PEDIATRIC NURSING C.

Lymphatic System
A. GROWTH AND DEVELOPMENT - Lymph nodes, Spleen, Thymus
Definition of Terms: - Grows rapidly during infancy and childhood (to provide
 Growth– increase in physical size of a structure or whole protection against infection)
quantitative structure - Tonsils is achieved in 5 years

Parameters of Growth D. Reproductive Organ – grows rapidly during puberty

1. Weight
- Most sensitive especially in low birth weight Primary factors affecting Growth and Development
- Weight doubles by 6 months Heredity
- Triples by 1 year  Race
- Quadruples by 2 ½ year  Intelligence
 Sex
2. Height  Nationality
- Increase by 1 inch per month during first 6 months
- And ½ inch per month from 7 – 12 months Environment
i. Quality of nutrition
 Development– increase in the skills or capacity to ii. Socio-Economic status
function qualitative change iii. Health
iv. Ordinal position in family
How to Measure Development? v. Parent-Child relationship
1. by simply observing a child doing specific task
2. by noting parent’s description of the child’s progress  Growth and Development occurs in a regular direction
3. by DDST (Denver Developmental Screening Test), MMDST reflecting a definite and predictable patterns or trends
(Metro Manila Developmental Screening Test)
 Directional Trends – occurs in a regular direction
4 Main Rated Categories reflecting the development of neuromuscular functions:
1) Language– for communication these apply to physical, mental, social and emotional
2) Personal Social developments and includes:
3) Fine Motor Adaptive – pre tensile ability (ability to use
hand movement)  Cephalo - caudal (head to tail)
4) Gross Motor Skills– ability to use large body movement - It occurs along bodies’ long axis in which control over head,
mouth and eye movements and precedes control over upper
 Maturation– synonymous with development (readiness) body torso and legs.

 Cognitive Development – is the ability to learn and  Proximo – distal (centro distal)
understand from experience, to acquire and retain - Progressing from the center of the body to the extremeties
knowledge to respond to a new situation and to solve
problems  Symmetrical
-Each side of the body develop on the same direction at the
same time at the same rate
B. BASIC DIVISION OF LIFE  Mass – specific (differentiation)
1. Pre-Natal– begins at conception and ends at birth - In which the child learns from simple operations before
2. Period of Infancy complex function or move from a broad general pattern of
- Neonatal (first 28 days or first 4 weeks) behavior to a more refined pattern.
- Formal Infancy (from 29thday to 1 year)
 Sequential – involves a predictable sequence of growth
3. Early Childhood and development to which the child normally passes.
- Toddler (1 – 3 years)
- Pre-School (4 – 6 years)  Locomotion
 Language and Social skills
4. Middle Childhood– school age 7 – 12 years

5. Period of Adolescent 1. Secular– refers to the worldwide trend of maturing earlier

- Pre-Adolescent/Late childhood (11 – 13 years)
- Adolescent (12 – 21 years)
C. PRINCIPLE OF GROWTH AND DEVELOPMENT
a. Growth and Development is a continuous process that
begins from conception and ends with death.
Principle: womb to tomb
b. Not all parts of the body grow at the same time or at the
same rate.
and growing larger as compared to succeeding
generations.
2. Behavior is a most comprehensive indicator of
developmental status
3. Play is the universal language of a child
4. A great deal of skill and behavior is leaned by practice
5. There is an optimum time for initiation of experience or
learning
6. Neonatal reflexes must be lost first before development
can proceed
- Persistent Primitive Infantile Reflex (suspect Cerebral Palsy)

Patterns of Growth and Development D. THEORIES OF DEVELOPMENT

 Renal, digestive, circulatory, musculo-skeletal (childhood)
 Neurologic Tissue
- Grows rapidly during 1 – 2 years of life
- Brain (achieve to its adult proportion by 5 years)
- Central Nervous System
- SC
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 - Give an opportunity no short assignment and projects
Sigmund Freud (1856-1939) – an Austrian neurologist,
Founder of psychoanalysis e) Identity vs. Role Confusion (12 – 20 years)
- Learn how he/she is or what kind of person he/she will
Phase of Psychosexual Theory become by adjusting to new body image
- Seeking emancipation or freedom from parents
I. Oral Phase(0 – 18 months)
- Mouth is the site of gratification f) Intimacy vs. Isolation (20 – 40 years)
- Biting, crying or sucking for enjoyment and to release tension - Focus on career or looking for lifetime partners
- Provide oral stimulation even the baby is NPO, offer pacifier
- Never discourage thumb sucking g) Generativity vs. Stagnation (40 – 60 years)

II. Anal Phase (18 months – 3 years) h) Ego Integrity vs. Despair(65 and above)
- Anus
- May show toilet training
- Elimination, defecation Jean Piaget – a Swiss psychologist
- Principle of Stages of Cognitive Development
- Holding on (child wins, hard headed, anti social and stubborn)
- Letting Go 1. Sensorimotor (0 – 2 years)
- Mother wins (kind, perfectionist, obedient, obsessive – - Practical intelligence because words and symbols are not
compulsive) applicable
- Babies are communicating through sense and reflex
III. 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

IV. 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

V. Genital Phase(12 – 18 years)

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

Eric Erickson
- Trained in psychoanalysis theory
- Transits the importance of culture and society to their
development of ones society

Stages of Psychosocial Theory

a) 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

b) 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

c) 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
2. 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) Industry vs. Inferiority (7 – 12 years)

- Learn how to do things well
- How industry is developed:
3. Formal Operational (12 and above)
- Period when cognition has achieved its final form 6 MONTHS
- They are capable - Reaches outs in anticipation of being picked up
- Can find scientific reasoning (can deal with the past, present - Handle bottle well
and future) - Sits with support
- Capable of abstract and mature thought - Uses palmar grasp by 6 months
- Do abstraction by talk time that will sort - Eruption of first temporary teeth (2 lower incisors)
- Says vowel sounds “Ah, ah”

Kohlberg (1984) –recognized the theory of moral 7 MONTHS

development as considered closely to approximate cognitive - Transfer objects hand to hand
stages of development - 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
DEVELOPMENT MILESTONE - Pincer grasp reflex
Period of Infancy - Combine two syllables “Papa, Mama”
 Play - Priority: safety
- Solitary play
- Non interactive 10 MONTHS
- Priority is safety - Pull self to stand
- Age who appreciate teddy bears - Understand word “No”
- Attitude: proper hygiene - Respond to own name
- Peak – a – boo
Fear - Pat a cake since they can clap
- Stranger anxiety
- Begin at 6 – 7 months 11 MONTHS
- Peak at 8 months - Cruises
- Diminish by 9 months - Stand with assistance

