NEWBORN

A. Immediate Care of the NB in DR B. Immediate Care of the NB in Nursery C. Cephalocaudal Assessment D. Physiologic Changes of the NB E. Newborn Reflexes F. Newborn Screening Test G. Selected Newborn Condition
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IMMEDIATE CARE OF THE NEWBORN: DELIVERY ROOM 1. ESTABLISH OF RESPIRATION a. With head extension, clear the mouth and nose to prevent meconium aspiration b. After expulsion * Place on SLIGHT TRENDEELENBURG position (10-15 degrees angle ) to drain secretions. * SUCTION briefly, gently from the mouth to the nose using bulb syringe for shallow suctioning. - Deep suctioning is contraindicated as this can cause stimulation of the vagus nerve, laryngospasm and bradycardia.
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* OXYGENATE in between suctioning using safe oxygen concentration ( NOT MORE THAN 40% concentration ) - Excessive oxygen concentration can result to oxygen toxicity leading to neonatal blindness: RETROLENTAL FIBROPLASIA . - CHOANAL ATRESIA is a congenital anomaly of the nose where the posterior nares are not patent. * check for patency of the nostrils by occluding one nostril at a time.

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2. KEEP WARM a. DRY and WRAP newborn to prevent heat loss. b. The newborn’s high temp. at birth 36.5 - 37.2 C- drops quickly at birth because of losing heat by the PROCESSES of: 1. EVAPORATION 2. CONDUCTION 3. CONVECTION 4. RADIATION

3. APGAR SCORING a. Done twice - 1 and 5 minutes after birth * First APGAR SCORE is to detect the cardio-respiratorynervous functioning of the newborn * Second APGAR score: used for planning nursing care

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APGAR SCORING ADAPTATIONS 0 1 Below 100 Weak cry 2 Above 100 Lusty cry

Heart rate Absent Respiratory Absent Effort respiration Muscle Tone Limp, flaccid Reflex Irritability No response Color Blue, pallor Interpretation:

Some flexion Acute flexion Grimace Sneezing, crying Acrocyanosis Pink

0-3 : POOR : severely depressed needs resuscitation
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4-6

:

FAIR : moderately depressed needs suctioning and oxygenation

7-10

:

GOOD : needs only routine admission care

•Most important - HEART RATE •Least important – COLOR •But the first thing the nurse is able to evaluate-Respi A score of 0 - means no HR A score of 9 - means ACROCYANOSIS
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4. PROPER IDENTIFICATION a. Bracelets and foot tags can be used with b. FOOTPRINTING - best way to identify c. Identification is done BEFORE THE BABY IS SEPARATED FROM THE MOTHER 5. CHECK FOR * Gestational Age * Birth Injuries * Congenital Defects * Gross Anomalies

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Immediate Care of the Newborn in Nursery • Bathing
• • • • • Cord care Vit. K injection Credes Prophylaxis Vital Measurements Vital Signs
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IMMEDIATE CARE : NURSERY 1. Continue with measures to keep newborn warm * Use droplight during admission care 2. CREDE’S PROPHYLAXIS or eye care a. Done to prevent OPTHALMIA NEONATRUM or gonorrheal conjunctivitis b. Mandatory - done to all newborns c. Drugs used - 1% Silver Nitrate 1-2 gtts into each conjunctival sac and Terramycin ophthalmic 1 cm from INNER TO OUTER CANTHUS d. CREDE’S PROHYLAXIS is delayed for 1-2 hours in order not to interfere with bonding process. EYE-TO-EYE CONTACT is prerequisite to bonding.
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3. SKIN CARE - done to prevent skin infection a. OIL BATH : given to premature and high-risk newborns and those with plenty of vernix caseosa b. SOAP AND WATER bath : given to normal fullterm 4. CORD DRESSING a. Strict asepsis prevents TETANUS NEONATORUM b. CHECK for 1 umbilical vein and 2 umbilical arteries * Report incomplete vessels c. In the first 24 hours, check the cord for bleeding called OMPHALANGHIA

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5. VITAMIN K Injection a. Mandatory, given to all newborns to prevent bleeding. b. Reasons for bleeding tendency : gastrointestinal tract of newborns INITIAL STERILE ------- no bacteria to synthesize vitamin K ----- decrease clothing factor ----- bleeding tendency c. Site for intramuscular injections in newborns : Thigh muscles - VASTUS LATERALIS ( best site ) RECTUS FEMORIS ( alternate site )

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6. Weighing and Taking of Other Antropometric Measurement Weight : 3000g - 3,400g (7-7.5 lbs.) - International Standard : 6-6.5 lbs. - average birth weight of a Filipino newborn * lower limit normal : 2,500 g Height HC CC : 19 - 21 inches ( ave. 50 cm ) : 33 - 35 cm/13 -14 inches : 31 - 33 cm/12 -13 inches

AC : 31 - 33 cm/12 -13 inches 7. Vital Signs Checking when infants is asleep/quiet 8. Gentle, minimal handling and watchful eyes
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C.

CEPHALOCAUDAL ASSESSMENT

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NEWBORN SKIN MARKS 1. LANUGO : fine, downy hair, more on preterms 2. VERNIX CASEOSA : whitish, cheesy, odorless usually on folds of skin; more in full term * protects skin and prevents heat loss 3. MILIA : white, pinpoint papules on the nose/chin/cheeks * disappears as early as 2 weeks or 3-4 weeks 4. MONONGOLIAN SPOT : grayish blue patch at the lower back from accumulation of pigment cells melanocytes * disappears school age 5. NEVI (STORK BITES) : red spots found at the back of the neck and above eyelids * disappears spontaneously before 1 year
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6. ERYTHEMIA TOXICUM NEONATORUM : newborn rash * pink papular rash appearing on the body within 24-28 hours after birth : harmless * disappears within a few days 7. DESQUAMATION : dry peeling of the skin particularly on the palm and soles, more in post terms

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• Skin color: Acrocyanosis Yellow –Erythroblastosis Fetalis Gray -- Infection Blue -- Congenital Heart Defects
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2. Head

• Fontanelles – closure, shape , size tense&bulging =ICP sunken =DHN

CRANIOSYNOSTOSIS – premature closure of the suture lines and cranial bones.
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Cont… Assessment

4 5. 6. 7. 8.

7. 8.

