PEDIATRIC NURSING REVIEW NOTES

References: Maternal & Child Health Nursing by Adelle Pillitteri

Wong's Essentials of Pediatric Nursing by Marilyn Hockenberry et.al

Saunder's Comprehensive NCLEX RN Examination by Linda Silvestri

A. GROWTH AND DEVELOPMENT

Definition of Terms:

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

2 Parameters of Growth

1.Weight

- Most sensitive especially in low birth weight

- Weight doubles by 6 months

- Triples by 1 year

- Quadruples by 2 ½ year

Height
- Increase by 1 inch per month during first 6 months

- And ½ inch per month from 7 – 12 months

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

How to Measure Development?

by simply observing a child doing specific task

by noting parent’s description of the child’s progress
by DDST (Denver Developmental Screening Test), MMDST (Metro Manila Developmental
Screening Test)

4 Main Rated Categories

Language– for communication

Personal Social
Fine Motor Adaptive – pre tensile ability (ability to use hand movement)
Gross Motor Skills– ability to use large body movement

Maturation– synonymous with development (readiness)

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

B. BASIC DIVISION OF LIFE

Pre-Natal– begins at conception and ends at birth
Period of Infancy
- Neonatal (first 28 days or first 4 weeks)

- Formal Infancy (from 29thday to 1 year)

Early Childhood
- Toddler (1 – 3 years)

- Pre-School (4 – 6 years)

Middle Childhood– school age 7 – 12 years

Period of Adolescent
- Pre-Adolescent/Late childhood (11 – 13 years)

- Adolescent (12 – 21 years)

C. PRINCIPLE OF GROWTH AND DEVELOPMENT

Growth and Development is a continuous process that begins from conception and ends with
death.
Principle: womb to tomb

Not all parts of the body grow at the same time or at the same rate.
Patterns of Growth and 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

Lymphatic System
- Lymph nodes, Spleen, Thymus

- Grows rapidly during infancy and childhood (to provide protection against
infection)

- Tonsils is achieved in 5 years

Reproductive Organ – grows rapidly during puberty

Each child is unique

2 Primary factors affecting Growth and Development

Heredity
Race

Intelligence

Sex

Nationality

Environment
Quality of nutrition

Socio-Economic status
 Health

Ordinal position in family

Parent-Child relationship

Growth and Development occurs in a regular direction reflecting a definite and predictable
patterns or trends
Directional Trends – occurs in a regular direction reflecting the development of neuromuscular
functions: these apply to physical, mental, social and emotional developments and includes:
Cephalo - caudal (head to tail)
- It occurs along bodies’ long axis in which control over head, mouth and eye movements and
precedes control over upper body torso and legs.

Proximo – distal (centro distal)

- Progressing from the center of the body to the extremeties

Symmetrical
-Each side of the body develop on the same direction at the same time at the same rate

Mass – specific (differentiation)

- In which the child learns from simple operations before complex function or move from a
broad general pattern of behavior to a more refined pattern.

Sequential – involves a predictable sequence of growth and development to which the child
normally passes.
Locomotion
Language and Social skills

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

Development Tasks is a skill or growth responsibility arising at a particular time in the

individual’s life. The successful achievement of which will provide a foundation for the
accomplishments of the future tasks.

THEORISTS

Sigmund Freud (1856-1939) – an Austrian neurologist, Founder of psychoanalysis

Phase of Psychosexual Theory

Oral Phase(0 – 18 months)

- Mouth is the site of gratification

- Biting, crying or sucking for enjoyment and to release tension

- Provide oral stimulation even the baby is NPO, offer pacifier

- Never discourage thumb sucking

Anal Phase (18 months – 3 years)

- Anus

- May show toilet training

- Elimination, defecation

- Principle of

- Holding on (child wins, hard headed, anti social and stubborn)

- Letting Go

- Mother wins (kind, perfectionist, obedient, obsessive – compulsive)

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

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

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

Trust vs. Mistrust (0 – 18 months)

- Trust is the foundation of all psychosocial task

- To give and to receive is the psychosocial theme

- How trust is developed:

- Satisfy needs on time

- Care must be consistent and adequate

- Give and experience that will add to security (touch, hugs and kisses, eye to eye contact, soft
music

Autonomy vs. Shame and Doubt(18 months – 3 years)

- Autonomy is independence or self governance

- How autonomy is developed

- Give an opportunity for decision making such as offering choices

- Encourage the child to make decisions rather than judge

Initiative vs. Guilt(4 – 6 years)

- Learns to do basic things

- Activity recommended are modeling clay, finger painting

- Develop creativity and imagination to facilitate fine motor development

- How initiative is developed:

- Give an opportunity of exploring new places and events

Industry vs. Inferiority (7 – 12 years)
- Learn how to do things well

- How industry is developed:

- Give an opportunity no short assignment and projects

Identity vs. Role Confusion (12 – 20 years)

- Learn how he/she is or what kind of person he/she will become by adjusting to new body
image

- Seeking emancipation or freedom from parents

Intimacy vs. Isolation (20 – 40 years)

- Focus on career or looking for lifetime partners

Generativity vs. Stagnation (40 – 60 years)

Ego Integrity vs. Despair(65 and above)

Jean Piaget – a Swiss psychologist

Stages of Cognitive Development

Sensorimotor (0 – 2 years)
- Practical intelligence because words and symbols are not applicable

- Babies are communicating through sense and reflex

SCHEMA
AGE

BEHAVIOR

Neonatal Reflex

Primary Circular Reaction

Secondary Circular Reaction

Coordination of Secondary

Tertiary Circular Reaction

Invention of new means thru mental combination

B. Preoperational Thought
SCHEMA

Pre-conceptual

Intuitive

1 month

1 – 4 months

4 – 8 months

8 – 12 months

12 – 18 months (1 – 1 ½ year)
18 – 24 months

2 – 7 years

AGE

2- 4 years

4 – 7 years

- All reflexes

- Activities related to bodies repetition of behavior (thumb sucking)

- Activity not related to body

- Discover object or persons code and code memory arises

- Anticipate familiar events

- Exhibit goal directed behavior

- Increase sense of separateness

- Use trial and error to discover change of places and events

- Code and Code invention of new means

- Capable of space and time perception

- Transitional phase to operational period

BEHAVIOR

- Egocentric (unable to view another point of view)

- Their thinking is basically concrete and static

- Their concept of time is only now and their concept of distance is only as far as they can see

- Not yet aware of the concept of reversibility

- Concept of animism (inanimate object is alive)

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

Formal Operational (12 and above)

- Period when cognition has achieved its final form
- They are capable

- Can find scientific reasoning (can deal with the past, present and future)

- Capable of abstract and mature thought

- Do abstraction by talk time that will sort

Kohlberg (1984) –recognized the theory of moral development as considered closely to

approximate cognitive stages of development
Stages of Moral Development

INFANCY

Age (Year)

Preconventional

2-3

4-7

Stage

(level I)

1
2

Description

Punishment/obedience orientation (“heteronomous morality”). Child does right because a parent

tells him/her to and to avoid punishment.

Individualism. Instrumental purpose and exchange. Carries out action to satisfy own needs
rather than

society. Will do something for another if that person do something for the child

Conventional

7-10
10-2

(level II)

Orientation to interpersonal relations

of mutuality. Child follows rules because of a need to be a “good” person in own eyes and the
eyes of others.

Maintenance of social order, fixed rules and authority. Childs finds following rules satisfying.

Follows rules of Authority figures as well as parents in an effort to keep the “system” working

Postconventional

Older than 12

(level III)

6
Social contract, utilitarian law-making perspectives. Follows standards of society for the good of
all people

Universal ethical Principle orientation. Follows internalized standards of conduct.

