the head remains level with the body. * Often the child's head is raised excessively, CSF may flow too rapidly and decompression may occur too rapidly, leading to possible tearing of cerebral arteries

•A valve is the shunt inserted to open when CSF has accumulated to the extent that pressure has increased. It closes when enough fluid has occurred to reduce the pressure. *Often infants are not turned to lie on the slide with the shunt to prevent putting pressure on the value, which might cause it to open and rapidly decompress. •Assess for signs of ICP after surgery: *tense fontanelles *increasing head circumference *irritability or lethargy *decrease level of consciousness *poor sucking *vomiting *increase in BP (difficult to measure accurately in infants unless Doppler instrumentation is used)

increasing temperature *decreasing in pulse and respiratory rates •Assess also for symptoms of infection: *increasing temparature *increasing pulse rate *general malaise *signs of meningitis such as stiff neck and marked irritability •Be certain the child receives adequate pain management to minimize any upset, because crying elevates CSF pressure • •

Nursing Diagnosis: - Risk for imbalance nutrition, less than body requirements r/t ICP. Outcome Identification: - Child will ingest adequate nutritional intake after shunt placement. Outcome Evaluation: - Childs weight remains within 5th to 95th percentile on height/weight chart; no vomiting occurs. •Because an abdominal incision is involved to thread the catheter into the peritoneum, most children have a nasogastric tube (NGT) placed during surgery. *Keep them NPO until bowel sounds return and the tube can be removed.

•vomiting that results from the introduction of fluid too soon after any surgery causes ICP. •when feeding, be certain to support their heads well when moving them to avoid strain on their neck *hold their head with the whole palm, not just the fingertips, because the skull is thinned to some degree and could actually be punctured with a stiff, forceful touch *urge parents to use a rocking chair with an armrest to provide support for their arm while feeding the infant •Note how the child sucks. ICP may be noted first because of poor or ineffective sucking. Vomiting after feeding, without nausea (difficult to detect in a small infant) is also a sign of ICP. •Observe for constipation, because straining while passing stool causes ICP *urge parents to increase fluid and roughage in the diet as a preventive measure

Nursing Diagnosis: Risk for impaired skin integrity related to weight and immobility of head. Outcome Identification: Child's skin will remain intact during course of illness. Outcome Evaluation: Child's skin remains clean, dry and intact, without signs of erythema or ulceration.

tic drainage possibly through the mastoid or sinuses or

by direct introduction

e obstruction leading to hydrocephalus d, causing increase production of antidiuretic horm te adequate urine

headaches seizures or shock (1st noticeable sign of illness) positive B to follow a light through full visual fields hritis

d is not as

e - CSF result indicative of meningitis include an increase WBC and

antibiotic from passing freely

into the CSF.

aforan) or Cefraxone (Rocephin) may be used for 8 to 10 days in some children otic diuretic, mannitol may be administered to reduce ICP and help prevent he d on respiratory precautions for 24 hours after the start of antibiotic therapy to pre e immediate family members of the ill child or others who were in close contact wit

ngeal irritation. or tolerable degree of pain during the course of illness.

n is tolerable; shows no facial grimacing or other signs of discomfort. treptococcal Meningitis

either in utero or from secretions in the birth canal at delivery. ns if good handwashing technique is not used. arly onset or late onset illness. ms of preumonia become apparent in the first few hours of life. ds to meningitis 2 weeks, the infant may gradually become: Lethargic developing a fever and upp ncreased ICP.

d cephalosporins effective against group B, bet


efective reality testing; and an inability to function in social s munication skills, and bizarre responses to various aspects be increasing in incidence-occurs most often in boys than


ailure to develop social relations tereotyped behaviors such as hand gestures xtreme resistance to change in routine bnormal responses to sensory stimuli ecreased sensitivity to pain nappropriate or decreased emotional expressio pecific, limited intellectual problem solving tereotyped or repetitive use of language mpaired ability to initiate or sustain conversatio

f age, parents report that were worried muc each to be picked up, they are unable to pla rbal skills- language may be totally absent. nd concrete interpretations also maybe prese

or changes in environment (screaming if a

ements are often observed such as a fan, the swirling water in the y be present.

ghing or giggling mood) t onversations that took place years before esting is difficult, however, because chil

some of the bizarre mannerisms that accompa

achment to parent and other familiar adults.

(ADHD) ivity impulsiveness revealed before the age 7 ng and drug exposure in utero ods have been used with success, which may

ss and hyperactivity ly, they become easily distracted often may no ifficulty with such tasks as awaiting turns i y to another, exhibiting excessive or exaggera .

very active “ or “on the go” until school age, when it is app

ne situation that their extremes of behavior are not apparen nts to describe any active child- have the parent give an ex uly exists.