NECK - Webbed neck, torticollis CHEST - Witch Milk – 1st – 3rd wk of life ABDOMEN BACK - SPINA Bifida UROGENITAL - Brick red dust vs. greenish blotches - Phimosis. Epispadias, hypospadias,hydrocele,cryptorchidism MUSCULOSKELETAL - CHD , Clubfoot SENSORY
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PHYSIOLOGIC CHANGES IN THE NEWBORN 1. Weight Loss : 7-10 days * 5% to 10% of BW * After day 10, weight gain of 1 lb per month from 1-6 months *BW is doubled at 6 months and tripled at 1 year ,quadruples by 2 yrs. 2. Jaundice : 2-7 days full terms and 3-10 days for preterm * N.Value : 2 – 6 mg/dl * Mgmt: early morning sun exposure decrease breastfeeding to every 3hrs
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* Because of liver immaturity and fetal increase in RBC’s (polycythemia) * Expose to morning sunlight, decrease breastfeeding 3. Fever : 2-4 days 4. Physiologic Anemia : 4-6 months

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SIGNIFICANT NEWBORN REFLEXES A. FEEDING REFLEXES 1. Rooting - if the cheek or corner of the mouth is touched, he turns to that side; for food location *May disappears at 3-4 months when he can 2. Sucking - anything that touches the lips is sucked; present follow moving objects even before birth 2. Swallowing Reflex – anything put in the posterior tongue will be swallowed 3. Extrusion Reflex – anything put in the anterior tongue will be extruded or spit out. A reflex that will protect the 21 infant from ingestion of inedible object.

B. PROTECTIVE REFLEXES
1. Sneezing and coughing - protect and clear the air passages 2. Yawning - protects cells from depleted oxygen 3. Blinking - protects eyes from objects coming near it

* Protective reflexes are the only permanent reflexes while the rest will disappear.

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• NEUROLOGICAL REFLEXES
2. MORO or STARTLE - embracing motion in the arms or the upper and lower extremities will flexed then gradually relaxes in response to loud noise, jarring of the crib and falling sensation * Nsg. Implications: Absence – Brain Damage Assymetrical -- Paralysis Non disapperance -- Brain Damage * Disappears by the end of 4th or 5th month
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2. DARWIN - dancing reflex: few quick alternating steps when the new born is held upright and his feet touch a hard surface * Disappears at 4 month * Implication if absent & legs scissors - Cerebral Palsy 3. MAGNET - If pressure is appLied on the soles of the feet while infant lies supine, he pushes back against the pressure * A test of spinal cord integrity 4. CROSSED EXTENSION - if one leg of a newborn lying supine is extended and the sole is irritated by rubbing it with a sharp object, he will raise the other leg and extend it as if trying to push away the hand irritating the first leg * A test of spinal cord integrity
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Cont…

5.TNR/FENCING/BOXING – newborn lying supine position when the head is turned to one side, the upper & lower extremities of that side will extend while the opposite will flexed 6. BABINSKI – fanning of the toes results when the soles of the feet is stroked with inverted ”J”.
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INBORN ERRORS OF METABOLISM
Inherited disorders caused by absence of a substance essential to cellular metabolism Characterized by abnormal fat, protein, or carbohydrate metabolism Usually inherited as autosomal recessive trait

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Phenylketonuria (PKU)
Data Base • A. Lack of the enzyme phenylalanine hydroxylase, which changes phenylalanine (essential amino acid) into tyrosine • B. Clinical findings
– 1. Mental retardation from damage to the nervous system by buildup of phenylalanine if untreated

– 2. Strong musty odor in urine from phenylacetic acid – 3. Absence of tyrosine reduces the production of melanin and results in blond hair and blue eyes – 4. Fair skin is susceptible to eczema
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• a. Often noticed by 4 months of age • b. IQ is usually below 50 and most frequently under 20

Phenylketonuria (PKU)
C. Therapeutic interventions • 1. Guthrie blood test: testing should be done after protein ingestion;if testing is done during initial 24 hours, it should be repeated by the third week of life • 2. Early detection is essential • 3. Dietary: low-phenylalanine: use Lofenalac or PKU-1 as a milk substitute and restrict foods to those low in this amino acid
– a. Use of phenylalanine-free formulas such as PKU-2 or Phenyl-Free for children over 3 – b. Dietary restrictions of phenylalanine through adolescence and possibly for life – c. Individuals with phenylketonuria who become pregnant mustconsume a low-phenylalanine diet

• 4. Treat eczema

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Galactosemia
Data Base • A. Missing enzyme that converts galactose to glucose • B. Clinical findings
– – – – 1. 2. 3. 4. Jaundice develops Weight loss/vomiting Hepatosplenomegaly Cataracts
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Galactosemia
C. Therapeutic interventions • 1. Early detection: test for galactosemia at birth; Beutler test(method similar to Guthrie test for PKU) mandatory in many states • 2. Dietary reduction of lactose: use a soy-based formula as a milk substitute and restrict foods to those low in lactose (usually continued until the child is 7 to 8 years of age), followed by a dietary modification throughout life
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Congenital Hypothyroidism
Data Base • A. Failure of embryonic development of the thyroid gland or inborn enzyme defect in the formation of thyroxine

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Congenital Hypothyroidism
B. Clinical findings • 1. Prolonged physiologic jaundice, feeding difficulties, inactivity(excessive sleeping, little crying), anemia, problems resulting from hypotonic abdominal muscles (constipation, protruding abdomen, and umbilical hernia) • 2. Appears at 3 to 6 months of age in formula-fed babies; may be delayed in breastfed babies
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Congenital Hypothyroidism
3. Impaired development of nervous system leads to mental retardation; level depends on degree of hypothyroidism and interval before therapy is begun 4. Decreased growth and decreased metabolic rate resulting in increased weight 5. Characteristic infant facies: short forehead; wide, puffy eyes;wrinkled eyelids; broad, short, upturned nose; large, protruding tongue; hair is dry, brittle, and lusterless with low hairline 6. Skin is mottled because of decreased heart rate and circulation 7. Skin is yellowish from carotenemia resulting from decreased conversion of carotene to vitamin A
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Congenital Hypothyroidism
C. Therapeutic interventions • 1. Detection: neonatal screening for thyroxine (T4) and thyroid-stimulating hormone (TSH)
– a. Test is routine and mandatory in many areas – b. Performed by heel-stick blood test at the same time as other neonatal metabolic tests

• 2. Treatment: replacement therapy with thyroid hormone; if therapy begun before 3 months of age, chances for normal growth and normal IQ increased

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I. IMPETIGO A. Bacteria infection of the superficial layers of the skin invaded by streptococci, staphylococci, or pneumococci; commonly found on the face B. Causes; poor skin care; overcrowding, malnutrition C. Characteristics: vesicle like, papules. Pustules, crusts D. Treatment: meticulous hygiene of skin; hexachlorophene scrubbing of lesions, antibiotics for widespread lesions to prevent nephritis and rheumatic fever. II. BOILS/FURUNCLES A. Bacterial infection of hair follicales common face neck, axilla buttocks B. Progresses from papules to postules than hard tender, hot nodless which form a pus ‘point’
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Selected Newborn Condition

1. 2. 3. 4. 5.