Milestones 12 MONTHS
Neonate - Stand alone
- Largely reflex - Take first step
- Complete head lag - Walk with assistance
- Hands fisted - Drink from a cup
- Cry without tears (due to immature larcrimal duct) - Cooperate in dressing
- Visual fixation of human face - Says the 2 words “Mama, Papa”
- Toys: pots and pans, pull toy and learn nursery rhymes
1 MONTH
- Dance reflex disappears TODDLER
- Looks at mobile objects Play
- Parallel (2 toddlers playing separately)
2 MONTHS - Provide two similar toys (squawky squeeze toy)
- Holds head up when in prone - Waddling duck to pull, pull truck, building block and pounding
- Social smile peg
- Baby “coos”
- Cry with tears Fear
- Closure of posterior fontanel by 2 – 3 months - Separation anxiety
- Head lag when pulled to a sitting position - Do not prolong goodbye, say goodbye firmly
- 3 Phases of separation anxiety
3 MONTHS Protest
- Holds head and chest when in prone Despair
- Follow object past midline Denial
- Grasp and tonic neck reflex are fading
- Hand regards (3 months) Milestones
15 months
4 MONTHS - Plateau stage
- Turns from front to back - Walks alone (delay in walking maybe a sign of mental
- Head control complete retardation)
- Bubbling sounds - Puts small pellets into small bottle
- Needs space to turn - Scribbles voluntarily with pencil
- Laugh aloud - Holds a spoon well
- Seat self on chair
5 MONTHS - Creep upstairs
- Roll over - Speaks 4 – 6 words
- Turn both ways
- Teething rings 18 months
- Handles rattle well - Hide of possessiveness
- Moro reflex disappear by 4 – 5 months - Bowel control achieved
- No longer rotates a spoon
- Run and jump in place 5 years
- Walk up and down stairs holding on (typically places both feet - Frustrating five
on one step before advancing) - Copy a triangle
- Able to name body part - Draw a 6 part
- Speaks 7 – 20 words - Imaginary playmates
24 months - 2100 words
- Can open doors by turning doorknobs
- Unscrew lids Character Traits
- Walk upstairs alone by still using both feet on the same step - Curious
at same time - Creative
- Daytime bladder control - Imaginative
- Speak 50 – 200 words - Imitative
- Why and How
30 months
- 3 year old do tooth brushing with little supervision Behavior Problems
- 2 – 3 year old is the right time to bring to the dentist - Telling tall tales (over imagination)
- Temporary teeth complete and last temporary teeth to - Imaginary friends (purpose: release their anxiety and tension)
appear is the posterior molars - Sibling rivalry (jealousy to a newly delivered baby)
- 20 deciduous teeth by age 2 ½ years - Bed wetting
- Can make simple lines or stroke for crosses with a pencil - Baby talk
- Can jump down from the stairs - Fetal position
- Knows full name - Masturbation is a sign of boredom and should divert their
- Copy a circle attention
- Holds up fingers
SCHOOL AGE (7 YEARS)
36 months Play
- Trusting three - Competitive play
- Able to unbutton - Tug – o – war
- Draw a cross
- Learns how to share Fear
- Full name and sex - School phobia
- speak fluently - To prevent phobia orient child to new environment
- Right time for bladder control (night time control) - Displacement from school
- Able to ride a tricycle - Significant person is the teacher and peer of the same sex
- Speak 300 – 400 words - Loss of privacy
- Clues for toilet training - Fear of death
Can stand, squat and walk alone
Can communicate toilet needs Significant Development
Can maintain himself dry with interval of 2 hours - Prone to bone fracture (green stick fracture)
- Mature vision
Character Traits
- Negativistic likes to say no (it is their way to search Milestones
independence) 6 years
- Limit questions and offer options - Temporary teeth begins to fall
- Temper tantrums (stomping feet and screaming) - Permanent teeth begins to appear (first molar)
- Ignore the behavior - Year of constant motion
- Rigid ritualistic: stereotype - Clumsy movement
- Cause: mastering - Recognizes all shapes
- Protruded abdomen - Teacher becomes authority figure that may result to nail
- Cause: biting
- Under development of abdomen - Beginning interest with God
- Unsteady gait
- Physiologic anorexia (give foods that last for a short period of 7 years
time) - Age of assimilation
- Copy a diamond
- Enjoys teasing and play alone
PRE-SCHOOL - Quieting down period
Play
- Associative play, Cooperative play 8 years
- Play house - Expansive age
- Role playing - Smoother movement
- Normal homosexual
Fear - Love to collect objects
- Body mutilation or castration fear - Count backwards
- Dark places and witches
- Thunder and lighting 9 years
- Coordination improves
Milestone - Tells time correctly
4 years - Hero worship
- Furious four (noisy and aggressive) - Stealing and lying are common
- Able to button - Takes care of body needs completely
- Copy a square - Teacher find this group difficult to handle
- Lace shoes
- Know the 4 basic colors 10 years
- Vocabulary of 1500 words - Age of special talents
- Writes legibly IMMEDIATE CARE OF THE NEWBORN
- Ready for competitive sports 1. The 8 Priorities of the Newborn in the first day of life
- More considerate and cooperative 2. Initiation and Maintenance of respiration
- Joins organization 3. Establishment of extra uterine circulation
- Well mannered with adults 4. Control of body temperature
- Critical of adults 5. Intake of adequate nourishment
6. Establishment of waste elimination
11-12 years 7. Prevention of infection
- Pre adolescent 8. Establishment of an infant-parent relationship
- Full of energy and constantly active 9. Development care that balances rest and stimulation for
- Secret language are common mental development
- Share with friends about their secrets 10. Initiation and Maintenance of respiration
- Sense of humor present
- Social and cooperative
Alerts
Character Traits - Second stage of labor initiate airway
- Industrious - Initiation of airway is a crucial adjustment among newborn
- Love to collect objects - Most neonatal deaths with in the first 24 – 48 hours is
- Cant bear to loose they will cheat primarily the inability to initiate airway
- They are modest - Lung function begins only after birth

SIGN OF SEXUAL MATURITY How

Girls Boys A.Removal of secretions by proper suctioning
Increase size of breast and Appearance of axillary and
genetalia pubic hair B.Proper Suctioning of catheter
Widening of hips Deepening of voice - Place baby’s head to side to facilitate drainage
Appearance of axillary and Development of muscles - Suction nose first because neonates are nasal obligates
pubic hair Increase in size of testes and - Suction for 5 – 10 seconds and should be gentle and quick
Menarch (last sign) scrotum (1st sign) because prolong deep suctioning may result to hypoxia,
- telarch is the 1st sign of Production of viable sperm bradycardia (caused by vagal nerve stimulation) and
sexual maturity (last sign) laryngospasm

ADOLESCENT PERIOD C.If not effective, requires effective laryngoscopy to open the
airway. After deep suctioning, an endotracheal tube can be
- They have distinctive odor because of the stimulation of
inserted and oxygen can be administered by a positive pressure
apocrine gland
- They have nocturnal emission (wet dreams) the hallmark for bag and mask with 100% oxygen at 40 – 60 b/min.
adolescent
- Testes and scrotum increase in size until age 17
Nursing Alerts:
- Sperm also viable
- No smoking sign to prevent combustion
- Breast and female genetalia increase until age 18
- Always humidify to prevent drying of mucosa
- Mask should cover nose and mouth
Fear
- Acne - Overdosage of oxygen may lead to scaring of retina which
may lead to blindness called retrolental
- Obesity
fibroplasias(retinopathy of prematurity)
- Homosexuality
- When meconium stained never administer oxygen because
- Death
pressure will force meconium to the alveolar sac and cause
- Replacement from friends
atelectasis
Significant Person
- Peer of opposite sex
Establishing extrauterine circulation
Alerts: circulation is initiated by pulmonary ventilation and is
Significant Development
completed by cutting of cord
- Experiences conflict between his needs for sexual satisfaction
and societies expectations
- Core concern is change of body image and acceptance from The Feto-placental Circulation
Placenta (via simple diffusion) – oxygenated blood is carried by
the opposite sex
the vein – liver – ductus venosus
Personality Trait Inferior vena cava – right atrium – 70% shunted to foramen
ovale- left atrium – mitral valve – left ventricle – aorta – lower
- Idealistic (parent-child conflict begins)
extremities.
- Rebellious
- Very conscious with body image
- Reformer The remaining 30% - tricuspid valve – right ventricle –
pulmonary artery – lungs (for nutrition) – vasoconstriction of
- Adventuresome
the lungs pushes the blood to the ductus arteriosus to aortato
Problems supply the extremities. The two arteries carry the
unoxygenated blood back to the placenta for reoxygenation.
- Vehicular accident
- Smoking
Alerts:Increase pressure on the left side of heart causes closure
- Alcoholism
- Drug addiction of foramen ovale
- Pre marital sex
SHUNTS
Ductus Venosus– shunt from umbilical vein to inferior vena
cava
Foramen Ovale– shunt between 2 atria (begin to close within
24 hours)
Ductus Arteriosus– shunt from pulmonary artery to aorta
(begin to close within 24 hours)
2 Way to facilitate Closure-of Foramen-oval
 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)
 Proper Positioning
- Right side lying
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)
Establish Adequate Nutritional Intake
Alerts: Breastfeed immediately for NSD and after 4 hours for CS
(colostrum is present on the 3rdtrimester)
Physiology of Breast milk Production
-decrease level
of estrogenand progestin, stimulatesthe anterior pituitary
gland, that stimulatesthe prolactin of the acinar cells(alveoli)
to producethe foremilk stored in lactiferous tubules
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

Temperature Regulation Stages of Breastmilk

Alerts: 1.Colostrum– available 2 – 4 days after delivery
- The goal in temperature regulation is to maintain it not less Contents:
than 97.7 oF – 36.5 oC - Low fats
- Maintenance of temperature is important for preterm and - Low carbohydrates
SGA because it may lead to hypothermia or cold stress - High protein
- High immunoglobulin
Factors Leading to the development of Hypothermia - High minerals
1) Preterm are bornpoikilothermic(cold blooded) they easily - High fat soluble vitamins
adapt to temperature of environment due to immaturity
of thermo regulating system of body 2.Transitional – covering 4 – 14 days
2) Inadequate subcutaneous tissue Contents:
3) Newborns are not yet capable of shivering (increase basal - High lactose
metabolism) - High minerals
4) Babies are born wet - High water soluble vitamins

