PEDIATRIC NURSING

I. A. GROWTH AND DEVELOPMENT

Definition of Terms:
Growth – increase in physical size of a structure or whole quantitative structure

2 Parameters of Growth
1. Weight
- Most sensitive especially in low birth weight
- Weight doubles by 6 months
- Triples by 1 year
- Quadruples by 2 ½ year
2. Height
- Increase by 1 inch per month during first 6 months
- And ½ inch per month from 7 – 12 months

Development – increase in the skills or capacity to function qualitative change

How to Measure Development?

1. by simply observing a child doing specific task
2. by noting parent’s description of the child’s progress
3. by DDST (Denver Developmental Screening Test), MMDST (Metro Manila Developmental
Screening Test)
4 Main Rated Categories
1. Language – for communication
2. Personal Social
3. Fine Motor Adaptive – pre tensile ability (ability to use hand movement)
4. Gross Motor Skills – ability to use large body movement

Maturation – synonymous with development (readiness)

Cognitive Development – is the ability to learn and understand from experience, to acquire and
retain knowledge to respond to a new situation and to solve problems

I. B. BASIC DIVISION OF LIFE

1. Pre-Natal – begins at conception and ends at birth
2. Period of Infancy
- Neonatal (first 28 days or first 4 weeks)
- Formal Infancy (from 29th day to 1 year)
3. Early Childhood
- Toddler (1 – 3 years)
- Pre-School (4 – 6 years)
4. Middle Childhood – school age 7 – 12 years
5. Period of Adolescent
- Pre-Adolescent/Late childhood (11 – 13 years)
- Adolescent (12 – 21 years)
I. C. PRINCIPLE OF GROWTH AND DEVELOPMENT

1. Growth and Development is a continuous process that begins from conception and
ends with death.
Principle: womb to tomb
2. Not all parts of the body grow at the same time or at the same rate.
Patterns of Growth and Development
1. Renal, digestive, circulatory, Musculo-skeletal (childhood)
2. Neurologic Tissue
- Grows rapidly during 1 – 2 years of life
- Brain (achieve to its adult proportion by 5 years)
- Central Nervous System
- SC
3. Lymphatic System
- Lymph nodes, Spleen, Thymus
- Grows rapidly during infancy and childhood (to provide protection against infxn)
- Tonsils is achieved in 5 years
4. Reproductive Organ – grows rapidly during puberty

3. Each child is unique

2 Primary factors affecting Growth and Development

A. Heredity
Race
Intelligence
Sex
Nationality
B. Environment
Quality of nutrition
Socio-Economic status
Health
Ordinal position in family
Parent-Child relationship

4. Growth and Development occurs in a regular direction reflecting a definite and

predictable patterns or trends
A. Directional Trends – occurs in a regular direction reflecting the development of
neuromuscular functions: these apply to physical, mental, social and emotional
developments and includes:
a. Cephalo - caudal (head to tail)
- It occurs along bodies’ long axis in which control over head, mouth and eye
movements and precedes control over upper body torso and legs.
b. Proximo – distal (centro distal)
- Progressing from the center of the body to the extremeties
c. Symmetrical
- Each side of the body develop on the same direction at the same time at the
same rate
 d. Mass – specific (differentiation)
- In which the child learns from simple operations before complex function or
move from a broad general pattern of behavior to a more refined pattern.
B. Sequential – involves a predictable sequence of growth and development to which the
child normally passes.
a. Locomotion
b. Language and Social skills

C. Secular – refers to the worldwide trend of maturing earlier and growing larger as
compared to succeeding generations.
5. Behavior is a most comprehensive indicator of developmental status
6. Play is the universal language of a child
7. A great deal of skill and behavior is leaned by practice
8. There is an optimum time for initiation of experience or learning
9. Neonatal reflexes must be lost first before development can proceed
→ Persistent Primitive Infantile Reflex (suspect Cerebral Palsy)

I. D. THEORIES OF DEVELOPMENT

Development Tasks is a skill or growth responsibility arising at a particular time in the individual’s
life. The successful achievement of which will provide a foundation for the accomplishments of the
future tasks.
THEORISTS
1. Sigmund Freud (1856-1939) – an Austrian neurologist, Founder of psychoanalysis

PHASE OF PSYCHOSEXUAL THEORY

a. Oral Phase (0 – 18 months)
- Mouth is the site of gratification
- Biting, crying or sucking for enjoyment and to release tension
- Provide oral stimulation even the baby is NPO, offer pacifier
- Never discourage thumb sucking

b. Anal Phase (18 months – 3 years)