Hypoglycemia Hypothermia Hyperbilirubinemia Erythroblastosis Fetalis RDS or Hyaline Membrane Disease 6. LBW 7. Premature vs. Postmature
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SELECTED NEWBORN CONDITIONS I. HYPOGLYCEMIA A. Etiologic Factors - babies born to diabetic mother, prematurity, postmaturity, SGA, birth injuries, congenital defects, low APGAR, inadequate intake, stresses (cold stress, difficult birth, CS) B. S/S-high pitch cry, poor sucking &feeding, irritability, jitteriness, apnea, tachypnea, tremors, and convulsion C. Nursing Implementation

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C. Nursing Implementation * Give oral glucose * Administered ordered 10%-25% IV glucose; monitor rate of flow strictly to prevent hyperglycemia * Keep warm * Prevent infection : handwashing - best measure * Prevent convulsion : decrease environmental stimuli * Monitor VS, behavior, serum glucose * Handle gently
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II. HYPOTHERMIA - low body temperature less than 36.5 C A. Etiologic Factors - prematurity, postmaturity, SGA, malnourished newborn ---- absence of inadequate brown fat to burn and with increased body surface area compared to decreased body weight B. Danger signs - low body temperature, mottling, cyanosis, crying, increased activity, tachypnea C. Nursing Implementation * Keep warm : maintain in incubator (best place for maintaining body warmth) * Prevent heat loss by evaporation, conduction, convection and radiation. ( Most heat is lost by radiation.) * Oxygenate PRN * Monitor temperature per axilla
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III. HYPERBILIRUBINEMIA-increase serum bilirubin more than 12-13 mg% * Normal serum bilirubin in newborns - 2-6 mg% A. Etiologic Factors - Rh and ABO incompatibility, infection, prematurity, drugs, breastfeeding (because of pregnanediol) polycythemia B. Assessment Findings * pathologic jaundice ( present in first 24 ) * dark, concentrated urine or tea colored urine * lethargy, poor feeding * Pallor due to hemolytic anemia C. Treatment : phototherapy and exchange transfusion D. Nursing Responsibility - Detect and report early pathologic jaundice

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IV. HEMOLYTIC DISEASE OF THE NEWBORN ERYTHROBLASTOSIS FETALIS A. Blood incompatibility characterized by : 1. Hemolytic anemia 2. hyperbilirubinemia

B. Types : Rh incompatibility and ABO incompatibility * Rh incompatibility is more severe: does not usually affect the first child. C. Danger Signs : severe paleness at birth and pathologic jaundice ( appears in the first 24 )

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D. Diagnosis : COOMBS’ TEST * Direct Coombs’ test uses newborn blood mixed with Coombs’ reagent whereas indirect Coombs’ test uses maternal blood mixed with Rh (+) bllod. * Positive result : with RBC agglutination; mother has produced antibodies ( + isoimmunization ) * Negative result : without RBC agglutination ; mother has not produced antibodies yet (- isoimmunization ) E. Prevention : RhoGAM * RhoGAM is given to an RH (-) mother, with Rh (+) fetus. Abortus or ectopic pregnancy, with negative COOMBS’ Test, for every delivery of preterm or fullterm, and stillbirth infant, and for every amniocentesis * Action - destroys fetal antigens ( fetal RBC’s ) before mother produces antibodies.

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* Given intramuscularly in the first 72Hrs@ a dose of 300ug/kg F. Treatment : phototherapy and exchange transfusion PHOTOTHERAPY - decreases serum bilirubin Nursing Responsibilities : * Undress infant leaving diapers * Cover eyes with eye shield * Have light 16 inches away from infant * Turn gently every 2 hours * Give sterile water in between regular milk feedings * Monitor temperature, I & O, serum bilirubin, jaundice and side effects: rise in temperature & dehydration
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Retinal damage if eyes are not shielded, sterility if genitalia is not covered, respiratory distress if shield is not properly anchored. EXCHANGE TRANSFUSION - decreases serum bilirubin and maternal antibodies, and elevates hemoglobin Nursing Responsibilities : * Have appropriate blood ready : Rh (-) and type ( O ), fresh, at room temperature with hematocrit 50% + and pH 7.1 or as specified by the physician; heparinized. * Check VS before and q 15 min. during especially CR. * NPO 3-4 hours before or aspirate stomach to prevent vomiting and aspiration * Have resuscitative equipments ready * Place infant on his back with arms and legs restrained and under radiant warmer

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* Albumin (1gm/kg) maybe given 1-2 hours before to allow more binding sites for bilirubin making exchange more effective. * Note and record the time of exchange more effective. * Note and record the time of exchange; monitor exchanges - 10% calcium gluconate maybe given after each 100 ml. of blood exchanged to prevent hypocalcalcemia. * Protamine sulfate maybe given after the exchange transfusion to prevent bleeding. * After transfusion: leave umbilical catheter with IV plug for a repeat exchange or remove catheter, small pressure dressing applied and site observed for bleeding.
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V. RESPIRATORY DISTRESS SYNDROME/HYALINE MEMRANE DISEASE 1. Pulmonary condition common in preterms and characterized by hyaline membrane formed in the alveoli causing atelectasis. 2. Etiologic Factors : prematurity, hypothemia, acidosis hypoxia 3. Main pathologic finding : inadequate surfactant 4. Major Assessment Findings : * Expiratory grunting * Flaring * See-saw breathing xiphoid process * Tachypnea (more than 70/min.) * Chest retractions: and lower chest
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THE PREMATURE INFANT A. Also called LOW-BIRTH-WEIGHT infant B. Classification of newborn infants is now based on GESTATIONAL, AGE AND BIRTH WEIGHT * The better measure is gestational age C. Low-birth-weight is one weighing 2,500g (5 1/2 lbs) or less D. An infant born at term, 37 weeks or over, is a fullterm whereas an infant born before completed 37 weeks is a preterm E. A full-term infant maybe of low-birth-weight F. Prematurity is the leading cause of neonatal deaths because of 1. Respiratory distress syndrome - leading cause of deaths 2. Intracranial hemorrhage 47 3. Infection/sepsis 4. Congenital defects

THE PREMATURE INFANT AND POSTMATURE INFANTS THE PREMATURE INFANT A. Born at 36 weeks or less B. Low-birth-weight, poorly developed muscles and fatty tissues C. Weak, lethargic with poor muscle tone and reflexes POSTMATURE INFANTS A. Born at 43 weeks or over B. Low-birth-weight: with placental insufficient from aging process C. Wide awake, mentally alert

