INTUSSUSCEPTION

GROUP 4 | CASE PRESENTATION WEEK 14

 CASE SCENARIO
A nine-month-old baby Elmo, who was formerly healthy, with a 36-hour history of vomiting after
every feed and one episode of blood-tinge per rectum. This was diagnosed as gastroenteritis in
primary care and oral rehydration of 50 to 100 ml after each BM therapy was advised. Prior to
this, he had a recent diarrheal illness.

The initial observations in the ED revealed a Temp of 37.7 °C; PR of 130 bpm; RR 36 cpm, Oxygen
saturation 98% and central capillary refill time of two seconds. PE revealed that he is not well
hydrated. He was uncomfortable when the doctor gently pressed on his abdomen and
noted a sausage shape mass on palpation. The parents report that Elmo will just suddenly cry
inconsolably with drawing up of the knees to the chest usually lasting for 10 minutes then
eventually will stop on his own. He was admitted in pedia ward, when after 6 hours after
admission he had vomited a yellow fluid, and passed blood-tinged per rectum and this time
Elmo continuously cried with drawing up of the knees to the chest and also look very tired.
 CASE SCENARIO
He was started on intravenous fluids of Lactate Ringers 100 ml/kg over 4 hours then 80 cc/hr for
the next 8 hours and was given an Aeknil 75 mg through IV. Blood investigations showed a C-
reactive protein level of 48mg/L but were otherwise within normal limits. A test for electrolytes
performed with the results potassium (K)-2.8 mEq/L, Sodium (Na) 129mEq/L. Abdominal X-
ray showed evidence of bowel obstruction. Although, the doctor knows that the clinical
history with the characteristic stools and physical findings are usually sufficiently typical for the
diagnosis, abdominal ultrasound scan was ordered, and Intussusception was confirmed.
Ultrasound-guided Hydrostatic (saline) enema was scheduled. Continue IV fluids, insert NGT
now, and Cefazolin 250 mg IV 1 hour prior to surgery
INTRODUCTION
According to Cleaveland Clinic
(2020). Intussusception is a
condition in which one segment
of intestine "telescopes" inside of
another, causing an intestinal
obstruction (blockage). Although
intussusception can occur
anywhere in the gastrointestinal
tract, it usually occurs at the
junction of the small and large
intestines. The obstruction can
cause swelling and inflammation
that can lead to intestinal injury.
 DISCUSS THE MAIN CONCEPT
INTUSSUSCEPTION IN THE FOLLOWING AREAS:
▪ Etiology/risk factors
▪ Clinical manifestations
▪ Diagnostic
▪ Management
▪ Possible complications

VILLANUEVA
 ETIOLOGY/RISK FACTOR

According to Hockenberry, Rodgers, & Wilson (2019), the exact cause of intussusception is
unknown.

RISK FACTORS FOR INTUSSUSCEPTION INCLUDE:

Idiopathic (75%-90% of cases) Underlying pathology

Most often occurs 5 months old to 3 3 Meckel's diverticulum (most common)
years old. But according to, Silbert-Flagg & Henoch-Schönlein purpura (causes
Pilliteri (2018), infants younger than 1 year thickening of the mucosa)
old. Lymphoma
Infection (causes Peyer's patch Intestinal polyps or tumors
enlargement):
Upper respiratory tract infection (30%),
Bacterial enteritis
Recent rotavirus immunization or
infection
CLINICAL MANIFESTATION DIAGNOSTIC TEST

Rectal Examination
Tender, distended abdomen
Aids to strengthen the diagnosis of
Inconsolable crying intussusception
Drawing up of knees on the chest Subjective or Objective Findings
Vomiting History
Palpable sausage-shaped mass in Abdominal X-ray
Target sign,
the abdomen
Crescent sign,
Currant jelly-like stool (blood stool} Absent liver edge sign
Lethargy Bowel obstruction
Child appearing normal and Barrium Enema
comfortable between episodes of This test consists of inserting liquid
barium into your rectum to obtain
pain
thorough X-ray picture of the lower
Sudden acute abdominal pain region of your small intestine.
 MANAGEMENT POSSIBLE COMPLICATION
Peritonitis
Non-surgical hydrostatic An infection of the lining of the
reduction (using enema or air abdominal cavity.
The blood flow to the affected part of the
pressure)
intestine can be cut off by
-This can help to push the intestine
intussusception. Lack of blood causes
back in normal. tissue in the intestinal wall to die if left
Not recommended if there are untreated. Tissue death can produce a
signs of perforation hole (perforation) in the intestinal wall,
resulting in an infection of the abdominal
Surgery: resection of non-viable
cavity lining (peritonitis).
portion (end to end anastomosis)
Abdominal destruction
NG decompression When left untreated, intestinal
IVF obstruction can cause the tissue in the
Antibiotic therapy affected part of the intestine
Intestinal bleeding
 PATHOPHSYIOLOGY
LEGEND:

ACEBEDO
DISEASE PROCESS
MANIFESTATION AND LABORATORIES
DIAGNOSIS
ETIOLOGY
BROKEN LINE - POSSIBLE COMPLICATION
 NON- MODIFIABLE FACTOR: MODIFIABLE FACTOR:

UNKNOWN ETIOLOGY

9-MONTH-OLD INFANT DIAGNOSED WITH

MALE GASTROENTERITIS

PROXIMAL SEGMENT OF THE BOWEL

FOLDS INTO A MORE DISTAL
SEGMENT,

TELESCOPING OF THE
BOWEL

THICKENING OF THE
RUQ PALPABLE OVERALL SIZE OF OBSTRUCTING THE PASSAGE ABDOMINAL DISTENTION
MASS AFFECTED AREA OF INTESTINAL CONTENTS

SAUSAGE SHAPE INTUSSUSCEPTION VAGUS NERVE STIMULATION

MASS ON
PALPATION

MESSENTERY AND THE SENDS SIGNAL TO THE BRAIN

VESSELS IS PULLED

TRIGGERS VOMITING REFLEX

THE MESENTERY IS
COMPRESSED AND ANGLED
 NON- MODIFIABLE FACTOR: MODIFIABLE FACTOR:

UNKNOWN ETIOLOGY

9-MONTH-OLD INFANT DIAGNOSED WITH

MALE GASTROENTERITIS

PROXIMAL SEGMENT OF THE BOWEL

FOLDS INTO A MORE DISTAL
SEGMENT,

TELESCOPING OF THE
BOWEL

THICKENING OF THE
RUQ PALPABLE OVERALL SIZE OF OBSTRUCTING THE PASSAGE
MASS AFFECTED AREA OF INTESTINAL CONTENTS

SAUSAGE SHAPE
MASS ON
PALPATION
NON- MODIFIABLE FACTOR: MODIFIABLE FACTOR:

UNKNOWN ETIOLOGY

9-MONTH-OLD INFANT DIAGNOSED WITH

MALE GASTROENTERITIS

PROXIMAL SEGMENT OF THE BOWEL

FOLDS INTO A MORE DISTAL
SEGMENT,

TELESCOPING OF THE
BOWEL

OBSTRUCTING THE PASSAGE ABDOMINAL DISTENTION

OF INTESTINAL CONTENTS

VAGUS NERVE STIMULATION

SENDS SIGNAL TO THE BRAIN

TRIGGERS VOMITING REFLEX

36-HOUR HISTORY OF
VOMITING AFTER FREQUENT VOMITING
EVERY FEED

NOT WELL STOMACH

HYDRATED IS EMPTY

REGURGITATION OF
THE BILE IN STOMACH

VOMITED A YELLOW
FLUID
 NON- MODIFIABLE FACTOR: MODIFIABLE FACTOR:

UNKNOWN ETIOLOGY

9-MONTH-OLD INFANT DIAGNOSED WITH

MALE GASTROENTERITIS

PROXIMAL SEGMENT OF THE BOWEL

FOLDS INTO A MORE DISTAL
SEGMENT,

TELESCOPING OF THE
BOWEL

THICKENING OF THE
RUQ PALPABLE OVERALL SIZE OF OBSTRUCTING THE PASSAGE ABDOMINAL DISTENTION
MASS AFFECTED AREA OF INTESTINAL CONTENTS

