IMMEDIATE CARE OF NEWBORN: DELIVERY ROOM

ESTABLISH OF RESPIRATION
With head extension, clear the mouth and nose to prevent meconium aspiration.
After expulsion:
place on SLIGHT TRENDELENBURG position (10 – 15 degrees angle) to drain secretions.
SUCTION briefly, gentle 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.
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.

Check for patency of the nostrils by occluding one nostril at a time.

CHOANAL ATRESIA is a congenital anomaly of the nose where the posterior nares are not patent.
Danger signs: persistent cry and difficult breathing relieved by crying and intensified by feeding

2. KEEP WARM
DRY and WRAP newborn to prevent heat loss.
The newborn’s high temperature at birth – 37.5 C – drops quickly at birth because of heat loss
c. NO SHIVERING in the newborn
d. initial temperature of the newborn is checked per rectum to rule out an imperforate anus.

3. APGAR SCORING
Done twice – 1 and 5 minutes after birth
First APGAR SCORE is to detect the cardiorespiratory-nervous functioning of the newborn
Second APGAR SCORE: used for planning nursing care

APGAR SCORING

ADAPTATIONS 0 1 2

Heart Rate Absent Below 100 Above 100

Respiratory Absent Weak cry Lusty cry
Effort respiration
Muscle Tone Limp, flaccid Some flexion Acute flexion
Reflex irritability No response Grimace Sneezing, crying
Color Blue, pallor Acrocyanosis Pink

Interpretation:

0 – 3: POOR: severely depressed

- needs resuscitation
4 – 6:FAIR: moderately depressed; needs suctioning and oxygenation
7 – 10:GOOD; needs only admission care

Heart rate is the most important ARGAR SCORE while color is least important
A total score of 0 means no heart rate
A score of 9 means acrocyanosis
4. PROPER IDENTIFICATION
a. Bracelets and foot tags can be used with -
maternal name date time of delivery hospital number/room number sex of the bab
b. FOOTPRINTING – best way to identify
c. Identification is done BEFORE THE BABY IS SEPARATED FROM THE MOTHER
5. CHECK FOR -
Gestational age
Congenital defects
Birth injuries
Gross anomalies

IMMEDIATE CARE: NURSERY

1. Continue with measures to keep newborn warm.

Use droplights during admission care

2. CREDE’S PROPHYLAXIS or eye care

Done to prevent OPTHALMIA NEONATORUM or gonorrheal conjunctivitis
Mandatory – done to all newborns
Drugs used – 1% Silver Nitrate 1 – 2 gtts into each conjunctival sac and Terramycin opthalmic 1 cm from
INNER TO OUTER CANTHUS
CREDE’S PROPHYLAXIS is delayed for 1 – 2 hours in order not to interfere with bonding process

EYE-TO-EYE CONTACT is prerequisite to bonding.

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
SOAP AND WATER bath: given to normal full term

4. CORD DRESSING
Strict asepsis prevents TETANUS NEONATORUM
CHECK for 1 umbilical vein and 2 umbilical arteries
Report incomplete vessels
c. Check for 1 OMPHALOCELE – protrusion of abdominal viscera into weakened portion of the umbilicus
because of absence of normal abdominal wall in the region of the umbilicus
In the first 24 hours, check the cord for bleeding called OMPHALANGHIA

5. VITAMIN K INJECTION
Mandatory, given to all newborns to prevent bleeding.
Reasons for bleeding tendency: gastrointestinal tract for newborns INITIALLY STERILE no bacteria to
synthesize vitamin K decrease clotting factor bleeding tendency
Site for intramuscular injections in newborns:
Thigh muscles – VASTUS LATERALIS (best site)
RECTUS FEMORIS (alternate site)

6. Weighing and taking of Other Anthropometric Measurements

Weight: 3000g – 3,400g (7 – 7.5 lbs.) – International standard

: 6 – 6.5 lbs. – average birth weight of a Filipino newborn
> lower limit normal : 2,500g
Height : 19 – 21 inches (ave. 50 cm)
HC : 33 – 35 cm/13 – 14 inches
CC : 31 – 33 cm/12 – 13 inches
AC : 31 – 33 cm/12 – 13 inches

7. Vital signs
Checking when infants is asleep/quiet
Gentle, minimal handling and watchful eyes

PHYSIOLOGIC CHANGES IN THE NEWBORN

1. Weight Loss : 7 – 10 days

5% to 10% of BW (6 – 10 oz)
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
2. Jaundice : 2 – 7 days for full terms and 3 – 10 days for preterm
Because of liver immaturity and fetal increase in RBC’s (polycythemia)
Expose to morning sunlight
3. Fever : 2 – 4 days
Primarily because of dehydration
4. Anemia : 4 – 6 months

NEWBORN SKIN MARKS

1. LANUGO - fine, downy hair, more in preterms

2. VERNIX CASEOSA - whitist, cheesy, odorless usually on folds of the skin; more in full term
protects skin and prevents heat loss
3. MILIA - white, pinpoint papules on the nose/chin/cheecks
disappears as early as 2 weeks or 3 – 4 weeks
4. MONGOLIAN SPOT - grayish blue patch at the lower back from accumulation of the pigment cells
melanocytes
disappears by school age
5. NEVI(STORK BITES) - red spots found at the back of the neck and above eyelids
disappears spontaneously before 1 year
6. ERYTHEMIA TOXICUM NEONATORUM - newborn rash
pink papular rash appearing on the body within 24 – 48 hours after birth; harmless
disappears within a few days