E. DEVELOPMENT MILESTONE

Period of Infancy

Play
- Solitary play

- Non interactive

- Priority is safety

- Age who appreciate teddy bears

- Attitude: proper hygiene

Fear
- Stranger anxiety

- Begin at 6 – 7 months

- Peak at 8 months

- Diminish by 9 months

Milestones
Neonate

- Largely reflex
- Complete head lag

- Hands fisted

- Cry without tears (due to immature larcrimal duct)

- Visual fixation of human face

1 MONTH

- Dance reflex disappears

- Looks at mobile objects

2 MONTHS

- Holds head up when in prone

- Social smile

- Baby “coos”

- Cry with tears

- Closure of posterior fontanel by 2 – 3 months

- Head lag when pulled to a sitting position

3 MONTHS

- Holds head and chest when in prone

- Follow object past midline

- Grasp and tonic neck reflex are fading

- Hand regards (3 months)

4 MONTHS

- Turns from front to back

- Head control complete

- Bubbling sounds

- Needs space to turn

- Laugh aloud

5 MONTHS

- Roll over

- Turn both ways

- Teething rings

- Handles rattle well

- Moro reflex disappear by 4 – 5 months

6 MONTHS

- Reaches outs in anticipation of being picked up

- Handle bottle well

- Sits with support

- Uses palmar grasp by 6 months

- Eruption of first temporary teeth (2 lower incisors)

- Says vowel sounds “Ah, ah”

7 MONTHS

- Transfer objects hand to hand

- Beginning fear of stranger

- Likes objects that are good sized

8 MONTHS

- Sits with support

- Peak of stranger anxiety

- Plantar reflex disappear

9 MONTHS

- Creeps/crawl

- Needs space for creeping

- Pincer grasp reflex

- Combine two syllables “Papa, Mama”

- Priority: safety

10 MONTHS

- Pull self to stand

- Understand word “No”

- Respond to own name

- Peak – a – boo

- Pat a cake since they can clap

11 MONTHS

- Cruises

- Stand with assistance

12 MONTHS

- Stand alone

- Take first step

- Walk with assistance

- Drink from a cup

- Cooperate in dressing

- Says the 2 words “Mama, Papa”

- Toys: pots and pans, pull toy and learn nursery rhymes

E.2. TODDLER

Play
- Parallel (2 toddlers playing separately)

- Provide two similar toys (squawky squeeze toy)

- Waddling duck to pull, pull truck, building block and pounding peg
Fear
- Separation anxiety

- Do not prolong goodbye, say goodbye firmly

- 3 Phases of separation anxiety

Protest
Despair
Denial

Milestones
15 months

- Plateau stage

- Walks alone (delay in walking maybe a sign of mental retardation)

- Puts small pellets into small bottle

- Scribbles voluntarily with pencil

- Holds a spoon well

- Seat self on chair

- Creep upstairs

- Speaks 4 – 6 words

18 months

- Hide of possessiveness

- Bowel control achieved

- No longer rotates a spoon

- Run and jump in place

- Walk up and down stairs holding on (typically places both feet on one step before advancing)
- Able to name body part

- Speaks 7 – 20 words

24 months

- Can open doors by turning doorknobs

- Unscrew lids

- Walk upstairs alone by still using both feet on the same step at same time

- Daytime bladder control

- Speak 50 – 200 words

30 months

- 3 year old do tooth brushing with little supervision

- 2 – 3 year old is the right time to bring to the dentist

- Temporary teeth complete and last temporary teeth to appear is the posterior molars

- 20 deciduous teeth by age 2 ½ years

- Can make simple lines or stroke for crosses with a pencil

- Can jump down from the stairs

- Knows full name

- Copy a circle

- Holds up fingers

36 months

- Trusting three
- Able to unbutton

- Draw a cross

- Learns how to share

- Full name and sex

- speak fluently

- Right time for bladder control (night time control)

- Able to ride a tricycle

- Speak 300 – 400 words

- Clues for toilet training

Can stand, squat and walk alone

Can communicate toilet needs
Can maintain himself dry with interval of 2 hours

Character Traits
- Negativistic likes to say no (it is their way to search independence)

- Limit questions and offer options

- Temper tantrums (stomping feet and screaming)

- Ignore the behavior

- Rigid ritualistic: stereotype

- Cause: mastering

- Protruded abdomen

- Cause:

- Under development of abdomen

- Unsteady gait
- Physiologic anorexia (give foods that last for a short period of time)

E.3. PRE-SCHOOL

Play
- Associative play, Cooperative play

- Play house

- Role playing

Fear
- Body mutilation or castration fear

- Dark places and witches

- Thunder and lighting

Milestone
4 years

- Furious four (noisy and aggressive)