- Anus
- May show toilet training
- Elimination, defecation
- Principle of
- Holding on (child wins, hard headed, anti social and stubborn)
- Letting Go
- Mother wins (kind, perfectionist, obedient, obsessive – compulsive)

c. Phallic Phase (4 – 6 years)

- Genitals
- May show exhibitionism
- Accept the child fondling his own genital area as the normal area of exploration
- Answer the child’s question early
d. Latent Phase (7 – 12 years)
- Period of suppression
- Because there is no obvious development
- Child’s energy or libido is diverted to more concrete type of thinking
- Help child achieve positive experiences

e. Genital Phase (12 – 18 years)

- Achieved sexual maturity
- Learn to establish satisfactory relationship with opposite sex
- Give an opportunity to relate with opposite sex

2. Eric Erickson
- Trained in psychoanalysis theory
- Transits the importance of culture and society to their development of ones society
STAGES OF PSYCHOSOCIAL THEORY
Trust vs. Mistrust (0 – 18 months)
- Trust is the foundation of all psychosocial task
- To give and to receive is the psychosocial theme
- How trust is developed:
- Satisfy needs on time
- Care must be consistent and adequate
- Give and experience that will add to security (touch, hugs and kisses, eye to eye contact,
soft music
Autonomy vs. Shame and Doubt (18 months – 3 years)
- Autonomy is independence or self governance
- How autonomy is developed
- Give an opportunity for decision making such as offering choices
- Encourage the child to make decisions rather than judge
Initiative vs. Guilt (4 – 6 years)
- Learns to do basic things
- Activity recommended are modeling clay, finger painting
- Develop creativity and imagination to facilitate fine motor development
- How initiative is developed:
- Give an opportunity of exploring new places and events
Industry vs. Inferiority (7 – 12 years)
- Learn how to do things well
- How industry is developed:
- Give an opportunity no short assignment and projects
Identity vs. Role Confusion (12 – 20 years)
- Learn how he/she is or what kind of person he/she will become by adjusting to new body image
- Seeking emancipation or freedom from parents
Intimacy vs. Isolation (20 – 40 years)
- Focus on career or looking for lifetime partners

Generativity vs. Stagnation (40 – 60 years)

Ego Integrity vs. Despair (65 and above)

3. Jean Piaget – a Swiss psychologist
STAGES OF COGNITIVE DEVELOPMENT
A. Sensorimotor (0 – 2 years)
- Practical intelligence because words and symbols are not applicable
- Babies are communicating through sense and reflex

SCHEMA AGE BEHAVIOR

Neonatal Reflex 1 month - All reflexes

Primary Circular Reaction
Secondary Circular Reaction
Coordination of Secondary
Tertiary Circular Reaction
Invention of new means thru
mental combination
1 – 4 months - Activities related to bodies
repetition of behavior (thumb
sucking)
4 – 8 months - Activity not related to body
- Discover object or persons code
and code memory arises
- Anticipate familiar events
8 – 12 months - Exhibit goal directed behavior
- Increase sense of separateness
12 – 18 months (1 – 1 ½ year) - Use trial and error to discover
change of places and events
- Code and Code invention of new
means
- Capable of space and time
perception
18 – 24 months - Transitional phase to operational
period

B. Preoperational Thought 2 – 7 years old

SCHEMA AGE BEHAVIOR
Pre-conceptual 2- 4 years - Egocentric (unable to view
another point of view)
- Their thinking is basically
concrete and static
- Their concept of time is only
now and their concept of distance
is only as far as they can see
Intuitive 4 – 7 years - Not yet aware of the concept of
reversibility
- Concept of animism (inanimate
object is alive)

C. Concrete Operational (7 – 12 years)

- Can find solutions to everyday problems with systemic reasoning
- They have concept of reversibility
- Activity recommended is collecting and classifying

D. Formal Operational (12 and above)

- Period when cognition has achieved its final form
- They are capable
- Can find scientific reasoning (can deal with the past, present and future)
- Capable of abstract and mature thought
- Do abstraction by talk time that will sort
4. Kohlberg (1984) – recognized the theory of moral development as considered closely to approximate
cognitive stages of development
STAGES OF MORAL DEVELOPMENT
INFANCY
Age (Year) Description
Preconventional Stage
2-3 (Level I)
1 Punishment/obedience orientation (“heteronomous
morality”). Child does right because a parent tells
him/her to and to avoid punishment.
4-7
2 Individualism. Instrumental purpose and exchange.
Carries out action to satisfy own needs rather than
society. Will do something for another if that person
do something for the child