D. Skin : red, wrinkled, trans- D. Skin : greenish (meconiumparent to translucent with visible stained) leatherly desquamating, capillaries, less sub- cutaneous parchment-like, absent or slight fats. MORE LANUGO, LESS lanugo and vernix caseosa VERNIX CASEOSA
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THE PREMATURE INFANT E. ASSOCIATED PROBLEMS 1. Respiratory Distress Syndrome 2. Hypothemia 3. Hypoglycemia 4. Hyperbilirubinemia 5. Infection 6. Rickets and Anemia 7. Mental Retardation from Kemicterus 8. Retrolental Fibroplasia

POSTMATURE INFANTS E. Associated Problems 1. Meconium Aspiration 2. Hypothemia 3. Hypoglycemia 4. Polycythemia = hyperbilirubinemia 5. Infection

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GROWTH & DEVELOPMENT
• Definition • Rates of G & D • Factors Affecting G & D • Principles • Theories • DDST / MMDST

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FACTORS IN INFLUENCING GROWTH AND DEVELOPMENT HEREDITY * Sets the upper limits of growth ENVIRONMENT - prenatal, natal, postnatal * Most important especially post-natal’s HEALTH & NUTRITION SOCIOECONOMIC STATUS RACE and CULTURE:
Tay Sachs Dse Ashkenazi Jewish Black Americans Europeans Mediterrenean
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Sickle Cell Anemia Celiac Dse Thalassemia -

PRINCIPLES OF GROWTH AND DEVELOPMENT 1. Each child is INDIVIDUALLY UNIQUE. 2. Each child is COMPETENT, equipped with capacity for growth and development 3. Upper limits of growth and development that can not be surpassed exist. Heredity sets the upper limits. 4. Growth is a regular process occuring the in an ORDERLY, PREDICTABLE sequence and directions. DIRECTION AND GROWTH Cephalo-caudal: from head to toes. Proximo-distal: from the center to periphery General to specific / grows to refined; simple to complex
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5. Each individual grows AT HIS OWN RATE. 6. Different body parts grow at different rates. 7. There are critical period of growth and development 8. Development continous throughout life. * Although physical growth may cease development occurs throughout life with new skills and knowledge acquired if basic potential is present. 9. There is an inherent urge for an individual to grow and develop 10. Growth and development are influence by many factors.
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PHYCHOSOCIAL THEORY OF PERSONALITY DEVELOPMENT (ERIC ERIKSONIAN THEORY) The most commonly used by health professionals INFANCY : trust vs mistrust TODDLER : autonomy vs shame and doubt PRESCHOOLER : initiative vs guilt SCHOOLER : industry vs. inferiority ADOLESCENCE : identity vs. role diffusion YOUNG ADULT : intimacy vs isolation LATER ADULT : generativity vs self-absorption SENeSCENE : adapts to triumphs and disappointments with a certain ego integrity.
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PHYCHOSEXUAL THEORY OF PERSONALITY DEVELOPMENT (SIGMUND FREUD’S THEORY) INFANCY : ORAL phase stage of “ID” TODDLER : ANAL phase stage of the “Ego” PRESCHOOLER : PHALLIC stage ELECTRA COMPLEX - the daughter is attached to daddy and is jealous of mommy OEDIPAL COMPLEX - the son is attached to mommy and is jealous of daddy. Stage of “Superego” SCHOOLER : LATENCY stage stage of “Strict superego” ADOLESCENCE : genital stage
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DDST / MMDST
• Target age group • Pre-requisite • The first nsg. Procedure • 4 sectors: Personal – Social Fine Motor Language Gross Motor
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SIGNIFICANT PERSONS INFANCY : Mother, mother substitute Primary Caregiver TODDLER : Parents PRESCHOOLER : Members of the Basic Family SCHOOLER : Teacher Peers of SAME SEX: neighbors and classmates; Adults other than parents are “HERO - WORSHIPPED” ADOLESCENCE : Peers - greatest determined of his behavior Models of leadership Sexual models * Adults other than parents are IDOLIZED Partners of same and OPPOSITE SEX ( Establish close relationship with opposite sex )
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FEARS OF CHILDREN INFANCY : Stranger Anxiety * Starts at 6 months; peaks at 7-8 months TODDLER : -Separation Anxiety * Phases : protest, despair, denial PRESCHOOLER : -Castration fears; ghost, dark and SCHOOLER inanimate objects : Fear of Displacement or Replacement Fear of death, disease and body injury

ADOLESCENCE : Fear of loss of identity: acne, obesity, Homosexuality, body odor, Fear of Unknown, Fear of Disease, death
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LEADING ACCIDENT/CAUSES OF INJURIES IN CHILDREN INFANCY : aspiration (leading) Falls, suffocation, burns; poisoning - lead paint TODDLER : falls (leading) Burns, drowning; poisoning ( most common drug that poisons)
* The natural curiosity of the toddler leads him to accidents.

PRESCHOOLER : Motor accident (leading) burns, drowning SCHOOLER : Motor accident (leading) Sports accident Sports accidents, burns, drowning Drug, Alcohol, Suicide
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ADOLESCENCE : Motor vehicular

+ DEATH & DYING +
• INFANCY no concept of d/d • TODDLER temporary,reversible • PRE-SCHOOL temporary,punishment • SCHOOL AGE - final,permanent, or irreversible • ADOLESCENCE- universal
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PLAY - THE LANGUAGE OF THE CHILD TYPES OF PLAY INFANCY : SOLITARY play * He plays alone with his body or his toys TODDLER : PARALLEL play * He plays alone in the presence of the other children; no sharing PRESCHOOLER : ASSOCIATIVE / COOPERATIVE play * He plays with the others; can be with large group of boys and girls SCHOOLER : COMPETITIVE play * Plays with peers of same sex; games have rules where winning is desired.
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ADOLESCENCE : RECREATION/LEISURE activities * Can be with friends of same and opposite sex * Leisure activities are meant to get closer to friends of opposite sex. GAMES/TOYS FOR CHILDREN INFANCY - Rattles, cribmobiles (best) teethers, pacifiers, musical boxes, squeeze toys, large cuddly toys
“Peek-a-boo” game played at 10 months

TODDLER - push and pull toys (best) building blocks, ball play telephone ( age of language training ) play hammer, drum, ball pots and pans (outlets for aggressive behavior) dolls (security blanket),riding rocking horse.
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PRESCHOOLER - tricycle (can ride it at 3 years) play house, coloring books, clay cutting and pasting tools, superheroes and costumes dress-up dolls, ball SCHOOLER - bicycle (can ride it at 7 years) quiet games like reading, painting, radio, T.V., family computer, sport games, table games, like scrabble handicrafts (late schooler) ADOLESCENCE - parties, outings, picnics, movies, fantasy and daydreaming (normal) telephone/conversations, reading romance novels, sports games hobbies.