nized-ex. In school, children with ADHD may run lass. swinging and finger tapping- at home, they may r door, unaware why they are running- this is d

bad moments- this type of variability causes child might add correctly like 2+2=4 but then ments without thinking, to objects they have j

an be offered an explanation

, before and after, in front of & in back of, yest logic signs such as inability to use a pencil or their attention span is so short- they often have nger after another with their thumb imitates what the other is attempting to do)

responses of: nize a shape that has been traced on the gnize an object by touch th arms outstretched (aimless movements) a s such as unilateral Babinski reflex or s

ce Scale for children (WISC) the test most often used,

ormance scale but average on the verbal scale. ut average or above in the performance scale ortions doing well on some portions and poorly on othe y those around them- neurologic examination also should

may include special instructions often appreciate support and advise- encourage han “here is blue shirt to wear today” y have the child’s attention before beginning

child forgets easily what he or she d not the child. because although they are intelligent,

excessive activity of the child with ADH classroom ed release form) has been prescribed a more regular nerve transmission

the drug early in the day that it only needs to be administer iods of time need careful height and

h care visits while their child is growing up o their ability to handle the challenge of raisin d irritable at times with a child who does not s at their child does not act this way on purpos


- seizures in children older than 3 years old • - seizures associated with high fever ( 38.9C to 40C) are the most common in preschool children or between 5mons-5yrs. Of age, although seizures may occur as early as 3mons. And as late as 7years. • - seizures shows an active tonic clonic pattern , which lasts 15-20 sec. • - may occur after immunization because of the fever that may accompany these.

• • •
PREVENTION OF FEBRILE SEIZURES • If acetaminophen is given to keep a developing fever below 38.4C, seizures rarely occur. They happen most often when children develop fever at night, when the parent is not aware of it, when the temperature

E the child with tepid water to reduce the fever q se it would be easy for the child to slip underwea ng causes shock to an immune nervous system,

ns such as acetaminophen, because the c

ponging are unsuccessful, advise parent htly clothed to a health care facility

OMOTOR) SEIZURES n with a sudden change in posture, su ura, but it is rarely as definite as that s symptoms tend to be the most dif

nclude automatisms (complex purpos

us. Circumoral pallor may develop s than 5mins.

ene), Phynetoin (Dilantin) and Phem d during therapy. If these drugs a

PARTIAL (FOCAL) SEIZURES •These type of seizure may be caused by something as specific as a rapid •Originate from a specific brain area

gers and spreads to the wrist, arm, and face i the seizure may become generalized and then is ling, paresthesia, or pain originating in one a

NCE SEIZURES known as Petit Mal, are classified as generalized seizur usually consist of a staring spell that lasts for a few sec hmic blinking and twitching of the mouth or an extremity EG usually shows a typical 3waves spike a slow-wave d

al age of occurrence is 6-7years though, if they have frequent episode the

m to hyperventilate and count-out loud. are for 3 seconds

acid en can participate in normal school activi o anticipate potentially hazardous situati

izures “outgrow them” by adulthood.


seizures, are generalized seizures, consisting of fo ays zziness, malaise, lack of coordination or tension. hat the child is “not himself” age, he may be able to predict from these vague preli

ortion of the brain in which the seizure originates nt odors ( often reported as feces ) an activity in the medial port ights suggests the occipital area ations arise from the temporal lobe tremity relates to the opposite parietal lobe grin” relates to the frontal lobe nable to describe or understand an aura, may scream in fright or ru symptoms the child experiences during this time, because this may h

d falls to the ground

about 20secs., the respiratory muscles are contracted ents swallowing so saliva collects in the mouth, the c initially, air is pushed through the glottis producing

and relax, producing quick jerky motions va and if he bit his tongue when his jaw spasm shut, he may have blood in his mouth ine secs falls into a sound sleep called the post-ictal period. He will sleep soundly for 1-4hrs and will ces a severe headache, he has no memory of the seizures , the possibility of nocturnal seizures must be considered h this type of seizure generally have an abnormal EEG pattern larly abnormal patterns without any symptoms.

e) and Carbamazepine ( Tegretol), Phenobarbital has the advantage of being an inexpensive use the body becomes dependent on it. m (Dilantin) for control. One non-toxic side effects of phynetoin is painless hypertrophy of th eason to discontinue the drug for 2-3years protein and carbohydrate- it causes the child to have a high level of ketones, which is believ

series of seizure from which the child does not return to his or her previous se, permanent brain injury, exhaustion, respiratory failure, and death may occu

s seizure dramatically

s incompatible with any other drugs, and any accidental infiltration into sub longer duration of action and also less respiratory depression in children o

ed bed-wetting?

to rule out metabolic or infectious processes- prepare the c y be stimulated with rhythm patterns or flashing lights or m

re is crucial use it is difficult for the adult and could resul

by the sight of a child having a seizure because

e of the illness.

ealth care team; parents discuss ways to accommodate illness(ex. M dren neglect their medication, seizure are apt to recur settle at the bottom, resulting in over diluted or over concentrated do

heir child’s seizure-this will help them feel that th that the treatment is known opiramate (Topamax), aborigine (Lamictal) and tailgati s status epilepticus occurs and the child becomes an

glandular changes or of the sudden growth and the nee

the inner ear).

de atmosphere and allow fluid and mucus to drain out of the m ian tube directly into the middle ear cavity and multiply in enlarged adenoids. Fluid produced by the inflammation cannot d s media.

lts because of the small size and hori Otitis media affects about 2/3 of you

ection, blockage of the eustachian tube

at infect the cells lining the eustachian tube, th to build behind the eardrum. Some of the most comm

a result of swollen tonsils or adenoids or pro

en with vitamin A, zinc and iron deficiencies with bottle feeding.