Conventional (Level II)

7-10 3 Orientation to interpersonal relations
of mutuality. Child follows rules because of a need
to be a “good” person in own eyes and the eyes of
10-2 4 others.
Maintenance of social order, fixed rules and
authority. Childs finds following rules satisfying.
Follows rules of Authority figures as well as parents
in an effort to keep the “system” working

Postconventional (Level III)

Older than 12 5 Social contract, utilitarian law-making perspectives.
Follows standards of society for the good of all
people

6 Universal ethical Principle orientation. Follows

internalized standards of conduct.

I. E. DEVELOPMENTAL MILESTONE
PERIOD OF INFANCY
a. Play
- Solitary play
- Non interactive
- Priority is safety
- Age who appreciate teddy bears
- Attitude: proper hygiene
b. Fear
- Stranger anxiety
- Begin at 6 – 7 months
- Peak at 8 months
- Diminish by 9 months
c. Milestones
E.I Neonate
- Largely reflex
- Complete head lag
- Hands fisted
- Cry without tears (due to immature larcrimal duct)
- Visual fixation of human face

1 MONTH
- Dance reflex disappears
- Looks at mobile objects

2 MONTHS
- Holds head up when in prone
- Social smile
- Baby “coos”
- Cry with tears
- Closure of posterior fontanel by 2 – 3 months
- Head lag when pulled to a sitting position

3 MONTHS
- Holds head and chest when in prone
- Follow object past midline
- Grasp and tonic neck reflex are fading
- Hand regards (3 months)

4 MONTHS
- Turns from front to back
- Head control complete
- Bubbling sounds
- Needs space to turn
- Laugh aloud

5 MONTHS
- Roll over
- Turn both ways
- Teething rings
- Handles rattle well
- Moro reflex disappear by 4 – 5 months

6 MONTHS
- Reaches outs in anticipation of being picked up
- Handle bottle well
- Sits with support
- Uses palmar grasp by 6 months
- Eruption of first temporary teeth (2 lower incisors)
- Says vowel sounds “Ah, ah”
7 MONTHS
- Transfer objects hand to hand
- Beginning fear of stranger
- Likes objects that are good sized

8 MONTHS
- Sits with support
- Peak of stranger anxiety
- Plantar reflex disappear

9 MONTHS
- Creeps/crawl
- Needs space for creeping
- Pincer grasp reflex
- Combine two syllables “Papa, Mama”
- Priority: safety

10 MONTHS
- Pull self to stand
- Understand word “No”
- Respond to own name
- Peak – a – boo
- Pat a cake since they can clap

11 MONTHS
- Cruises
- Stand with assistance
12 MONTHS
- Stand alone
- Take first step
- Walk with assistance
- Drink from a cup
- Cooperate in dressing
- Says the 2 words “Mama, Papa”
- Toys: pots and pans, pull toy and learn nursery rhymes

E.2. TODDLER
a. Play
- Parallel (2 toddlers playing separately)
- Provide two similar toys (squawky squeeze toy)
- Waddling duck to pull, pull truck, building block and pounding peg
b. Fear
- Separation anxiety
- Do not prolong goodbye, say goodbye firmly
- 3 Phases of separation anxiety
a. Protest
b. Despair
 c. Denial

c. Milestones
15 months
- Plateau stage
- Walks alone (delay in walking maybe a sign of mental retardation)
- Puts small pellets into small bottle
- Scribbles voluntarily with pencil
- Holds a spoon well
- Seat self on chair
- Creep upstairs
- Speaks 4 – 6 words

18 months
- Hide of possessiveness
- Bowel control achieved
- No longer rotates a spoon
- Run and jump in place
- Walk up and down stairs holding on (typically places both feet on one step before advancing)
- Able to name body part
- Speaks 7 – 20 words
24 months
- Can open doors by turning doorknobs
- Unscrew lids
- Walk upstairs alone by still using both feet on the same step at same time
- Daytime bladder control
- Speak 50 – 200 words

30 months
- 3 year old do tooth brushing with little supervision
- 2 – 3 year old is the right time to bring to the dentist
- Temporary teeth complete and last temporary teeth to appear is the posterior molars
- 20 deciduous teeth by age 2 ½ years
- Can make simple lines or stroke for crosses with a pencil
- Can jump down from the stairs
- Knows full name
- Copy a circle
- Holds up fingers