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CALORIE REQUIREMENTS OF CHILDREN Newborn Infant Toddler Preschooler Schooler Adolescence 400 (45-55 kcal/lb or 80-120cal/kg) 800 - 1200 1300 1700 2400 2200- 2700

Males have higher caloric requirements
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FEEDING PROBLEM IN CHILDREN I. Infancy Aspiration tendency Burping Colic - more common Weaning Supplementary food introduction Diarrhea Food allergies II. Toddlers Physiologic anorexia Iron-deficiency anemia
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III. Preschool Food likes and dislikes IV. School Food junks Zero-caloric foods (soft drinks) V. Adolescence Food fats Obesity False dieting Anorexia Nervosa Iron-deficiency anemia
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THE TODDLER I. Behavioral traits : A. Negativism ; “no” - “no” age * an attempt to show autonomy B. Temper tantrums ; crying and screaming when he does not get what he wants * an attempt to show autonomy and NOT a sign of poor discipline C. Ritualism ; doing thing over over and over again RESPECT HIS RITUALS; if hospitalized, adhere to his rituals to minimize separation anxiety D. Dawdling : slowness in accomplishing tasks * be patient ; allow to dawdle; do not give him tasks he cannot accomplish E. Egocentricity ; selfishness *normal 67

II. Developmental Tasks: Toilet Training, Dentition, Language Training, & Discipline I. Language Training Principles A. Teach one language at a time B. Talk to child in simple, clear words C. Do not baby talk D. Talk to child at eye level E. Provide a good model of speech F. Provide plenty of sensory stimulation II. Schedule 9-10 mo : says 2 words “ma” and “pa” 11-12 mo : says 4-5 words with gesture language 18 mo : has 20 words
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TOILET TRAINING A. Sphincter control - most important B. Ability to understand and walk to the bathroom C. Understands the act of elimination D. Can express need to eliminate E. Desire to please the mother

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DISCIPLINE IN CHILDREN I. FORMS OF DISCIPLINE Ignoring Diverting attention Time - out Corporal punishment Explaining, reasoning and reprimanding for other children Withdrawal of privileges II. PRINCIPLES OF GOOD DISCIPLINE A. Consistency
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B. Discipline a toddler RIGHT WAY after wrongdoing C. Explain the reason for discipline and allow child to explain first D. Disapprove of the behavior and NOT OF THE CHILD E. Withdraw privileges and NOT BASIC NEEDS. * You don’t send a child to bed without food for a wrongdoing F. Provide physical care after “ignoring” of temper tantrums G. Methods of discipline should be SAFE.

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BREASTFEEDING REFLEXES A. Milk secretion reflex - Prolactin reflex * The best way to stimulate mild secretion reflex is to TOTALLY EMPTY the breast with each feeding -always start with the breast that was used last. B. Milk ejection reflex - Letdown reflex * Licking and sucking of the nipples plus POSITIVE / RELAXED MATERNAL ATTITUDE stimulate the letdown reflex * Most important to success of breastfeeding
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“ESSENTIALS” OF BREASTFEEDING A. START * Right on the delivery table PRIMARILY to promote bonding. * 30 min. after birth in normal spontaneous delivery * 4 hours after cesarean section B. DURATION OF FEEDING * 5 min. per breast after establishment of feeding : - the first 10 min. for nourishment - the 2nd 10 min. is for sucking pleasure - total breastfeeding time: 20 min.
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MILK STOOLS
Breastfed 1st 24 hrs of life 2nd – 3rd day of life 3rd-5th day onwards Formula fed Blackish green Brownish green Pale yellow formed 74

Meconium = Transition al Golden stools
yellow loose

SUPPLEMENTARY FEEDING A. REQUISITES/CUES TO START SOLID FOODS 1. Feeding reflexes are fading 2. Can sit with support 3. A Nutritional requirement for iron to be met 4. Developed salivary glands and presence of intestinal enzymes needed for digestion B. SCHEDULE : Earliest (4 mos) Best time(6 mos) C. SIMPLE RULES TO FOLLOW * Introduce one food at a time * Small amount ( 1 tsp.) each time
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* Have an interval of 4-7days to 2 weeks between new foods to detect what food he is allergic to * Do not mix new food with formula * Do not force, bribe, plead nor threaten D. SEQUENCE OF INTRODUCING SOLIDS 1. Cereals 2. Vegetables (yellow, green, eggplant) 3. Fruits 4. Egg 5. meat 6. citrus fruits & ascorbic acid
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MARASMUS I. Synonyms : infantile stropy, inanition, athrepsia II. Marasmus is caloric malnutrition III. Causes * insufficient diet * improper feeding habits * emotional cause - disturbed mother-child relationship * metabolic disorders * congenital malformations IV. Signs * underweight, emaciated * “old-man’s” facies * all skin and bones look

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* pot belly (distended abdomen) * skin wrinkled and loose with no subcutaneous fat * muscle wasting * hypotonia, hunger * subnormal temperature, slow pulse * usually constipated or with “starvation diarrhea frequent, small tools with mucus V. Treatment : FOOD - Increase calories in the diet

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KWASHIORKOR I. This is PROTEIN MALNUTRITION II. Cause * insufficient protein intake * impaired protein absorption - diarrhea * abnormal losses - proteinuria in nephrosis * infection * burns III. Signs * lethargy, apathy, irritability * edema * loss of muscular tissue * with hair sign - flag sign : thinning, straight with alternate - dark light bands
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THE ILL AND HOSPITALIZED CHILD I. Factors Affecting Responses To Illness And Hospitalization A. Developmental stage in which child is in B. Nature of illness or injury; seriousness of illness or injury C. Level of anxiety of both child and parents D. Type of relationship that exists between parents & the child E. Past experiences with hospitalization, medical treatments and surgical procedures F. Support systems G. Sociocultural status, race culture and education II. Major Sources of Fears of Hospitalization A. Separation D. Immobility E. Body Injury B. Pain C. Loss of control F. Punishment and rejection
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Preparation Of Child For Admission 1. Under 2 years : explanations are ineffective : allow to take security blanket - the favorite toy or objects 2. 2-7 years : tell child ahead in days equal to years of age : c.g. 2 years old = tell the child 2 days ahead; 5 years = 5 days ahead 3. Over 7 years : determine what parents know 4. Adolescent : provide him with full explanations; answer questions completely and honestly.
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NEUROLOGIC AND COGNITIVE DYSFUNCTION

1. 2. 3. 4. 5. 6. 7. 8.