SIGNIFICANT NEWBORN REFLEXES

A. FEEDING REFLEXES
Rooting – if the cheeck or the corner of the mouth is touched, hr turns to that side; for food location
Diasappears at 3 – 4 months when he can follow moving objects
Last period of disappearance : 7 months
2. Sucking – anything that touches the lips is sucked; present even before birth
disappears at 6 months
3. Extrusion or spitting up – anything that touches the anterior tongue is extruded, protects infant from
swallowing inedible substances
- disappears at 4 – 6 months
Swallowing – swallows anything that touches the posterior tongue

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

C. MORO or STARTLE – embracing motion of the arms in response to loud noise, jarring of the crib and
falling sensation
Best index of CNS integrity; absence indicates BRAIN DAMAGE
Disappears by the end of 4th or 5th month

D. TONIC NECK REFLEX/FENCING – when head is turned to one side, the arm and leg on that side extend
and opposite arm and leg flex
disappears at 3 – 4 months

E. BABINSKI – fanning or hyperextension of the toes when the sole is stroked from the heel upwards

F. DARWIN – dancing reflex; few quick alternating steps when the newborn is held upright and his feet
touch a hard surface
Disappears at 4 weeks

G. 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
H. 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

SKIN DISORDERS IN INFANT

1. DIAPER DERMATITIS
1. Diaper rash/contact dermatitis : inflammation of the skin caused by irritants moisture, heat and
chemical substances
Erythemia in the genital signals the beginning of the rash
Progresses from macules and papules to eroded, moist or crushed lesions
2. Ammonia dermatitis: diffuse erythema in the perianal and gluteal areas caused by breakdown of urea
in the urine to ammonia by bacteria in the feces.
Progresses to shiny, red and excoriated skin.
3. INTERTRIGO: maceration of any two skin surfaces in close opposition/chafing of the skin.
Common in obese infants in gluteal and neck folds due to poor ventilation, high humidity and poor
hygiene.
4. Nursing responsibilities: provide health teachings
Meticulous skin/care hygiene particularly along skin creases
Keeping areas involved well ventilated and free of irritating substances, use loose diaper/clothing
Quickly changing diapers after soiling after washing the area with water or bland soap and water if
needed. Pat dry areas with soft cloth or towel; expose to air for few minutes before dipering
II. MILARIA/HEAT RASH/PRICKLY HEAT
A. Fine; erythematous papular rash over shoulders neck and skin folds due to warm weather or
overdressing.
B. Intervention – frequent bathing with cool plain water avoiding soap; light dressing. Keeping
environment cool, application of bland dusting powder and calamine lotion
III. SEBORRHREA DERMATITIS
A. Common recurrent skin disease called CRADLE CAP in neonates, dermatitis of the scalp in infants and
dandruff in other children.
Cause – accumulation of sweat, sebum and dirt causing flat, adherent and greasy scales with pruritus,
crushing usually indicates a secondary infection.
C. Prevention – Keeping involved areas clean, dry and cool and free of irritants.
Treatment – mineral oil, ointment or lotion to soften the scales before shampooing.
IV. IMPETIGO
Bacteria infection of the superficial layers of the skin invaded by streptococci, staphylococci, or
pneumococci, commonly found on the face
Causes: poor skin care, overcrowding, malnutrition
Characteristics: macules, papules, pustules, crusts
Treatment: meticulous hygiene of skin, hexachlorophene scrubbing of lesions to prevent nephritis and
rheumatic fever.
V. BOILS/FURUNCLES
Bacterial infection of hair follicles common face, neck, axila, buttocks
Progresses from papules to pustules than hard tender, hot nodless which form a pus “point”.
Treatment – personal hygiene, no squeezing, topical neomycin cream and diet high in protein, low in
fats and carbohydrates.
VI. ORAL MONILIASIS
Also called oral thrush
Fungi infection of the mouth
Cause – Candida Albicans
Seen and white patches on the tongue
Prevented by oral hygiene, care of maternal nipples, proper sterilization of feeding bottles/nipples
Treatment – Mycostatin or Nystatin oral paint

SELECTED NEWBORN CONDITIONS

I. HYPOGLYCEMIA – low blood sugar

less than 30 mg % in the first 72 of the full term and less than 45 mg % after 72
less than 20 mg % in the preterm
A. Etiologic factors – prematurity, postmaturity, SGA, birth injuries, congenital defects, low APGAR,
inadequate intake, stresses (cold stress, CS)

B. Danger Signs – jitteriness, apnea, tachypnea, irregular breathing plus signs of increased intracranial
pressure:
tense, bulging fontanel
lethargy
high-pitch shrill cry
projectile vomiting
absent MORO reflex
tremors/convulsion

C. Nursing implementation
Give oral glucose
Administer 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

II. HYPOTHERMIA – low body temperature less than 36.5 C

A. Etiologic Factor – prematurity, postmaturity, SGA, malnourished newborn

absence of adequate brown fat to burn

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
Oxygenate PRN
Monitor temperature per axila