36 months
- Trusting three
- Able to unbutton
- Draw a cross
- Learns how to share
- Full name and sex
- speak fluently
- Right time for bladder control (night time control)
- Able to ride a tricycle
- Speak 300 – 400 words
- Clues for toilet training
a. Can stand, squat and walk alone
b. Can communicate toilet needs
c. Can maintain himself dry with interval of 2 hours

d. Character Traits
- Negativistic likes to say no (it is their way to search independence)
- Limit questions and offer options
- Temper tantrums (stomping feet and screaming)
- Ignore the behavior
- Rigid ritualistic: stereotype
- Cause: mastering
- Protruded abdomen
- Cause:
- Under development of abdomen
- Unsteady gait
- Physiologic anorexia (give foods that last for a short period of time)

E.3. PRE-SCHOOL
a. Play
- Associative play, Cooperative play
- Play house
- Role playing

b. Fear
- Body mutilation or castration fear
- Dark places and witches
- Thunder and lighting

c. Milestone
4 years
- Furious four (noisy and aggressive)
- Able to button
- Copy a square
- Lace shoes
- Know the 4 basic colors
- Vocabulary of 1500 words

5 years
- Frustrating five
- Copy a triangle
- Draw a 6 part
- Imaginary playmates
- 2100 words

d. Character Traits
- Curious
- Creative
- Imaginative
- Imitative
- Why and How

e. Behavior Problems
- Telling tall tales (over imagination)
- Imaginary friends (purpose: release their anxiety and tension)
- Sibling rivalry (jealousy to a newly delivered baby)
- Bed wetting
- Baby talk
- Fetal position
- Masturbation is a sign of boredom and should divert their attention

E.4. SCHOOL AGE (7 YEARS)

a. Play
- Competitive play
- Tug – o – war

b. Fear
- School phobia
- To prevent phobia orient child to new environment
- Displacement from school
- Significant person is the teacher and peer of the same sex
- Loss of privacy
- Fear of death

c. Significant Development
- Prone to bone fracture (green stick fracture)
- Mature vision
d. Milestones
6 years
- Temporary teeth begins to fall
- Permanent teeth begins to appear (first molar)
- Year of constant motion
- Clumsy movement
- Recognizes all shapes
- Teacher becomes authority figure that may result to nail biting
- Beginning interest with God

7 years
- Age of assimilation
- Copy a diamond
- Enjoys teasing and play alone
- Quieting down period

8 years
- Expansive age
- Smoother movement
- Normal homosexual
- Love to collect objects
- Count backwards

9 years
- Coordination improves
- Tells time correctly
- Hero worship
- Stealing and lying are common
- Takes care of body needs completely
- Teacher find this group difficult to handle

10 years
- Age of special talents
- Writes legibly
- Ready for competitive sports
- More considerate and cooperative
- Joins organization
- Well mannered with adults
- Critical of adults

11-12 years
- Pre adolescent
- Full of energy and constantly active
- Secret language are common
- Share with friends about their secrets
- Sense of humor present
- Social and cooperative

e. Character Traits
- Industrious
- Love to collect objects
- Cant bear to loose they will cheat
- They are modest
SIGNS OF SEXUAL MATURITY
Girls Boys
Increase size of breast and genetalia Appearance of axillary and pubic hair
Widening of hips Deepening of voice
Appearance of axillary and pubic hair Development of muscles
Menarch (last sign) Increase in size of testes and scrotum (1st sign)
- telarch is the 1st sign of sexual maturity Production of viable sperm (last sign)

E.5. ADOLESCENT PERIOD

- They have distinctive odor because of the stimulation of apocrine gland
- They have nocturnal emission (wet dreams) the hallmark for adolescent
- Testes and scrotum increase in size until age 17
- Sperm also viable
- Breast and female genetalia increase until age 18

a. Fear
- Acne
- Obesity
- Homosexuality
- Death
- Replacement from friends

b. Significant Person
- Peer of opposite sex

c. Significant Development
- Experiences conflict between his needs for sexual satisfaction and societies expectations
- Core concern is change of body image and acceptance from the opposite sex

d. Personality Trait
- Idealistic (parent-child conflict begins)
- Rebellious
- Very conscious with body image
- Reformer
- Adventuresome

e. Problems
- Vehicular accident
- Smoking
- Alcoholism
- Drug addiction
- Pre marital sex