the ear canal and prevents reflux of particle ther’s antibodies crossing over to the baby in

aining in the middle ear for a long period of time may nnitus (ringing or buzzing in the ear), sense of fullne king from the ear, nausea and difficulty in speaking an us and relief of pain.

nclude otitis externa (inflammation of the outer ear) ation of the membranes covering the brain and spinal cor es in the middle ear (sometimes causing total deafness)

e ear with an otoscope. ormation that cannot be learned pitches. An audiogram is used to dle ear; this indicates how well respond to treatment, it may be

through observation only: measure how much hearing loss has the eustachian tube is functionin necessary to obtain a culture from

sidered, taking into account the patient’s age, risk factors hold antibiotics for 24 hours and recheck the following da with analgesic eardrops, and then do not need any antibiotic use of prophylactic antibiotics to prevent recurrent otiti

antibiotics , if the ear infections are chronic or hearing loss is indic recurrent ear infections or persistent fluid in the middle ear, which can n the eardrum and inserts a tiny ventilation tube called a tympanostomy l fall out on its own within 3 to 18 months. Additional myringotomies may

suggest removing the adenoids (adenoidect ed three months or more and the adenoids

llectomy). This procedure is only recommended for children 4 y

noplasty (a plastic operative procedure to repair a damage

nt of the stapes (stirrup) with a prosthesis).

potentially fatal injuries. They can cause life-threatening shock through serious f

WHAT ARE THE RISKS FROM BURNS? In burns, fluid is lost in three main ways: •Blistering •Swelling around the injury •Directly from the injury

he victim it is nevertheless lost from the blood

ovides little or no resistance to infection and ser victim will probably suffer from shock as well.


e most common type of burn and includes burns caused by hot objects suc

wn as a scald, wet heat usually refers to hot water or steam but it can also i

o objects rub together very quickly friction generates heat, causing another

urns and household chemicals can cause serious burns.

Chemical burns Industrial and household chemicals can c burns.

ppliances around the home or from the high-voltage cables scattered ar by

ound dramatic, most of us have suffered some degree of radiation burn at som

arred tissue often surrounded by white waxy areas of dead skin with damaged nerves, th

d, and pain. The risk of shock is high with second degree burns and any burn of this type needs medi

eatening unless a very large surface area of the body is covered. The burned area is very sore and is usually red an


Any burn to the face or neck needs urgent medical attention. As sons to suspect that his or her condition is more serious, then ca
U TELL HOW SEVERE A BURN IS? re minor and can be safely treated at home or with help from local size and depth of the burn will tell you if it needs urgent medical tre

Head = 9% Chest (front) = 9% Abdomen (front) = 9% Upper/mid/low back and buttocks = 18% Each arm = 9% Each palm = 1% Groin = 1%

Each leg = 18% total (front = 9%, back

initial fluid requirement in the first 24 hours, with half given in the first 8 The Parkland formula


of burn, there are some additional considerations for chemical burns. The k label, empty chemical containers, or guidance from bystanders. If in dou

en do so carefully. elf from contamination. s affect breathing. oth the victim and yourself. It may be necessary to flood the injured part for longer to en hemical burn so that the additional help can be sent for if necessary and so that any an tim because this may keep burning, but only do this if you can do it without contaminati propriate and tie loosely in place if necessary. cy help arrives the scene.

SIGNS AND SYMPTOMS OF CHEMICAL BURNS TO THE EYE 1.Known exposure to the chemical 2.Intense pain 3.Redness and swelling 4.Reluctance or inability to open the eye 5.Tears from the eye

ous. Early rinsing of the eye with cold water will help flush away the chemical and r

working with them should have been trained in the use of an antidote. If the

wing the injured person to blink periodically. You may need to hold the e

pital treatment may be delayed.


or a foreign body in the eye. oves to prevent infecting the eye. n place if it will be some time until medical help arrives. Remember that this will effectively b se she will need medical attention. NS TO THE EYE (which may happened some time ago)

hing in the eyes

eyeball. Recovery can take some time and in some instances the damage can


y or permanent harm. Some substances, such as ac ken in very small amounts to be harmful.


Vomiting This is common response to many poisons, particularly those that have been eaten, as body tries to remove th Impaired consciousness A person may be confused and slowly lapse into full unconsciousness. Breathing difficulties Poison may eventually cause breathing to stop. Change in heart rate Some poisons speed up the heart rate; others slow it down. Poisons may eventually cause the heart to stop. Erratic and confused behavior Always suspect poisoning in these instances.

Burns Some poisons burn the skin, some swallowed poisons burn the digestive tract, bringing the additional risk of sw Pain Some poisons will cause pain. Liver and kidney problems As the liver and kidneys struggle to remove poisons from the body they may become affected themselves.