Process of Heat Loss 3.Mature milk– 14 days and above

1. Evaporation – body to air Contents:
2. Conduction – body to cold solid object - High fats (linoleic acid responsible for integrity of skin and
3. Convection – body to cooler surrounding air development of skin)
4. Radiation – body to cold object not in contact with body - High carbohydrates (lactose, easily digested, responsible for
sour milk smelling odor of stool)
Effects of Hypothermia (Cold Stress) - Low protein (lactalbumin)
1) Hypoglycemia – due to utilization of glucose (40 – 45
gm/dl is the normal blood sugar of a newborn) Cow’s milk
2) Metabolic Acidosis – due to catabolism of brown fats (best Contents:
insulator of a newborn) - High fats
3) High risk for kirnecterus (bilirubin in brain) - Low carbohydrates (add sugar)
4) Additional fatigue to already stressful heart - High protein (casein) has a curd that is hard to digest
- High minerals, has traumatic effect on kidneys of baby
Prevention of Cold Stress - High phosphorus that may cause inverse proportion with
 Dry and wrapped newborns calcium
 Mechanical measures
Health Teachings
- Radiant warmer 1. Proper Hygiene
- Isolette (square acrylic sided incubator, must be pre heated - Importance of hand washing
first) - Removal of caked colostrum
 Prevent unnecessary exposure – cover areas not being
examined Position
 Use tin foil in absence of electricity - Upright sitting avoid tension to properly empty breast milk
 Embrace baby (called kangaroo care) 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
Sucking - Passed with in 24 – 36 hours
- by touching the middle of lips then baby will suck - Failure to pass meconium suspect GIT obstruction
- purpose:take in food
- disappear at 6 months 1. hirschsprung
- easily disappear when not stimulated 2. imperforate anus
3. meconium ileu (cystic fibrosis)
Swallowing
- food touches posterior portion of tongue automatically Transitional
swallowed - Become green, loose and slimy that may appear to be a slight
- never disappear cough, gag, sneeze diarrhea to the untrained eye

Extrusion/Protrusion reflex Breastfed stool

- food touches anterior portion of tongue and tongue - Golden yellow, soft, mushy with sour milk smelling odor
automatically extruded/protruded frequently passed occurring almost nearly every feeding
- purpose:prevent from poisoning
- disappear by 4 months because baby can already spit out Bottlefeed stool
- Light yellow, formed, hard with a typical offensive odor
The criteria of effective sucking seldom passed 2 – 3 times a day
 baby’s mouth is hike well up to areola
 mother experiences after pain With supplementary foods added
 other nipple is flowing with milk - Brown and odorous
 To prevent from crack nipples and initiate proper
production of oxytocin B.Indication of Stool Changes
- Light stool: jaundice baby
- begin 2 – 3 minutes per breast - Bright green: phototherapy
- increase 1 minute per day each breast until you reach 10 - Mucous mixed with stool: allergy
minutes each breast or 20 minutes per feeding - Clay colored: obstruction to bile duct
- Chalk clay/whitish clay: barium enema
For proper emptying and continuous milk production per - Black stool: GIT hemorrhage
feeding - Blood flecked: anal fissure
- feed baby on the last breast that you fed him - Curant jelly: intususeption
- Ribbon like: hirschsprung
Problems experienced in Breastfeeding -Steatorrhea: fatty, bulky, foul smelling – suspect
a.Engorgement malabsorption a case of cystic fibrosis or celiac disease
- soft and non tender (1 day)
- feeling of tension and fullness of breast
- while feeding warm compress III. Assessment for Well-being
- bottle feeding cold compress and wear supportive bra
APGAR SCORING
Sore nipple Special Considerations
- cracked, wet and painful nipple - Taken on first 1 minute, shows the general condition of baby
- exposure to air is the management or 20 watt bulb - 15 minutes is optional
- avoid wearing plastic liner bra, instead wear cotton bra - 5 minutes, baby’s capability to adapt/adjust extrauterinely

Mastitis Components
- inflammation of breast Appearance
- causative factor:staphylococcus aureus - color: slightly cyanotic, after first cry baby becomes pinkish
- improper breast emptying
- unhealthy sexual practices Pulse rate
- breast feed on unaffected breast - apical pulse (left lower nipple)
- express your breast on affected side
- take antibiotic Grimace
- increase 500 calories when breastfeeding - reflex irritability (foot slap, catheter insertion)
- involution of breast is 4 weeks
Activity
Contraindications in Breastfeeding - degree of flexion (muscle tone)
Maternal Conditions
- HIV, Hepatitis B, CMV, comadin/warfarin sulfate intake Respiration

Newborn Conditions APGAR SCORING CHART

- erythroblastosis fetalis
- hydrops fetalis
- phenylketonuria (PKU)
- galactocemia
- tay-sachs disease

Establishment of waste-elimination
Different stools
Meconium
- Physiologic stool
- Blackish green
- Sticky
- Tar like
- Odorless (because of sterile intestines)
- No bacteria
Interpretation of Apgar Result
 0-3: severely depressed, need CPR, admission to NICU Post tem Babies
 4-6: moderately depressed, additional suction and oxygen - More than 42 weeks
administration - Old mans face (classic sign)
 7-10: good/healthy - Desquamation (peeling of neonate skin characterized by
extreme dryness than begin from sole and palm within 24
CARDIO PULMONARY-RESUSCITATION hours
Airway (Clear Airway)
1. Shake, no response call for help Neonate in the Nursery
2. Place flat on bed *Special and Immediate Interventions
3. Head tilt – chin lift maneuver
Upon receiving
- Contraindicated to spinal cord injury - Proper identification (foot print with mothers thumb print)
- Over extension may occlude airway - Take antropometric measurement

Breathing (Ventilating the lungs) Then Take anthropometric measurements

4. Check for breathlessness a) Length – 19.5 – 21 inches/47.5 – 53.75 cm average of 50
5. Administer 2 rescue breaths cm
b) Head Circumference – 33 – 35 cm average of 34 cm/13 –
Circulation (by cardiac compression) 14 inches
6. Check for pulselessness c) Chest Circumference – 31 – 33 cm average of 32 cm/12 –
7. Do CPR (when breathless and pulse less) 13 inches
d) Abdominal Circumference – 31 – 33 cm average of 32
Respiration Evaluation cm/12 – 13 inches
Silverman Anderson Index
Chart Bathing Baby
Score - Normal oil bath
Criteria 0 1 2 - Cleanse and spread vernix
- Babies of HIV positive mothers are given full bath to lessen
Chest Lag on transmission of infection
Synchronized See saw
movement respiration - Insulator
Intercostal - Bacteriostatic
No retractions Just visible Marked
retraction - Full bath is safely given when cord falls
Xiphoid
None Just visible Marked Dressing the umbilical cord
retraction
Nares dilation None Minimal Marked - Follow strict asepsis to prevent infection/tetanus
- Use povedone iodine
Expiratory - Check for 3 vessels (2 arteries and 1 vein)
None Stethoscope Naked ear
grunt - AVA (2 vessel cord suspect kidney malformation)
- Leave about 1 inch of cord
Interpretation of Result - 8 inches if anticipating IV or BT
0 – 3: Normal no respiratory distress syndrome - Check for the cord q 15 minutes for the first 6 hours
4 – 6: Moderate RDS - For bleeding:
7 – 10: Severe RDS - 30 cc is bleeding to newborn
- Hemophilia is excessive bleeding
Assessment of Gestational Age - Ompalagiais bleeding of the cord
Ballards and Dobowitz - Cord turns black on the third day
Clinical Criteria - Falls by 7th– 10thday
Gestational Age (Weeks) - Failure to fall is umbilical granulation (silver nitrate)
Findings Less 36 37-38 39 and up - Use saline to clean
Anterior
Occasional Sole covered Credes Prophylaxis
Sole creases transverse
creases in 2/3 with creases - Purpose: prevent opthalmia neonatorum (use erythromycine
crease only
ophthalmic ointment)
Breast nodule 4mm or 3 – 5 7 mm – 7.5
2 mm
(dm.) mm mm
Administration of Vitamin K
Coarse and - Action: prevent hemorrhage
Scalp hair Fine and fuzzy Fine and fuzzy
silky - Related to physiologic hypoprothrombinemia
Ear Lobe Pliable Some Thick - Give Aquamephyton, phytomenadione, konakoib (.5 – 1.5 mg,
Testes and IM)
Testes
scrotum in
pendulous, Weight-taking
Testes lower canal,
Intermediate scrotum full Normal Weight: 3000 – 3400 grams/3 – 3.4 kg/6.5 – 7.5 lbs
Scrotum scrotum is
with extensive Arbitrary Lower Limit: 2500 grams
small with few
rugae Low Birth Weight: below 2500 grams
rugae
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
Pre term Babies
deviation of the mean
- 28 – 32 weeks
Physiological Weight Loss: 5 – 10 percent occurs a few days
- Frog leg or lax position
after birth
- 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
Physical Examination and Deviations from the Normal WITH DECREASE PULMONARY BLOOD FLOW
Components:
Vital signs  Pulmonary Stenosis
- Temperature is taken rectally to rule out imperforate anus - Narrowing of valve of pulmonary artery
and thermometer is inserted 1 inch
- Don’t force insertion because it may lead to pruritus Signs and Symptoms
1. Typical systolic ejection murmur
Types of imperforate anus 2. ECG reveals hypertrophy of right ventricle
 Atretic– no anal opening, causing failure to pass 3. S2 sound is widely split
meconium
 Agenetic  Aortic Stenosis
- no anal opening, causing failure to pass meconium - Narrowing of valve of aorta
- abdominal distention
- foul smelling stool Signs and Symptoms
- vomitus of fecal materials 1) Left ventricular hypertrophy
- respiratory problems 2) Typical murmur

