MULTI-EDUCATIONAL REVIEW GROUP EXPERTS, INC.

*BAGUIO CITY*ILOILO CITY * DAVAO CITY *KIDAPAWAN*CABANATUAN CITY*

MAKATI CITY*METRO CEBU*BACOLOD*VIGAN CITY*GEN SANTOS CITY *PAMPANGA*LUCENA CITY*NAGA*TUGUEGARAO
CITY*DASMA*
MANILA HEAD OFFICE
www.merge-review.com

CHILD HEALTH NURSING

Growth and Development
I. Growth – increase in physical size (quantitative change) of the body
Development – progression in skill (qualitative change) and or ability to function

II. Principles:

A continuous process
Body systems don’t develop at the same rate
Cephalocaudal
Development proceeds from proximal to distal
Elevation from gross motor to refined skills
For play is the universal language of children
Growth rate varies
Has to follow a definite and predictable pattern of trends
Important indicator of development is the behaviour
Just as each child is unique

III. Stages of Growth & Development

A. Infancy Period

 A rapid growth and development

 Birth until 1 year
 Erikson : Trust vs. Mistrust
 Freud : Oral (ID)
 Piaget’s : Cognitive development

Sensorimotor stage (0-2 years old)

1 month = neonatal reflex

1-4 months = primary circular reaction (body is center of attention)
4-8 months = secondary circular reaction (from body to environment)
8-12 months = coordination of secondary reaction
12-18 months = tertiary circular reaction (trial & error)

 Fear : Stranger Anxiety

 Play : Solitary
 Toys : mobile, rattle, teething rings, musical toys, crib, gym

B. Toddler

 Age 1 to 3 years
 Bow-legged
 Characterized by alternating rapid and slow rate of growth & development
 Erickson : Autonomy vs. Shame & doubt
 Freud : Anal (EGO)
 Piaget’s : Cognitive development

Preconceptual / Preoperational stage (3-4 years old)

A toddler draws conclusion only from the obvious facts that they see
18-24 month = invention of new means through mental combinations

 Kohlberg: Moral development

Level 1 : Preconventional (2-3 years old)

Morals are thought to be motivated by punishment and rewards

 Fear : Separation Anxiety

 Play : Parallel
 Toys : Push and pull

C. Pre school period

 Age 4 to 6 years
 Erickson : Initiative vs. Guilt
  Freud : Phallic
 Piaget’s : Cognitive development

Intuitive stage (5-6 years old)

Assimilation
By magical thinking
Centering
Don’t aware of reversibility
Egocentrism
Fantasy role

 Kohlberg: Moral development

Level 1 : Preconventional (4-7 years old)

Individualism

 Fear : Mutilation and castration

 Play : Associative & Imitation
 Toys : a simple jigsaw puzzle, dolls, coloring book, pencils, pens, crayons

D. School period

 Age 7 to 12 years
 By having a slow period of growth and development
 Erickson : Industry vs. Inferiority
 Freud : Latency
 Piaget’s : Cognitive development

Concrete operations (5-6 years old)

Aware of reversibility
By inductive reasoning
Conservation & Classification
Development of Logical thought patterns

 Kohlberg: Moral development

Level II : Conventional (7-10 years old)

Orientation to interpersonal relations of mutuality

 Fear : Displacement from school

 Play : Cooperative & Collectibles
 Toys : Computer games, game ball, table games

E. Adolescence

 Age 13 to 20 years
 Accelerated growth and maturation influenced by hormonal changes
 Characterized by growth spurt which begins early in girls, about 1-2 years ahead than boys
 Erickson : Identity vs. Role confusion
 Freud : Puberty/Genital
 Piaget’s : Cognitive development

Formal stage (13-16 years old)

Abstract thinking
By deductive reasoning

 Kohlberg: Moral development

Level III : Post-conventional (12 years and over)

Social contract (follows standards of society for the good of all people)

 Fear : Displacement from peers

 Play : Athletic & Sports
 Toys : Music gadgets etc.
IV. Maternal-Infant bonding

 A special mutual relationship between mother and infant

 Best initiated immediately after birth
 Can be achieved within the first 30 minutes or
 During the first period of reactivity
 Exhibited through: Breastfeeding
Rooming-in
Senses stimulation

V. Assessment
 A. Apgar Screening test (by Dr. Virginia Apgar)
- Done twice at 1 and 5 minutes respectively

Criteria 0 1 2
HR: absent <100 >100
RR: absent weak cry vigorous cry
Reflex Irritability: no response grimace vigorous cry
Muscle tone: limp/flaccid minimal full flexion
Skin color: blue acrocyanosis pink

Scores: Interpretation

1-3 Poor - needs immediate CPR

4-7 Fair - needs further observation & stimulation
8-10 Good - healthy

B. Estimation of Age of Gestation by Dr. Ballard’s and Dubowitz

Criteria:

1. Physical characteristics

Pre-mature Term Full-term

Skin: very thin, gelatinous, & smooth, thick, less visible parchment, leathery,
visible blood vessels blood vessels cracked, wrinkled
Lanugo: abundant thinning bald
Plantar creases: anterior transverse 2/3 with creases entire sole w/ creases
Breast: strippled areola raised areola full areola
Ear: flat & folded thin & soft thick & firm
Genital (M): undescended testes intermediate fully descended
Genital (FM): prominent labia & clitoris labia minora & clitoris partly completely covers
covered by labia majora minora & clitoris

2. Neuromuscular characteristics

Pre-mature Full term

Posture: extension flexion
Square window: 90° angle 0° angle
Arm recoil: >90° angle <90° angle
Scarf sign: elbow passed midline not passed
Polpliteal angle: >90° angle <90° angle
Heel to ear: positive negative

3. Neurological assessment

Reflexes:

 Rooting - elicited when NB cheek is touched and turns towards the stimulus
 Extrusion - food placed on infant’s tongue is thrust forward and out of mouth
 Tonic neck - as head is turned to one side, arm & leg on that side extends with opposite
extremities in flexion
 Palmar grasp - elicited by placing finger in the NB palm
 Moro - NB symmetrically abducts and extends arms
 Stepping - hold the NB in a vertical position allowing one foot to touch a table surface
 Babinski - dorsiflexion of big toe and fanning of all four toes as sole foot is stroked from heel

VI. Profile of a Newborn

A. Birth weight: 2.5 to 3.4 kg (5.5 to 7.7 lbs)

BW: doubles at 6 months

triples at 12 months
quadruples at 2 ½ years

LBW: < 2,500 grams

th
Very LBW: <10 percentile
th
LGA >4,000 grams or >90 percentile

B. Birth length: 46 to 54 cm (18-22 inches)

C. Head Circumference: 34 to 35 cm (13-14 inches)

D. Chest Circumference: 32 to 33 cm (12-13 inches)

E. Vital Signs

 Temperature : 97.6 to 98.6°F axillary

  Heart rate : 120 to 140 bpm
 RR : 30 to 60 breaths per minute
 BP : 80/46 mmHg

VII. Physical Assessment

A. Head

1. Anterior fontanel - soft, flat diamond shaped, 3 to 4 cm wide by 2 to 3 cm long

- closes between 12-18 months

2. Posterior fontanel - triangular, 0.5 to 1 cm wide

- closes 2-3 months

3. Caput succedaneum - swelling of scalp caused by prolonged labor

- crosses over suture line
- gradually disappears at about third day of life

4. Cephalhematoma - collection of blood caused by increase pressure of birth

- caused by rupture of periosteal capillary
- absorbed within 3-6 weeks

5. Craniotables - localized softening of the cranial bones

- caused by pressure of the fetal skull against the mother’s pelvic bone in utero
- condition corrects itself without treatment in few months
B. Face

Observe for symmetry

C. Eyes

Assume permanent color between 3 & 12 months of age

Blue or gray irises
Cornea round
Due until 4-6 months – strabismus
Erythromycin antibiotic ointment at birth…
For protection against Chlamydia infection or ophthalmia neonatorum
Gets subconjunctival hemorrhage – a red spot on sclera on inner aspect of eye due to pressure at birth
(absorbed in 2-3 weeks)

D. Nose

Nasal flaring indicates respiratory distress

E. Ears

The pinna normally align from inner t outer canthus of the eye
The low set ears indicate:
1. Chromosomal disease
2. Kidney disease
3. Craniofacial lesions
Test newborn hearing by ringing a bell held 6 inches from each ear
F. Mouth

Moniliasis (Oral thrush)/Candidiasis – white cheesy patches in mucous membrane and tongue
Observe for Cleft lip and palate
Usually blowing bubbles/mucus/drooling indicates tracheoesophageal fistula and esophageal atresia
Tongue appears large and prominent
Teeth (Natal) – must be evaluated for stability, if loose, needs extraction to prevent aspiration
Having white glistening well circumscribed cyst commonly seen in palate caused by extraload of maternal
calcium – Epstein pearl

G. Neck

Short chubby with creased skin folds

Check for rigidity of neck – Congenital Torticollis/Meningitis

H. Chest

An engorged breast due to influence of maternal hormones

(hormones cleared in about 1 week and subsides)

I. Abdomen

Abdominal contour slightly protruberant

Bowel sounds occur 1 hour after birth
Check for Gastrochisis and Omphalocele
Due after an hour – umbilical cord stump appears white gelatinous, with red and blue streaks
 Encourage inspecting cord clamp for bleeding and:
st
1. 1 hour of life = cord is shrinked & dry, turns brown-like
nd rd
2. 2 to 3 day = black
th th
3. 6 to 10 day = breaks free
(leaves a granulated area that heals following a week)
*** Single umbilical artery:
1. CHD
2. Renal anomaly
For presence of:
1. peristalsis and palpable olive shaped mass – Pyloric stenosis
2. palpable sausage shaped mass – Intussusception

J. Imperforate anus

Types of stools:
st
1. Meconium – 1 stool passed by the newborn characterized by
= sticky, greenish black, or tar-like (odourless)
nd rd
2. Transitional – passed by NB beginning 2 or 3 day of life
= greenish yellow & loose (odourless)

3. Milk stool

a) Breast-fed baby stool

= light yellow and soft (sweet smelling)
b) Formula-fed baby stool
= bright yellow and formed (noticeable odor)

K. Genital

1. Male genitalia

Agenesis – absence of organ

By urinary meatus of penis located:
a) Dorsal (above) – Epispadias
b) Ventral (below) – Hypospadias
Cryptorchidism – undescended testes, may lead to…

D’ following complications:
a) Inguinal hernia
b) Sterility
c) Testicular cancer
Ectopic testes – inability of testes to enter scrotum due to closure of
scrotal sac

2. Female genitalia

Swollen due to effect of maternal hormone

Pseudomenstruation

L. Extremities

Arms and legs appear short

By clenched & fisted hands
Crease (simian) – associated with down syndrome
Digits (fingers & toes) assessment:
1. Syndactyly – webbing
2. Polydactyly – extra fingers & toes
3. Adactyly – absence of one or more digits
Extra pad of fat in sole of foot – flat sole (normal)
Feet is plantar flexed – indicates clubfoot
Gets bowed & short NB legs (normal)
Hip dislocation or Dysplasia by Ortolani test
In abducting the hips of the NB:
both hips should abduct completely so they lie almost flat
against the mattress 180°

M. Back

By normally flat and straight

A mass, tuft of hair, dimple (incomplete closure of vertebrae) – indicates Spina Bifida
Curve of back usually develops at 5-6 months

N. Skin
 Assessment:

A red pink skin (normal)

Blue hands and feet – Acrocyanosis
Cyanosis – Hypoxia
D’ colors:
1. pallor – Anemia
st
2. yellow – Jaundice (1 day = Pathologic)