INCIPLES FOR DEALING WITH POISONS nd bystanders from the source of the poison by making the scene safe and wearing protective clo tain the victim’s airway and breathing and be prepared to resuscitate if necessary. medical help or call the Poison Control Hotline to deal with dangerous substances. ’s level of consciousness and be prepared to turn into the recovery position if necessary. m if he vomits and place in the recovery position until medical help arrives. aused by corrosive poisons by flooding the affected area with running water. source of poison because this will help determine appropriate medical treatment.

ne an appropriate course of treatment. ay be able to provide include: eans that all the pills were taken).

get a description of the creature. If it is safe to do so, take the poisonous a

an get close enough to do so without putting yourself at risk. Do not touch these yo


you to approach. Do not inadvertently kneel in chemicals or otherwise irway and breathing. Be prepared to resuscitate if necessary. he person becomes unconscious, put into the recovery position. trol Hotline for advice on how to proceed. rotective clothing if necessary. omits and place in the recovery position if necessary. you are waiting for emergency assistance to arrive. ble because this will help medical staff determine what treatment is ap

PTOMS ottles, information from the victim, or from bystanders e mouth

onsciousness reathing

e the person vomit. If a poison burns on the way down t

s because the poison was corrosive, you must take care not to put yourself at risk. Use

chin as you would normally. Then close the mouth (using a piece of material as a barri between breaths to let the air out.

cold water. This will help relieve the pain and reduce swelling.

SEHOLD SUBSTANCES dicines up high out of the reach of children in a locked cupboard ome household chemicals should be used only in well-venti came in or a clearly marked alternative. Never store chem d or garage in a locked container materials in childproof containers. *

f children. Most child abuse occurs in a child's home, with a ychological/emotional abuse, and sexual abuse. sexual, psychological, and neglect.

diffuse axonal injury, and oxygen deprivation; which leads to patterns such as failure to thriv

are likely to receive bone fractures, particularly rib fractures, and may have

r older adolescent abuses a child for sexual stimulation. For phy to a child, actual sexual contact against a child, physical

could include name-calling, ridicule, degradation, destruction of pers

internalizing the abusive words, or fighting back by insulting the abu ve behavior.

to know whether marital strife is a cause of child abuse, or if bo rents with substance abuse problems. This study specifically fo

ric problems, or a disorganized attachment style. Disorganized

children. TSD), clinical depression, and anxiety. It also includes a compone nced physical abuse. ing the experience of domestic violence. It targets trauma-related

are ways to get children more comfortable with therapy by working

essive, non-contagious motor conditions that cause physical disability in human develo

The word cerebral means having to do with the brain. The word palsy means a we

t because CP affects the brain, depending on what part of the bra

and parents to suspect that something is wrong. In the f

he or she is picking up movement skills slower than normal. Infants with cere diately diagnosed as having cerebral palsy. More often, however, medical profes such as rolling over and sitting up

nctioning Static encephalopathy, meaning abnormal brain function that is not g

over while sitting), reflexes, or motor development and coo

s (e.g. facial gestures), unsteady gait, problems with balanc

can contribute to a gait reminiscent of a marionette) are co

s, such as spinal curvature, a small jawbone, or a small r other communication disorders, eating problems, se

tal stage at 6/12 to 9/12 months and is starting to mobil

emy of Neurology published an article in 2004 reviewing the literatu an MRI is preferred over CT due to diagnostic yield and safety. W arteriovenous malformation, subdural hematomas and hygromas psy and mental retardation.

events at time of delivery; in most instances it is related to events th k of bleeding, and when severe enough, it can result in cerebral palsy. +

f brain development , genetic disorders, stroke due to abnormal blood vess of cerebral palsy is a lack of oxygen to the brain during delivery (birth

d to cerebral palsy. This abuse often takes the form of severe shaking fr

order to function and live more effectively. ming developmental disabilities or learning new ways to accom

nes, baclofen and intrathecal phenol/baclofen);

during hospital stay was related to neurological function at 18 and 22 months e in the development of cerebral palsy. improved gait and volitional movement, together with stretching programs to li

y as possible.

egularities. AFOs have been found to improve several measures of ambula nication. Just as CP can affect the way a person moves their arms and legs chool and continues throughout the school years. eating certain foods.

hips, knees, hamstrings, and ankles. In rare cases, this surgery may ung adult. This is usually placed in the left abdomen. It is a pump tha effects of spasticity.

or antetorsion) and tibia (tibial torsion). This is a secondary complicatio hen set in the correct alignment. , called a rhizotomy, "rhizo" meaning root and "tomy" meaning "a cuttin

lsy, cerebral means the brain and

sive, non-contagious motor conditions that cause phys

can lead doctors and parents to suspect that

herapy is used to draw away the symptoms

apy rapy

physical abuse are at risk of developing

terventions for burn patients, which is s

possibly get poisoned are the follow n of fumes of addictive drug of excessive iron HAZMAT labels

ASTHMA: CHRONIC AIRFLOW LIMITATION -immediate hypersensitive (type I) response -most common chronic illness in children, long term, poorly controlle -occurs before 5 years of age with hypersensitivity to allergens (ant CHARACTERISTICS: 1. Inflammation- causes swelling of the bronchules 2. Bronchoconstriction- because of swelling 3. Increased mucus production- bronchial secretions -all these processes act to reduce the size of the airway lumen distress


evere bronchonstriction can occur because of: osure to cold air ENT: odors- turpentine, smog ting ation of allergens- pollens, molds, house dust d - audible in all lung fields on g in only 1 lobe, suggest smoke, fumes ollutants- cigarette that 1 bronchus is plugged gn body, e.g. peanut is more likely responsible respiratory infections- most common creased

est/shield like - from constant over inflation of air in alveoli, increased antero-posterior diameter nger - because of poor tissue oxygenation in distal parts growth - long periods on steroid therapy