IMMEDIATE CARE OF THE NEWBORN

A. THE 8 PRIORITIES OF THE NEWBORN IN THE FIRST DAY OF LIFE

1. Initiation and Maintenance of respiration

2. Establishment of extra uterine circulation
3. Control of body temperature
4. Intake of adequate nourishment
5. Establishment of waste elimination
6. Prevention of infection
7. Establishment of an infant-parent relationship
8. Development care that balances rest and stimulation for mental development
1. Initiation and Maintenance of respiration
Alerts
- Second stage of labor initiate airway
- Initiation of airway is a crucial adjustment among newborn
- Most neonatal deaths with in the first 24 – 48 hours is primarily the inability to initiate airway
- Lung function begins only after birth
How
A. Removal of secretions by proper suctioning

B. Proper Suctioning of catheter

- Place baby’s head to side to facilitate drainage
- Suction nose first because neonates are nasal obligates
- Suction for 5 – 10 seconds and should be gentle and quick because prolong deep suctioning may result
to hypoxia, bradycardia (caused by vagal nerve stimulation) and laryngospasm

C. If not effective, requires effective laryngoscopy to open the airway. After deep suctioning, an
endotracheal tube can be inserted and oxygen can be administered by a positive pressure bag and mask
with 100% oxygen at 40 – 60 b/min.

Nursing Alerts:
- No smoking sign to prevent combustion
- Always humidify to prevent drying of mucosa
- Mask should cover nose and mouth
- Overdosage of oxygen may lead to scaring of retina which may lead to blindness called
RETROLENTAL FIBROPLASIAS (retinopathy of prematurity)
- When meconium stained never administer oxygen because pressure will force meconium to the alveolar
sac and cause atelectasis

2. Establishing extrauterine circulation

Alerts: circulation is initiated by pulmonary ventilation and is completed by cutting of cord

THE FETO-PLACENTAL CIRCULATION

Placenta (via simple diffusion) – oxygenated blood is carried by the vein – liver – Ductus venosus
Inferior vena cava – right atrium – 70% shunted to Foramen ovale - left atrium – mitral valve – left
ventricle – aorta – lower extremities.

The remaining 30% - tricuspid valve – right ventricle – pulmonary artery – lungs (for nutrition) –
vasoconstriction of the lungs pushes the blood to the Ductus arteriosus to aorta to supply the
extremities. The two arteries carry the unoxygenated blood back to the placenta for reoxygenation.

Alerts: Increase pressure on the left side of heart causes closure of foramen ovale

SHUNTS
1. Ductus Venosus – shunt from umbilical vein to inferior vena cava
2. Foramen Ovale – shunt between 2 atria (begin to close within 24 hours)
3. Ductus Arteriosus – shunt from pulmonary artery to aorta (begin to close within 24 hours)

A. 2 Way to facilitate Closure-of Foramen-ovale

1. Tangential foot slap
- So baby will cry to expand lungs
- Never stimulate baby to cry when not yet properly suctioned
- Check characteristics of cry (strong vigorous and lusty cry)
- Cri – du – chat (meow cry)
2. Proper Positioning
- Right side lying
STRUCTURE APPROPRIATE TIME STRUCTURE FAILURE TO CLOSE
OF OBLITERATION REMAINING
Foramen Ovale 24 hours complete by 1 Fossa Ovalis Atrial Septal Defect
year
Ductus Arteriosus 24 hours complete by 1 Ligamentum Arteriosum Patent Ductus Arteriosus
month
Ductus Venosus 2 months Ligamentum Venosum
Umbilical Arteries 2 – 3 months Lateral Umbilical
Ligament
Inferior Iliac Artery
Umbilical Vein 2 – 3 months Lateral Umbilical
Ligament
Inferior Iliac Artery
Ligamentum Teres
(round ligament of liver)

B. Best position immediately after birth:

NSD – trendelendberg
CS – supine or crib level position

Signs of increase ICP

1. Abnormally large head
2. Bulging and tense fontanel
3. Projectile vomiting (surest sign of cerebral irritation)
4. Increase blood pressure but widening pulse pressure
5. Decrease respiratory rate
6. Decrease pulse rate
7. High pitch shrill cry (late sign)
8. Diplopia (sign of ICP from 6 months – 1 year)