III. HYPERBILIRUBINEMIA – Increased serum bilirubin more than 12 – 13 mg %

- Normal serum bilirubin in newborn: 2 – 6 mg %
A. Etiologic factors – Rh and ABO incompatibility, infection, prematurity, drugs, breastfeeding (because
of pregnanedial), polycythemia

B. Assessment/Findings -
pathologic jaundice (present in first 24)
dark, concentrated urine
lethargy, poor feeding
pallor
signs of increased urine
C. Treatment: phototherapy and exchange transfusion
D. Nursing responsibility: Detect and report early pathologic jaundice

HEMOLYTIC DISEASE OF THE NEWBORN

ERYTHROBLASTOSIS FETALIS

A. Blood incompatibility characterized by:

hemolytic anemia
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)
Newborn is not jaundiced at birth because there is placental excretion of excess bilirubin.

D. Diagnosis: COOMBS TEST

- Direct Coombs test uses newborn blood mix with Coombs reagent whereas indirect Coombs test uses
maternal blood mixed with Rh (+) blood.
Positive result: with RBC agglutination, mother has produced antibodies (+ isoimmunization)
Negative result: without RBC agglutination; mother has not produced antibodies yet (- isoimmunizatiion)
E. Prevention: RhoGAM
RhoGAM is given to an Rh (-) mother, with Rh (+) fetus, abortus or ectopic pregnancy, with (_) COOMBS
test.
Action – destroys fetal antigens (fetal RBC’s) before mother produces antibodies.
Given intramuscularly in the first 72 after delivery of a fullterm, abortus or ectopic pregnancy.

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,
priapism (painful penile rection), bronze skin, dark and concentrated urine, loose and green stools.
Retinal damage if eyes are not shielded, sterility if genitalia is not covered .

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 after 15 minutes during specially CR.
NPO 3 – 4 hours before or aspirate stomach to prevent vomiting and aspiration
Have resuscitation equipment ready
Place infant on his back with arms and legs restrained and under radiant warmer
Albumin (1 gm/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 time of exchange, monitor exchanges – 10 % calcium gluconate maybe given after each
100 ml of blood exchanged to prevent hypocalcemia.
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.

V. RESPIRATORY DISTRESS SYNDROME/HYALINE MEMBRANE DISEASE

Pulmonary condition common in preterms and characterized by hyaline membrane formed in the alveoli
causing atelectasis.
Etiologic Factors: prematurity, hypothermia, acidosis, hypoxia.
Main pathologic finding: inadequate surfactant
Major Assessment Findings:
*Expiratory grunting -Tachypnea (more than72 minutes)
* Flaring
*See-saw breathing - Chest retractions and Lower chest

THE PREMATURE AND POSTMATURE INFANTS

PREMATURE INFANT POSTMATURE INFANT

a. Born at 36 weeks or less a. Born at 43 weeks or over

b. Low birth-weight, poorly b. low birth-weight with placental
developed muscles and insufficiency from aging process
fatty tissues
c. Weak, lethargic, with poor c. wide awake, mentally alert
muscle tone and reflexes
d. Skin: red, wrinkled, transparent d. Skin: greenish (meconium
to translucent with visible stained, lethery desquamating
capillaries, less subcutaneous parchment-like, absent or slight
fats, MORE LANUGO, LESS lanugo and vernix caseosa
VERNIX CASEOSA
PREMATURE INFANT POSTMATURE INFANT

e. Associated Problems e. Associated Problems

1. Respiratory Distress Syndrome 1. Meconium aspiration

2. Hypothermia 2. Hypothermia
3. Hypoglycemia 3. Hypoglycemia
4. Hyperbilirubinemia 4. Polycythemia = Hyperbilirubinemia
5. Infection 5. Infection
6. Rickets and anemia
7. Mental retardation from kenicterus
8. Retrolental Fibroplasia

NURSING RESPONSIBILITIES FOR LOW BIRTH-WEIGHT INFANTS

A. Establish and maintain airway.

Resuscitation mostly necessary at birth because of poor APGAR.
Suction using a sterile catheter and brief suctioning LESS THAN 5 SECONDS per suctioning time as
necessary.
Safe use of oxygen to prevent oxygen toxicity.

B. Keep warm inside ISOLETTE/INCUBATOR = the best place to keep him warm
Monitor temperature per axilla
Maintain heat and humidity

C. Prevent infection
Hand washing is the BEST way to prevent and its spread. Masking is the LEAST.
(NOSOCOMIAL NURSERY INFECTIONS are hospital acquired infection and the MOST COMMON CAUSE is
staphylococcus aureus).

D. Monitor respiration, color, VS, I & O and weight

E. Maintain hydration and nutrition to promote rapid growth.
Usually led by NGT or GAVAGE because sucking and swallowing are poor; adhere to safety rules in
gavage feeding

F. Gentle and minimal handling

G. Support parents; encourage verbalization, allow parenteral care as much as possible AFTER
APPROPRIATE TEACHING.

H. PREVENT maturity or low birth-weight conditions

early and regular PRENATAL CARE is the best prevention to complications of pregnancy, labor and
puerperium are also the best way to prevent high-risk newborn.