ASSESSMENT: - after exposure to allergen episode begins with: 1. Dry cough - often at night 2. Dyspnea – difficulty breathing 3. Wheezing on expiration 4. Copious mucus production - contain white cast bearing t

lse oximeter ngs to oxygenate rease because of allergic reaction because carbon dioxide trapping and retention ause of an acute feeling of suffocation percussion - louder and hallower noise er than inspiration ns - children use intercostal accessory muscle to achieve full breathing, when

nge of gases, oxygen plus carbon dioxide and when there is adequate volume and dist

thing is when the match is held at 6” expiratory flow overtime

le the peak flow meter result

THERAPEUTIC MANAGEMENT •Avoidance of the allergen by environmental control •Skin testing and hyposensitization to identify allergens •Relief of symptoms by pharmacologic agents

PHARMACOLOGIC MEASURES: Mild Persistent Asthma -inhaled corticosteroid anti inflammatory: (flovent) Fluticasone daily Moderate Persistent Symptoms -give anti inflammatory inhalation daily (corticosteroid) -long-acting broncho dilator at bedtime Persistent Severe Symptoms -increase dose of both, oral and inhaled corticosteroid daily -broncho dilator at bedtime -give short acting beta-2- agonist broncodilator e.g. albuterol (pronentil, ventolin) *action: cause bronchodilation and vasodilationfor relief of broncho spasm -metoproterenol: side/effects - irregular heartbeat, tachycardia -cromolyn sodium: mast cell stabilizers given by nebulizer or metered dose inhaler *action: prevent broncho constriction and prevent symptoms of asthma *not effective once symptoms have begun Prophylaxis -Leukotriene receptor antagonists- prophylaxis e.g. montelukast (singulair, kastair) -chronic effects of asthma and prophylaxis in children over six years old

sthma attack

rate ability to manage sudden attacks within one month

ow a child enough for growth and development ursed lip breathing) he nebulizer and metered dose inhaler prevention of asthma attacks and its effects

will demonstrate understanding of ways to prevent attacks and

NFECTION (UTI) tion or extent of the infection is unknown

to enter the urinary tract as an ascending infection from the perineum CTORS: s e.g. bubble bath, feminine hygiene sprays

tercourse- teach females to void after sexual intercourse


er spasm esence of RBC because of mucosal irritation on is confined to the bladder

pain, enuresis(bedretting) confined in the pyelo

ank pain, vomiting and malaise

infants because the sight of the syringe is frightening to older children, it can introduce infe potential source of infection

TS: bacteriuria e presence of bacteria sal irritation causing rapture of the minute capillaries RBCs, WBCs and bacteria (Ph 7)


causative organism that is cultured (continued full course of therapy) the infection out of the Urinary Tract acidifying urine, making it more resistant to bacterial growth causing inability to void- advise to sit in a bath tub of warm water and void hen (Tylenol) may help reduce pain and facilitate voiding advice to make a reminder sheet of the drug schedule on the refrigerator d ually obtained at 72 hrs to assess effectiveness of the antibiotic effects of bacteria, obtain at least 3 sterile specimens

WILM’S TUMOR (NEPHROBLASTOMA) -malignant tumor that rises from the metanephric mesoderm cells of the upper pole of the kid -it occurs unilaterally or bilaterally -20% of solid tumor in childhood -most common renal tumor in children ETIOLOGY -unknown PREDISPOSING FACTORS -it occurs in association with congenital anomalies such as: 1. Aniridia (lack of color in the uris) 2. Cryptorchidism, hypospadias, cystic kidneys, hemangioma and talipes disorders -metastatic spread is most often to the lungs (specifically), liver, bone, regional lymph nodes,

STIC EVALUATION: bdomen- initial study done to detect a solid intrar agnetic resonance imaging nal computed tomography (CT scan) adiography and chest CT to confirm the diagnosis moglobin count ytes: hyper/hypo d createnine- kidney functioning before surgery after surgery: a definitive diagnosis

peak at 3-4 yearsd) (mobile), most common presenting sign

y diseased kidney, pallor, weakness, anorexia and lethargy tumor metastasize rapidly because of the large blood supp s e seeding of the tumor and spread of cancerous cells and carefully

TIC MANAGEMENT horough diagnostic work up my- excision of the affected kidney (tumor is removed) herapy- if tumors respond poorly to chemotherapy rapy with dactinomycin, doxorubicin, vincristin IONS OF THERAPY el obstruction from fibrotic scarring mage from radiation to the lesion can occur n the kidney girls because of radiation pneumonia- radiate to lungs spine radiation