- Able to button

- Copy a square

- Lace shoes

- Know the 4 basic colors

- Vocabulary of 1500 words

5 years

- Frustrating five

- Copy a triangle

- Draw a 6 part

- Imaginary playmates

- 2100 words

Character Traits
- Curious

- Creative

- Imaginative

- Imitative

- Why and How

Behavior Problems
- Telling tall tales (over imagination)

- Imaginary friends (purpose: release their anxiety and tension)

- Sibling rivalry (jealousy to a newly delivered baby)

- Bed wetting

- Baby talk

- Fetal position

- Masturbation is a sign of boredom and should divert their attention

E.4. SCHOOL AGE (7 YEARS)

Play
- Competitive play

- Tug – o – war

Fear
- School phobia

- To prevent phobia orient child to new environment

- Displacement from school

- Significant person is the teacher and peer of the same sex

- Loss of privacy

- Fear of death

Significant Development
- Prone to bone fracture (green stick fracture)

- Mature vision

d Milestones

6 years

- Temporary teeth begins to fall

- Permanent teeth begins to appear (first molar)

- Year of constant motion

- Clumsy movement

- Recognizes all shapes

- Teacher becomes authority figure that may result to nail biting

- Beginning interest with God

7 years

- Age of assimilation

- Copy a diamond

- Enjoys teasing and play alone

- Quieting down period

8 years

- Expansive age

- Smoother movement

- Normal homosexual

- Love to collect objects

- Count backwards

9 years

- Coordination improves

- Tells time correctly

- Hero worship

- Stealing and lying are common

- Takes care of body needs completely

- Teacher find this group difficult to handle

10 years

- Age of special talents

- Writes legibly

- Ready for competitive sports

- More considerate and cooperative

- Joins organization

- Well mannered with adults

- Critical of adults

11-12 years

- Pre adolescent

- Full of energy and constantly active

- Secret language are common

- Share with friends about their secrets

- Sense of humor present

- Social and cooperative

Character Traits
- Industrious

- Love to collect objects

- Cant bear to loose they will cheat

- They are modest

SIGN OF SEXUAL MATURITY

Girls

Boys

Increase size of breast and genetalia

Widening of hips

Appearance of axillary and pubic hair

Menarch (last sign)

- telarch is the 1st sign of sexual maturity

Appearance of axillary and pubic hair

Deepening of voice

Development of muscles

Increase in size of testes and scrotum (1st sign)

Production of viable sperm (last sign)

E.5. ADOLESCENT PERIOD

- They have distinctive odor because of the stimulation of apocrine gland

- They have nocturnal emission (wet dreams) the hallmark for adolescent

- Testes and scrotum increase in size until age 17

- Sperm also viable

- Breast and female genetalia increase until age 18

Fear
- Acne

- Obesity

- Homosexuality

- Death

- Replacement from friends

Significant Person
- Peer of opposite sex

Significant Development
- Experiences conflict between his needs for sexual satisfaction and societies expectations

- Core concern is change of body image and acceptance from the opposite sex

Personality Trait
- Idealistic (parent-child conflict begins)

- Rebellious

- Very conscious with body image

- Reformer

- Adventuresome

Problems
- Vehicular accident

- Smoking

- Alcoholism
- Drug addiction

- Pre marital sex

IMMEDIATE CARE OF THE NEWBORN

The 8 Priorities of the Newborn in the first day of life

Initiation and Maintenance of respiration
Establishment of extra uterine circulation
Control of body temperature
Intake of adequate nourishment
Establishment of waste elimination
Prevention of infection
Establishment of an infant-parent relationship
Development care that balances rest and stimulation for mental development
Initiation and Maintenance of respiration
Alerts

- Second stage of labor initiate airway

- Initiation of airway is a crucial adjustment among newborn

- Most neonatal deaths with in the first 24 – 48 hours is primarily the inability to initiate airway