- Management: surgery with temporary colostomy Management

Balloon stenotomy
TWO MAJOR TYPES Surgery (last resort)
Acyanotic Heart Defects
- Left to right shunting  Duplication of aortic arch
- With increased Pulmonary Blood Flow - Doubling of arch of aorta causing compression to trachea and
esophagus
 Ventricular Septal Defect
- Opening between 2 ventricles Signs and Symptoms
Dysphagia
Signs and Symptoms Dyspnea
1. Systolic murmur at lower border of sternum and no other
significant signs Management
2. Cardiac catheter reveals oxygen saturation at right side of Close heart surgery
heart
3. ECG reveals hypertrophy of right side of heart Coarctation of the Aorta
- Narrowing of arch of aorta
Management
 Long term antibiotic therapy to prevent development of Signs and Symptoms
sub acute bacterial endocarditis 1. Blood pressure in upper extremities is increased
 Open heart surgery 2. Blood pressure in lower extremities is decreased
3. Outstanding sign is absent femoral pulse
 Atrial Septal Defect
- Failure of foramen ovale to close Management
Take blood pressure in 4 extremities
Signs and Symptoms Close heart surgery
1) Systolic murmur at upper border of sternum and no other
significant signs  CyanoticHeartDefects
2) Cardiac catheter reveals increase oxygen saturation at - Right to left shunting
right side of heart
3) ECG reveals hypertrophy of right side of heart WITH INCREASE PULMONARY BLOOD FLOW
Transposition of Great Arteries
 Endocardial Cushion Defects - Situation where aorta is arising from the right ventricle and
- AV canal affecting both tricuspid and mitral valve pulmonary artery of the left ventricle

Signs and Symptoms Signs and Symptoms

Only confirmed by cardiac catheter 1. Cyanosis after 1stcry (outstanding sign)
2. Polycythemia (compensatory mechanism to decrease
Management oxygen supply
- Open heart surgery 3. Prone to thrombus leading to embolism resulting to
stroke (complications)
 Patent Ductus Arterious
- Failure of ductus arteriosus to close Management
Palliative repair – kashkind procedure
Signs and Symptoms Complete repair – mustard procedure
1. Continuous machine like murmur
2. Prominent radial pulse Total Anomalous Pulmonary Venous Return
3. Hypertrophy of left ventricle upon ECG - Pulmonary vein enters the right atrium or superior vena cava

Management Signs and Symptoms

 Endomethiacine (prostaglandin inhibitor that facilitate 1) Mixed blood supplying the body (oxygenated and
closure of PDA unoxygenated)
 Ligation of PDA by 3 – 4 years old 2) Open foramen ovale
3) Aspleenia(absent spleen)
4) Mild to moderate cyanosis

Management
 Restructuring of the heart
 Truncus Arteriosus
 - Pulmonary artery and aorta is arising from one common Signs and Symptoms
trunk or single vessel with VSD MAJOR MINOR
- Polyarthritis (multi joint pain)
Management - Arthralgia (joint pain)
- Chorea (sydenhanns chores) st.
Positive cyanosis and polycythemia - Low grade fever
vitus dance,
Restructuring of the heart - Increase diagnostic tests
purposeless/involuntary hand
a. Antibody
and shoulder movement
Hypoplastic Left Heart Syndrome b. C-reactive protein
accompanied by grimace
- Non functioning left ventricle c. Erythrocyte Sedimentation
- Carditis
Rate
- Errythema marginatum
Signs and Symptoms d. Anti-streptolysin O titer
(macular rash)
Cyanosis (ASO)
- Subcutaneous nodules
Polycythemia
Management
Management
- CBR (avoid contact sports)
Heart transplant
- Culture and sensitivity (throat swab)
- Antibiotic management (to prevent recurrence)
WITH DECREASE PULMONARY BLOOD FLOW
- Aspirin (anti inflammatory)
Tricuspid atresia
- Side Effects: Reye’s Syndrome
- Failure of tricuspid valve to open
- Non recurring encephalopathy accompanied by fatty
infiltration of organs such as liver and brain
Signs and Symptoms
Open foramen ovale
RESPIRATION
Cyanosis
- Abnormal/diaphragmatic
- Short period of apnea without cyanosis
Management
- Normal apnea of newborn is less than 15 seconds
Fontan procedure
Respiration Check
Tetralogy Fallot
New born 40-90
4 Anomalies Present
1 year 20-40
Pulmonary stenosis
2-3 years 20-30
VSD
5 years 20-25
Overriding aorta
10 years 17-22
Right ventricular hypertrophy
15 and above 12-20
Signs and Symptoms
Breath Sounds Heard on Auscultation
High degree of cyanosis
Polycythemia Sound Characteristics
- Increase red blood Soft, low pitched, heard over periphery
- Thrombus, embolus, stroke Vesicular of lungs, inspiration longer than
- Mental retardation expiration, normal.
- Clubbing of fingernails (chronic tissue hypoxia) late sign
- X-ray reveals boot shape heart Soft, medium-pitched, heard over major
Bronchovesicular bronchi, inspiration equals
Severe dyspnea expiration, normal.
- Relieved by squatting position
Growth retardation Loud, high-pitched, heard over trachea,
Tet Spells Bronchial expiration longer than
- Blue spells, short episode of hypoxia inspiration, normal.

Management Snoring sound made by air moving

Morphine – for hypoxic episode Rhonchi through mucus in bronchi, normal.
Propranol (Inderal) – decrease heart spasm
Palliative Repair – Blaylock Taussig procedure Crackles (like cellophane) made by air
Complete Repair – Brock procedure moving through fluid in
Rales alveoli. Abnormal; denotes pneumonia or
pulmonary edema which is fluid in
ACQUIRED HEART DISEASE alveoli.
Rheumatic heart Disease
- Inflammatory disease following an infection caused by Group- Whistling on expiration made by air
A beta hemolytic streptococcus (thrives in aerobic environment) being pushed through narrowed
Wheezing bronchi. Abnormal; seen on children with
Affected Body Parts asthma or foreign-body obstruction.
- Musculo skeletal – cardiac muscles and valves
- Integumentary Crowing or rooster like sound made by
- CNS air being pulled through a constricted
- Aschoff bodies Stridor larynx, Abnormal, seen in infants with
- Rounded nodules containing of multi nucleated cells and respiratory obstruction.
fibroblasts that stays in mineral valve
Loud, low tone, percussion sound over
Resonance normal lung tissue.

Louder, lower sound than resonance, a

Hyperresonance percussion sound over hyperinflated lung
issue.
RESPIRATORY DISTRESS SYNDROME - To small cuff results to false high BP
- Hyalin membrane disease
- Cause:lack of surfactant SKIN
- Common in preterm infants - Acrocyanosis (body pink extremities blue)
- Hypoxic - Generalized mottling due to the immaturity of the circulatory
- Formation of hyalin system
- Causing atelectasis
Birthmarks
Signs and Symptoms 1. Mongolian Spots– slate-gray-or-bluish
- Definite within 4 hours of life discoloration/patches commonly seen across he sacrum
Increase RR with retractions (early sign) or buttocks
Expiratory grunting (major sign) - Due to increase melanocytes
Flaring alae nassi - Common in asian newborn
Xiphoid retractions Disappear by 1 year, preschool, 5 years old
Intercoastal retractions
Respiratory acidosis 2. Milla– plugged unopened sebaceous gland usually seen as
white pinpoint patches on nose, chin and cheek,
Management disappears by 2 – 4 weeks
Keep head elevated
Proper suctioning 3. Lanugo– fine downy hair
- Oxygen administration 4. Desquamation– peeling of the newborn skin within 24
- Place on continuous positive airway pressure hours, common among post term
- Positive end expiratory pressure (maintain alveoli partially 5. Stork bites (talengeictasis nevi)– pink patches at the nape
open and prevent collapse) of the neck
Monitor skin color, vital signs, ABG - Never disappear but is covered by hair
Surfactant replacement and rescue 6. Erythema Toxicum (flea bite rash)– first self limiting rash
to appear sporadically and unpredictably as to time and
LARYNGOTRACHEOBRONCHITIS place.
- Infection of larynx, trachea and bronchi 7. Harlequin sign– dependent part is pink, independent part
is blue (RBC settles down)
Assessment 8. Cutis marmorata– transitory motling of neonates skin
- Barking cough/croupy cough when exposed to cold
- Respiratory acidosis 9. Hemangiomas– vascular tumors of the skin

Laboratory Studies 3 types

 ABG Nervus Flammeus– macular purple or dark red lesions usually
 Throat culture seen on the face or thigh
 CBC - Portwine stain: never disappear can be removed surgically

