UPump Pediatric Nursing

URS
Luzon. Visayas. Mindanao
CHILD HEALTH NURSING

Growth and Development
I. Growth – increase in physical size of the body (quantitative change)

Development – progression in skill and or ability to function (qualitative change)
II. Principles:
A continuous process
B ody systems don’t develop at the same rate
C ephalocaudal
D evelopment proceeds from proximal to distal
E levation from gross motor to refined skills
F or play is the universal language of children
G rowth rate varies
H as to follow a definite and predictable pattern of trends
I mportant indicator of development is the behaviour
J ust as each child is unique
III. Stages of Growth & Development
Basic Divisions of Childhood

Stage:
Neonate first 28 days of life
Infant 1 mo – 1 yr
Toddler 1 – 3 yr
Preschooler 3 – 5 yr
School Age 6 – 12 yr
Adolescent 13 – 20 yr
A. Infancy Period
 A rapid growth and development
 1 month until 1 year
 Erikson : Trust vs. Mistrust
 Freud : Oral (ID)
 Piaget’s : 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 : Preconceptual / Preoperational stage (3-4 years old)
 A toddler draws conclusion only from the obvious facts that they see
1
MERGEMANILA- Don Lorenzo Bldg.Rm 201 P.Paredes St. Samp.Manila Tel:(02)523-1862/708-6459
 18-24 month: invention of new means through mental combinations
 Kohlberg : Level 1: Preconventional
 Stage 1: (2 -3 years old)
 Punishment/Obedience orientation
 Fear : Separation Anxiety

 Play : Parallel
 Toys : Push and pull
C. Pre school period

 Erickson : Initiative vs. Guilt
 Freud : Phallic
 Piaget’s : Intuitive stage (5-6 years old)
 A ssimilation
 B y magical thinking
 C entering
 D on’t aware of reversibility
 E gocentrism
 F antasy role
 Kohlberg : Level 1: Preconventional
 Stage 2: 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
 By having a slow period of growth and development
 Erickson : Industry vs. Inferiority
 Freud : Latency
 Piaget’s : Concrete operations (7-12 years old)
 Aware of reversibility
 By inductive reasoning
 Conservation & Classification
 Development of Logical thought patterns
 Kohlberg : Level II: Conventional
 Orientation to interpersonal relations of mutuality
 Maintenance of social order
 Fear : Displacement from school
 Play : Cooperative & Collectibles
 Toys : Remote control games, game ball, table games
E. Adolescence
 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 : Formal stage (12 years old & above)
 Abstract thinking
 By deductive reasoning
 Kohlberg : Level III: Post-conventional
 Stage 5: 12 years and over
 Social contract (follows standards of society for the good of all
people)
 Stage 6: 12 years and over
 Universal ethical principle orientation
2
 Fear : Displacement from peers
 Play : Athletic & Sports
 Toys : Music gadgets etc.
IV. Maternal-Infant bonding