- Lung function begins only after birth

How

A.Removal of secretions by proper suctioning

B.Proper Suctioning of catheter

- Place baby’s head to side to facilitate drainage

- Suction nose first because neonates are nasal obligates

- Suction for 5 – 10 seconds and should be gentle and quick because prolong deep suctioning
may result to hypoxia, bradycardia (caused by vagal nerve stimulation) and laryngospasm

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

Nursing Alerts:

- No smoking sign to prevent combustion

- Always humidify to prevent drying of mucosa

- Mask should cover nose and mouth

- Overdosage of oxygen may lead to scaring of retina which may lead to blindness called
retrolental fibroplasias(retinopathy of prematurity)

- When meconium stained never administer oxygen because pressure will force meconium to
the alveolar sac and cause atelectasis

Establishing extrauterine circulation

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

The Feto-placental Circulation

Placenta (via simple diffusion) – oxygenated blood is carried by the vein – liver – ductus
venosus

Inferior vena cava – right atrium – 70% shunted to foramen ovale- left atrium – mitral valve – left
ventricle – aorta – lower extremities.

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

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

SHUNTS

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

STRUCTURE

APPROPRIATE TIME OF OBLITERATION

STRUCTURE REMAINING

FAILURE TO CLOSE

Foramen Ovale
Ductus Arteriosus

Ductus Venosus

Umbilical Arteries

Umbilical Vein

24 hours complete by 1 year

24 hours complete by 1 month

2 months

2 – 3 months

2 – 3 months

Fossa Ovalis

Ligamentum Arteriosum

Ligamentum Venosum

Lateral Umbilical Ligament

Inferior Iliac Artery

Lateral Umbilical Ligament

Inferior Iliac Artery

Ligamentum Teres (round ligament of liver)

Atrial Septal Defect

Patent Ductus Arteriosus

Best position immediately after birth:

NSD – trendelendberg

CS – supine or crib level position

Signs of increase ICP

Abnormally large head

Bulging and tense fontanel
Projectile vomiting (surest sign of cerebral irritation)
Increase blood pressure but widening pulse pressure
Decrease respiratory rate
Decrease pulse rate
High pitch shrill cry (late sign)
Diplopia (sign of ICP from 6 months – 1 year)

Temperature Regulation
Alerts:

- The goal in temperature regulation is to maintain it not less than 97.7 oF – 36.5 oC

- Maintenance of temperature is important for preterm and SGA because it may lead to
hypothermia or cold stress
Factors Leading to the development of Hypothermia
Preterm are bornpoikilothermic(cold blooded) they easily adapt to temperature of environment
due to immaturity of thermo regulating system of body
Inadequate subcutaneous tissue
Newborns are not yet capable of shivering (increase basal metabolism)
Babies are born wet

Process of Heat Loss

Evaporation – body to air
Conduction – body to cold solid object
Convection – body to cooler surrounding air
Radiation – body to cold object not in contact with body

Effects of Hypothermia (Cold Stress)

Hypoglycemia – due to utilization of glucose (40 – 45 gm/dl is the normal blood sugar of a
newborn)
Metabolic Acidosis – due to catabolism of brown fats (best insulator of a newborn)
High risk for kirnecterus (bilirubin in brain)
Additional fatigue to already stressful heart

Prevention of Cold Stress

Dry and wrapped newborns
Mechanical measures
- Radiant warmer

- Isolette (square acrylic sided incubator, must be pre heated first)

Prevent unnecessary exposure – cover areas not being examined

Use tin foil in absence of electricity
Embrace baby (called kangaroo care)

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

- Decreasein 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

Stages of Breastmilk
1.Colostrum– available 2 – 4 days after delivery

Contents:

- Low fats

- Low carbohydrates

- High protein
- High immunoglobulin

- High minerals

- High fat soluble vitamins

2.Transitional – covering 4 – 14 days

Contents:

- High lactose

- High minerals

- High water soluble vitamins

3.Mature milk– 14 days and above

Contents:

- High fats (linoleic acid responsible for integrity of skin and development of skin)

- High carbohydrates (lactose, easily digested, responsible for sour milk smelling odor of stool)

- Low protein (lactalbumin)

Cow’s milk
Contents:

- High fats

- Low carbohydrates (add sugar)