Diagnostic Studies Strawberry hemangiomas (nevus vasculosus)– dilated

Chest and neck x-ray (to rule out epiglotitis) capillaries in the entire dermal or subdermal area continuing to
enlarge but disappear after 10 years old.
Management
 Bronchodilators Cavernous hemangiomas –Consist of communicating network
 Oxygen with increase humidity of venules in the subcutaneous tissue that never disappear
 Prepare tracheostomy set when necessary with age.
- Dangerous type may lead to internal hemorrhage
BRONCHOLITIS
- Inflammation of bronchioles characterized by production of 10. Vernix Caseosa – white cheese like substance for
thick tenacious mucous lubrication
- Color of vernix is same as amniotic fluid
Signs and Symptoms
- Cold like/flu like symptoms SKIN COLOR AND THEIR SIGNIFICANCE
- Causative agent: respiratory syncitial virus Blue– cyanosis/hypoxia
- Drug:Ribavirin (anti viral drug) White– edema
- End stage epiglotitis (emergency condition or URTI), sudden Gray– infection
onset Yellowish– jaundice/carotinemia (increase carotin)
Pale– anemia
Management
- Tripod position (leaning forward with tongue protrusion) Burn Trauma
- Never use tongue depressor - is injury to body tissue cause by excessive heat
- Prepare tracheostomy set
- Encircle age Assessment
- Mist tent “croup tent”, croupette Depth
- Nursing management
Check edges if properly tucked 1st(partial thickness)
Washable plastic material Ex. Sunburn
Avoid toys that cause friction and hairy and furry materials
2nd(partial thickness)
BLOOD PRESSURE Ex. Scalds
- 80/46 mmHg after 10 days 100/50
- Normal blood pressure taking begins by 3 years old 3rd(full thickness)

Alerts
- BP cuff must cover 50 – 75% (2/3) of upper arm
- To large cuff results to false low BP
Characteristics - Wash face with soap and water
Involves only the superficial epidermis characterized by - Use sulfur soap or mild soap
erythema, dryness and pain - Retin A
Heals 1 -10 days
PALLOR-ANEMIA
Involves the entire epidermis, and portion of dermis Possible cause of Anemia
characterized by erythema, blistered and moist from exudates  Early cutting of cord
which is extremely painful.  Bleeding Disorder/blood dyscracia

Involves both skin layers, epidermis and dermis/may involve HEMOPHILIA

adipose tissue, fascia, muscle and bone. It appears leathery, - Deficient clotting factor
white or black and not sensitive to pain since nerve ending had - X link recessive inheritance
been destroyed. - Sex link
- Excessive bleeding upon cutting of cord or circumcision
Management - Carrier mother passed to son, when son becomes a father he
First Aid will pass it to his daughter
1) Put out flames by rolling the child on a blanket
2) Immerse the burned part on cold water Hemophilia A (classic)– deficiency of the coagulation
3) Remove burned clothing component (Factor VIII)
4) Cover burn with sterile dressing
5) Maintenance of a patent airway Hemophilia B(Christmas disease) – deficiency in clotting factor
6) Suction as needed IX
7) Oxygen administration
8) ET tube Hemophilia C– deficiency in clotting factor XI
9) Tracheostomy
10) Prevention of Shock and Fluid and Electrolyte Balance Assessment
11) Colloids to expand blood volume - Newly delivered baby receive maternal clotting factor
12) Isotonic saline to replace electrolytes - Sudden bruising of bumped area
13) Dextrose and water provide calories - Continuous bleeding to hemarthrosis
14) A booster dose of tetanus toxoid - Bleeding or damage of synovial membrane
15) Relief of pain such as IV analgesic (morphine sulfate)
Diagnostic Test
Prevention of wound infection - High risk for injury (prevent injury)
1. Cleaning and debriding of wound - Partial thromboplastin time
2. Open/close method of wound care
3. Whirlpool therapy Management
4. Skin grafting - Avoid contact sports
5. Big skin xenograft - Significance: determine case before doing any invasive
6. Taken from cadaver procedure
7. Diet - No aspirin
8. High protein - Immobilize and elevate upon injury
9. high calorie - Apply gentle pressure
- Cold compress
Atopic Dermatitis - Blood transfusion: cryoprecipitate, fresh frozen plasma
- Infantile exema
- Skin disease characterized by maculo vesicular errythematous LEUKEMIA
lesion with weeping and crusting - Group of malignant disease characterized by rapid
- Cause: allergens (main), milk, eggs, citrus juices, tomatoes and proliferation of immature WBC
wheat - WBC (soldiers of body)
- Characterized by extreme pruritus - Ratio: 500 RBC:1WBC
- Sign:linear excoriation, lichenified – scaling
Classification (depends on affected part)
Management  Lympho – lymphatic system
- Treat main cause  Myelo – bone marrow
- Prosorbbee or Isomil (milk)  Acute/Blastic – immature cells
- Hydrate skin with burrow’s solution  Chronic/cystic – mature cells
- Prevent infection  Acute lymphocytic – common among children
- Cut short the nails
Signs and Symptoms
Impetigo  From the invasion of bone marrow
- Cause:group A beta hemolytic streptococcus - Anemia (pallor, fatigue, constipation)
- Characterized by populo vesicular surrounded by localized - Bleeding (bruising, petechiae, epistaxis, bleeding in urine,
errythema becoming purulent and ooze forming a honey emesis)
colored crust - Infection
- Pediculosis capitis (kuto) - Fever
- Give oral penicillin - Poor wound healing
- AGN complication - Bone weakens and causes fracture

Acne  From the invasion of organs

- Self limiting inflammatory disease affects sebaceous glands - Hepatosplenomegaly
common in adolescence - CNS affectation (headache and signs of increase ICP)
- Signs:Comodones (sebum causing white heads)
- Sebum is composed of lipids Diagnostic Tests and studies
1. PBS (peripheral blood smear)– determine immature WBC
Management 2. CBC– anemia, neutropenia, thrombocytopenia
- Proper hygeine
3. Lumbar Puncture – place in fetal position without flexion Management
of neck, C position or shrimp position 1. Initiation of feeding, temporary suspension of breast
4. Bone Marrow Aspiration feeding to prevent kernikterus
- Site for aspiration is the iliac crest 2. Pregnanediole – delays action of glucorinyl
- Put pressure after aspiration transferace(liver enzyme that converts indirect bilirubin to
- Place on affected side direct bilirubin)
5. Bone Scan – determine bone involvement 3. Use of Phototherapy
6. CTscan– determine organ involvement 4. Exchange Transfusion of Rh or ABO affectations that tend
7. Surgery to cause continuous decrease in hemoglobin during the
8. Irradiation first 6 months because bone marrow fails to produce
9. Chemotherap erythrocytes in response to continuing hemolysis.

Therapeutic Management ‘Yellow – Jaundice

Medications Hyperbilirubinemia
4 Levels of Chemotherapy - Normal: indirect bilirubin 0 – 3 mg/dl
1) For Induction – achieve remission (main goal) - More than 12 mg/dl of indirect bilirubin in fullterm
a. IV vincristine
b. L-aspariginase Kernicterus
c. Oral prednisone - Bilirubin encephalopathy more than 20 mg/dl indirect
bilirubin in fullterm
2) For Sanctuary – treat leukemic cells that has invaded - Less than 12 mg/dl in preterm because of immature liver
testes and CNS
a. Methotrexate (intrathecally via CNS/spine) Physiological Jaundice
b. Cytocin - Icterus neonatorum
c. Arabinoside - 48 – 72 hours
d. Extra irradiation - Expose to sunlight

For Maintenance – continue remission Pathological Jaundice

a) Oral methotrixate - Icterus gravis neonatorum
b) Oral 6 mercaptopurine - Clinical jaundice within 24 hours
c) Cytarabine
Breastfeeding Jaundice
For Reinduction – treat leukemic cells after relapse occurs - Pregnaniliol
a. IV vincristine - 6 – 7 days
b. L-aspariginase
c. Oral prednisone Assessment
- Blanching the neonates forehead , nose or sternum
Antigout Agents – treat/prevent hyperuricemic nephropathy - Yellow skin and sclera
a) Allopurinol (Zyloprim) - Light stool
b) Increase fluid intake - Dark urine