 A special mutual relationship between mother and infant
 B est initiated immediately after birth
 C an be achieved within the first 30 minutes or
 D uring the first period of reactivity
 E xhibited through: Breastfeeding
Rooming-in
Senses stimulation
V. Assessment
A. Initial care of the newborn
 Assessment
 observe or assist with initiation of respirations
 assess apgar score (pls see table below)
 monitor for nasal flaring, grunting, retractions & abnormal respirations
 obtain vital signs
 observe newborn for signs of hypothermia or hyperthermia
 assess gross anomalies
 Interventions
 Suction mouth, then nares with bulb syringe
 Dry newborn and stimulate crying by rubbing
 Maintain temperature stability; wrap newborn in warm blankets and place stockinette
cap on newborn’s head
 Keep newborn with mother to facilitate bonding
 Place newborn at mother’s breast if breastfeeding is planned, or place on mother’s abdomen
 Place newborn in warmer
 Position newborn on side or abdomen or in modified Trendelenburg position to
facilitate drainange of mucus
 Ensure newborn’s proper identification
 Footprint newborn and fingerprint mother on identification sheets
 Place matching identification bracelets on mother & newborn
B. 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
4-6 Fair - needs further observation & stimulation
7-10 Good – healthy
C. 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
3
Genital (M): undescended testes intermediate fully descended
Genital (FM): prominent labia & labia minora & clitoris completely covers minora
clitoris partly covered by labia & clitoris
majora
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/Startle: newborn 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
Very LBW: <10th percentile
LGA >4,000 grams or >90th percentile
B. Birth length: 46 to 54 cm (18-22 inches)
C. Head Circumference: 34 to 35 cm (13.5-14 inches)
D. Chest Circumference: 32 to 33 cm (12-13.2 inches)
E. Vital Signs
 Temperature : 97.6 to 98.6°F (36.5 to 37 °C) 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, 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
4
B. Face: observe for symmetry
C. Eyes
A ssume permanent color between 3 & 12 months of age
B lue or gray irises
C ornea round
D ue until 4-6 months: strabismus
E rythromycin antibiotic ointment at birth
F or protection against chlamydia infection or ophthalmia neonatorum
G ets 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 to the 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
M oniliasis (Oral thrush)/Candidiasis – white cheesy patches in mucous membrane and tongue
O bserve for Cleft lip and palate
U sually blowing bubbles/mucus/drooling indicates tracheoesophageal fistula and esophageal
atresia
T ongue appears large and prominent
T eeth (Natal) – must be evaluated for stability, if loose, needs extraction to prevent
aspiration
H aving white glistening well circumscribed cyst commonly seen in palate caused by extra
load 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
I. Abdomen
A bdominal contour slightly protruberant
B owel sounds occur 1 hour after birth
C heck for gastrochisis and omphalocele
D ue after an hour: umbilical cord stump appears white gelatinous, with red and blue streaks
E ncourage inspecting cord clamp for bleeding and:
1. 1st hour of life = cord is shrinked & dry, turns brown-like
2. 2nd to 3rd day = black
3. 6th to 10th day = breaks free
(leaves a granulated area that heals following a week)
F or presence of:
1. peristalsis and palpable olive shaped mass ( Pyloric stenosis)
2. palpable sausage shaped mass (Intussusception)
J. Imperforate anus
Types of stools:
1. Meconium – 1st stool passed by the newborn
 sticky, greenish black, or tar-like (odourless)
2. Transitional – passed by NB beginning 2nd or 3rd 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)
5
K. Genital
1. Male genitalia
A genesis – absence of organ
B y urinary meatus of penis located:
a) Dorsal (above) – epispadias
b) Ventral (below) – hypospadias
C ryptorchidism – undescended testes, may lead to…
D’ following complications:
a) Inguinal hernia
b.) Sterility
c) Testicular cancer
E ctopic 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
A rms and legs appear short
B y clenched & fisted hands
C rease (simian) – associated with down syndrome
D igits (fingers & toes) assessment:
1. Syndactyly – webbing
2. Polydactyly – extra fingers & toes
3. Adactyly – absence of one or more digits
E xtra pad of fat in sole of foot – flat sole (normal)
F eet is plantar flexed – indicates clubfoot
G ets bowed & short NB legs (normal)
H ip dislocation or Dysplasia by Ortolani test
I n abducting the hips of the newborn:
both hips should abduct completely so they lie almost flat
against the mattress 180°
M. Back
A mass, tuft of hair, dimple (incomplete closure of vertebrae) – indicates Spina Bifida
B y normally flat and straight
C urve of back usually develops at 5-6 months
N. Skin
Assessment:
A red pink skin (normal)
B lue hands and feet – acrocyanosis
C yanosis – hypoxia
D’ colors:
1. pallor – anemia
2. yellow – jaundice (within 24 hours = pathologic)
VIII. Major Developmental Milestone