OSIS esulting to surgery with nephrectomy ENTION are initially focuses on pre operation teachings on

d be placed on the bed warning against palpating OME parents will express less anxiety about the o

r in children (2-6 years old) uncontrolled proliferation of the number of WBCs ymphoblast, an immature lymphocyte (WBCs) last, the production of RBCs, platelet falls (Thrombocytopenia ) and invasion of body organs beg of metabolic nutrients that results in cellular starvation em invasion: Spleen, Liver and Lymph nodes ms such as headache and unsteady gait, ICP, meningeal irritation

tic leukemia (ALL): 70% most common type of leukemia in children reme proliferal of immature lymphocyte (blast cells) eukemia (AML): over proliferation of granulocytes type of leukemia in adulthood about 20% of all childhood leukemia

CTORS: osure or: defect in DNA synthesis, alteration in genetic make up me, Fanconi’s syndrome s on: children should be submitted to few x-rays even while in utero.

e marrow, normal production of other blood components (RBCs and p eakness, pallor, lethargy, low grade fever thrombocyte) count

outh ration of abnormal cells

s mental and neurologic status n on, disturbing the body’s defense system, infection and fever

firmatory test, microscopic exam of the bone marrow, identify the type of rated in the posterior iliac crest, it yields more marrow ast cells present (positive) for leukemia k for blast cells in the (CSF) cerebrospinal fluid ave crossed the old brain barrier

mic cells doxorobicin and methotraxate)

ction to chemotherapy, they release uric acid into the serum, which can compromise kidney


weeks event disease in the sanctuary sites (CNS and testes) mic therapy is poorly delivered to these areas

sion, induction and consolidation therapy e to lead normal lives when they reach this stage of treatment emaining leukemic cells, blood values must be monitored at least a mon r years are considered cure e to reinduce a remission or go back to the first phase, second … usual


and recurrent meningeal irritation

and papilledema methotrexate(injection of drugs into the CSF by lumbar puncture) dren IV or P.O. together with intrathecal because of toxic reactions invasion of leukemic cells eakdown of WBC during chemotherapy uric acid crystals the use of chemotherapy agents because they can not be excrete

s, leukemic cells tend to invade the testes to destroy this sanctuary sites for cells. Sterilization later in life erty, sperm bank is advised before chemotherapy and preserve sperm

d to, non functioning WBC and immunosuppressive effects creased and the drugs for treatment are immunosuppressive, t

c streptococcal infection. Rheumatic fever is not an infection, t any age, it is most frequent in children 5 to 15 years old.

valves, in particular the mitral valve, as well as in the major body joi cus.

peak incidence at 8years. e previously been exposed to streptococcal infe

eas. the infection recurs thus rheumatic fever also re

occal infection subside in a few days with or without antimicrobial therap

making undulating, jerky movements.

nless affect or grimace

ndon sheaths by the joints


dic movements of the limbs, trunk and facial muscle

ndings: tococcal titer (ASO)


ts with a medical history and physical examination. The hea

uate for a history of strep infection) f the heart

shortness of breath or chest pain. The physician may susp

moving from joint to joint. uch as difficulty with handwriting (known as Sydenham's ch y areas).

Minor criteria include: •Fever •Arthralgia (pain in one or more joints without inflammat •Abnormal interval measurement on an electrocardiogra •Blood test indicating inflammation •New abnormal heart murmur

herapy related to knowledge deficit about importanc

absence of symptoms of throat infection; vital signs ed to chorea movements secondary to rheumatic fe

inability to control movements; continues to feed an

s NOT present, ESR decreases, and C-reactiv

ent E is preferred

ATMENT: apy or Benzathine penicillin ( single dose intramuscularly ) e group A beta-hemolytic streptococci completely al) nflammation and joint d therapy ( if not responding to Ibuprofen alone ) effects include:

ndrome ( moon face ) sceptibility to infection l and Diazepam reduce the purposeless movements of Chorea. Diuretics ( if heart failure is present ) chances of heart failure

destruction from formation of Aschoff’s bodies ( fibrin deposits )may result

mong children 2 to 6 years old. Impetigo is not as common in adults. The name formed from dried serum, and is often found on the arms, legs, or face. The in

ma rusts secondary infections of insect bites

ute glomerulonephritis, a kidney condition producing in age. Another is rheumatic fever.

does not leave scars. Affected skin looks red for a whil

atch for skin that is injured, or irritated — including cuts, scr

ens with anyone else.

of cloth towels can also help keep the infection from spreading od idea at any time but more risky if you or your friend have imp

of cloth towels can also help keep the infection from spreading ot a good idea at any time but more risky if you or your friend ha

•Medication treatment: 1.Penicillin or Erythromycin ( oral ) 2.Mupirocin (Bactroban) ointment for 7-10day •Contact precautions for 24hours = if child develops impetigo in the hospital


itch mite Sarcoptes scabiei. Mites are small eight-legged worse at night. The mites that cause scabies are not visib

of the symptoms of the pruritic rash varies. If the indivi a prior infestation symptoms can occur one to four day

station occurs, the mite deposits eggs under the skin of the of the individual. A person is considered to be no longer co

sitive to their environment. They can only live off of a host body for 24-36 hours un contact of the skin-to-skin variety. catch scabies by shaking hands, hanging your coat next to someone who has it, o

ransmission among sexually active young people. ontact dren, close friends and relatives can contract the disease in this mode too. not provide the level of prolonged personal contact necessary for transmission of

skin; the associated itching is often most prevalent at night.