Nursing Management Management

- Assess for common side effects Phototherapy
- Nausea and vomiting - Photo oxidation
- Administration of anti emetics 30 minutes before chemo and - Height of 18 – 20 inches away from baby
continue until 1 day after
- Check for stomatitis, ulcerations and abscess of oral mucosa Nursing Responsibilities
- Oral care (alcohol free mouthwash) no toothbrush a) Cover the eyes – prevent retinal damage
- Diet (soft and bland) according to child’s preference b) Cover genitals – prevent priapism (painful continuous
- Alopecia (temporary side effects) erection)
- Hirsutism c) Change position – for even exposure to light
- To parents (always repeat instruction) d) Increase fluid intake – to prevent dehydration
e) Monitor I & O – weigh baby 1 gram:1 cc
HEMOLYTIC DISORDER f) Monitor Vital Signs
Rh Incompatibility - Avoid use of lotion or oil because it may result to bronze baby
- Mother negative, fetus positive syndrome
- 4thbaby affected
- Mother negative, no antigen (no protein factor) HEAD
- Erythroblastosis fetalis: hemolysis leading to decrease oxygen Structures
carrying capacity with pathologic jaundice within 24 hours Sutures: 3
- Test:Comb’s Test Fontanels: 12 – 18 months close
- Vaccine:Rhogam
- Given to RH negative mother within first 72 hours to destroy Anterior fontanel
fetal RBC therefore preventing antibody formation - Craniostenosis/craniosinustosis (premature closure of
anterior fontanel)
ABO Incompatibility
- Mother is type O, fetus is type A, B, AB Posterior fontanel
- Most common is O, and A - 1 x 1 cm
- Severe O and B - Closes by 2 – 3 months
- First pregnancy can be affected
Microcephaly
Assessment - Small/slow growing brain
- Coomon is hydrops fetalis, edematous on lethal state with - Fetal alcohol and HIV positive
pathologic jaundice within 24 hours
Anencephaly
- Absence of cerebral hemisphere
Noticeable Structure of the head 3.3yr – school age - Pre school
- E charttest for stereosis or
Craniotabes depth of perception
- Localized softening of cranial bones to 1stborn child due to - Allen cards for visual acuity
early lightening - Ishiharas plates for color
- Ricketts in older children blindness
4. School Age – Adult - Cover testing for strabismus,
Caput Succedaneum eye deviation
- Edema of scalp due to prolonged pressure at birth
- Characteristics - Snellen’s test
- Present at birth
- Crosses the suture line RETINOBLASTOMA
- Disappear after 2 – 3 days - Malignant tumor of retina
- Red painful eye often accompanied by glaucoma
Cephalhematoma (pathognomonic sign: cat’s eye reflex)
- Collection of blood due to rupture of periostial capillaries - Management: enucleation
- Characterisitcs
- Present after 24 hours Senses of Smell (Nose)
- Never cross the suture line - Flaring or alae nasi (RDS)
- Disappear after 4 – 6 weeks - Pale with creases nasal membrane, chronic rhinitis
- Inflamed: infection
Seborrheic Dermatitis - Cocaine abuse:
- Cradle cap - No hair
- Scaling, greasy appearing salmon colored patches usually seen - Ulceration with abscess at the nasal mucosa
on scalp, behind ears and umbilicus - Perforation of nasal septum
- Primary cause:improper hygiene - Epistaxis:
- Management:proper hygiene, apply oil the night before - Nose bleed
shampooing (use baby oil or coconut oil) - Sit upright with head tilted forward
- Cold compress
Hydrocephalus - Apply pressure
- Collection of CSF - Give epinephrine
2 types
Communicating – extra ventricular hydrocephalus Sense of Hearing (Ears)
Non communicating – intra ventricular hydrocephalus also - First to develop and last sense to disappear
called obstructive - Properly aligned to outer canthus of eye

Signs and Symptoms

- Sign of increase ICP 1.Kidney Malformation
- Sign of frontal bossing (prominent forehead) - Low set ears
- Prominent scalp vein - Renal agenesis
- Sunset eyes - Unilateral/bilateral
- Oligohydramnios (sign of renal agenesis in utero)
Therapeutic Management - Failure to fade 24 hours
- Place client in low semi fowlers position (30o) - Kidney transplant
- Osmotic diuretic
- Diamox (Acetazolamide) to decrease CSF production 2.Chromosomal Aberrations
- Seizure precaution - More than 35 years
- Surgery (AV shunt, VP shunt)
- Shave just before surgery 3 Nondisjunction
- Place in side lying position on non operated side 4 Trisomy 21
- Monitor for good drainage - Down syndrome
- Sunken fontanel is a good sign - Extra chromosome 21
- Mental retardation depend on extent of hydrocephalus - 47 XX + 21 or 47 XY + 21
- Cause: advance paternal age
SENSES - Mongolian slant in eyes
Sense of Sight (Eyes) - Low set ears
Sclera– light blue becomes dirty white - Broad flat nose
Pupils – round and adult size - Protruding tongue
Coloboma – part of iris is missing - Puppy’s neck
Congenital cataract – whiteness and opacity (caused by german - Hypotonic (respiratory problem unable to cough out)
measles) - Simian crease (single transverse line of palm)
Cornea– round and adult size, larger in congenital glaucoma - Educable

Test of blindness
AGE COMMON TEST
1. Newborn - General appearance
- See 10 – 12 inches
- Doll’s eye testdone
on 10th day
- Glabellars test blink reflex
5 Trisomy 18
6 Trisomy 13
7 Turners
8 Klinefilters Syndrome
 Deletion Abnormalities
 Cri-du-chat Syndrome
 Fragile X Syndrome

2. Infant and children - General appearance  Translocation Abnormalities

- Ability to follow object past  Balance Translocation Carrier
midline  Unbalanced Translocation Syndrome
 Kawasaki Disease
Others - Common in Japan
1. Mosaicism – a situation wherein the nondisjunction of - Mucocutaneous lymph node syndrome
chromosomes occurs during the mitotic cell division after - Drug of choice: Aspirin, Salicylates
fertilization resulting to different cells contains different
numbers of chromosomes. Criteria for diagnosis of Kawasaki Disease
1. Fever lasting more than 5 days
2. Isochromosomes – a situation wherein the chromosomes 2. Bilateral Conjunctivitis
instead of dividing vertically it divides horizontally 3. Change of lips and oral cavity
resulting to chromosomal mismatch. 4. Dry, red, fissure lips
5. Strawberry tongue
6. Diffuse erythema of mucous membrane
OTITIS MEDIA 7. Changes of peripheral extremities
- Inflammation of middle ear, common in children due to wider 8. Erythema of the palms and sole
and shorter eustachian tube 9. Indurative edema of the hands and feet
- Common with cleft lip and palate 10. Membranous desquamation from fingertips
- Bottle propping, may also result to dental caries 11. Polymorphous rash (primarily on trunk)
- Otoscopic: bulging tympanic membrane and absence of light 12. Acute nonpurulent swelling of cervical lymph node to >
reflex 1.5 cm in diameter
- Observe for passage of milky, purulent and foul smelling odor
discharge
- Observe for URTI Cleft Lip
- Failure of the median maxillary nasal processes to fuse by 5 –
Management 8 weeks of pregnancy
- Side lying on affected side to facilitate drainage - Common in boys
- Supportive care (TSB, antipyretic) - Can be unilateral or bilateral
- Massive dosage of antibiotic (may lead to bacterial meningitis)
- Apply ear ointment Cleft Palate
 below 3 years down and back - Failure of the palate to fuse by 9 – 12 weeks of pregnancy
 above 3 years up and back - Common in girls
- Mucolytics to shrink mucous
- Myringotomy:surgical procedure done by making a slight Signs and Symptoms
incision of the tympanic membrane Evident at birth
- Place client on the operated side Ultrasound/3 dimensional UTZ
- To prevent permanent hearing loss Milk escape to the nostril
Common URTI (otitis, cholic)
Mouth and Tongue
Bells Palsy Therapeutic Management
- Facial nerve paralysis - Surgery
- VII cranial nerve injury - Cleft lip: cheiloplasty done as early as 1 – 3 months to save
- Related to forcep delivery sucking reflex
- Cleft palate: uranoplasty done 4 – 6 months to save speech
Signs and Symptoms
- Continuous drooling of saliva Nursing Responsibility (Pre Op)
- Inability to open 1 eye and close other eye - Emotional support
- Proper nutrition
Management - Use Rubber tipped medicine dropper
- Artificial tears - Prevention of cholic
- Refer to PT (self limiting)  Feed upright position
 Burp twice
TEF/TEA  Prone position/on abdomen
- Tracheo Esophageal Fistula. Tracheo Esophageal Atresia - Orient parents to feeding technique
- No connection between esophagus and stomach Cleft Lip
- 4 C’s:coughing, choking, cyanosis, continuous drooling - Use rubber tipped syringe
- Emergency surgery
Cleft Palate
Epstein Pearls - Use paper cup, plastic cup, soup spoon
- White glistening cyst usually seen on palate or gums related - Use elbow restraints (pre op)
to hypercalcemia - So baby can easily adjust post op