2 months head lag
social smile
cooing
3 months lifts head & shoulders
4 months lifts chest
5 months roll over
6 months sit with support
palmar grasp
7 months transfer object hand to hand
8 months sit without support
9 months crawls
10 months pulls self to standing
11 months cruises (walks with support)
12 months stands alone
6
holds cup & spoon
15 months walks alone
18 months run & jump in place
24 months open doors by turning door knobs
30 months can jump down from chairs
Pediatric Disorders
I. Neurological Disorders
A. Hydrocephalus – excess of CSF in the ventricles or the subarachnoid space
> Communicating hydrocephalus or extraventricular hydrocephalus: fluid can reach the spinal cord
> Obstructive hydrocephalus or intraventricular hydrocephalus: with blockage on passage of fluid
- Causes of Excess CSF: Overproduction of fluid by choroid plexus in 1 st or 2nd 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: A nterior fontanel bulging
B ones of the head are widely separated that produces a cracked-pot sound =Macewen’s sign
B row bulges (bossing)
C heck for sun-setting eyes
D’ increase in ICP
E rritability – shrill high pitched cry
- Management:
1) acetazolamide (Diamox): promote excretion of fluid
2) Ventriculoperitoneal shunt: fluid drains into the peritoneum
> headache & lack of appetite: earliest common signs of malfunction
- Nursing Diagnosis with Intervention/s:

1) Risk for Ineffective Cerebral Tissue Perfusion r/t  ICP
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
Support heads when feeding – hold head w/ whole palm to avoid puncture of the skull
Watch out for poor, ineffective sucking – sign of  ICP
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 discolored 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

S/Sx: Flaccid & lack of sensation of the lower extremities
Loss of bladder and bowel control
- Causes: Lack of folic acid

Heredity

1) Risk for Infection r/t rupture or bacterial invasion of neural tube sac
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 & separate one behind their
lower back (no pressure on the lesion)
- put folded diaper between the legs (prevents skin surface from touching
& rubbing)
Place a sturdy plastic wrap below the meningocele
7
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
Ensure lesion is not pressed by supporting arm during feeding
When bubbling infant, advise not to pat back over the disorder
If lesion is large – prone or side lying when feeding w/ pillow or folded diaper under
the head
C. Meningitis - infectious process of the meninges due to bacteria, viruses, trauma & infections
- Dx: CSF analysis obtained by lumbar puncture
- S/Sx: A nuchal rigidity
B rudzinski’s
K ernig’s sign
- Nursing Intervention: Respiratory isolation within 24 hrs during antibiotic treatment
D. Cerebral Palsy - neuromuscular disability in which the voluntary muscles are poorly controlled
- Causes: Low birth weight
Birth injury
Premature birth
- S/Sx: P osture is abnormal, rigid & fixed
A rching of the back (Opisthotonus)
L imp or floppy body posture
S cissoring of legs
Y et 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
–S/Sx: 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

-Causes:
in 3 y/o: viral
in school age: GABHS
- S/Sx: drooling, difficulty swallowing, high fever, lethargy, enlarged, bright red palatine tonsils
-  ASO Titer
- Management:
1) Antipyretic, analgesic
8
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
- Restrict child’s activity (no gymnastics & swimming) until after 7 th day
> 1st day: clots form 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: C rackles/Wheezes
R uddy, brassy spasmodic cough
Retractions
O bstruction of airway
U sually a hoarse voice
P ersistent laryngospasm
- 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

1) Ineffective Airway Clearance r/t edema & constriction of airway
Do not elicit a gag reflex
Keep child from crying
D. Epiglottitis – inflammation of the epiglottis

- Causes: pneumococci, streptococci, staphylococci
- S/Sx: 3D’s:
Drooling
Dyspnea
Dysphagia
- Management:
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
4) O2 hood, Mist tent, Croupette, Cool O2
5) cephalosporin (Cefuroxime)
6) Prophylactic tracheostomy to prevent total obstruction
7) Prophylaxis for siblings
E. Asthma – chronic inflammatory disease of the airways

- S/Sx:
Difficulty exhaling Wheezing
Dyspnea Copious w/ white casts mucus
Long expiratory rate Dehydration
- Management:
1) Avoid cough suppressants
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
9
5) theophylline/aminophylline
> S/E: tachycardia
> A/E: hypotension
6) Increase fluid intake