SAUSAGE SHAPE INTUSSUSCEPTION VAGUS NERVE STIMULATION

MASS ON
PALPATION

MESSENTERY AND THE SENDS SIGNAL TO THE BRAIN

VESSELS IS PULLED

TRIGGERS VOMITING REFLEX

THE MESENTERY IS
COMPRESSED AND ANGLED
 36-HOUR HISTORY OF
VOMITING AFTER FREQUENT VOMITING
EVERY FEED

NOT WELL STOMACH

HYDRATED IS EMPTY

REGURGITATION OF
THE BILE IN STOMACH

RECENT VOMITED A YELLOW

DIARRHEAL ENLARGED LYMPH NODE VENOUS OBSTRUCTION FLUID
ILLNESS DUE TO GASTROENTERITIS

SQUEEZES THE BLOOD

VESSEL
LYMPHATIC OBSTRUCTION

DECREASED BLOOD FLOW

IN THE AFFECTED AREA
INCREASES PRESSURE ON THE
WALL OF TRAPPED BOWEL
INCREASE VENOUS
PRESSURE
 VENOUS ENGORGEMENT

PRESSURE WITHIN THE AREA OF LEAKAGE OF BLOOD INTO

INTUSSUSCEPTION INCREASES INTESTINAL LUMEN

ARTERIAL BLOOD FLOW STOPS

ISCHEMIA

ANAEROBIC
METABOLISM

LACTIC ACID
PRODUCTION

STIMULATION OF
NOCICEPTORS INFARCTION IN
SOME PART OF THE
INTESTINE

PAIN
UNCOMFORTABLE FEELING SLOUGHING OFF OF
UPON PALPATION
INCONSOLABLE CRYING INTENSTINAL MUCOSA RED CURANT
WITH DRAWING UP OF THE AND POURING OF MUCUS JELLY STOOL
KNEES TO THE CHEST IN THE INTESTINAL LUMEN

PASSED BLOOD-
DUE TO CONTINOUS CRYING
THE BABY LOOKS TIRED TINGED PER
RECTUM
DESCRIBE THE IMPORTANCE OF
DIAGNOSTIC AND LABORATORY
TEST IN THE GIVEN SCENARIO

AMBEGUIA

PACLE
C-reactive Protein According to MedlinePlus (2020), a C-reactive protein
test or CRP measures the level of c-reactive protein in
Test (CRP) the blood.

Indication:

To determine any inflammation in the bowel.

Patient's case:

48mg/L protein level. Normal is less than 10mg/L

Analysis:

A high protein level may indicate inflammation in

the bowel/intestines however a CRP test doesn't
explain the cause or location of the inflammation
so further laboratory tests may be needed.
Electrolytes An electrolyte panel is often part of a routine blood
screening or a comprehensive metabolic panel. This
Panel Test panel measures levels of four minerals in the blood.
Electrolytes are important to the normal function of
the body. They help maintain healthy amounts of fluids
in the body and balance the pH in the blood.

Indication:
An electrolyte panel is a blood test to measure
electrolytes (minerals) in blood such as Potassium,
Sodium, Chloride, and Carbon dioxide

Patient's case:
Potassium is 2.8 mEq/L
Sodium is 129mEq/L
Normal Potassium level (3.5-5.0 mEq/L)
Normal Sodium level (135mEq/L -145mEq/L)
Electrolytes Analysis:
The patient have hypokalemia and Hyponatremia.
Panel Test As water is lost during vomiting, the delicate balance
of electrolytes is also altered, which can lead to
severe complications.
 According to Ansari (2021) Abdominal X-ray is a diagnostic
Abdominal Xray test that may show the intestinal obstruction. A radiologist
may see an increased density of the telescoped bowel or
other sights indicative of bowel obstruction.

Indication:
It is used to diagnose causes of abdominal pain. These
can include things such as masses, holes in the
intestine, or blockages.

Patient's case:
The test result shows evidence of bowel obstruction

Analysis:
On the imaging test shows, an obstruction in which a
loop of bowel has slipped into another section of
bowel, this may cause swelling, reduced blood flow
and tissue damage
 According to Dennis, Anupindi, Khwaja (2021) Ultrasound
is the gold standard for evaluating a suspected
Abdominal intussusception with a positive predictive value of 86.6%.