Hydrocephalus NTDs or Neural Tube Defects Epilepsy and Seizure disorder Cerebral Palsy Mental Retardation Down’s Syndrome Reye Syndrome Lead Poisoning (Plumbism)
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GASTROINTESTINAL DYSFUNCTION 1. 2. 3. 4. 5. 6. 7. 8. Cleft lip and palate Tracheoesophageal fistula GER /Chalasia Pyloric Stenosis Intussusception Celiac Disease Hirschsprung Disease Imperforate Anus

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CHALASIA/ GER A. Abnormal relaxation of the cardiac sphincter of the stomach resulting to self-limiting vomiting. B. Etiology : unknown; common in babies of tense mothers C. Signs and symptoms a. Self-limiting, non-projectile, non-bile vomiting b. Regurgitation after feeding c. Dehydration d. Increased hunger e. Weight loss D. Effect of frequent vomiting : METABOLIC ALKALOSIS
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E. Nursing Care : 1. Correct feeding techniques - Feed slowly in upright position - Burp/bubble frequently - Do not overfeed ( overfeeding is the most common cause of vomiting ) - Maintain upright for 30 minutes more after feeding - Put on right side after - Refeed with thicker formula ( more difficult to vomit ) - Allow play before feeding time to relax mother 2. Provide psychological support 1. Encourage verbalization of concerns and feelings about feeding/breastfeeding 3. Observe for signs dehydration.
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PYLORIC STENOSIS A. Congenital hyperthrophy / hyperplasia of the muscle of the pylorus causing obstruction of the pyloric sphincter B. Etiology : unknown C. Signs and Symptoms 1. Non-bile,projectile vomiting 2. Increasing hunger, dehydration in children 3. Visible gastric peritalsis 4. Olive shaped mass @ the RUQ 5. Abdominal distention 6. S/S of Fluid&electrolyte imbal as well as DHN

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b. As the child cries, gas in colon rises to reveal pouch in relation to anal membrane c. X-ray pictures taken ) no need for dye=danger of aspiration D. Treatment : Surgery a. Anoplasty for the simple type b. Pull-through operation with or without temporary colostomy E. Nursing Care 1. Provide preop care : - Npo - NGT to decompress stomach - Warmth supervision - VS monitoring - Prepare parents for surgical procedure & for temporary colostomy if necessary
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2. Provide postop care

a. Prevent infection

* meticulous skin care : provide perirectal care with anoplasty or pull through procedure observing strict aseptic techniques b. Administer and maintain IV fluids * Monitor rate of flow ( single most important in caring for a child with IV therapy ) * Maintain strict I & O * Check weight daily c. Provide oral feedings * With pull-through, begin oral feedings slowly when peristalsis returns * With colostomy, begin oral feedings slowly tools are passed d. Provide parental teaching : colostomy care if appropriate
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* empty pouch as needed * skin care

* change pouch as necessary

- clean peristomal area with mild soap and water, dry thoroughly, apply clean pouch - use skin barrier as ordered to protect skin from irritation HIRSCHSPRUNG’S DISEASE / CONGENITAL MEGACOLON A. A mechanical obstruction of the bowels due to the absence of autonomic parasympathetic nerve ganglion cells in the distal bowel = inadequate motility B. Etiology : a. Real cause is Unknown
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C. Signs and Symptoms 1. Newborn - No meconium stools in 24-48 hours - Bile-stained vomitus - Abdominal distention - Abdominal pain : - Feeding difficulties irritability, crying 2. Infants - Chronic constipation - Hallmark of megacolon - Bile-stained vomiting - Explosive diarrhea - Failure to thrive / - Abdominal distention malnutrition 3. Older Children - Chronic constipation - hallmark - Ribbon-like stools like pellets - Palpable fecal masses - Fecal odor of the breath

- Abdominal distention - Visible peristalsis - Anemia - Malnutrition
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D. Diagnosis Barium Enema Abdominal X-ray Rectal biopsy : confirms megacolon E. Treatment Surgery a. Bowel resection with temporary colostomy b. Abdomino-perineal pull-through by about 1 year F. Nursing Care a. NPO - pacifier (newborn) b. NGT c. I & O
d. Provide emotional need-touch, pacifier, consistent parental care f. Administer : - low resudue, high-protein, high calorie diet if appropriate (childhood) - parental nutrition as ordered g. Bowel cleansing - Liquid diet - Stool softeners as ordered -digital removal - daily isotonic saline enemas/colonic irrigation
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c.) Keep incision site clean and dry d.) Assess for correct colostomy functioning/provide colostomy care : emphasize meticulous skin care e.) Provide pain relief - analgesics PRN f.) Monitor for signs of complications + Skin infection + Respiratory infection; coughing; deep-breathing, turning every two hours g.) Maintain NG tube to low suction; maintain patency h.) Provide psychological support + stroke, hold, cuddle infant + explain to parents diagnostic and treatment procedure
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Intussusception
Data Base • A. Telescoping of one portion of the intestine into another; occurs most frequently at the ileocecal valve • B. Males affected two times more frequently than females • C. Usually occurs between 3 to 12 months of age
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Intussusception
E. Clinical findings • 1. Healthy, well-nourished infant or child who wakes up with severe paroxysmal abdominal pain, evidenced by kicking and drawing legs up to the abdomen • 2. One or two normal stools, then bloody mucus stool ("currant jelly-like“ stool) • 3. Palpation of sausage-shaped mass • 4. Other signs of intestinal obstruction usually present
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Intussusception
F. Therapeutic interventions • 1. Medical reduction by hydrostatic pressure (barium enema) • 2. Surgical reduction; sometimes with intestinal resection

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Intussusception
Nursing Care of Infants and Children with Intussusception A. Assessment • 1. Sudden, acute, intermittent abdominal pain • 2. Vomiting • 3. Red "currant jelly-like" stools • 4. Tender, distended abdomen
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Intussusception
B. Analysis/Nursing Diagnoses • 1. Pain related to invaginating bowel • 2. Altered family processes related to having a child with life-threatening illness • 3. Altered nutrition: less than body requirements related to: • 4. Risk for fluid volume deficit related to: • 5. Refer to General Nursing Diagnoses for the Family of a Child with Special Needs and General Nursing Diagnoses for Infants with Health Problems
– a. Vomiting – b. Diarrhea – a. Decreased intake – b. Increased peristalsis

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IMPERFORATE ANUS A. Congenital anorectal malformation where the rectum ends in a blind pouch or with a fistula connecting to the vagina (rectovaginal fistula) or to the urethra (rectourethral fistula) B. Signs and Symptoms a. No anal opening on inspection b. Non-insertion of the rectal thermometer c. Progressive abdominal destention d. Difficult defecation, inability to defecate e. No meconium stool in the first 24 f. Meconium from inappropriate opening ( fistula ) C. Diagnosis : Wangesteen - Rice Method a. infant held upside down
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Respiratory Tract Infections
D. Classification • Tonsillitis • Acute laryngotracheobronchitis • Cystic Fibrosis

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Respiratory Tract Infections
Nursing Care of Infants and Children with Respiratory Tract Infections A. Assessment • 1. Respirations: rate, depth, ease, and rhythm • 2. Color: cyanosis • 3. Lungs: adventitious sounds • 4. Nasal discharge • 5. Presence of sputum, cough • 6. Occurrence of laryngeal spasms