- High protein (casein) has a curd that is hard to digest

- High minerals, has traumatic effect on kidneys of baby

- High phosphorus that may cause inverse proportion with calcium

Health Teachings
1.Proper Hygiene

- Importance of hand washing

- Removal of caked colostrum

Position
- Upright sitting avoid tension to properly empty breast milk

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
- by touching the middle of lips then baby will suck

- purpose:take in food

- disappear at 6 months

- easily disappear when not stimulated

Swallowing
- food touches posterior portion of tongue automatically swallowed

- never disappear cough, gag, sneeze

Extrusion/Protrusion reflex
- food touches anterior portion of tongue and tongue automatically extruded/protruded

- purpose:prevent from poisoning

- disappear by 4 months because baby can already spit out

The criteria of effective sucking
baby’s mouth is hike well up to areola
mother experiences after pain
other nipple is flowing with milk
To prevent from crack nipples and initiate proper production of oxytocin
- begin 2 – 3 minutes per breast

- increase 1 minute per day each breast until you reach 10 minutes each breast or 20 minutes
per feeding

For proper emptying and continuous milk production per feeding

- feed baby on the last breast that you fed him

Problems experienced in Breastfeeding

a.Engorgement

- soft and non tender (1 day)

- feeling of tension and fullness of breast

- while feeding warm compress

- bottle feeding cold compress and wear supportive bra

Sore nipple
- cracked, wet and painful nipple

- exposure to air is the management or 20 watt bulb

- avoid wearing plastic liner bra, instead wear cotton bra

Mastitis
- inflammation of breast

- causative factor:staphylococcus aureus

- improper breast emptying

- unhealthy sexual practices

- breast feed on unaffected breast

- express your breast on affected side

- take antibiotic

- increase 500 calories when breastfeeding

- involution of breast is 4 weeks

Contraindications in Breastfeeding

Maternal Conditions

- HIV, Hepatitis B, CMV, comadin/warfarin sulfate intake

Newborn Conditions

- erythroblastosis fetalis

- hydrops fetalis

- phenylketonuria (PKU)

- 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

- Passed with in 24 – 36 hours

- Failure to pass meconium suspect GIT obstruction

hirschsprung
imperforate anus
meconium ileu (cystic fibrosis)

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

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

Bottlefeed stool
- Light yellow, formed, hard with a typical offensive odor seldom passed 2 – 3 times a day

With supplementary foods added

- Brown and odorous

B.Indication of Stool Changes

- Light stool: jaundice baby

- Bright green: phototherapy

- Mucous mixed with stool: allergy

- Clay colored: obstruction to bile duct

- Chalk clay/whitish clay: barium enema

- Black stool: GIT hemorrhage

- Blood flecked: anal fissure

- Curant jelly: intususeption

- Ribbon like: hirschsprung

- Steatorrhea: fatty, bulky, foul smelling – suspect malabsorption a case of cystic fibrosis or
celiac disease

III. Assessment for Well-being

APGAR SCORING

Special Considerations

- Taken on first 1 minute, shows the general condition of baby

- 15 minutes is optional

- 5 minutes, baby’s capability to adapt/adjust extrauterinely

Components

Appearance

- color: slightly cyanotic, after first cry baby becomes pinkish

Pulse rate
- apical pulse (left lower nipple)

Grimace

- reflex irritability (foot slap, catheter insertion)

Activity

- degree of flexion (muscle tone)

Respiration

APGAR SCORING CHART

Score

Criteria

Heart rate

Absent

Less than 100

More than 100

Respiratory effort

Absent

Slow irregular weak cry

Good strong cry

Muscle tone

Flaccid extremities

Some flexion

Well flexed

Reflex irritability

Catheter

No response

Grimace

Cough or sneeze

Tangential Footslap

No response

Grimace

Cry

Color

Blue/Pale

Acrocyanosis (body and extremities blue)

Pink

Interpretation of Apgar Result

0-3: severely depressed, need CPR, admission to NICU

4-6: moderately depressed, additional suction and oxygen administration

7-10: good/healthy

CARDIO PULMONARY-RESUSCITATION

Airway (Clear Airway)