Ultrasound This imaging test uses sound waves and a computer to

generate images inside your body. An ultrasound does
not expose you to any radiation and can accurately
confirm, or rule out, intussusception in almost 100
percent of cases

Indication:
To confirm the diagnosis of the Intussusception

Patient's case:
There are no quantitative results indicated in the case
but the patient was diagnosed with Instussusception
 Analysis:
Abdominal Despite the evidence of the intussusception was
clear, the doctor ordered this test to further
Ultrasound strengthen and confirm the diagnosis of the
Intussuception
NURSING CARE PLAN
LOPEZ
ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

OBJECTIVE: Deficient SHORT TERM INDEPENDENT: INDEPENDENT SHORT TERM

History of 36- After 1 hour of nursing This may create After 1 hour of nursing
[isotonic] fluid
intervention the patient intervention the patient
hour after volume related Identify relevant fluid volume
will maintain fluid maintained fluid
every feed diagnoses depletion
to active fluid volume at functional volume at functional
and one
loss as level evidenced by level evidenced by
episode of individually adequate Determine the Infants and individually adequate
evidenced by
blood-tinge urinary output with effects of age, children have urinary output with
per rectum. vomiting after normal specific gravity, gender, weight, normal specific gravity,
relatively high
Vomited a every feeding stable vital signs, moist subcutaneous fat stable vital signs, moist
percentage of
yellow fluid and diarrheal mucous membranes, and muscle mass TBW, are sensitive
mucous membranes,
good skin turgor, and good skin turgor, and
Recent
illness.

to loss and are

prompt capillary refill. prompt capillary refill.

diarrheal less able to control
Illness their fluid loss Goal was met
Not well Y___ N___
hydrated To evaluate the Partially met?
Passed a Review laboratory Y___ N___
body’s response to
bloody stool data Not Met?
fluid loss and to Y___ N___
determine the Why?
replacement ______________
needs
ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Compare current To ensure an

fluid intake to fluid accurate picture of
goal. Monitor intake fluid status
and output (I&O)
balance

Assess skin and oral For signs of

mucous membranes dehydration, such
as dry skin and
mucous



membranes,
poor

skin turgor, delayed

capillary refill, and
flat neck veins

Weigh the client and To evaluate if the

compare with recent nursing intervention
weight history is effective
ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Assess vital signs, These changes in

noting low blood vital signs are
pressure—severe associated with
hypotension, rapid fluid volume loss
heartbeat, and and/or
thready peripheral hypovolemia.
pulses.

Observe/measure A number higher

urinary output than 1.25 is


(hourly/24-hr

totals). associated
with

Note the color and dehydration, with

note the color usual range being
1.010–1.025); color
may be dark
greenish brown
because of
concenration
ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Offer fluids on To increase the

regular basis for client’s daily fluid
patient intake.

Provide frequent To prevent injury

oral and eye care from dryness

Engage client, Significant others

family, and all should be involved
caregivers in fluid for the prevention or

management plan treatment of

dehydration and in
the planning and
provision of
adequate fluid on
DEPENDENT: daily basis
Administer
medication as DEPENDENT:
indicated by the To stop the fluid loss
physician
ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

SHORT TERM INDEPENDENT INDEPENDENT SHORT TERM

RISK FACTORS: Risk for shock
After 1 hour of nursing Assess for history or These conditions After 1 hour of nursing
related to intervention the intervention the
presence of deplete the body’s
HYPOVOLEMIA hypovolemia patient will display conditions leading circulating body patient displayed
hemodynamic stability to hypovolemic volume and ability hemodynamic stability
as evidenced by vital as evidenced by vital
shock to maintain organ
signs within normal signs within normal
perfusion and
range for client; range for client;
function
prompt capillary refill; prompt capillary refill;
adequate urinary adequate urinary
output with
normal Assess vital signs, For changes output with
normal

specific gravity; usual tissue and organ associated with specific gravity; usual
level of mentation perfusion shock states level of mentation

Monitor for Persistent or heavy Goal was met

Y___ N___
persistent or heavy fluid loss may lead
Partially met?
fluid loss, including to hypovolemic Y___ N___
wounds, drains, shock Not Met?
vomiting, Y___ N___
gastrointestinal Why?
______________
tube, chest tube.
ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Note for Skin Noting overall

color and flushing or pallor
moisture bluish lips and
fingernails, slow
capillary refill or
cool clammy skin

Reflecting
Note for Bowel
hypoperfusion of
sounds
gastrointestinal

tract

One of the most

sensitive
Note for Urine indicators of
output change in
circulating
volume or poor
perfusion
ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Note for Blood May indicate

pressure hypovolemia
and/or failure of
cardiac pumping
or compensatory
mechanisms.