Pediatric Disorders

I. Neurological Disorders

A. Hydrocephalus – excess of CSF in the ventricles or the subarachnoid space

st nd rd th
CSF: Forms in 1 & 2 Ventricles  Passes 3 Ventricle  Flows in Aqueduct of Sylvius  4 Ventricle  Subarachnoid
space  Reabsorbed in Arachnoid membrane
- specific gravity: 1.004 – 1.008 protein: 15-45 mg/100 mL
normal pressure: 50-175 mmH2O glucose: 60-80%
normal volume: 125-150 mL

- Communicating Hydrocephalus or Extraventricular Hydrocephalus: fluid can reach the spinal cord
Obstructive Hydrocephalus or Intraventricular Hydrocephalus: with blockage on passage of fluid

- Risk Factors: Toxoplasmosis

Infant Meningitis/Encephalitis – leave adhesions behind
Hemorrhage or Tumor – blocks passage of fluid
th
Arnold-Chiari disorder – elongation of the lower brainstem & displacement of the 4
ventricle into upper cervical canal
Surgery for Meningocele – portion of subarachnoid space is removed

st nd
- Causes of Excess CSF: Overproduction of fluid by choroid plexus in 1 or 2 ventricle
Obstruction of the passage of fluid in the narrow aqueduct of Sylvius
(most common)
Interference with the absorption of CSF from subarachnoid space

- S/Sx: Anterior fontanel bulging

Bones of the head are widely separated that produces a cracked-pot sound = Macewen’s sign
- Brow bulges (bossing)
Check for sun-setting eyes
D’ increase in ICP
Erritability – shrill high pitched cry

- Nursing Diagnosis with Intervention/s:

1) Risk for Ineffective Cerebral Tissue Perfusion r/t  ICP
Int: Flat on bed – prevent rapid drainage of CSF leading to rupture of cerebral arteries
Avoid lying on side w/ shunt – prevent pressure on valve
Carefully elevate 15 – 30 degrees if  ICP

2) Risk for Imbalance Nutrition, less than body requirements r/t  ICP
Int: Support heads when feeding – hold head w/ whole palm to avoid puncture of the skull
Watch out for poor, ineffective sucking – sign of  ICP

- Management:
1) acetazolamide (Diamox): promote excretion of fluid
2) Laser surgery: reopen route of flow
3) Ventriculoperitoneal shunt: fluid drains into the peritoneum
- headache & lack of appetite are earliest common signs of malfunction

B. Neural Tube Disorders

1) Spina Bifida Occulta – posterior laminae of vertebra fail to fuse during embryonic development
S/Sx: Dimpling at the point of poor fusion
w/ abnormal tufts of hair or discoloured skin on site

2) Meningocele – meninges covering the spinal cord herniate through unformed vertebrae
S/Sx: Protruding mass at the center of the back
Covered by a layer of skin or clear dura mater

3) Myelomeningocele – spinal cord & meninges protrude through the vertebrae

- spinal cord ends at that point
S/Sx: Motor & sensory function absent beyond cut spinal cord
 Flaccid & lack of sensation of the lower extremities
Loss of bladder and bowel control

- Causes: Lack of folic acid

Heredity
- Management: Surgery
- Nursing Diagnosis with Intervention/s:
1) Risk for Infection r/t rupture or bacterial invasion of neural tube sac
Int: Prone – keeps flow of feces & urine away from the disorder; put folded towel under the
abdomen to flex infant’s hips reducing pressure to sac
Side lying – put rolled blanket or diaper behind upper, lower back & in between legs; prevent
pressure on meninges
Place a sturdy plastic wrap below the meningocele
Sterile, wet compress w/ NSS over the lesion – do not remove, just add fluid

2) Risk for Imbalance Nutrition, less than body requirements r/t difficulty assuming normal feeding position
Int: Ensure lesion is not pressed by supporting arm during feeding
Advise not to pat back over the disorder
If lesion is large – prone or side lying when feeding w/ pillow under head

3) Risk for Ineffective Cerebral Perfusion r/t  ICP

C. Meningitis - infectious process of the meninges due to bacteria, viruses, trauma, and infections
- spread through droplet
- Dx: Lumbar puncture -  pressure, cloudy CSF,  Protein & WBC, and  glucose

- S/Sx: A nuchal rigidity

Brudzinski’s
Kernig’s sign
- Nursing Intervention: Respiratory isolation within 24 hrs during antibiotic treatment

D. Seizure- involuntary contraction of muscle caused by abnormal electrical brain discharges

- Causes: Infection Tumor growth
Trauma
- Types: Partial – only one area of the brain is involved
Generalized – includes entire brain; loss of consciousness usually occurs
 Tonic (stiffening & rigidity) Clonic (hyperventilation & jerking)
 Absence (Petit Mal) – day dreaming
 Myoclonic – brief jerking
 Atonic or Akinetic (Drop attacks)
* AURA = sensation that warns client of impending seizure

- Nursing Diagnosis with Intervention/s:

1) Risk for Injury
Int: Clear the area
Avoid inserting tongue blade between the teeth – risk of aspiration due to loosened teeth
No restraints & oral temperature
Turn child on her side during attacks
- Management:
1) Anticonvulsant – carbamazepine, phenytoin

E. Cerebral Palsy - neuromuscular disability in which the voluntary muscles are poorly controlled
- Causes: Low birth weight Birth injury
Premature birth
- S/Sx: Posture is abnormal, rigid & fixed
Arching of the back (Opisthotonus)
Limp or floppy body posture
Scissoring of legs
Yet crawls instead of walking
- Types:
1) Spastic – excessive tone in the voluntary muscles
2) Dyskinetic or Athetoid – involves abnormal involuntary movement
3) Ataxic – w/ awkward, wide based gait
4) Mixed – spastic + athetoid or ataxic + athetoid