Natal Tooth Post Op Nursing Care

- Tooth at moment of birth related to hypervitaminosis - Maintenance of airway
(rootless) - Side lying (cheiloplasty)
- Prone (uranoplasty)
Neonatal Tooth - Facilitate drainage
- Tooth within 28 days - Monitor for developing RDS
- Proper nutrition
Oral Trush - NPO 4 hours post op
- Oral moniliasis, white cheese/curd like patches that coats - Check for colds or nasopharyngitis
mouth and tongue - May cause septicemia
- Treat with anti fungal (Nistatin/Mycostatin) - Begin with clear liquid
- Observe for signs of hemorrhage (frequent swallowing)
Anodontia - Usually happens 6 – 7 days post op
- No eruption of temporary teeth - Protect site of operation
- Maintain integrity of logan bar
1. Half strength hydrogen peroxide and saline
2. Prevent baby from crying GASTROINTESTINAL SYSTEM
3. Prevent cholic 1.Functions
4. Check for wet diaper a) Assists in maintaining fluid and electrolyte and acid/base
balance
Neck b) Processes and absorbs nutrients to maintain metabolism
- Check for symmetry and support growth and development
c) Excrete waste products from the digestive system
Congenital Torticolis d) Recommended Daily Allowance
- Wry neck e) Calories: 120 calories per kilo body weight per day (360 –
- Birth injury of sternocleidomastoid muscle due to excessive 380 calories)
traction during cephalic delivery f) Fluids: 16 – 20 cc per kilo body weight
g) Protein: 2.2 grams per kilo body weight
- Management:
- Passive stretching exercises daily Supplementary Feeding
- Surgery (last) - 4 – 6 months
- Complication is scoliosis
Principles
Solid food is offered to the following sequence
Congenital Cretinism (congenital hypothyroidism) – absence - Cereals: rich in iron (because at 6 months iron is
or non functioning thyroid glands completely catabolized)
- Fruits
Signs and Symptoms - Vegetables
Change in sucking (early sign) - Meat
Change in crying 1. Begin with small quantities
Sleep excessively due to decrease metabolism 2. Finger food is deferred by 6 months
Constipation 3. Soft table food/modified family menu by 1 year
Moon face baby 4. Dilute fruit juices (6 months)
Mental retardation (late sign)
- Ratio:1 oz. fruit to 4 oz. water
Diagnostic Exam -Never give half cooked egg, may cause
- Radio active iodine uptake gastroenteritis/salmoneliosis diarrhea
- Protein bound iodine - Avoid giving honey cause infant botulism
- radio immuno assay test - Offer new food 1 at a time with interval of 4 – 7 days to
determine food allergies
Reasons for delayed diagnosis
- Thyroid glands are covered by sternocleidomastoid
- Baby receive maternal thyroxine Major concepts of fluid and electrolyte balance
- Sleep 16 – 20 hours a day Distribution of body fluid
- Total body fluids comprises of 65 – 85% body weight among
Management infants and children
- Synthroid (synthetic thyroid) - Fluids are greater ECF compartment among infants and
- Sodium Levothyroxine (given lifetime) children (prone to dehydration)

Chest 5.Acid-base balance

- Check for symmetry Dependent on the following
- Breast produces witch milk a transparent fluid related to  Chemical buffers
hormone changes  Renal and respiratory system involvement
 Dilution of strong acids and bases on blood
Abdomen
- Inspection, Auscultation, Palpation, Percussion Imbalance of acid
Respiratory acidosis
Diaphragmatic hernia - Carbonic acid excess
- Protrusion of stomach contents through a defect in the - Hypoventilation
diaphragm due to failure of pleuroperitoneal canal to close - Asthma
- Pneumonia
Signs and Symptoms - Emphysema
Sunken abdomen - Laryngo tracheo bronchitis
Signs of RDS - RDS
Related to shunting
Respiratory alkalosis
Management - Carbonic acid deficit
- CPAP (continuous positive airway pressure) - Hyperventilation
- Diaphragmatic repair within 24 hours - Fever
- Encephalitis
Ompalocele
- Protrusion of stomach contents between junction of Metabolic acidosis
abdominal wall and umbilicus - Carbonate deficit
- Small: surgery - Diarrhea
- Large: - Severe malnutrition
- Suspension of surgery - Dehydration
- Wrap with sterile wet dressing - Celiac crisis
- Apply silver sulfadiazine ointment to prevent infection
Metabolic alkalosis
- Carbonate excess
- Uncontrolled vomiting
- Gastric lavage
- NGT aspiration Assessment
- Pyloric stenosis Neonatal Period
- Failure to pass meconium after 24 hours
Conditions that produce fluids and electrolytes imbalance
Vomiting Early Childhood
- Forceful expulsion of stomach contents Ribbon like stool
Constipation
Signs and Symptoms Diarrhea
Nausea Foul smelling stool
Dizziness
Abdominal cramping Signs and Symptoms
Flushing of face - Foul odor breath with stool
Teary eyes - Vomitus of fecal materials

Management
Assessment - NGT feeding
- Amount - Surgery
- Frequency Temporary colostomy (at 2 -3 months)
- Force (projectile:IC, pyloric stenosis) Anastomosis and pull through procedure
- Diet:high calorie and low residue (spaghetti and chicken)
Management
Banana Diagnostic Procedures
Rice, cereal i. Barium Enema – reveals the narrowed portion of the
Apple sauce bowel
Toast ii. Rectal Biopsy
iii. Abdominal x-ray – reveals dilated loops on intestine
Diarrhea iv. Rectal manometry – reveals failure of intestinal sphincter
- Exaggerated excretion of intestinal content to relax

1. Acute diarrhea are associated with the following Therapeutic Management and Nursing Care
2. Gastroenteritis, caused by salmoneliosis (half cooked egg) Gastroesohageal Reflux (GER)
3. Antibiotic use - Chalasiapresence of stomach contents in esophagus
4. Dietary indescretions
5. CNSD (Chronic Non Specific Diarrhea) Assessment Findings
6. Food intolerance 1. Chronic vomiting
7. Carbohydrates and Protein malabsorption 2. Failure to thrive syndrome (organic)
8. Excessive fluid intake 3. Esophageal bleeding manifested by

Assessment Effects and complication

- Frequency - Esophagitis
- Consistency - Aspiration
- Appearance of green color stool - Carcinoma

Complications Diagnostic procedures

Dehydration Barium Esophogram
 Mild – 5% weight loss Esophageal Manometry – reveals lower esophageal sphincter
 Moderate – 10% weight loss pressure
 Severe – 15% weight loss Intraesophageal pH content – reveals pH of distal esophagus

Signs of dehydration Medications

1) Tachycardia 1) Cholinergics
2) Tachypnea 2) Betanicole (Urecholine) - to increase esophageal tone and
3) Hypotension peristaltic activity
4) Increase temperature 3) Metochlopromide (Reglan)– to decrease esophageal
5) Sunken fontanel and eyeballs pressure by relaxing pyloric and duodenal segments
6) Poor skin turgor/dry skin and mucous membrane increasing peristalsis without stimulating secretion
7) Absence of tears 4) Histamine receptor antagonist (Ranitidine/Zantac)– to
8) Scanty urine (mark oliguria sign of severe dehydration) decrease gastric acidity and pepsin secretion
9) Weight loss 5) Antacid (Maalox)– to neutralize gastric acid between
10) Prolonged capillary refill time feedings

Management Management
1. Acute – NPO to rest bowel, IV infusion 1. Administration of thickened feeding with cereal to
2. Potassium Chloride – check if baby can void because it prevent vomiting
can lead to hyperkalemia leading to cardiac arrest 2. Feed slowly
3. Sodium Bicarbonate – metabolic acidosis, administered 3. Burp often every 1 oz.
slowly to prevent cardiac arrest 4. Position: below 9 months place in prone with head of
mattress slightly elevated on a 30O angle
Gastric Motility Disorder 5. Surgery: fundoplication
Hirschprungs Disease
- Congenital gagnlionic mega colon Obstructive Disorders
- Absence of gagliion cells for peristalsis Pyloric Stenosis
- Hypertrophy of pylorus muscle causing narrowing and
obstruction
Assessment Assessment
Projectile vomiting  Early signs
Nursing Alerts:  Diarrhea; failure to regain weight ff diarrheal episodes
- Vomiting is an initial symptom of upper GI obstruction  Constipation
- Vomitus of upper GI can be blood tinged not bile streaked  Vomiting
- Vomitus of lower GI is bilous  Abdominal Pain
- Projectile vomiting is either a sign of ICP or GI obstruction  Steatorrhea
- Abdominal distention is the major symptom of lower GIT  Late signs
obstruction  Behavioral changes: irritability and apathy
Failure to gain weight  Muscle wasting and loss of subconscious fats (protuberant
abdomen)
Palpate olive shape mass  Celiac Crisis
 Exaggerated form of vomiting (emergency condition)
Peristaltic wave visible from left to right across epigastrium
Diagnostic Procedures
Diagnostic Procedures  Laboratory Studies: Stool Analysis
 ABG – metabolic alkalosis  Serum antigliadin and antireticulin antibodies – presence
 Serum electrolyte: increase Na and K, decrease chloride indicates disorder
 Ultrasound  Sweat test – to rule out cystic fibrosis
 X-ray of upper abdomen with barium swallow reveals
string sign Therapeutic Management
 Vitamin supplements
Therapeutic Management  Mineral supplements
- Surgery: pyloromyotomy  Steroids