TERMINOLOGY

GROWTH - quantitative increased in size of the whole of any of its part, measurable
WEIGHT - the best measure of growth

DEVELOPMENT - quantitative increase in skills or capacity of functioning.

MATURATION - development of traits carried through genes

GENES - basic element in the transmission of hereditary traits

GENETICS - study of heredity

EUGENICS - study of ways to improve hereditary traits

EUTHENICS - study of ways to improve health

CRITICAL PERIOD - specific time period during which certain environmental stimuli has greatest effect on
a child’s development

RATES OF DEVELOPMENT

INFANCY AND ADOLESCENCE – with fast growth periods

1.Infancy is the most rapid growth
Birth weight doubles at six months
Birth weight triples at twelve months

Toddler through school age period – slow growth period

- toddler stage is characterized by “PLATEAU” stage.

TODDLER AND PRESCHOOL PERIODS trunk grows faster than other tissues

SCHOOLER – limbs grow more rapidly

PUBERTY/ADOLESCENCE – characterized by “SPURTS” of growth both in height and in weight

trunk grows faster than other tissues
pre-adolescence girls grow faster than boys

FACTORS INFLUENCING GROWTH AND DEVELOPMENT

HEREDITY – sets the upper limits of growth

ENVIRONMENT – pre-natal, natal, postnatal
HEALTH
NUTRITION
RACE and CULTURE
SOCIOECONOMIC STATUS

PRINCIPLES OF GROWTH AND DEVELOPMENT

Each child is INDIVIDUALLY UNIQUE.

Each child is COMPETENT, equipped with capacity for growth and development.
Upper limits of growth and development that cannot be surpassed exist. Heredity sets the upper limits.
Growth is a regular process occurring in an ORDERLY, PREDICTABLE sequence and directions.

DIRECTION OF GROWTH

Cephalo-caudal: from head to toe

Proximo-distal: from the center to periphery
General to specific/grows to refined; simple to complex

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 continuous throughout life.
Although physical growth may cease development occurs throughout life with new skills and knowledge
acquired if basic potential is present.
10. There is an inherent urge for an individual to grow and develop.
Growth and development are influence by many factors.

PSYCHOSOCIAL THEORY OF PERSONALITY DEVELOPMENT (ERIC ERIKSONIAN THEORY)

The most common used by health professionals

INFANCY trust vs. mistrust

TODDLER autonomy vs. shame and doubt
PRESCHOLER initiative vs. guilt
SCHOOLER industry vs. inferiority
ADOLESCENCE identity vs. role diffusion
YOUNG ADULT intimacy vs. isolation
LATER ADULT generativity vs. self-absorption
SENSCENCE adapts to triumphs and disappointments with a certain ego integrity.

PSYCHOSEXUAL THEORY OF PERSONALITY

DEVELOPMENT (SIGMUND FREUD’s THEORY)

INFANCY ORAL phase stage of the “ID”

TODDLER ANAL phase stage of the “Ego”
PRESCHOOLER PHALLIC stage
- ELECTRA COMPLEX – the daughter attached to father and is jealous of mother
OEDIPAL COMPLEX – the son is attached to mother and is jealous of father.
Stage of “SUPEREGO”

SCHOOLER LATENCY stage – stage of strict superego.

ADLOSCENCE genital stage

SIGNIFICANT DEVELOPMENT MILESTONE

1 mo. - heads sags; follows moving object to midline of vision

- smiles indiscriminately, crying is differentiated
- differentiates objects and face SWEATS

2 mo. - turns from side to back; holds rattles briefly; smiles socially, TEARS

3 MO. - follows moving objects up to 180 degrees

- lifts head and chest of bed discovers, plays with fingers
holds head erect, DROOLS (needs bibs)

4 mo. - turns from back to side, reaches for objects

- drools a lot, recognizes others with social interaction
- demands attention
laugh (3 – 4 mos.)

5 – 6 mo. Rolls over completely

- sits with support and without support briefly
- transfer object from one hand to another
- begins to imitate sounds
- recognizes the parents
birth weight doubles

7-8 mos. Sits for longer period without support

- hitches
- discovers feet
- fears strangers

9-10 mos. creeps

- stands with support
- with develop pincer grasp
- with good hand-to-mouth coordination
- feeds self with bottle
- with patterned speech
- says first two words “ma” and “pa”

11-12 mos. Stands without support

- walks help (cruising)
- shows emotions
- begins to explore the environment
- birth weight triples
- start of closure of anterior fontanel
- knows name
- says 4 – 5 words
- with gesture language

18 mo. Walks alone – sideways and backward

- climbs stairs and furniture
- anterior fontanelle usually closed

- feeds self
- drinks from a cup
- physiologically ready for toilet training (with nerve tract myelinization at 15 – 18 months – earliest time
for toilet training)

2 yr. - Runs fairly well

- walks up and down stairs one foot after another
- uses spoon without spilling
- jumps with both feet in place
- scribbles