y especially in immunocompromised people (HIV positive or eld cci or Staphylococci bacterial skin infection, after scratching. Ce

eet, are characteristic symptoms of scabies in infants. e bites called nodules that may look like pimples he body, such as the webs of fingers, toes, feet, buttocks, elbo

aining the pinpoint mite; however, these may not be present on elbows, thighs, breasts, or genitalia. The lesions may also app ted individuals usually complain of severe nighttime itchin

Confirmation of Diagnosis: Suspicious lesions should be scraped with a sterile needle or scalpel blade. Health care personnel can be trained to perform skin scrapings according to the following procedure: 1. Choose lesions without significant excoriation. = A magnifying glass may be used to locate burrows. When a possible burrow is detected, mark with a wide felt tip pen. Apply an alcohol pad to remove the surface ink. If a burrow is present, the ink will remain within the burrow. The burrow will then appear as a dark, irregular line. 2. Apply sterile mineral oil to the surface of the lesion to be sampled. 3. With a glass slide held at a 90 angle to the surface of the lesion, scrape the lesion. Collect the scraping on the glass slide. =Scrapings from several lesions may be collected onto a single glass slide.
4. Place a coverslip over the scrapings and examine with a microscope under low power. The presence of a mite, eggs of a mite, or mite fecal material confirms the diagnosis of scabies.

ASSESSMENT: •Residents and staff should have skin examination by inspection. •New residents or those accepted in transfer from another care facility should be examined on the first day of arrival. •If a resident is undergoing treatment for scabies but requires transfer to another care facility, the accepting facility must be notified of the current diagnosis of scabies in this resident prior to transfer.

Treatment: •The recommended treatment for scabies is 5% permethrin ( Elimite ) cream. = Application of this cream to the skin of an infested resident should be supervised. Usually the cream is best applied prior to bedtime. The cream must cover all skin areas from the neck down. = In the case of an incontinent resident, the nurse must ensure that any cream that is removed during bouts of incontinence is promptly replaced. Following 8-14 hours of skin contact, the cream should be removed by shower or bath. Treatment may need to be repeated in seven days if there is evidence of persistent or recurrent lesions.

•Alternative treatments are occasionally prescribed. These may include 1% lindane cream or lotion, 6% precipitated sulfur in petroleum, or 10% crotamiton cream or lotion. = simply wash the area using either of those creams. •An infested individual should be considered contagious until 24 hours after start of effective treatment. Itching often persists in spite of treatment and may require additional therapy for symptomatic relief. •Caution adolescent that groin infestations might be spread by physical intimacy.


Pediculosis is an infestation of lice. Humans can be infested with three kinds of lice: Pediculus capitis (head lice), Pediculus corporis (body lice), and Phthirus pubis (pubic, or crab, lice). Lice feed on human blood and deposit their eggs (nits) on the hair shafts (head lice and pubic lice) and along the seams of clothing (body lice).

the an allergic reaction to the bites); sore c thing, to be sure)

DIAGNOSIS Head lice can be detected by looking closely through the hair and scalp for nits, nymphs, or adults. Locating a nymph or adult may be difficult; there are usually only a few of them, and they can move quickly from searching fingers.

e. Overuse, misuse, or accidentally swallowing Lindane can be toxic to the brain a

ation drug and is mixed with isopropyl alcohol (rubbing alcohol) and terpineol (a na

tion, wo times with the same medication (if it does not seem to

and their families. Follow these treatment steps:

extra long hair, you may need to use a second bottle. WARNING: Do

before, do not retreat. Comb dead and remaining live lice out of the e medicine may not be working. See your health-care provider for a d

e packages should be used to remove nits and lice from the hair shaft. Man its and lice from hair every two to three days.

you are sure all lice and nits are gone.

days before treatment (to kill the lice and nits). Use the hot water cycle (13 mals, comforters, etc., that cannot be washed or dry cleaned into a plastic b

one hour in rubbing alcohol, Lysol, or wash with soap and hot (130 d e. Do not use fumigant sprays. (They can be toxic if inhaled.)

cating head lice. g alcohol, and prolonged water submersion. These all fail to eliminate infest

s, it should prevent the lice from multiplying. This is not always considered

n and how it uses glucose (sugar). Insulin is a hormone that helps dependent diabetes mellitus (IDDM) or juvenile-onset diabetes.

ETIOLOGY: Unknown in its occurrence. Type 1 diabetes may be an autoimmune disease. An autoimmune disease is a condition where your child's defense system attacks some of his own cells. Normally, when your child's blood glucose level increases, the pancreas (an organ that lies behind the stomach) makes insulin. In type 1 diabetes, the cells in the pancreas that make insulin are destroyed. Diabetes may also be inherited as it runs in families. If one child has diabetes, the chance that a sibling will also develop the illness is higher than in other families, because siblings also tend to have one of the specific Human Leukocyte Antigen (HLA) that lead to the development of the disease.

the bloodstream (hyperglycemia ) and this underlying defect leads ess glucose into the urine, causing glycosuria . While attempting

k down protein and fat for cell utilization. Ketones, the acid end-pro en, therefore, lose weight, are acidotic due to the buildup of ketone b gy, which are also growth components, may lead to children being low i

ASSESSMENT: •Identify specific onset of signs and symptoms •Polydipsia •Polyuria = may begin as bedwetting in a previously toilettrained child •Constipation because of the dehydration •Losing weight without trying. •Blurred vision (eyesight).

ypoglycemia. This usually happens when a diabetic has taken his regular normal d

a lot.

ried along.

and is thereby not beneficial. ious.

d Keto-acidosis.

minal pain and drowsiness. In milder cases the child becomes excessively thirsty and goes

en will always need insulin. en take the help of a dietician.

ild will then be given a glucose drink or IV administration of a concentrated glucose solution. Two hours

abnormally high.