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Respiratory Tract Infections
B. Analysis/Nursing Diagnoses • 1. Ineffective airway clearance related to: a. Mechanical obstruction b. Inflammation c. Increased secretions d. Pain
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Respiratory Tract Infections
• 2. Ineffective breathing pattern related to: a. Inflammatory process b. Pain • 3. Risk for injury related to presence of infective organisms • 4. Pain related to: a. Inflammatory process b. Excessive coughing

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Respiratory Tract Infections
C. Planning/Implementation • 1. Increase fluid intake a. Prevents dehydration from fever and perspiration b. Loosens thickened secretions • 2. Increase humidity and coolness a. Liquifies secretions b. Decreases the febrile state and inflammation of the mucous membrane • c. Causes vasoconstriction and bronchiolar dilation
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Respiratory Tract Infections
• 3. Promote nasal and pulmonary drainage a. Clean the nares with a bulb syringe b. Suction the oronasal pharynx c. Perform postural drainage, clapping, and vibrating • 4. Provide rest by decreasing stimulation • 5. Increase oxygen • 6. Never use tongue blade to visualize posterior pharynx in children with epiglottitis • 7. Keep a tracheostomy set at bedside; if a tracheostomy is necessary
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SKELETAL MALFORMATIONS

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Clubfoot
Data Base • A. Foot has been twisted out of normal shape or position • B. Most common type: talipes equinovarus: foot is fixed in plantar flexion (downward) and deviated medially (inward) • C. Clinical findings
– 1. Deformity is readily apparent at birth – 2. Deformity may be rigid or flexible
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Clubfoot
D. Therapeutic interventions • 1. Treatment is most successful when started early in infancy because delay causes muscles and bones of legs to develop abnormally, with shortening of tendons • 2. Nonsurgical treatment: gentle, repeated manipulation of the foot with casting; done every few days for 1 to 2 weeks then at 1- to 2-week intervals • 3. Surgical treatment: done if nonsurgical treatment not effective
– a. Tight ligaments released – b. Tendons lengthened or transplanted
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Clubfoot
Nursing Care of Infants and Children with Clubfoot A. Assessment • 1. Parental understanding of treatment regimen • 2. Skin and circulation of affected limb B. Analysis/Nursing Diagnoses • 1. Risk for injury related to knowledge deficit and use of corrective devices • 2. Risk for impaired skin integrity related to use of corrective devices • 3. Refer to General Nursing Diagnoses for the Family of a Child with Special Needs and General Nursing Diagnoses for Infants with Health Problems

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Clubfoot
C. Planning/Implementation • 1. Observe toes for signs of circulatory impairment; make sure toes are visible at the end of the cast • 2. Watch for signs of weakness and wear of the cast, especially if the child is allowed to walk on it • 3. Teach parents all the necessary care and emphasize the need for follow-up, which may be prolonged • 4. For other areas of cast care, see Congenital Hip Dysplasia • 5. See Meeting the Needs of the Family of an Infant or Child with Special Needs

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Congenital Hip Dysplasia
Data Base • A. Imperfect development of hip can affect femoral head, acetabulum, or both • B. Head of the femur does not lie deep enough within the acetabulum and slips out on movement • C. Occurs in females seven times more often than in males

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Congenital Hip Dysplasia
D. Classification • 1. Acetabular dysplasia
– a. Mildest form – b. Femoral head remains in acetabulum

• 2. Subluxation
– a. Most common form – b. Femoral head partially displaced

• 3. Dislocation
– a. Femoral head not in contact with acetabulum – b. Displaced posteriorly and superiorly
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Congenital Hip Dysplasia
E. Clinical findings • 1. Limitation in abduction of leg on the affected side • 2. Asymmetry of gluteal, popliteal, and thigh folds • 3. Audible click when abducting and externally rotating the hip on the affected side: Ortolani's sign • 4. Apparent shortening of the femur: Galeazzi's sign • 5. Waddling gait and lordosis when the child begins to walk
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Congenital Hip Dysplasia
F. Therapeutic interventions • 1. Directed toward enlarging and deepening the acetabulum by placing the head of the femur within the acetabulum and applying constant pressure • 2. Proper positioning: legs slightly flexed and abducted a. Pavlik harness b. Frejka pillow: a pillow splint that maintains abduction of the legs c. Bryant's traction d. Spica cast: from the waist to below the knees e. Brace • 3. Surgical intervention such as open reduction with casting
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Congenital Hip Dysplasia
B. Analysis/Nursing Diagnoses • 1. Altered family processes related to having a child with a physical defect • 2. Altered growth and development related to immobilization • 3. Impaired physical mobility related to immobilizing device • 4. Risk for injury related to: • 5. Refer to General Nursing Diagnoses for the Family of a Child with Special Needs and General Nursing Diagnoses for Infants with Health Problems
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– a. Corrective device – b. Immobility

Congenital Hip Dysplasia
C. Planning/Implementation • 1. Respiratory problems: hypostatic pneumonia
– a. Change position frequently from back to stomach; raise head of mattress rather than head to prevent flexion of neck – b. Teach parents postural drainage and exercises for child, such as blowing bubbles to increase lung expansion – c. Encourage parents to seek immediate medical care if the child develops congestion or cough

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Congenital Hip Dysplasia
2. Infection and excoriation of skin • a. Observe for circulation to toes, pedal pulses, and blanching • b. Do not let the child put small toys or food inside cast • c. Use gauze strips inside cast as a scratcher • d. Alert parents to signs of infection, such as odor • e. Protect cast edges with adhesive tape or waterproof material, especially around perineum • f. Use diapers and plastic lining to minimize soiling of cast by feces and urine
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Congenital Hip Dysplasia
3. Constipation from immobility • a. Teach parents to observe for straining on defecation and constipation • b. Increase fluids and fiber to prevent constipation 4. Nutrition • a. Provide small, frequent meals because of inflexibility of cast around waist (a window may be made over the abdominal area to allow for expansion with meals) • b. Adjust calorie intake, because less energy expenditure can lead to obesity
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SPECIAL TOPICS
• SIDS • AOI • OTITIS MEDIA • DOWN SYNDROME • MENTAL RETARDATION • CHILD ABUSE

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Sudden Infant Death Syndrome (SIDS; Infant Crib Death) Data Base • A. A definite syndrome with unknown cause • B. The number one cause of death in infants between 1 week and 1 year of age; incidence of 1.4 in every 1000 live births • C. Peak age of occurrence: healthy infants 2 to 4 months of age - 90% occur by 6 months
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Sudden Infant Death Syndrome (SIDS; Infant Crib Death)