- Nursing Interventions: S afety

S elf Esteem
S upport groups

II. Respiratory Disorders

A. Pharyngitis – infection and inflammation of the throat

1) Viral – sore throat, fever & general malaise; enlarged regional lymph nodes, erythema in the back
of pharynx & palatine arch
 - Management:
a) acetaminophen, ibuprofen
b) Warm heat to the external neck area for comfort
c) Gargle w/ warm water

2) Streptococcal – caused by GABHS

- S/Sx: eythema in the back of throat & palatine tonsils, enlarged tonsils, white exudates in tonsillar crypts, petechiae on
palate, high fever, extremely sore throat, difficulty swallowing, overall lethargy, headache
- Management:
a) Full 10 days antibiotic treatment (Penicillin G or Clindamycin); advise parents to strictly follow the course to
prevent hypersensitivity or autoimmune reaction to group A strep causing rheumatic fever or
glomerulonephritis

B. Tonsillitis - infection and inflammation of the palatine tonsils

- in 3 y/o, cause is viral, in school age, GABHS
- S/Sx: drooling, difficulty swallowing, high fever, lethargy, enlarged, bright red palatine tonsils
-  ASO Titer

- Management:
1) Antipyretic, analgesic
2) Full 10 days antibiotic treatment (Penicillin or Amoxicillin)
3) Tonsillectomy: for chronic tonsillitis; done when organs aren’t infected
- Prone or side lying position: head lower than chest to drain blood
- Check signs of bleeding:  pulse & RR, frequent swallowing, throat clearing, feeling of
anxiety
th st
- Restrict child’s activity (no gymnastics & swimming) until after 7 day (1 day – clots from
on area, 5-7 days – clots lyse/dissolve)
- Offer sips of clear liquid, popsicles or ice chips
- Avoid acid & carbonated beverages
- Avoid red fluid such as Kool Aid

C. Croup or Laryngotracheobronchitis – inflammation of larynx, trachea & major bronchi

- Cause: 6 mos-3 y/o – parainfluenza virus
- S/Sx happens at night: Crackles/Wheezes
Ruddy, brassy spasmodic cough
- Retractions
Obstruction of airway
Usually a hoarse voice
Persistent laryngospasm
- Nursing Diagnosis with Intervention/s:
1) Ineffective Airway Clearance r/t edema
Int: Do not elicit a gag reflex
Keep child from crying
- Management:
1) Run shower or hot water tap in bathroom: keep child in this warm, moist environment
2) Cool moist air w/ dexamethasone or racemic epinephrine

D. Epiglottitis – inflammation of the epiglottis

- Causes: pneumococci, streptococci, staphylococci
- S/Sx: A cherry red epiglottis & muffled voice
Bacterial infection
Causes inspiratory stridor
Drooling, Dyspnea, Dysphagia
- Interventions:
1) Never attempt to visualize the epiglottis directly w/ a tongue blade or obtain a throat culture to
prevent gagging and obstruction of glottis
2) Tripod position
3) Encourage HiB vaccine
- Management:
1) O2 hood, Mist tent, Croupette, Cool O2
Avoid mobile toys – soft, non-flammable toys, non battery operated only
Be sure to provide cotton clothes
Change & check the clothes & linens if it’s wet
Determine if the linens are properly tucked
Ensure to prevent the escape of O2
2) cephalosporin (Cefuroxime)
3) Prophylactic tracheostomy to prevent total obstruction
4) Prophylaxis for siblings

E. RSV Bronchiolitis
- S/Sx: Lethargy Respiratory distress (nasal flaring, retractions, grunting, rales, rhonchi)
Cyanosis Dehydration
- Nursing Interventions:
Airway – position: neck slightly extended
 o
Bed – head elevated 30-45
Cool humidified O2
Dehydration monitoring
Encourage handwashing
For contact precaution
Globulin immunization
- Management:
1) Ribavirin (teratogenic) – via O2 tent
2) Supplemental O2 & hydration

F. Asthma – immediate hypersensitivity response

- allergen  mast cells release histamine & leukotrienes  inflammation, bronchoconstriction,  mucus production
- S/Sx: Difficulty exhaling Wheezing
Dyspnea Copious w/ white casts mucus
Long expiratory rate Dehydration
- Peak expiratory flow rate – put in mouth, blows out as hard & fast as possible, repeats 2x more, record highest reading

- Management:
1) Avoid cough suppressants – allow child to cough up mucus
2) For mild but persistent asthma – inhaled anti-inflammatory corticosteroid: fluticasone
Moderate persistent symptoms – long acting bronchodilator + fluticasone
Severe persistent – oral & inhaled corticosteroid + long acting bronchodilator + short acting beta 2 agonist
bronchodilator: albuterol or terbutaline
3) Cromolyn sodium – mast cell stabilizer; prevent bronchoconstriction thereby preventing symptoms of asthma
4) montelukast (Singulair) – leukotriene receptor antagonist; used as prophylaxis & for chronic asthma
5) theophylline/aminophylline – SE is tachycardia; adverse effect is hypotension
6) Increase fluid intake – avoid milk & milk products (causes thick mucus & difficulty swallowing)
7) Advise to wash linens in hot water
8) Position – upright & lean forward

G. Pneumonia – infection & inflammation of alveoli

- Causes: Bacterial – pneumococcal, streptococcal, staphylococcal, chlamydial
Viral – RSV, myxovirus, adenovirus
Aspiration of lipid or hydrocarbon subs
Newborn born 24 hrs after rupture of membranes
Newborn who aspirated amniotic fluid & meconium

1) Pneumococcal – abrupt, follows an URTI

- S/Sx: Blood tinged sputum b4 24 hrs Retractions Nasal flaring
Thick purulent sputum after 24-48 hrs Chest pain Dyspnea
High fever Chills Tachypnea
Crackles Dullness on percussion
- Management:
rd
a) ampicillin or 3 gen cephalosporin
b) amoxicillin-clavulanate (Augmentin) – for penicillin resistant organisms
c) Bed rest – plan nursing care
d) Reposition child frequently – avoid pooling of secretions
e) Humidified O2 – alleviate labored breathing & hypoxemia
f) CPT – encourages movement of mucus
g) Encourage to cough
h) Small, frequent feedings