HbA becomes. In nondiabetic children normal is 1.8-4.0. A value greater than 6.0 reflects an

usses plans for an exercise and hygiene program.

will affect their lifestyle. They state a specific plan for daily routine child care and identify potential proble

0-110mg/dL fasting; child states that nutrition and exercise program is being followed.

THERAPEUTIC MANAGEMENT: •Initial Regulation of Insulin = IV administration of 0.1-0.2U per kg of body weight per hour (depending on the severity of the symptoms ). This initial IV infusion of insulin is followed by further dose reductions ONCE the blood glucose level is lower than 200mg/dL. The dosage depends on the change in the acidosis and the degree of glycosemia and ketonuria. •Insulin Administration = Regular insulin is usually referred to as short acting (Lispro) = intermediate Acting insulin 1.Humulin-L and Humulin-N = Long Acting Insulin (Humulin-U) Dosage: Most common mixture for children -intermediate acting insulin and regular acting usually in a 2:1 ratio (i.e. 2/3U of inte ractinginsulin and 1/3U regular insulin) and given in one syringe, although this prescription varies for individual children. + this means that if a child takes in regular insulin before breakfast will notice a peak Effect at 10am-12noon; that is the time of day when hypoglycemia (a reaction to an excessive insulin level) is most likely to occur. The peak effect period of the intermediateacting insulin is at 8 to 14hours, or late afternoon, just before dinner. This is another prime time for hypoglycemia.

s an accidental mixture in the bottle, the time of effectiveness of the short-acting (which needs to

insulin making it unable to meet its desired length of time of effect.

erum glucose levels better than periodic injections do. It has the potential to decrea

oof. Remove only the pump and NOT the syringe and the tubing. am.

ergies, absorption is reduced. Absorption is dependent to child’s position during

5% & fat 30%. d afternoon and evening.

ria. Presence of acetone is a sign that fat is used for energy; the situation occu

follow, during which only a minimal amount of insulin, or none at all, is needed for insulin regulation. BU

ke informing the teacher that the child is not ill so that he/she can still join sports or school activities. In

he need for more insulin. Teach parents to notify their primary health care provider diate postoperative period is essential, especially if oral fluids will be restricted.

hragm and condoms.

bulin, cyclosporine, prednisone, or azathioprine (Imuran) are administered afte s are rejected) and the outcome of immunosuppressive medication for life- ma

gest the following: e time can cause your child's blood sugar to rise to a very high level. Carbohydrates are found in

ry (chicken and turkey), and low fat milk are good examples. If your child is a baby or t the same time every day. ldren with diabetes can go through fussy eating phases just like other children. Conti

active at least 30 minutes every day. Playing can be a very good exercise. Work with y

INCIDENCE: PEAK is twice in childhood: 1-3years and 8-12years. May start as early as in 6months of age More common to girls than boys Acute changes rarely continue past 19years of age

tissues. To be classified as JA, symptoms must begin before 16yo and last longer s (immunoglobulins) against his or her own body cells. This is revealed by the pres

vement. as they are expecting that it is for adults only. he signs and symptoms and for the effects their disease is having on self-care. ness and planned therapy because they bear most of the responsibility during hom

nflammation of the iris, ciliary body and choroid membrane of the eye). Severe uve

management is needed to help children able to function effectively. Therapy inc

a set program of daily range-of-motion exercises to strengthen muscles and p ays” to initiate involvement of family members. cellent activities.

e because of joint pains. ending. nts/skirts trips not only help children feel good but boosting their feeling of being able to

ivities like running, jumping, prolonged walking and rents other alternative exercises that avoids such m umption of Calcium or decalcification of bones and s to be in midmorning so that the child can have a war

nd motion. event rebound effect of the application).

are effective and efficient in reducing joint inflammation. Import

tion caused by NSAID, help parents plan mealtimes for “best times”

en (Naprosyn)

morning stiffness but may contribute to improvement in malaise and ucate parents to have administration of drugs with food. Even witho

disease-modifying antirheumatic drugs (DMARDs) are used. he natural progress of the disease over weeks or months. Ex. Gold salts, Penici

hioprine, Chlorambucil and MethoTrexate.

ng system disease, the drug is added. t discouraged in use for its numerous adverse effects. d in a lower dose.

immune system that play a role in destruction of body join

ed teratogenic effect, it is NOT the drug of choice for a sex

ed to care necessary to control disease symptoms.

instructions regarding exercise and medication.

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