Intussusception Poisoning
- Telescoping of one portion of the bowel to another - Common among toddlers
- Complication of peritonitis
Principles
Signs and Symptoms 1. Determine the substance taken, assess LOC
- Acute paroxysmal abdominal pain 2. Unless the poison was corrosive, caustic (strong alkali
- Vomiting such as LYE) or a hydrocarbon, vomiting is the most
- Curant jelly stool effective way to remove the poison from the body
- Sausage shape mass 3. Syrup of ipecac– oral emetic to cause vomiting after drug
over dose or poisoning
Diagnostic test 4. 15 ml to adolescent, school age and pre school
- X-ray with barium enema reveal staircase sign 5. 10 ml to infant
6. Universal antidote– charcoal, milk of magnesia, and
Management burned toast
- Hypostatic reduction with barium enema 7. Never administer the charcoalbefore ipecac
8. Antidote for Acetaminophen poisoning. Acetylsysteine
Inborn Errors of Metabolism (Mucomyst)
- Deficient liver enzyme 9. For caustic poison
10. Prepare tracheostomy set
Phenylketeinuria 11. Kerosine (use mineral oil to coat the intestine to prevent
- Deficiency of liver PHT (Phenylalanine Hydroylase Transferase) absorption)
- No tyrosine, melanin, tyroxine – basal metabolism 12. Give vinegar to neutralize acid (for muriatic acid ingestion)

Signs and Symptoms Lead Poisoning

- Fair skin - Destroy RBC functioning
- Blonde hair - Resulting to hypochromic mycrocytic anemia
- Blue eyes - Leading to kidney destruction
- Accumulation of phenyl pyrobic acid in the blood - That leads to accumulation of amonia
- Musty or mousy odor urine - Then encephalitis
- Atopic dermatitis
- Seizure Assessment
- Mental retardation 1) Beginning symptoms of lethargy
2) Impulsive and
Diagnostic Tests 3) As lead increases, severe encephalophaty with seizures
Guthrie test and permanent mental retardation

Management Diagnostic Procedure

- Low phenylalanine indefinitely 1. Blood Smear
- No food rich in protein (chicken, eggs, meat, legumes, peanut) 2. Abdominal X-ray
- Lofenalac 3. Long bones

Celiac Disease Management

- Gluten Enteropathy
- Intolerance to foods containing barley, rye, oats, wheat
(normally converted to gluten)
- With celiac disease gluten is converted to gliadin (toxic to the
epithelial cells of villi leading to malabsorption of:
- Fats (steatorrhea), Protein and Carbohydrates (malnutrition),
Calcium (osteomalacia), Vitamin K (bleeding), Vitamin
B12 (anemia)
- Remove from source
- If higher than 20 mg/dl last management is chelating
agent(balance dimmer parol, CAEDTA) less side effects
- Binds with lead and excreted slowly via kidney
- Side Effects: nephrotoxicity
Anogenital Spina bifida Cystica
- With sac
Alerts
Female Types
- Pseudo menstration  Meningocele – protrusion of CSF and meninges
- Slight bleeding related to hormonal changes  Myelomeningocele– protrusion of CSF, meninges and
- Rape spinal cord
- Tearing of forchet  Encephalocele – cranial meningocele or
- Concerned with child’s care myelomeningocele
- Wound follow different stages of healing
- Identical wound Common Complication
- Report to authorities within 48 hours (barangay captain, - Common problem is rupture of sac (place wet sterile dressing
bantay bata) and place in prone position)
- Shape of pubic hair is inverted triangle - Infection
- Urinary and fecal incontinence
Male - Paralysis of lower extremities
- Check testes (undescended) - Hydrocephalus (CNS complication)
- Cryptorchidism common in preterms and management - Always check for a wet diaper
is orchidopexy
- Warm room and hand Treatment
- Check for arch of urine - Surgery to prevent infection
- Hydrocele: fluid filled scrotum (translumination reveal a
glowing sign) Scoliosis
- Phimosis:tight foreskin (balanitis infection of glans penis) - Lateral curvature of spine common in school age and
- Varicocele:veins in scrotum is increased adolescent
- Uneven hemline
Epispadias – meastus is located dorsal (above glans penis) - S shape back
Hypospadias – meatus is located ventral (below glans penis) - When bending 1 hip is higher and 1 shoulder prominent
Chordee – fibrous band causing penis to curve downward
Management
Conservative
Renal Assessment Nursing Exercise
Causes Treatment
Disorder Findings Care Avoid obesity
- Anasarca Preventive
1. - Steroid
(general Milwaukee brace worn 23 hours a day
Nephrotic (Prednisone) - Monitor
body Corrective
Syndrome - Infectious - Diuretics (Lasix) hydration
edema) Surgery – insertion of Harrington rod (post op do log rolling or
status
- Massive move as 1 unit)
(weight
proteinuria
everyday
- No
hematuria
with same Extremities
clothing) Digits
- Serum lipid
- Decrease  Syndactyly – webbing of digits (ginger like foot) congenital
increase
sodium,  Polydactyly – extra digit
- Fatigue
normal
- Normal or  Olidactyly – lacking digit
protein
low BP  Amelia – total absence of extremities
- Increase
potassium  Pocomelia– absence of distal part of extremities
intake  - Both are caused by talidomides
(beef
broth) Erb-duchennse paralysis/Brachial Plexus injury/Brachial palsy
- Primary - Birth injury due to lateral and excessive traction during a
2. AGN breech delivery
peripheral
Autoimmune Anti - Monitor
periorbital
Grp. A beta hypertensive weight
edema Signs and Symptoms
hemolytic hydralasine - Monitor
- Moderate - Inability to abduct arm from shoulder, rotate arm externally
streptococcus (appresoline) BP
proteinuria and supinate forearm
- Hypertensive -
- Gross - Absence/asymmetrical moro reflex
encephalopathy Neurologic
hematuria
(complication status
(smoky
urine)
anemia) - Increase Management
- Iron infusion iron - Abduct from shoulder with elbow flexed
- Serum
- Decrease
potassium
potassium
increased
- - Decrease
- Fatigue III.Congenital Hip Dislocation
sodium
- Increase - The head of femur is outside acetabulum
-
BP
Types
Subluxated – most common type
Back Dislocated
- Check for symmetry and flatness
Signs and Symptoms
Spina bifida Occulta Shortening of the affected leg
- Failure of posterior laminae of vertebrae to fuse Asymmetrical gluteal fold
- Signs and Symptoms:dimpling at lower back Limited movement (early sign)
- Abnormal tuffs of hair Positive ortolani’s sign – clicking sound during abduction
When able towalk the child limps (late sign)
Management
Triple the diaper Crossed extension reflex– when the sole of foot is stimulated
Carry a stride by a sharp object, it causes the foot to rise and the other foot
Frejka Splint extend (test for spinal cord integrity)
Pavlik Harness
Hip Spica Cast Truck Incurvation reflex– while in prone position and the
paravertical area is stimulated, it causes flexion of the trunk
Talipes and swing his pelvis toward the touch.
- Club foot
Landau reflex –while prone position and the trunk is being
Types supported, the baby exhibit some muscle tone (test for muscle
Equinos – plantar flexion (horse foot) tone and present by 6 – 9 months)
Calcaneous or Dorsiflexion – the heel is held lower than the
foot/the anterior portion of foot is flexed towards the anterior Parachute reaction – while on ventral suspension with the
leg sudden change of equilibrium, it causes extension of the hands
Varus – foot turns in and legs (present by 6 – 9 months)
Valgus– foot turns out
- Common combination is talipes equino varus andtalipes Babinski reflex– when the sole of foot is stimulated by an
calcaneo valgus inverted “J”, it causes fanning of toes (disappear by 2 months
but may persist up to 2 years)
Assessment
- Make a habit of straightening legs and flexing to improve to
midline position

Management
- Corrective shoes (dennis brown)
- Spica cast

Autoimmune System
Types of immunity
 Passive Natural – maternal antibodies through placenta or
breast milk
 Active Natural – contract disease and produce memory
cells
 Passive Artificial – receive anti serum with anti bodies
from another host (Hepa B)
 Active Artificial – receive vaccination and produce
memory cell

Immunity from mother (last for 9 – 12 months)

- Diptheria
- Polio
- Pertusis
- Tetanus
- Measles

Neuromuscular System:
Reflexes
Blink reflex – rapid eyelid closure when strong light is shown

Palmar grasp reflex – solid object is placed on palm and baby

grasp object
- Purpose: cling to mother for safety (disappear by 6 weeks – 2
months)

Step in/Walk-in Place Reflex – neonate placed on a vertical

position with their face touching a hard surface will take few
quick, alternating steps.
- Placing Reflex: almost the same with step in place reflex only
that you are touching anterior surface of a newborn’s leg.
Plantar grasp reflex – when an object touches the sole of a
newborn’s foot at the base of toes, the toes grasp in the same
manner as fingers do (disappear by 8 – 9 months in preparation
for walking)

Tonic-neck-reflex– when newborns lie on their backs, their

heads usually turn to one side or the other. The arm and the leg
on the side to which the head turns extend, and the opposite
arm and leg contract.

Moro reflex – test for neurological integrity (jarring crib, loud

voice) assume a letter C position (disappear by 4 – 5 months)

g.Magnet reflex – when there is pressure at the sole of the foot

he pushes back against the pressure.