2) Chlamydial – common in newborns up to 12 weeks

- S/Sx: Nasal congestion Tachypnea Rales
Sharp cough Wheezing
- Management
a) Macrolide antibiotic – erythromycin

3) Viral
- S/Sx: Low grade fever Tachypnea Rales
Non productive cough Diminished breath sounds
- Management:
a) Bed rest
b) Antipyretic
c) IVF

III. Cardiovascular Disorders

A. Congenital Heart Disorders -

- Causes: Failure of heart to progress beyond embryonic development
Maternal rubella
Heredity
- Classifications:
1) Acyanotic heart disease – has stricture to blood flow or shunt that moves blood from arterial to venous system
(oxygenated to unoxygenated or left to right)
2) Cyanotic – venous to arterial

OR

1) Disorders w/ increased pulmonary blood flow – left to right through abnormal opening or connection between 2
systems/arteries

a) Ventricular Septal Defect – w/ opening in septum of 2 ventricles

- results to right ventricular hypertrophy &  pressure to pulmonary artery
- S/Sx: Easy fatigability
Loud, harsh pansystolic murmur
Palpable thrill/vibration
- Management:
1) Cardiac catheterization
2) Open heart surgery -  2 y/o to prevent pulmo artery hypertension
- put Silastic or Dacron patch
- post op: be alert for arrhythmias

b) Atrial Septal Defect – abnormal communication between 2 atria

- results to right ventricular hypertrophy &  pressure to pulmonary artery
- S/Sx: Harsh systolic murmur
Fixed splitting
- Management:
1) Surgery – between 1-3 y/o; put Silastic or Dacron patch; post op WOF arrhythmias
2) Cardiac catheterization

c) Patent Ductus Arteriosus – blood shunt from aorta to pulmonary artery

- results to right ventricular hypertrophy
- S/Sx: Wide pulse pressure
Low diastolic pressure
Continuous machinery like murmur
- Management:
1) IV indomethacin – assess side effects (reduced glomerular filtration, impaired platelet aggregation,
diminished GI & cerebral blood flow)
2) ibuprofen – fewer side effects
3) Cardiac catheterization – insert Dacron coated stainless steel coils; 6 mos-1 y/o
4) Ductal ligation

2) Disorders with obstruction to blood flow

a) Pulmonary Stenosis – narrowing of pulmonary valve or pulmonary artery

- results to right ventricular hypertrophy
- S/Sx: Cyanosis Thrill
nd
Systolic ejection murmur Widely split 2 heart sound
- Management:
1) Balloon angioplasty

b) Aortic Stenosis – stricture of aortic valve

- results to  pressure & hypertrophy of left ventricle & pulmonary edema
- S/Sx: Rough systolic murmur Chest pain
Thrill
If severe – faint pulses, hypotension, tachycardia, inability to suck
- Management:
1) Beta blocker or Ca channel blocker – for stabilization
2) Balloon valvuloplasty
3) Artificial valve replacement
c) Coarctation of the Aorta – narrowing of the aorta
- S/Sx:  BP in heart & upper body Vertigo
Headache No palpable femoral pulses
Leg pain Nodules on ribs – enlarge collateral arteries
Moderately loud systolic murmur
- Management:
1) Angiography
2) Surgery – digoxin & diuretics b4 surgery to reduce CHF; done 2 y/o

3) Disorders with mixed blood flow

a) Transposition of Great Arteries – aorta arises from right ventricle instead of the left, pulmonary artery arises from
the left instead of the right
- S/Sx: Cyanotic birth

- Management:
 1) PGE – prostaglandin
2) Balloon atrial septal pull through
3) Arterial switch – 1 wk-3 mos age

4) Disorders w/ decreased pulmonary blood flow

a) Tetralogy of Fallot – with pulmonary stenosis, VSD, overriding of the aorta & hypertrophy of right ventricle
- S/Sx: Polycythemia Clubbing of fingers
Severe dyspnea Squatting position when resting
Growth restriction Tet spells
- Management:
1) Blalock-Taussig procedure – no BP & venipunctures on right arm after procedure
2) Keep hypoxic episode to minimum – O2, squatting, morphine or propanolol
3) Brock procedure – repair all anomalies

B. Rheumatic Fever – autoimmune that occurs as a reaction to a GABHS infection

Signs & Symptoms (Jones Criteria)

Minor Major
Prolonged PR & QT interval Polyarthritis
Elevated sedimentation rate Erythema marginatum
C-reactive protein Carditis
Leukocytosis Chorea
Arthralgia Subcutaneous nodules
Fever

- Nursing Diagnosis with Intervention/s:

1) Risk for nonadherance to drug therapy
Int: Drug level must be maintained for 10-14 days
Prophylactic antibiotic therapy for atleast 5 yrs after initial attack – also when having dental surgery
- Management:
1) penicillin – erythromycin
2) benzathine penicillin IM
3) Corticosteroids – side effects are hirsutism, round moon face,  susceptibility to infection
4) Phenobarbital & diazepam

C. Kawasaki Disease – mucocutaneous lymph node syndrome; febrile, multisystem disorder

- vasculitis is the principal & life threatening finding because it can lead to MI or aneurysm

Criteria for Diagnosis of Kawasaki Disease

1. Fever 5 days duration
2. Bilateral congestion of ocular conjunctivae
3. Changes of mucous membrane of URT (red pharynx,
lips; “strawberry tongue”)
4. Changes of peripheral extremities (peripheral
erythema & edema, desquamation of palms & soles)
5. Rash – truncal, polymorphous
6. Cervical lymph node swelling

- Nursing Diagnosis with Intervention/s:

1) Risk for Ineffective Peripheral Tissue Perfusion
Int: Observe for signs of heart failure – tachycardia, dyspnea, rales & edema
Inspect extremities for color & warmth
Check capillary refill
2) Pain r/t swelling of lymph nodes & inflammation of joints
Int: Provide rocking & holding
Protect edematous areas from pressure
Keep child free from heavy blankets or clothing
Use a soft padded toothbrush for brushing
- Management:
1) aspirin or ibuprofen
2) abciximab – platelet receptor inhibitor
3) IV Ig
4) Avoid steroids -  aneurysm formation
IV. Hematologic Disorders

A. Sickle Cell Anemia – presence of abnormally shaped RBCs

- autosomal recessive inherited disorder
- S/Sx: Fever Protruding abdomen Vomiting
Swelling of hands & feet Yellowed sclera Enlarged liver
Enlarged spleen Acute back pain

- Sickle Cell Crisis: sudden, severe onset of sickling; occurs when dehydrated, w/ respiratory infection causing low O2
exchange & low arterial O2 level, after strenuous activities
 - Nursing Diagnosis with Intervention/s:
1) Ineffective Tissue Perfusion
Int: O2 therapy
Bed rest
No supplemental Fe
- Management:
1) Pain relief – acetaminophen
2) Adequate hydration
3) Oxygenation
4) Hydroxyurea –  hgb; causes anorexia
5) Exchange transfusion

B. Thalassemia Major – autosomal recessive; abnormal beta chains of adult hgb

- or Cooley’s anemia

Effects of Thalassemia Major

Body Organ or System Effect
Bone Marrow Increased facial mandibular growth
Skin Bronze colored
Spleen Splenomegaly
Liver & Gallbladder Cirrhosis & cholelithiasis
Pancreas Destruction of islet cells & DM
Heart Failure from circulatory overload

- Management:
1) digitalis, diuretics, low sodium diet
2) Transfusion of packed RBC
3) deferoxamine – remove excess Fe

C. Hemophilia
1) Hemophilia A – factor VIII deficiency
- sex linked recessive trait
- S/Sx: Extremely bruised lower extremities when bumped
Swollen & warm joints
- PTT to test
- Management:
a) Fresh whole blood or frozen plasma
b) desmopressin

2) Von Willebrand’s Disease – inherited autosomal dominant

- or angiohemophilia
- with factor VII defect, platelets unable to aggregate
- epistaxis is a major problem, w/ heavy menstrual flow
- Management:
a) blood transfusion
b) arginine desmopressin

3) Christmas Disease – or Hemophilia B; factor IX deficiency

- sex linked recessive trait

4) Hemophilia C – factor XI deficiency

- or thromboplastin antecedent deficiency
- autosomal recessive

V. GastroIntestinal Disorders

A. Cleft Lip – fusion of maxillary and median nasal processes fail

- normal: fuse between 5-8 weeks intrauterine life
- more common among boys
Cleft Palate – closes at 9-12 weeks intrauterine life
- involves anterior hard palate and/or posterior soft palate
- more common among girls

- Causes/Risk Factors: Heredity

Viral Infection during intrauterine life
Lack of folic acid

- Nursing Diagnosis with Intervention/s:

1) Risk for Imbalance Nutrition, less than body requirements r/t feeding problems
Int: Cleft lip – support baby in upright position and feed gently using commercial cleft lip nipple (Breck feeder or
Haberman)
- Breastfeed 7-10 days after surgery
- Bubble well the infant after feeding
- Offer sips of fluid to prevent dryness, cracks & fissures
 Cleft palate – commercial cleft palate nipple with rubber
- Offer soft food

2) Risk for Ineffective Airway Clearance r/t oral surgery

Int: Suction (be gentle, don’t touch suture lines)

3) Impaired Tissue Integrity at incision line r/t surgery

Int: Cleft lip - turn infant on their side to prevent pressure on suture line
- Suture line is held by a Logan bar
- Avoid infant crying as much as possible

Cleft Palate - keep elbow restraints

- No spoon & straw during feeding
- Keep on prone position

- Management:
Cleft Lip – Cheiloplasty between 2-10 weeks of age and revision at 4-6 y/o
Cleft Palate – Uranoplasty between 6-18 mos (allow anatomic palate change to happen first)

B. Tracheoesophageal Atresia Fistula – trachea & esophagus are connected

Esophageal Atresia – obstruction of the esophagus
- Cause: Teratogens
- S/Sx: Abdominal Distention Coughing Cyanosis
Regurgitation Choking Drooling

- Nursing Diagnosis with Intervention/s:

1) Risk for Imbalance Nutrition, less than body requirements
Int: Gastrostomy feeding – after feeding, keep tube elevated with covered sterile gauze

2) Risk for Infection r/t aspiration

Int: PreOp – position in an upright position or on right side to prevent gastric juice from entering the lungs
Frequent oropharyngeal suctioning
Keep infant from crying
Post Op – suction shallowly
- Turn frequently
- Management:
1) Surgery – prevent pneumonia & dehydration
- close fistula & anastomose esophageal segments
- observe closely for 7-10 days to check for leaks
2) Gastrostomy – empty secretions & prevent reflux into the lungs

C. Gastroesophageal Reflux – called achalasia in infants

- cardiac sphincter & lower portion of the esophagus are lax & allow easy regurgitation
- Causes: Cerebral palsy
Hiatal Hernia
- S/Sx: Effortless vomiting
Irritable
Episodes of apnea
- Management:
1) Formula thickened rice cereal – 1 tbsp cereal/1 oz formula or breast milk
- feed in upright & keep them upright for 1 hour
2) ranitidine or omeprazole
3) Tightening of esophageal sphincter
4) Fundoplication
5) Do not lie down 2 hrs after eating