3. Temperature Regulation
Alerts:
- The goal in temperature regulation is to maintain it not less than 97.7 oF – 36.5 oC
- Maintenance of temperature is important for preterm and SGA because it may lead to hypothermia or
cold stress
A. Factors Leading to the development of Hypothermia
1. Preterm are born poikilothermic (cold blooded) they easily adapt to temperature of environment due
to immaturity of thermo regulating system of body
2. Inadequate subcutaneous tissue
3. Newborns are not yet capable of shivering (increase basal metabolism)
4. Babies are born wet
B. Process of Heat Loss
1. Evaporation – body to air
2. Conduction – body to cold solid object
3. Convection – body to cooler surrounding air
4. Radiation – body to cold object not in contact with body
C. Effects of Hypothermia (Cold Stress)
1. Hypoglycemia – due to utilization of glucose (40 – 45 gm/dl is the normal blood sugar of a newborn)
2. Metabolic Acidosis – due to catabolism of brown fats (best insulator of a newborn)
3. High risk for KERNICTERUS (bilirubin in brain)
4. Additional fatigue to already stressful heart

D. Prevention of Cold Stress

1. Dry and wrapped newborns
2. Mechanical measures
- Radiant warmer
- Isolette (square acrylic sided incubator, must be pre heated first)
3. Prevent unnecessary exposure – cover areas not being examined
4. Use tin foil in absence of electricity
5. Embrace baby (called kangaroo care)

4. Establish Adequate Nutritional Intake

Alerts: Breastfeed immediately for NSD and after 4 hours for CS (Colostrum is present on the 3 rd trimester)

A. Physiology of Breast milk Production

- Decrease in level of estrogen and progestin, stimulates the anterior pituitary gland, that
stimulates the prolactin of the acinar cells (alveoli) to produce the foremilk stored in lactiferous
tubules

B. Advantage of Breastfeeding
- Very economical
- Always available
- Promotes bonding
- Helps in rapid involution
- Decrease incidence of breast cancer
- Breast fed babies has higher IQ
- It contains anti body (IgA) lactobacillus bifidus that interfere attack of pathogenic bacteria in GIT
- Contains macrophages (store in plastic container, good for 6 months when stored in freezer)
- Disadvantages of breast milk and cow’s milk
- Both has no iron
- Possibility of transfer of HIV, Hepatitis B
- Father cannot feed or bond as well

C. Stages of Breastmilk
1. Colostrum – available 2 – 4 days after delivery
Contents:
- Low fats
- Low carbohydrates
- High protein
- High immunoglobulin
- High minerals
- High fat-soluble vitamins

2. Transitional – covering 4 – 14 days

Contents:
- High lactose
- High minerals
- High water soluble vitamins

3. Mature milk – 14 days and above

Contents:
- High fats (linoleic acid responsible for integrity of skin and development of skin)
- High carbohydrates (lactose, easily digested, responsible for sour milk smelling odor of stool)
- Low protein (lactalbumin)

D. Cow’s milk
Contents:
- High fats
- Low carbohydrates (add sugar)
- High protein (casein) has a curd that is hard to digest
- High minerals, has traumatic effect on kidneys of baby
- High phosphorus that may cause inverse proportion with calcium

E. Health Teachings
1. Proper Hygiene
- Importance of hand washing
- Removal of caked colostrum
2. Position
- Upright sitting avoid tension to properly empty breast milk
3. Stimulate and evaluate feeding reflexes
a. Rooting
- touch side of lips or cheek and baby will turn to the stimulus
- purpose: to look for food
- disappear at 6 weeks because baby can already focus
b. Sucking
- by touching the middle of lips then baby will suck
- purpose: take in food
- disappear at 6 months
- easily disappear when not stimulated
c. Swallowing
- food touches posterior portion of tongue automatically swallowed
- never disappear cough, gag, sneeze
d. Extrusion/Protrusion reflex
- food touches anterior portion of tongue and tongue automatically extruded/protruded
- purpose: prevent from poisoning
- disappear by 4 months because baby can already spit out
4. The criteria of effective sucking
a. baby’s mouth is hike well up to areola
b. mother experiences after pain
c. other nipple is flowing with milk

5. To prevent from crack nipples and initiate proper production of oxytocin

- begin 2 – 3 minutes per breast
- increase 1 minute per day each breast until you reach 10 minutes each breast or 20 minutes per feeding
6. For proper emptying and continuous milk production per feeding
- feed baby on the last breast that you fed him