Signs associated
Note for Pulses
with changes in
and neck veins -
circulating


noting
rapid,

volume, cardiac
weak, thready
ouput, and
peripheral
progressive
pulses;
changes in
congested or vascular tone
flat neck veins. and/or capillary
permeability
ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Review To identify
laboratory data potential sources
of shock and
degree of organ
involvement

DEPENDENT: DEPENDENT:
To rapidly restore
Administer fluid
or restore
electrolytes,
circulating


colloids,

blood

volume,
or blood
electrolyte
products as
balance and
indicated
prevent shock
state
ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

COLLABORATION COLLABORATION
Collaborate in To maximize
prompt systemic
treatment of circulation and
underlying tissue and organ
condition perfusion

To provide foods
Refer to
in nutrients,
nutritionist or
vitamins, and


dietician

minerals needed
to promote
healing and
support immune
system health
DRUGY STUDY
SUSA

VILLARUEL
 INDICATIONS
COMMON
NURSING

MECHANISM
CONTRAINDI

DRUG NAME OF DRUG

SIDE
CONSIDERATIO

OF ACTION CATION
RATIONALE EFFECTS N

GENERIC NAME: Antipyresis is

Treatment of
No
Headache. Check that the

Acetaminophen or
caused by the
fever and
contraindicati
Insomnia patient is not taking

Paracetamol any other

drug's
pain. on related to
(difficulty in
medication

BRAND NAME/S: influence on

patient’s case. sleeping) containing

Aeknil the
Paracetamol
Constipati paracetamol.
hypothalamu
is a mild
on
CLASSIFICATION
s; heat
analgesic and
Allergy Evaluate

: therapeutic

dissipation

is
antipyretic
Anxiety
Antipyretic and



response.

analgesic increased due

that is used to
Nausea
to
treat a variety
Tell the parents to

DOSAGE: vasodilation
of painful and
consult prescriber

75 mg and increased
febrile
before giving drug

to children younger

peripheral
symptoms.
FREQUENCY: than age 2.
blood flow.
ROUTE:
IV
 INDICATIONS
COMMON
NURSING

MECHANISM
CONTRAINDI

DRUG NAME OF DRUG

SIDE
CONSIDERATIO

OF ACTION CATION
RATIONALE EFFECTS N

Advise parents that

drug is only for

short term use.

 INDICATIONS
COMMON
NURSING

MECHANISM
CONTRAINDI

DRUG NAME OF DRUG

SIDE
CONSIDERATIO

OF ACTION CATION
RATIONALE EFFECTS N

Generic Name: Lactate Ringers is Use to replenish No Allerg -Monitor infusion

Dextrose 5% in Lactated the compensatory electrolyte Swelling of the site; input and

Ringer's Injection
contraindicati
base of lactic acid. balance, fluid, eyes, face or output, weight,

Under aerobic
ons related to
and also acts as Throat serum electrolyte

Brand Name: patient’s case.

physiologic alkalizing agent. Coughing levels (e.g. Na, K,

Lactated Ringer’s
conditions, the Sneezing Cl, Ca,

Solution
metabolism of RATIONALE: Difficulty bicarbonate), acid-

Classification:
glucose leads to Ringer's lactate breathing base balance, and

Alkalinizing Agents the production of solution, is an Fever osmolarity.

pyruvate
into isotonic, crystalloid Infection
at the

cellular fluid used for fluid

Dosage: injection site - Patients on any

replacement. Ringer's
(a.) 100 ml/kg respiration. Redness/red
lactate is made up of intravenous fluid