2 ½ yr. Jumps from furniture or stairs

- balance on one foot
- feeds self well
- drinks from a straw
- walks backwards
- with complete primary teeth (20)
3 yr. - rides and pedals a tricycle
- goes upstairs with alternating feet
- climbs and jumps well
- draws a circle and a cross
- stands on one foot
- attempts to print letters
4 yr. - goes up and down the stairs like an adult
- hops two or more times
- dresses with minimal help
- can buttoned buttons and lace shoes
- catches ball
- copies a square
5 yr. - can jump rope, skip
- balance on one foot (10 sec.) with eyes closed
- dresses and washes self without assistance
- roller skates
- throws and catches ball well
- can draw a picture of a person
- ties shoelaces
- copies rectangle and triangle
- uses scissors well
- with improve balance
- prints, cuts, paste, hammers
7 yr. - rides a tricycle
- vision mature – hand to eye coordination developed completely (20/20 vision)
- with fine hand movements – can print sentences
- can swim
8 yr. - writes rather than prints
- with grace and balance even in sports
- with increase smoothness and speed
- since arms and legs begins to grow, may stumble on furniture and spill milk
9 yr. - “on the go” constantly
- uses both hands independently
- fully developed hand-to-eye coordination to enjoy baseball
- more mature writings

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
- Adults other than parents are IDOLIZED
Partners of same and OPPOSITE SEX (establish close relationship with the opposite sex)

FEARS OF CHILDREN

INFANCY - Stranger anxiety

- Starts at six months, peaks at 7 – 8 months
TODDLER - Separation anxiety
- Phases: protest, despair, denial
PRESCHOOLER Castration fears: ghost, dark, and inanimate objects
SCHOOLER - 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 the unknown
Fear of disease, death

LEADING ACCIDENTS/CAUSES OF INJURIES IN CHILDREN

INFANCY - aspiration (leading)

- falls
suffocation
burns
poisoning – lead paint
TODDLER - falls (leading)
burns
drowning
poisoning aspirin (most common drug that poisons children)
> The natural curiosity of a toddler leads him to accidents
PRESCHOOLER Motor accident (leading)
burns
drowning
SCHOOLER - Motor accident (leading)
- Sports accident
ADOLESCENCE Motor vehicular
Sports accidents
Burns
Drowning
Drugs
Alcohol
Suicide

PLAY – THE LANGUAGE OF A CHILD

TYPES OF PLAYGAMES

INFANCY - SOLITARY play

- He plays alone with his body or with his toys
TODDLER - PARALLEL play
- He plays alone in the presence of other children, no sharing
PRESCHOOLER COOPERATIVE play
He plays with 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
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

APPROPRIATE GAMES/TOYS FOR CHILDREN

INFANCY - rattles
cribmobiles (best) teethers
pacifiers
musical boxes
squeeze toys
large cuddly toys
“Peak-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 of aggressive behavior)
dolls (security blanket)
“Throwing and Retrieving” game.
PRESCHOOLER tricycle (can ride if at 3 years)
play house
coloring books
clay cutting and pasting tools
superheroes costumes dress-up
dolls
ball
SCHOOLER - bicycle (can ride it at 7 years)
quiet games like reading
painting
radio, TV
Family computer sports game
table games like scrabbles
handicraft (late schooler)
ADOLESCENCE parties, outings, picnics, movies
fantasy and daydreaming (normal)
telephone conversations
reading romance novels
sports games
hobbies

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 things 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”

II. Developmental Tasks:

Toilet training
Language training
Learning social behavior

LANGUAGE TRAINING

I. Language Training Principles

Teach one language at a time
Talk to child in simple, clear words
Do not baby talk
Talk to child at eye level
Provide a good model of speech
Provide of plenty sensory stimulation

II. Schedule
9 – 10 mos. - says two words “ma” and “pa”
11 – 12 mos. - has 4 – 5 words in gesture language
18 mos. - has 20 words
2 years - with short sentences (1 – 2 words/sentence)
- uses and says first name; with 300 words
3 years - 900 words; uses first and last name; names one color
5 years - with adult length sentences
- last year for normal stuttering
- (dysfluency): 2000 – 2100 words with increase of 600
per year. 1 counts to 10
School age - with passwords/secret language, with rapidly
Expanding vocabulary

TOILET TRAINING

I. Requisites:
Sphincter control – most important
Ability to stand and walk to the bathroom
Understands the act of elimination
Can express need to eliminate
Desire to please the mother

Positive maternal attitude and not “strictness” is important to success in toilet training

II. Schedule:

Start - as early as 15 – 18 months as late as 18 mos. – 2 years

Bowel control - 2 – 2 ½ years
Bladder daytime control - 2 ½ - 3 years
Night time bladder control - 3 – 4 years

III. PRINCIPLES OF TOILET TRAINING

Consistency
Firmness
Positive Maternal Attitude

DICIPLINE IN CHILDREN

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

DENTITION

I. IMPORTANT SCHEDULE
6 – 7 MONTHS - eruption of FIRST milk teeth
- LOWER CENTRAL INCISORS
12 months - has 8 teeth
24 months - has 16 teeth
2 ½ years - with COMPLETE milk teeth - 20
Late preschool - eruption of the first permanent teeth
- the first MOLARS
6 years - brags about “dancing teeth”
12 years - has all permanent teeth
except FINAL MOLARS

II. CARE OF THE TEETH

Brush and floss (with parent’s help) twice daily.
Limit concentrated sweets.
If water is not fluorinated, supplements can be given
0.25 – 0.5 mg/day.
D. Do not allow child a bottle of milk or juice to bed; produces BOTTLE
MOUTH CARRIES.
E. Have the FIRST dental visit as soon as all deciduous teeth are out; 2 ½ years.