PROBLEMS EXPERIENCED IN BREASTFEEDING

a. Engorgement
- soft and non tender (1 day)
- feeling of tension and fullness of breast
- while feeding warm compress
- bottle feeding cold compress and wear supportive bra
b. Sore nipple
- cracked, wet and painful nipple
- exposure to air is the management or 20 watt bulb
- avoid wearing plastic liner bra, instead wear cotton bra
c. Mastitis
- inflammation of breast
- causative factor: staphylococcus aureus
- improper breast emptying
- unhealthy sexual practices
- breast feed on unaffected breast
- express your breast on affected side
- take antibiotic
- increase 500 calories when breastfeeding
- involution of breast is 4 weeks

CONTRAINDICATIONS IN BREASTFEEDING
Maternal Conditions
- HIV, Hepatitis B, CMV, comadin/warfarin sulfate intake

Newborn Conditions
- erythroblastosis fetalis
- hydrops fetalis
- phenylketonuria (PKU)
- galactosemia
- tay-sachs disease

5. Establishment of waste-elimination

A. Different stools
1. Meconium
- Physiologic stool
- Blackish green
- Sticky
- Tar like
- Odorless (because of sterile intestines)
- No bacteria
- Passed with in 24 – 36 hours
- Failure to pass meconium suspect GIT obstruction
a. hirschsprung
 b. imperforate anus
c. meconium ileu (cystic fibrosis)

2. Transitional
- Become green, loose and slimy that may appear to be a slight diarrhea to the untrained eye

3. Breastfed stool
- Golden yellow, soft, mushy with sour milk smelling odor frequently passed occurring almost nearly every
feeding

4. Bottle-fed stool
- Light yellow, formed, hard with a typical offensive odor seldom passed 2 – 3 times a day

5. With supplementary foods added

- Brown and odorous

B. Indication of Stool Changes

- Light stool: jaundice baby
- Bright green: phototherapy
- Mucous mixed with stool: allergy
- Clay colored: obstruction to bile duct
- Chalk clay/whitish clay: barium enema
- Black stool: GIT hemorrhage
- Blood flecked: anal fissure
- Curant jelly: intususeption
- Ribbon like: hirschsprung
- Steatorrhea: fatty, bulky, foul smelling – suspect malabsorption a case of cystic fibrosis or celiac
disease

ASSESSMENT FOR WELL-BEING

A. APGAR SCORING
Special Considerations
- Taken on first 1 minute, shows the general condition of baby
- 15 minutes is optional
- Taken again after 5 minutes, to determine baby’s capability to adapt/ adjust extrauterinely
Components
Appearance
- Color: slightly cyanotic, after first cry baby becomes pinkish
Pulse rate
- Apical pulse (left lower nipple)
Grimace
- Reflex irritability (foot slap, catheter insertion)
Activity
- Degree of flexion (muscle tone)
Respiration

APGAR SCORING CHART

Score
Criteria 0 1 2
 Heart rate Absent Less than 100 More than 100
Respiratory effort Absent Slow irregular weak cry Good strong cry
Muscle tone Flaccid extremities Some flexion Well flexed
Reflex irritability
Catheter No response Grimace Cough or sneeze
Tangential Footslap No response Grimace Cry
Color Blue/Pale Acrocyanosis Pink
(body and extremities
blue)

Interpretation of APGAR Result

0-3: severely depressed, need CPR, admission to NICU
4-6: moderately depressed, additional suction and oxygen administration
7-10: good/healthy

CARDIO PULMONARY-RESUSCITATION
Airway (Clear Airway)
1. Shake, no response call for help
2. Place flat on bed
3. Head tilt – chin lift maneuver
- Contraindicated to spinal cord injury
- Over extension may occlude airway
Breathing (Ventilating the lungs)
4. Check for breathlessness
5. Administer 2 rescue breaths
Circulation (by cardiac compression)
6. Check for pulselessness
7. Do CPR (when breathless and pulse less)

B. RESPIRATION EVALUATION
SILVERMAN ANDERSON INDEX CHART
Score
Criteria 0 1 2
Chest movement Synchronized Lag on respiration See saw
Intercostal retraction No retractions Just visible Marked
Xiphoid retraction None Just visible Marked
Nares dilation None Minimal Marked
Expiratory grunt None Stethoscope Naked ear

Interpretation of Result
0 – 3: Normal no respiratory distress syndrome
4 – 6: Moderate RDS
7 – 10: Severe RDS