D. Pyloric Stenosis – hypertrophy of the muscle surrounding the pyloric sphincter

- S/Sx: Projectile vomiting immediately after feeding – sour, no bile
Dehydration – lack of tears, dry mouth, sunken fontanelles, fever,  urine output, poor skin
turgor, weight loss
Alkalosis
Hypopnea – slowed respiration
Olive shaped mass
- Dx: Barium Swallow
- Nursing Diagnosis with Intervention/s:
1) Risk for Fluid Volume Deficit
Int: Monitor weight & urine output

- Management:
1) Pyloromyotomy – electrolyte imbalance, dehydration & starvation must be corrected first
2) No oral feedings
3) Fredet Ramstedt procedure

E. Intussusception – invagination of one intestine to another

- Causes: Meckel’s diverticulum Hypertrophy of Peyer’s patches
 Polyp Bowel tumors
- S/Sx: Sudden drawing up of legs & cry because of pain
Vomiting – with bile
Currant jelly stool
Abdominal distention
Sausage shaped mass
- Nursing Diagnosis:
1) Pain
2) Risk for Fluid Volume Deficit
- Management:
1) Surgery
2) Instillation of water soluble solution, barium enema or air

F. Celiac Disease – sensitivity or abnormal immunologic response to gluten found in wheat, rye, oats & barley
- S/Sx: Steatorrhea Abdominal distention
Vit ADEK deficiency Malnutrition
- Rickets, hypoprothrombinemia, hypochromic anemia & hypoalbuminemia may occur
- Nursing Diagnosis with Intervention/s:
1) Imbalanced Nutrition, less than body requirements
Int: Record characteristics of stools
Read food labels carefully
Avoid spaghetti, pizza, hotdogs, cake, cookies
- Management:
1) Gluten free diet for life
2) Water soluble forms of Vit A & D
3) Fe & folate

G. Hirschsprung’s Disease – or aganglionic megacolon

- absence of ganglionic innervation to the muscle of a section of the bowel
- no peristaltic waves
- S/Sx: Chronic constipation Abdominal distention
Ribbon like stools Failure to pass meconium by 24 hrs
- Nursing Diagnosis with Intervention/s:
1) Constipation r/t reduced bowel function
Int: Normal saline for enemas – 2 tsp noniodized salt + 1 quart water
2) Imbalanced Nutrition, less than body requirements
Int: No fried foods & highly seasoned foods
Post op assess for bowel sounds & passage of flatus

H. Imperforate Anus – stricture of the anus

- S/Sx: Abdominal Distention
Membrane filled w/ black meconium protruding from anus
st
Failure to pass meconium in the 1 24 hrs after birth
Absent “wink” reflex
Stool in vagina or urine
- Nursing Diagnosis with Intervention/s:
1) Risk for Imbalance Nutrition, less than body requirements
Int: NGT to relieve vomiting & pressure to abdominal organs
Low residue diet (rice cereal, strained fruits & vegetables)

2) Impaired Tissue Integrity

Int: Avoid rectal temperatures, enemas, suppositories
Clean suture lines with normal saline after bowel movements
Place diaper under, not on, the infant to cleanse at once the bowel movements
Place in side lying position to avoid tension in the perineal area
Rectal dilatation 1x or 2x/day

VI. Urinary Tract Disorders

A. Hypospadia – urethral opening is on the ventral (lower) aspect of the penis

Epispadia – opening is on the dorsal surface of the penis
- S/Sx: Cobra head appearance
Cryptorchidism
- Management:
1) No circumcision – portion of foreskin may be used during repair
2) Meatotomy
3) Testosterone – for penis growth

B. Glomerulonephritis – inflammation of glomeruli that occurs as a immune complex disease after GABHS infection
- S/Sx: Hematuria Reddish brown/Smoky urine Hypertension
Proteinuria Oliguria Abdominal pain
Fever Edema Anorexia
Vomiting Headache T wave inversion
Prolonged PR interval
- Management:
 1) furosemide
2) Semi fowlers, digitalization & O2 – if w/ heart failure
3) Ca channel blockers
4) Kayexalate – for  K & Phosphate
5) Normal salt & protein diet
6) Weigh child daily
C. Nephrotic Syndrome – abnormal loss of protein from the urine due to altered glomerular permeability
- Causes: Antigen-Antibody reaction
Autoimmune
T lymphocyte dysfunction
- S/Sx: Proteinuria Hypoalbuminemia
Edema Hyperlipidemia
- Nursing Diagnosis with Intervention:
1) Imbalanced Nutrition, less than body requirements
Int: Good protein & potassium intake
Monitor fluid intake
Monitor weight daily (same clothing, time & scale)
- Management:
1) Corticosteroids – monitor protein loss
- can cause cushingoid appearance (moon face, extra fat at base of neck,  body hair)
- do not stop abruptly: can cause adrenal insufficiency
2) cyclophosphamide (Cytoxan)
3) Diuretics & K supplement
Comparison of Features of AGN & Nephrotic Syndrome
Factor AGN Nephrotic Syndrome
Cause Immune reaction to GABHS Idiopathic; Hypersensitivity rxn
Onset Abrupt Insidious
Hematuria Profuse Rare
Edema Mild Extreme
Hypertension Marked Mild
Hyperlipidemia Rare or mild Marked
Peak age frequency 5-10 y/o 2-3 y/o
Interventions Limited activity; antihypertensives; Corticosteroid; cyclophosphamide;
symptomatic therapy for CHF diuretics; K supplement
Diet Normal for age High protein, low sodium
Prevention Prevention or thorough tx of GABHS None known
infection
VII. Endocrine or Metabolic Disorders

A. PKU – autosomal recessive

- no phenylalanine hydroxylase:  phenylalanine in the blood
- Dx: Guthrie blood test
- S/Sx: Mousy odor Light blonde hair
Very fair skinned Blue eyes
- Management:
1) Lofenalac – low phenylalanine formula
2) Low protein diet
3) Avoid Nutrasweet – w/ aspartane