PERMANENT TEETH
6 – 7 years - 4 “six-year molars”
12 – 13 yr - 4 additional molars
7 – 21 yr - 4 molars “wisdom teeth”
6 yr - age of “dancing Teeth”

Note: Check the SCHOOL AGE child for any loose teeth before any surgery.

BREASTFEEDING

A. This is the best type of feeding that supplies the infant with all essential nutrients in the first six
months.

B. ADVANTAGES OF BREASTFEEDING

MOTHER BABY
1. Promotes bonding 1. Contains antibodies (IgA) that
protects infant from GI infection
2. Promotes uterine involution 2. Always available in sterile form
and at correct temperature.
3. Delays fertility (But not safe to use as a 3. Less incidence of colic,
sole means of family planning constipation, diarrhea and
allergies
4. Economical in time, effort and money 4. Its protein, lacalbumin, is easy
to digest.
5. Less incidence of breast cancer 5. Contains taurine that enhances
brain development.

BREASTFEEDING REFLEXES

A. Milk secretion reflex – Prolactin reflex

> The best way to stimulate milk secretion reflex is to TOTALLY EMPTY the breast with each feeding
always start with the breast that was last used.

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.
PROLACTIN REFLEX LETDOWN REFLEX

Brought about by hormone prolactin Brought about by hormone oxytocin

Secreted by anterior pituitary gland secreted by posterior pituitary gland (APG). (PPG).

Prolactin stimulates ACINI to secrete Oxytocin stimulates BREAST TUBULES

Milk. to eject milk.

Total emptying of the breasts is the Relaxed and secured maternal feelings
BEST STIMULUS to more milk BEST stimulates letdown reflex.
secretion.

“ESSENTIALS” OF BREASTFEEDING
A. START
Right on the delivery table PRIMARILY to promote bonding
30 minutes after birth in normal spontaneous delivery.
4 hours after cesarean section.

B. DURATION OF FEEDING
5 minutes /breast, after establishment of feeding: the first 10 minutes is for nourishment, the 2nd 10
minutes is for sucking pleasure. Total breastfeeding time: 20 minutes.

C. CARE OF THE BEASTS

Daily bath: towel-dry nipples to strengthen them
Clean bra, non-plastic-lined, day and night.
Use nursing pads inside the bra cup to absorb milk leaking between feedings.
Washing of the nipples with plain water once daily.
If source of water and its mode of transport to home is reliably safe, NO NEED FOR STERILE WATER TO
WASH/CLEANSE NIPPLES.
RATIONALE: The mouth of the infant is NOT STERILE. No soaping or use of alcohol on nipples.

ARTIFICIAL FEEDING
Not recommended if only breastfeeding is possible.
Some advantages
Provides an alternative to breastfeeding.
More accurate assssment of intake.
May meet the needs of working mothers.
Maybe indicated in cases of congenital deformities (cleft palate), inborn errors of metabolism, allergies.

C. Factors to Success
Pasteurization of milk.
Sanitation in milk handling
Adequate sterilization, refrigeration and storage
Tuberculin testing of cows
To equal mother’s milk in nutrients: add sugar to increase energy value (Mother’s milk has more
carbohydrates, water and fats). Dilute with water to reduce mineral and protein concentration. (Cow’s
milk is higher in protein casein and mineral content)

C. BOTTLE-FEEDING TECHNIQUES
A. Never prop bottle; always hold infant during feeding.
provides warm body contact.
Provides attachment (bonding)
Allows continued observation during feeding, thus, preventing he usual complication of propping bottles
– ASPIRATION.
The closeness and eye-to-eye contact are the ones that promote bonding. The mother can be close to
her bottle-fed baby provided she holds him during feeding.
B. Hold bottle so nipple is always filled with milk to prevent swallowing of gas and colic.
C. Burp or bubble during and after feeding.
D. Hold upright for 30 minutes more before putting down best on his right side to avoid digestion and
prevent vomiting and aspiration.
Whether breasfeeding or bottle feeding, the best is DEMAND FEEDING which is feeding the infant
according to his NEEDS.

SUPPLEMENTARY FEEDING

A. REQUISITES/CUES TO START SOLID FOODS

Extrusion and sucking reflexes fading.
Can sit support.
A nutritional need for iron to be met.
Develop salivary glands and presence of intestinal enzymes needed for digestion.
B. The usual age for introducing solid foods: 4 – 6 months.
C, SIMPLE RULES TO FOLLOW
Introduce one food at a time
Small amount (1 tsp.) each time
Have an interval of 4 – 7 between new foods to detect what food he is allergic to.
Do not mix new food with formula.
Feed when infant is hungry after few sucks of milk increases his patience for a new food.
Do not force, bribe, plead nor threaten.
D. SEQUENCE OF INTRODUCING SOLIDS
Cerelac – “Am” 5. Eggyolk
Fruits 6. Fish
Vegetables 7. Teething foods at 6 – 7 mo
Whole eggs 12 months 8. Meats
Eggwhite is hyperallergenic