(b.) 80 cc/hr sodium, chloride, streaking and

replacement need

potassium, calcium, swelling from the

Frequency: and sodium lactate,
to be monitored for

injection site
(a.) over 4 hours which is combined fluid overload.
(b.) for the next 8 hours into a solution with an

osmolarity of 273

mOsm/L and a pH of
Route:

roughly 6.5.
Intravenously (IV)
 INDICATIONS
NURSING

MECHANISM
CONTRAIND
COMMON SIDE

DRUG NAME OF DRUG

CONSIDERATIO

OF ACTION ICATION EFFECTS

RATIONALE N
- Educate

patients and

families. Teach

patients and

families to

recognize signs

and symptoms of

fluid volume

overload. Instruct

patients to notify

their nurse if they

have trouble

breathing or

notice any

swelling.
 INDICATIONS
NURSING

MECHANISM
CONTRAIND
COMMON SIDE

DRUG NAME OF DRUG

CONSIDERATIO

OF ACTION ICATION EFFECTS

RATIONALE N

GENERIC NAME: It inhibits the To treat Hypersensitiv Fever Obtain culture

Cefazolin cell wall infection ity to Chills and sensitivity test
synthesis by Headache results, if possible
cefazolin,
BRAND NAME: binding specific Dyspnea and as ordered,
Ancef, kefzol Rationale: other Nausea before
penicillin-
This is to cephalospori Pain in injection administering the
binding protein
CLASSIFICATION prevent the ns or their site drug.
inside the
Cephalospirin patient from components Abdominal cramps
Antibiotic bacterial cell Diarrhea
wall. getting

Elevated liver

DOSAGE: Interrupting the infection by enzymes

250 mg third and last killing the Hepatic failure
stage of cell wall bacteria
ROUTE: synthesis.
IV
D
MOA

I
C

S
NURSING CONSIDERATION

Obtain culture and sensitivity test results, if possible and as

ordered, before administering the drug.

For direct I.V. injection, further dilute reconstituted solution with

at least 5 ml sterile water for injection. Inject slowly over 3 to 5
minutes through tubing of a flowing compatible I.V. solution.
Store reconstituted drug up to 24 hours at room temperature or
10 days refrigerated.

Monitor IV site for irritation, phlebitis

and extravasation.

Monitor fluid intake and output; decreasing urine output may

indicate nephrotoxicity.
D
MOA

I
C

S
NURSING CONSIDERATION

WOF evidence superinfection: cough, diarrhea, drainage, fever,

malaise, pain, perineal itching, rash, redness, and swelling.

Teach the patients parents that allergic reaction may occur a

few days after theraphy starts.

REFERENCES:
Cleaveland Clinic. (2020). Intussusception. Retrieved from:
https://my.clevelandclinic.org/health/diseases/10793-intussusception
Mayo Clinic. (2021). Intussuception. Retrieved from: https://www.mayoclinic.org/diseases-
conditions/intussusception/symptoms-causes/syc-20351452
Parswa Ansari ( 2021 September ) Intestinal Obstruction:
https://www.msdmanuals.com/professional/gastrointestinal-disorders/acute-abdomen-and-
surgical-gastroenterology/intestinal-obstruction
Rebecca Dennis, Sudha Anupindi, Asef Khwaja ( 2021 January 19 ) How to diagnose
Inussusception: https://www.appliedradiology.com/communities/Pediatric-Imaging/how-to-
diagnose-intussusception-in-children
Singh1, S., Kerndt2, C. C., & Davis3., D. (2021, September 2). ncbi.nlm.nih.gov. From *
https://www.ncbi.nlm.nih.gov/books/NBK500033/.
-https://www.mims.com/philippines/
-https://www.mayoclinic.org/drugs-supplements/lactated-ringers-intravenous-route/side-
effects/drg-20489612?p=1
-https://nurseslabs.com/iv-fluids
REFERENCES:
Hockenberry, M., Rodgers, C. C., & Wilson, D. (2019). Wong's Essentials of Pediatric Nursing (10th
edition). Elvesier Inc.
Silbert-Flagg, J., & Pilliteri, A. (2018). Maternal & Child Health Nursing: Care of the Childbearing
& Childrearing (8th. Edition). China: Wolters Kluwer.
 PEER REVIEW

QUESTION 1 PATHOPHYSIOLOGY LAB TEST NCP DRUG STUDY

ACEBEDO

AMBEGUIA

LOPEZ

MENDOZA

PACLE

SUSA

VILLANUEVA

VILLARUEL

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