> avoid milk & milk products (causes thick mucus & difficulty swallowing)
F. Pneumonia – infection & inflammation of alveoli

- Causes: Bacterial – pneumococcal, streptococcal, staphylococcal, chlamydial
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
Dullness on percussion Crackles
- Management:
a) ampicillin or 3rd gen cephalosporin
b) amoxicillin-clavulanate (Augmentin) – for penicillin resistant organisms
c) Bed rest
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 – RSV, myxovirus, adenovirus

- S/Sx:
Low grade fever Tachypnea
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
- 1st Classifications: (according to effect)

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 shunts)
2) Cyanotic – venous to arterial (unoxygenated to oxygenated or right to left shunts)
- 2nd Classifications: (addresses the hemodynamic & blood flow patterns)

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
10
> 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 pulmonary 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 – diagnostic of ASD
- Management:
1) Surgery – between 1-3 y/o
> put Silastic or Dacron patch
> post op: watch out for 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; prophylaxis for preterm infants
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

Systolic ejection murmur Widely split 2nd 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 Moderately loud systolic murmur

Headache No palpable femoral pulses
Leg pain Nodules on ribs – enlarge collateral arteries
Vertigo
- Management:
1) Angiography by balloon catheter
2) Surgery – digoxin & diuretics b4 surgery to reduce CHF (done by 2 y/o)
11
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 switc: 1 wk -3 mos age
4) Disorders w/ decreased pulmonary blood flow
a) Tetralogy of Fallot – with pulmonary stenosis, VSD, overriding of the aorta & right
ventricular hypertrophy
- S/Sx: Polycythemia Clubbing of fingers

Severe dyspnea Squatting/knee-chest position when resting
Growth restriction Tet spells/hypoxic episodes
- Management:
1) Blalock-Taussig procedure – no BP & venipunctures on right arm after
procedure
2) Keep hypoxic episode to minimum – O2, squatting/knee-chest, morphine or
propanolol
3) Brock procedure – repair pulmonary stenosis, VSD & overriding aorta
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
- Management:
1) penicillin – erythromycin
2) benzathine penicillin IM (Bicillin)
3) Corticosteroid: S/E: hirsutism, round moon face,  susceptibility to infection
4) Phenobarbital & diazepam: for chorea

1) Risk for nonadherance to drug therapy
Drug level must be maintained for 10-14 days
Prophylactic antibiotic therapy for atleast 5 yrs after initial attack
& when having dental or tonsillar surgery
C. Kawasaki Disease – mucocutaneous lymph node syndrome
> 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
- Management:
1) aspirin or ibuprofen
12
2) abciximab – platelet receptor inhibitor
3) IV Ig
4) Avoid steroids -  aneurysm formation

1) Risk for Ineffective Peripheral Tissue Perfusion
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

Provide rocking & holding
Protect edematous areas from pressure
Keep child free from heavy blankets or clothing
Use a soft padded toothbrush for brushing
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 or w/ respiratory infection that results in lowered O2
exchange & low arterial O2 level or after extremely strenuous exercise
- Management:
1) Pain relief – acetaminophen
2) Adequate hydration
3) Oxygenation
4) Hydroxyurea
5) Exchange transfusion

1) Ineffective Tissue Perfusion r/t generalized infarcts due to sickling
O2 therapy
Bed rest
B. Thalassemia Major/Cooley’s anemia – autosomal recessive anemia associated with abnormal beta
chains of adult hemoglobin
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
- Management:
a) Fresh whole blood or frozen plasma
b) desmopressin
13
2) Von Willebrand’s Disease/Angiohemophilia – inherited autosomal dominant
> with factor VII defect (platelets unable to aggregate)
- S/Sx: epistaxis (major problem)
heavy menstrual flow
- Management:
a) 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
- Management:
Cleft Lip: Cheiloplasty between 6-12 weeks
Cleft Palate: Uranoplasty between 1-2 y/o