COMMON FOOD STARTER

I. Cereals/”Am” - first solid food
iron-rich
easy to digest
hypoallergenic
can be continued – up to 18 months
II. Common Vegetables Starters
Squash, Sayote, Potato
III. Common Fruits Starters
banana, papaya, mango

CALORIE REQUIREMENTS OF CHILDEN

Newborn - 400 (45 – 55 Kcal/lb or 80 –120 Kcal/kg)
Infant - 800 - 1200
Toddler - 1300
Preschool - 1700
Schooler - 2400
Adolescence - 2200 - 2700
Note: Males have higher caloric requirements

FEEDING PROBLEMS IN CHILDREN

I. Infancy
Aspiration tendency
Colic – more common
Constipation – more common
Supplementary food introduction
Diarrhea
Food allergies
Burping
weaning
II. Toddlers
Physiologic anorexia
Iron-deficiency anemia
III. Preschool
Food likes and dislikes
IV. School
Junk foods
Zero-caloric foods (soft drink)
MARASMUS
I. Marasmus is caloric malnutrition.
II. Causes:
Insufficient diet, Improper feeding habits
Emotional cause – disturbed mother-child relationship
Metabolic disorders
Congenital malformations
IV. Signs
Underweight, emanciated
“Old man’s” face
all skin and bone look
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 stools with mucus
V. Treatment:
FOOD – increase calories in the diet

KWASHIORKOR

I. This is PROTEIN MALNUTRITION

II. Causes:
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 bands
with flack dermatosis
liver enlargement
increase susceptibility to infection
anorexia
IV. Treatment:
Food is the only cure for malnutrition
High protein, high energy milk feed is the easiest way to give the severely malnourished child food.
Kwashiorkor is the MOST SERIOUS AND PREVALENT form of malnutrition in the world today.
HEALTH PROBLEMS OF THE SCHOOLER AGE GROUP

PRESCHOOLER SCHOOLER ADOLESCENT

Fear of the dark, uni- Stealing (7 years) Acne vulgaris – hallmark

versal fear of the age of the age

Imaginary friends Shoplifting

Tell tales/tattling lying speech dificulties – articu- poor posture, slouchy walk,
lation is most common fatigue, Suicide – causes
Sibling rivalry preparation of malnu- include: 1.Anger to another
Hurting others trition. 2. Desire to punish or ma-
Bad language nipulate someone. 3. To
Malnutrition signal distress.
Goal of therapy:
Sex education: started Sex education: health Improve self-image
At about 5 yrs; parents care personnel are usual Sex education:
Are sources of inform- resource person Menstrual hygiene
ations.

Stuttering Handedness: consistent Adolescent pregnancy

Right or left-handedness
Is stabilized by 9 yrs Alcoholism
(AMBIDEXTROUS -
Regression (thumb- uses hand interchangeably) Drug experimentation
sucking), bedwetting, a form of adolescent
negativism) Drug Experimentation - rebellion
because of preadolescent
Preparing for school rebellion and poor
Judgment.

THE ILL AND HOSPITALIZED CHILD

I. Factors Affecting Responses To Illness And Hospitalization

Developmental stage in which the child is in
Nature of illness or injury; seriousness of illness or injury
Level of anxiety of both child and parents
Type of relationship that exist between parents and the child
Past experiences with hospitalization, medical treatment and surgical procedures.
Support systems
Sociocultural status, race, culture and education

II. Major Sources of Fears of Hospitalization.

Separation D. Immobility
Pain E. Body Injury
Loss of Control F. Punishment and rejection

PREPARATION OF CHILD FOR ADMISSION

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
example: 2 years old – tell the child two days ahead.
3. Over 7 years – tell the child when parents know
4. Adolescent – provide him with full explanations; answer questions completely and honesty.

CHOLASIA

Abnormal relaxation of the cardiac sphincter of the stomach resulting to self-limiting vomiting.
Etiology: unknown; common in babies of tense mothers.
Signs and symptoms:
Self-limiting, non-projectile, non-bile vomiting
Regurgitation after feeding
Dehydration
Increased hunger
Weight loss
D. Effect of frequent vomiting: METABOLIC ALKALOSIS (due to loss of HCL acid).
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
Re-feed with thicker formula (more difficult to vomit)
Allow play before feeding time to relax mother.
2. Provide psychological support.
Encourage verbalization of concerns and feelings about feeding/breastfeeding.
Observe for signs of dehydration.
PYLORIC STENOSIS

Congenital hyperthropy/hyperplasia of the muscles of the pylorus causing obstruction of the pyloric
sphincter.
Etiology: unknown
Signs and symptoms
Non-bile, non-projectile vomiting
Increasing hunger, dehydration in children.
Signs of dehydration in children
sunken fontanelles (first sign of dehydration in infants)
sunken eyeballs
oliguria
dry mucus, tears
fever, rapid thready pulse
poor skin turgor/non-elastic skin
3. Visible gastric peristalsis
4. Olive-shape mass at the right upper quadrant
5. Abdominal distention
6. Constipation, or decreased number of schools
7. Failure to thrive/decreased weight
D. Treatment
1. Medical
Monitor IV and IO
Measures to prevent vomiting
2. Surgical: Pyloroplasty/Pyloromyotomy/Fredet – Ramstedt Surgery: creation of a longitudinal incision
into the muscles of the pylorus to create a gaping wound.
E. PREOPERATIVE CARE
NPO with IV and NGT
Observe, monitor I & O, vomiting, NGT drainage, stools, weight.
Keep warm
Monitor I & O, IV, weight
Feed about 2 – 8 hours or 4 – 6 after with dextrose water; only by RN in the first 24 – 48 hours as
vomiting tends to continue in immediate postoperative period.
Frequent burping – before, during, and after feeding
IMPERFORATE ANUS