B. IDDM – absolute deficiency of insulin

- Dx: confirmed if finding one of the ff on 2 separate occasions
 Symptoms of diabetes w/ random blood glucose level 200 mg/dL
 Fasting blood glucose level 126 mg/dL
 2 hr plasma glucose level 200 mg/dL during an OGTT
- S/Sx: Hyperglycemia Hypoglycemia
 Glycosuria - Nervousness/palpitations
 Polyuria - Confusion
 Polydipsia - Tachycardia
 Polyphagia - Sweats
- Management:
1) Insulin – 2 doses (b4 breakfast & dinner)

Type of Insulin Example Peak

Short Acting Humulin Regular 2 – 4 hours
Intermediate Acting Humulin NPH/Lente 4 – 12 hours
Long Acting Humulin Ultralente 16 – 18 h
Pre-Mixed 70% NPH & 30 % Regular 2 – 12 hours
- rotate injection sites
- give at room temperature
2) Regulation of nutrition & exercise – 3 spaced meals + snack in midmorning, midafternoon & evening
3) Stress management
4) Blood glucose & urine ketone monitoring

C. Cystic Fibrosis – w/ generalized dysfunction of the exocrine glands

 - autosomal recessive trait
- Cause: Abnormality of the long arm of chromosome 7 – inability to transport small molecules across cell membranes
leading to dehydration of epithelial cells in the airway & pancreas
- Dx: Pilocarpine Iontophoresis - 60 mEq/L (+)
- S/Sx: Tenacious secretions in pancreas & lungs
 Cl concentration of sweat – salty perspiration
Boys have persistent blocking of the vas deferens (tenacious seminal fluid)
Girls have thick cervical secretions
Large, bulky & greasy (steatorrhea) – can’t digest fat, protein, sugars bec. no pancreatic enzymes on
duodenum
Rectal prolapse
Meconium ileus
Protuberant abdomen
Malnutrition – emaciated extremities, loose flabby folds of skin on buttocks
Fat soluble vitamin deficiencies
Clubbed fingers
Enlarged anterior-posterior diameter of chest
Respiratory acidosis
Hypoalbuminemia – edema

- Nursing Diagnosis with Intervention/s:

1) Risk for Imbalance Nutrition, less than body requirements r/t inability to digest fat
Int: High calorie, high protein, moderate fat diet
Adequate salt intake
Water miscible Vit. A, D, E
Breastfeeding w/ supplemental formula – soybean formula for milk allergy or Probana
Take synthetic pancreatic lipase (Cotazym or Pancrease) b4 each meal – add to  teaspoonful of food, no hot
foods, don’t add to formula milk
Offer water frequently
Guard against overexertion or heat exposure
2) Ineffective Airway Clearance r/t inability to clear mucus
Int: Nebulization or aerosol therapy then CPT
Humidified O2
Add acetylcysteine (Mucomyst) to mist
No cough suppressants
Frequent reposition
Bed rest – plan activities & rest period b4 meals

VIII. Skeletal Disorders

A. Talipes Disorders – or clubfoot; hereditary

- Types:
1) plantarflexion – equinus or horsefoot position, forefoot lower than heel
2) dorsiflexion – heel is held lower than forefoot or anterior foot is flexed toward anterior leg
3) varus deviation – foot turns in
4) valgus deviation – foot turns out
5) equinovarus – combination of all types
6) calcaneovalgus – child walks on heel with foot elevated
- Management:
1) Cast: foot placed in an overcorrected position
extends above the knee to ensure firm correction
change diapers frequently to prevent soaking of cast w/ urine or meconium
check infant’s toes for coldness, blueness & circulation
2) Denis Browne splints: shoes attached to metal bar to maintain position
3) Surgery

B. Developmental Hip Dysplasia – often referred to as CHD

- improper formation & function of the hip socket
- subluxation or dislocation of the head of femur
- acetabulum of pelvis is flat or shallow
- Causes: Heredity
Uterine position
- S/Sx: Affected leg is shorter, knee is lower than the other
Unequal skin folds on posterior thighs
Ortholani’s sign (click heard on abduction)
- Management:
1) Splints, Halters, or Casts: position hip into flexed, abducted position; traction for older children
 Frejka splint: keep in place at all times except when bathing the infant & changing diapers
 Good diaper area care: change diapers frequently, wash area w/ clear water, apply ointment after each
diaper change
 Pad edges of braces to decrease irritation
 Pavlik harness: adjustable chest halter; worn continually except bathing
 Spica cast or Frog Leg cast: assess for circulation
 2) Surgery: pin is inserted to stabilize the hip

IX. Integumentary Disorders

A. Impetigo - GABHS or Staphylococcus aureus

- crusted lesions ruptures leaving a honey colored crust
- Nursing Interventions:
Handwashing
On contact isolation
No sharing of plates and towels etc.
Encourage washing in hot water
You expose lesions to air
- Management:
1) penicillin or erythromycin
2) mupirocin ointment – 7 to 10 days

B. Scabies
Sarcoptes scabiei (itch mite)
Contagious disorder of the skin
Avoid reinfestation
Bathing, washing in diluted “Lice R Gone” shampoo
Inspect for burrows (fine grayish red lines that maybe difficult to see) on the skin
Examine all family members
Scabicide topical application: from neck to down
X. Chromosomal Disorders

A. Trisomy 13 (Patau syndrome)

B. Trisomy 18 (Edwards syndrome)

C. Trisomy 21 (Down’s syndrome)

D. Cri du chat syndrome (Cat cry syndrome)

E. Turner’s syndrome (Missing X-chromosome)

F. Klinefelter syndrome (Extra X-chromosome)

G. Di george’s syndrome (22q11.2 deletion syndrome)

H. Wilson’s mikity syndrome (Pulmonary dysmaturity syndrome)

I. Pierre Robin syndrome (PR-complex/sequence)

J. Cringler Najjar Syndrome (Glucoronyl transferase deficiency)

AIM HIGH NURSES! GOD BLESS

This is just an outline for PEDIATRIC Nursing. Supplemental reading is highly suggested. 