1) Risk for Imbalance Nutrition, less than body requirements r/t feeding problems
*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 between feedings (keeps mucous membrane moist & prevents cracks &
fissures)
*Cleft palate
Commercial cleft palate nipple with rubber
Offer soft food (if surgery is delayed beyond 6 mos)
2) Risk for Ineffective Airway Clearance r/t oral surgery

Suction (be gentle, don’t touch suture lines)
3) Impaired Tissue Integrity at incision line r/t surgery
*Cleft lip
Turn infant lateral to the repair or on back (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
B. Tracheoesophageal Atresia & Fistula – trachea & esophagus are connected

Esophageal Atresia – obstruction of the esophagus
- Cause: Teratogens
- S/Sx: 3C’s
Coughing
Cyanosis
Choking
- Management:
14
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

1) Risk for Imbalance Nutrition, less than body requirements
Gastrostomy feeding
 after feeding: keep the end of the tube elevated with covered sterile gauze
2) Risk for Infection r/t aspiration

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
C. Gastroesophageal Reflux – called achalasia in infants

> cardiac sphincter & lower portion of the esophagus are lax & allow easy regurgitation
- S/Sx: Effortless vomiting

Irritable
Episodes of apnea
- Management:
1) Formula thickened rice cereal – 1 tbsp cereal/1 oz formula or breast milk
> hold infant in upright position & keep them upright in an infant chair for 1 hour
2) ranitidine or omeprazole
3) Tightening/suturing 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 fontanels, fever,  urine output, poor skin
turgor, weight loss
Alkalosis
Hypopnea – slowed respiration
Olive shaped mass
- Dx: Barium Swallow
- Management:
1) Pyloromyotomy – electrolyte imbalance, dehydration & starvation must be corrected first
2) No oral feedings

1) Risk for Fluid Volume Deficit r/t inability to retain food
Monitor weight & urine output
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 (URQ)
- Management:
1) Surgery
2) Instillation of water soluble solution, barium enema or air (pneumatic insufflation)
- Nursing Diagnosis:
15
1) Pain r/t abnormal abdominal peristalsis
2) Risk for Fluid Volume Deficit r/t bowel obstruction
F. Celiac Disease – sensitivity or abnormal immunologic response to gluten found in BROW (barley,
rye, wheat & oat)
- S/Sx: Steatorrhea Abdominal distention

Vit ADEK deficiency Malnutrition
- Management:
1) Gluten free diet for life
2) Water soluble forms of Vit A & D
3) Fe & folate

1) Imbalanced Nutrition, less than body requirements r/t malabsorption of food
Record characteristics of stools
Read food labels carefully
Avoid spaghetti, pizza, hotdogs, cake, cookies
G. Hirschsprung’s Disease/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

1) Constipation r/t reduced bowel function
Normal saline for enemas: 2 tsp noniodized salt + 1 quart water
2) Imbalanced Nutrition, less than body requirements

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
Failure to pass meconium in the 1st 24 hrs after birth
Absent “wink” reflex
Stool in vagina or urine

1) Imbalance Nutrition, less than body requirements r/t bowel obstruction and inability for
oral intake
NGT to relieve vomiting & pressure to abdominal organs
Low residue diet (rice cereal, strained fruits & vegetables)
2) Impaired Tissue Integrity at rectum r/t surgical incision

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
16
2) Meatotomy
3) Injectable 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 Prolonged PR interval
Vomiting Headache T wave inversion
Anorexia
- 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
- 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
- Nursing Diagnosis with Intervention:

1) Imbalanced Nutrition, less than body requirements r/t poor appetite & protein loss
Good protein & potassium intake
Monitor fluid intake
Monitor weight daily (same clothing, time & scale)
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; Corticosteroid; cyclophosphamide;
antihypertensives; symptomatic diuretics; K supplement
therapy for CHF
Diet Normal for age High protein, low sodium
Prevention Prevention or thorough tx of None known
GABHS infection
VII. Endocrine or Metabolic Disorders
A. PKU – autosomal recessive