C. ASSESSMENT OF GESTATIONAL AGE

BALLARD AND DOBOWITZ CLINICAL CRITERIA
Gestational Age (Weeks)
 Findings Less THAN 36 37-38 39 and up
Sole creases Anterior transverse Occasional creases in Sole covered with
crease only 2/3 creases
Breast nodule (dm.) 2 mm 4mm or 3 – 5 mm 7 mm – 7.5 mm
Scalp hair Fine and fuzzy Fine and fuzzy Coarse and silky
Ear Lobe Pliable Some Thick
Testes Scrotum Testes and scrotum in Intermediate Testes pendulous,
lower canal, scrotum is scrotum full with
small with few rugae extensive rugae

PRE TERM BABIES

- 28 – 32 weeks
- Frog leg or lax position
- Hypotonic muscle tone
- Scarf sign (elbow passes the midline)
- Square window wrist (90o angle)
- Heel to ear sign
- Abundant lanugo
- Prominent labia minora and clitoris

POST TERM BABIES

- More than 42 weeks
- Old mans face (classic sign)
- Desquamation (peeling of neonate skin characterized by extreme dryness than begin from sole and palm
within 24 hours

D. Neonate in the Nursery

*Special and Immediate Interventions
1. Upon receiving
- Proper identification (foot print with mothers thumb print)
- Take antropometric measurement

2. Then take anthropometric measurements

a. Length = 19.5 – 21 inches/47.5 – 53.75 cm average of 50 cm
b. Head Circumference = 33 – 35 cm average of 34 cm/13 – 14 inches
c. Chest Circumference = 31 – 33 cm average of 32 cm/12 – 13 inches
d. Abdominal Circumference = 31 – 33 cm average of 32 cm/12 – 13 inches

3. Bathing Baby
- Normal oil bath
- Cleanse and spread vernix
- Babies of HIV positive mothers are given full bath to lessen transmission of infection
- Insulator
- Bacteriostatic
- Full bath is safely given when cord falls

4. Dressing the umbilical cord

- Follow strict asepsis to prevent infection/tetanus
- Use Povidone iodine
- Check for 3 vessels (2 arteries and 1 vein)
- AVA (2 vessel cord suspect kidney malformation)
- Leave about 1 inch of cord
- 8 inches if anticipating IV or BT
- Check for the cord q 15 minutes for the first 6 hours
- For bleeding:
- 30 cc is bleeding to newborn
- Hemophilia is excessive bleeding
- Ompalagia is bleeding of the cord
- Cord turns black on the third day
- Falls by 7th – 10th day
- Failure to fall is umbilical granulation (silver nitrate)
- Use saline to clean

5. Credes Prophylaxis
- Purpose: prevent opthalmia neonatorum (use erythromycine ophthalmic ointment)

6. Administration of Vitamin K
- Action: prevent hemorrhage
- Related to physiologic hypoprothrombinemia
- Give Aquamephyton, phytomenadione, konakoib (.5 – 1.5 mg, IM)

7. Weight-taking
Normal Weight: 3000 – 3400 grams/3 – 3.4 kg/6.5 – 7.5 lbs
Arbitrary Lower Limit: 2500 grams
Low Birth Weight: below 2500 grams
Small for Gestational Age: less 10 percentile rank
Large for Gestational Age: more than 90 percentile rank
Appropriate for Gestational Age: within the 2 standard deviation of the mean
Physiological Weight Loss: 5 – 10 percent occurs a few days after birth

E. PHYSICAL EXAMINATION AND DEVIATIONS FROM THE NORMAL

A. Important Considerations
a. If the client is new born, cover areas that is not being examined
b. If the client is infant, the first vital sign to take is RR (due to fear of stranger)
- Begin at east intrusive to the most intrusive
c. If the client is toddler and preschool, let them handle an instrument play syringe, stethoscope,
d. If the client is school age and adolescent explain procedure
COMPONENTS:
1. Vital signs
- Temperature is taken rectally to rule out imperforate anus and thermometer is inserted 1 inch
- Don’t force insertion because it may lead to pruritus
- Types of imperforate anus
a. Atretic – no anal opening, causing failure to pass meconium
b. Agenetic
- no anal opening, causing failure to pass meconium
- abdominal distention
- foul smelling stool
- vomitus of fecal materials
- respiratory problems
- Management: surgery with temporary colostomy
c. Membranous

CARDIAC RATE 120-160/min

- Irregular
- Radial pulse is absent, if present suspect PDA