D. Higher incidence in: • 1. Males • 2. Premature infants • 3. Multiple births • 4. Newborns with low Apgar scores • 5. Infants with CNS disturbances • 6. Infants with respiratory disorders such as bronchopulmonary dysplasia • 7. Infants sleeping on abdomen • 8. Infants using soft, moldable pillows and/or mattresses
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Sudden Infant Death Syndrome (SIDS; Infant Crib Death)

E. Feeding habits not significant; breastfeeding does not prevent SIDS F. May be a greater incidence in siblings of children with SIDS G. Pulmonary edema and intrathoracic hemorrhages found on autopsy H. Clinical findings • 1. Sudden, unexplained death of an infant under 1 year of age • 2. Frothy, blood-tinged fluid fills mouth and nose I. • • • Therapeutic interventions 1. Avoid implying wrongdoing, abuse, or neglect 2. Support parents 3. Be nonjudgmental about parents' attempts at resuscitation

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Sudden Infant Death Syndrome (SIDS; Infant Crib Death) Nursing Care of Families of Infants with Sudden Infant Death Syndrome A. Assessment • 1. Parental knowledge of SIDS • 2. Parental support system

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Sudden Infant Death Syndrome (SIDS; Infant Crib Death)

B. Analysis/Nursing Diagnoses • 1. Family coping: potential for growth related to successfully coping with loss • 2. Ineffective family coping: disabling related to situational crisis • 3. Altered family processes related to disruption of life-style • 4. Dysfunctional grieving related to loss of child • 5. Risk for altered parenting of other children related to grief
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Sudden Infant Death Syndrome (SIDS; Infant Crib Death)

C. Planning/Implementation • 1. Know signs of SIDS to distinguish it from child neglect or abuse; do or say nothing that instills guilt in the parents • 2. Reassure the parents that they could not have prevented the death or predicted its occurrence • 3. Reinforce that an autopsy should be done on every child to confirm diagnosis • 4. Visit the parents at home to discuss the cause of death and help them with their guilt and grief • 5. Refer the parents to a national SIDS parent group

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Sudden Infant Death Syndrome (SIDS; Infant Crib Death) D. Evaluation/Outcomes • 1. Family exhibits positive coping behavior • 2. Family members avail themselves of support services • 3. Family exhibits positive bereavement behavior • 4. Parents maintain supportive relationship with other children
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Apnea of Infancy (AOI)
Data Base • A. Apnea of 15 seconds or less is normal at any age • B. Pathologic apnea lasts at least 20 seconds • C. May be symptomatic of sepsis, seizures, upper airway abnormalities, gastroesophageal reflux, hypoglycemia, or impaired regulation of sleep or feeding
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Apnea of Infancy (AOI)
• D. No cause identified in 50% of cases • E. Less than 7% of SIDS cases • F. Clinical findings
– 1. Usually presents as an apparent life-threatening event – 2. Is associated with cyanosis, marked pallor, hypotonia, or bradycardia
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Apnea of Infancy (AOI)
G. Therapeutic interventions • 1. Continuous home monitoring of cardiorespiratory rhythm • 2. Use of respiratory stimulant medication such as theophylline • 3. Treatment discontinued when child has gone 2 to 3 months without a significant number of alarms or with apneic episodes that did not require intervention

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Apnea of Infancy (AOI)
Nursing Care of Infants with Apnea A. Assessment • 1. Parental fears and concerns • 2. Knowledge about cardiopulmonary resuscitation (CPR) and home monitoring • 3. Description of apparent lifethreatening event

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Apnea of Infancy (AOI)
B. Analysis/Nursing Diagnoses • 1. Ineffective breathing pattern related to periods of apnea • 2. Caregiver role strain related to constant monitoring • 3. Ineffective family coping: compromised; related to prolonged need for monitoring that exhausts supportive capacity of parents • 4. Altered family processes related to constant monitoring • 5. Fear related to possible loss of child • 6. Anticipatory grieving related to loss of perfect child • 7. Knowledge deficit related to home monitoring, CPR

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Apnea of Infancy (AOI)
C. Planning/Implementation • 1. Monitor type and quality of apneic episodes • 2. Teach parents about home monitoring • 3. Teach parents how to stimulate/resuscitate infant • 4. Assist parents to identify support system
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Apnea of Infancy (AOI)
D. Evaluation/Outcomes • 1. Parents can demonstrate proper use of equipment for home monitoring • 2. Parents demonstrate CPR • 3. Parents verbalize fears • 4. Family identifies support system

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Respiratory Tract Infections
Data Base • A. Frequent cause of morbidity • B. Young children have four to five infections per year • C. Children between 6 months and 3 years react more severely

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Otitis Media
Data Base • A. Acute infection of the middle ear; causative organism usually Streptococcus pneumoniae, Haemophilus influenzae, or Staphylococcus aureus • B. One of most common diseases of early childhood • C. Highest incidence between ages 6 months to 2 years
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Otitis Media
D. Classification • 1. Otitis media: inflammation of middle ear without reference to cause or pathogenesis • 2. Acute otitis media: rapid, short onset of signs and symptoms lasting about 3 weeks • 3. Otitis media with effusion: middle ear inflammation with fluid present • 4. Subacute otitis media: lasts more than 3 weeks • 5. Chronic otitis media with effusion: lasts more than 3 months

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Otitis Media
E. Clinical findings • 1. Acute otitis media a. Pain: infant frets and rubs ear or rolls head from side to side b. Drum bulging, red, may rupture; no light reflex • 2. Otitis media with effusion a. No pain or fever, but "fullness" in the ear b. Drum appears gray, bulging c. Possible loss of hearing from scarring of the drum
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Otitis Media
F. Therapeutic interventions • 1. Antibiotic therapy • 2. Surgery including myringotomy or insertion of tympanotomy tubes

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Otitis Media
Nursing Care of Infants and Children with Otitis Media A. Assessment • 1. Pain • 2. Signs and symptoms of infection • 3. Allergies
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Otitis Media
B. Analysis/Nursing Diagnoses • 1. Altered family processes related to having child with an infection • 2. Risk for infection related to: a. Inadequate treatment b. Infectious organism • 3. Risk for injury related to: a. Inadequate treatment b. Infectious organism • 4. Pain related to pressure caused by inflammatory process
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Otitis Media
C. Planning/Implementation • 1. Teach parents proper administration of antibiotics; stress importance of full course of therapy • 2. Teach parent proper instillation of ear drops a. If the child is under 3 years of age, pull the auricle down and back b. For an older child, pull the auricle up and back • 3. Minimize recurrence a. Eliminate environmental allergens b. Feed in upright position • 4. Encourage medical follow-up to check for complications such as chronic hearing loss, 140 mastoiditis, or possible meningitis

Otitis Media
D. Evaluation/Outcomes • 1. Child sleeps and rests without signs of discomfort • 2. Child remains free from infection • 3. Family verbalizes importance of antibiotic therapy

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