> no phenylalanine hydroxylase:  phenylalanine in the blood
- Dx: Guthrie blood test
17
- 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. Cystic Fibrosis – w/ generalized dysfunction of the exocrine glands

> autosomal recessive trait
- Dx: Pilocarpine Iontophoresis: 60 mEq/L (+ Cystic Fibrosis)
- S/Sx: Tenacious secretions in pancreas & lungs

 Cl concentration of sweat – salty perspiration
Blocking of the vas deferens (tenacious seminal fluid)
Thick cervical secretions
Steatorrhea
Meconium ileus
Malnutrition
Fat soluble vitamin deficiencies
Respiratory acidosis

1) Risk for Imbalance Nutrition, less than body requirements r/t inability to digest fat
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) with meals or within 30 minutes
of eating
 add to a 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

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
- 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 Congenital Hip Dysplasia
18
> 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
TIPS 101
LATCH BREASTFEEDING CHARTING SYSTEM
LATCH 0 1 2
L Latch Too sleepy or reluctant Repeated attempts: Grasps breast: tongue
No latch achieved holds nipple in mouth: down: lips flanged:
stimulate to suck rhythmic sucking.
A Audible Swallowing NONE A few with stimulation Spontaneous and
intermittent under 24
hr old: spontaneous
and frequent over 24 hr
old
T Type of Nipple Inverted Flat Everted
C Comfort Engorged: cracked: Filling: reddened/ small Soft and non tender
bleeding: large blisters blister or bruises:
or bruises: severe mild/moderate
discomfort discomfort
H Hold Full assist ( staff holds Minimal assist ( ie. Place No assist from staff:
(positioning) infant at breast) pillows for support: mother able to
elevate head of bed) position/ hold baby by
teach one side, mother self
does other: staff holds
and then mother takes
over.
Silverman-Andersen Score.
A system for evaluation of breathing performance of premature infants. It consists of five items: (1) chest
retraction as compared withabdominal retraction during inhalation; (2) retraction of the lower intercostal
muscles; (3) xiphoid retraction; (4) flaring of the nares withinhalation; and (5) grunting on exhalation. Each
of the five factors is graded 0, 1, or 2. The sum of these factors yields the score.
Adequate ventilation is indicated by a 0, severe respiratory distress is indicated by a score of 10.
Score 10 = Severe respiratory distress

Score ≥ 7 = Impending respiratory failure
Score 0 = No respiratory distress
19
Feature observed 0 1 2
Chest Synchronized Lag on inspiration Seesaw respirations
respirations
movement
Intercostal NONE Just visible Marked
retraction
Xiphoid NONE Just visible Marked
retraction
Nares dilatation NONE Minimal Marked
Expiratory grunt NONE Audible by Audible by unaided

stethoscope ear
Clinical Criteria for Gestational Assessment

FINDING 0-36 weeks 37-38 weeks 39 and over
Sole creases Anterior transverse Occasional creases in Sole covered with

crease only anterior 2/3 creases
Breast Nodule 2 4 7
Scalp hair Fine and fuzzy Fine and Fuzzy Coarse and silky
Ear Lobe Pliable: no cartilage Some Cartilage Stiffened by thick

cartilage
Testes and Testes in lower canal: Intermediate Testes pendulous,

scrotum small: few scrotum full: extensive
Scrotum rugae rugae
20
ESSENTIAL NEWBORN CARE
DESIGNED BY: DOH
FOLLOWING INTERNATIONAL STANDARDS OF: WHO
UNDER THE UMBRELLA: UNANG YAKAP
IMMEDIATE INTERVENTIONS/TIME BOUNDED

STEP ONE Immediate drying
Using a clean, dry cloth, thoroughly dry the baby, wiping the face, eyes, head, front and back, arms and legs.
STEP TWO Uninterrupted skin-to-skin contact