Congenital anorectal malformation where the rectum ends in a blind pouch or with a fistula connecting
it to the vagina (rectovaginal fistula) or to the urethra (rectourethral fistula).
Signs and Symptoms
No anal opening on inspection
Non-insertion of the rectal thermometer
Progressive abdominal distension
Difficult defacation, inability to defecate
No meconium stool in the first 24 hours
Meconium from inappropriate opening (fistula)
C. Diagnosis Wangesteen – Rice method
Infant held upside down
As the child cries, gas in colon rises to reveal pouch in relation to anal membrane
X-ray pictures taken (no need for dye – danger of aspiration)
D. Treatment: Surgery
Anoplasty for the simple type
Pull-through operation with or without temporary colostomy
E. Nursing Care
1. Provide preoperative care:
NPO
Vital signs monitoring – prepare parents for surgical procedure and for temporary colostomy if
necessary
NGT to decompress stomach
Warmth provision
2. Provide postoperative care:
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 whem peristalsis returns.
With colostomy, begin oral feedings slowly, stools are passed.
d. Provide parental teaching: colostomy care if appropriate
Empty pouch as needed
Skin care
Change pouch as necessary
Clean peristomal areawith mild soap and water, dry thoroughly, apply clean pouch
Use skin barrier as ordered to protect skin from irritation

HIRSCHSPRUNG’s DISASE/CONGENITAL MEGACOLON

A mechanical obstruction of the bowels due to the absence of autonomic parasympathetic nerve
ganglion cells in the distal bowel – inadequate motility.
Etiology: real cause is unknown
C. Signs and symptoms:
a. Newborn
No meconium stools in 24 – 48 hours
Bile-stained vomitus
Feeding difficulties
Abdominal distention
Abdominal pain: Irritability, crying
b. Infants:
Chronic constipation – hallmark of megacolon
Abdominal distention
Explosive diarrhea
Bile-stained vomiting
Failure to thrive malnutrition
c. Older children:
Chronic constipation – hallmark
Ribbon-like stools – like pellets
Palpable fecal masses
Fecal odor of the breath
Abdominal distention
Visible peristalsis
Anemia- malnutrition
D. Diagnosis:
Barium Enema
Rectal biopsy – confirms megacolon
Abdominal X-ray
E. Treatment: Surgery
Bowel resection with temporary colostomy
Abdomino-perineal pull-through by about 1 year
F. Nursing Care:
1. Provide PREOPERATIVE CARE
NPO – pacifier (newborn)
NGT
I&O
Provide emotional need – touch, pacifier
consistent parental care
administer – low residue, high-protein, high calorie diet if appropriate (childhood) – parental nutrition as
ordered
bowel cleansing – liquid diet – stool softeners as ordered – digital removal – daily isotonic saline
enemas/colonic irrigation

Volume of fluid:
Infant - 150 – 250 ml
Preschool - 300 – 500 ml
Toddler - 250 – 350 ml
School - 500 – 700 ml

2. Provide POSTOPERATIVE CARE

Monitor VS
I & O, electrolytes
Stools
Respiratory status
Bowel sounds
b. Maintain hydration and nutrition
Oral fluid as soon as bowel sounds return, advance diet s tolerated
Monitor for abdominal distention
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 2 hours
g. Maintain NG tube to low Gomco suction; maintain patency
h. Provide psychological support
stroke, hold cuddle infant
explain to parents diagnostic and treatment procedure
SPINA BIFIDA

A congenital defect of the spinal/neural tube; incomplete closure of the spinal column.
Classifications
Spina bifida oculta – missing L5-S1; usually asymptomatic; seldom creates health problems; no
treatment
Meningocele – sac-like cyst that contains meninges and spinal fluid that protrudes through the bony
defect

3. Meningomyelocele – herniated sac of meninges, spinal fluid, and portion of the spinal cord and its
nerves that protrudes through the defect in the spine; 80 % in the lumbosacral region
C. Etiology/Incidence – Exact cause unknown
D. Signs and Symptoms
Visible sac-like structure or dimpling of the skin at any point on the spinal E.
E. Nursing Care:
1. Provide skin care to prevent infection of the site
Clean site with H2O2, sterile saline (NSS).
Apply sterile, moist soaks to site 2 – 4 hours as ordered.
Prevent pressure on the site.
Position properly: Prone
Turn every 2 hours: side-prone-side
Doughnut ring around site.
NO DIPERS until site has been repaired or healed.
d. provide meticulous skin care to areas around the site; apply lotion to areas of skin 3 times a day.
2. Maintain hydration and nutrition
Use soft nipples for feeding
Elevate head for feeding
Feed slowly
Maintain strict I & O