Aside from the warmth and immediate bonding between mother and child, it has been found that early skin-to-
skin contact contributes to a host of medical benefits such as the overall success of breastfeeding/colostrum
feeding, stimulation of the mucosa—associated lymphoid tissue system, and colonization with maternal skin
flora that can protect the newborn from sepsis and other infectious disease and hypoglycemia.
STEP THREE Proper cord clamping and cutting

Waiting for up three minutes or until the pulsations stop is found to reduce to chances of anemia in full term and
pre-term babies. Evidence also shows that delaying cord clamping has no significant impact on the mother.
STEP FOUR Non-separation of the newborn from the mother for early breastfeeding initiation and rooming-in.
The earlier the baby breastfeeds, the lesser the risk of death. Keeping the baby latched on to the mother will not
only benefit the baby (see skin-to-skin contact) but will also prevent doing unnecessary procedures like putting
the newborn on a cold surface for examination (thereby exposing the baby to hypothermia), administering
glucose water or formula and foot printing (which increases risk of contamination from ink pads) and washing
(the WHO standard is to delay washing up to 6 hours; the vernix protects the newborn from infection). On the
other hand, necessary actions such as eye care, vitamin K administration must be timed. Eye care must be done
after the infant has located the mother’s breast.
NON-IMMEDIATE/NON-TIME BOUNDED
1. EYE CARE ( CREDES PROPHYLAXIS)

2. IMMUNIZATIONS (BCG/HEP B)
3. VITAMIN K ADMINISTRATION (IM/PO)
4. WEIGHING
5. WASHING
21

UPump Pediatric Nursing

Uploaded by

Copyright:

Available Formats

You might also like

UPump Pediatric Nursing

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

UPump Pediatric Nursing

Uploaded by

Copyright:

Available Formats

URS

Luzon. Visayas. Mindanao

CHILD HEALTH NURSING

I. Growth – increase in physical size of the body (quantitative change)

III. Stages of Growth & Development

Basic Divisions of Childhood

 Fear : Separation Anxiety

C. Pre school period

IV. Maternal-Infant bonding

B. Apgar Screening test (by Dr. Virginia Apgar)

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

Pre-mature Term Full-term

Pre-mature Full term

VI. Profile of a Newborn

VII. Physical Assessment

2. Posterior fontanel: triangular, 1 cm wide

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

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

5. Craniotables: localized softening of the cranial bones

D. Nose: nasal flaring indicates respiratory distress

VIII. Major Developmental Milestone

- Causes of Excess CSF: Overproduction of fluid by choroid plexus in 1 st or 2nd ventricle

- Nursing Diagnosis with Intervention/s:

B. Neural Tube Disorders

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

- Causes: Lack of folic acid

- Nursing Diagnosis with Intervention/s:

- Nursing Interventions: S afety

II. Respiratory Disorders

A. Pharyngitis – infection and inflammation of the throat

2) Streptococcal – caused by GABHS

B. Tonsillitis - infection and inflammation of the palatine tonsils

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

- Nursing Diagnosis with Intervention/s:

D. Epiglottitis – inflammation of the epiglottis

E. Asthma – chronic inflammatory disease of the airways

6) Increase fluid intake

F. Pneumonia – infection & inflammation of alveoli

1) Pneumococcal – abrupt, follows an URTI

2) Chlamydial – common in newborns up to 12 weeks

3) Viral – RSV, myxovirus, adenovirus

III. Cardiovascular Disorders

A. Congenital Heart Disorders

- 1st Classifications: (according to effect)

- 2nd Classifications: (addresses the hemodynamic & blood flow patterns)

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

- S/Sx: Easy fatigability

b) Atrial Septal Defect – abnormal communication between 2 atria

- S/Sx: Harsh systolic murmur

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

- S/Sx: Wide pulse pressure

2) Disorders with obstruction to blood flow

- S/Sx: Cyanosis Thrill

b) Aortic Stenosis – stricture of aortic valve

- S/Sx: Rough systolic murmur Chest pain

c) Coarctation of the Aorta – narrowing of the aorta

- S/Sx:  BP in heart & upper body Moderately loud systolic murmur

- S/Sx: Cyanotic birth