Shake, no response call for help

Place flat on bed
Head tilt – chin lift maneuver
- Contraindicated to spinal cord injury

- Over extension may occlude airway

Breathing (Ventilating the lungs)

Check for breathlessness

Administer 2 rescue breaths
Circulation (by cardiac compression)

Check for pulselessness

Do CPR (when breathless and pulse less)

Respiration Evaluation
Silverman Anderson Index

Chart

Score

Criteria

1
2

Chest movement

Synchronized

Lag on respiration

See saw

Intercostal retraction

No retractions

Just visible

Marked

Xiphoid retraction

None

Just visible

Marked

Nares dilation

None

Minimal

Marked

Expiratory grunt

None

Stethoscope

Naked ear
Interpretation of Result

0 – 3: Normal no respiratory distress syndrome

4 – 6: Moderate RDS

7 – 10: Severe RDS

Assessment of Gestational Age

Ballards and Dobowitz

Clinical Criteria

Gestational Age (Weeks)

Findings

Less 36

37-38

39 and up

Sole creases

Anterior transverse crease only

Occasional creases in 2/3

Sole covered with creases

Breast nodule (dm.)

2 mm

4mm or 3 – 5 mm

7 mm – 7.5 mm

Scalp hair
Fine and fuzzy

Fine and fuzzy

Coarse and silky

Ear Lobe

Pliable

Some

Thick

Testes Scrotum

Testes and scrotum in lower canal, scrotum is small with few rugae

Intermediate

Testes pendulous, scrotum full with extensive rugae

Pre term Babies

- 28 – 32 weeks

- Frog leg or lax position

- Hypotonic muscle tone

- Scarf sign (elbow passes the midline)

- Square window wrist (90o angle)

- Heel to ear sign

- Abundant lanugo

- Prominent labia minora and clitoris

Post tem Babies

- More than 42 weeks

- Old mans face (classic sign)

- Desquamation (peeling of neonate skin characterized by extreme dryness than begin from
sole and palm within 24 hours

Neonate in the Nursery

*Special and Immediate Interventions

Upon receiving
- Proper identification (foot print with mothers thumb print)

- Take antropometric measurement

Then Take anthropometric measurements

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

Bathing Baby
- Normal oil bath

- Cleanse and spread vernix

- Babies of HIV positive mothers are given full bath to lessen transmission of infection

- Insulator

- Bacteriostatic

- Full bath is safely given when cord falls

Dressing the umbilical cord
- Follow strict asepsis to prevent infection/tetanus

- Use povedone iodine

- Check for 3 vessels (2 arteries and 1 vein)

- AVA (2 vessel cord suspect kidney malformation)

- Leave about 1 inch of cord

- 8 inches if anticipating IV or BT

- Check for the cord q 15 minutes for the first 6 hours

- For bleeding:

- 30 cc is bleeding to newborn

- Hemophilia is excessive bleeding

- Ompalagiais bleeding of the cord

- Cord turns black on the third day

- Falls by 7th– 10thday

- Failure to fall is umbilical granulation (silver nitrate)

- Use saline to clean

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

Administration of Vitamin K
- Action: prevent hemorrhage

- Related to physiologic hypoprothrombinemia

- Give Aquamephyton, phytomenadione, konakoib (.5 – 1.5 mg, IM)

Weight-taking
Normal Weight: 3000 – 3400 grams/3 – 3.4 kg/6.5 – 7.5 lbs

Arbitrary Lower Limit: 2500 grams

Low Birth Weight: below 2500 grams

Small for Gestational Age: less 10 percentile rank

Large for Gestational Age: more than 90 percentile rank

Appropriate for Gestational Age: within the 2 standard deviation of the mean

Physiological Weight Loss: 5 – 10 percent occurs a few days after birth

Physical Examination and Deviations from the Normal

Important Considerations
If the client is new born, cover areas that is not being examined
If the client is infant, the first vital sign to take is RR (due to fear of stranger)
- Begin at east intrusive to the most intrusive

If the client is toddler and preschool, let them handle an instrument play syringe, stethoscope,
If the client is school age and adolescent explain procedure

Components:
Vital signs
- Temperature is taken rectally to rule out imperforate anus and thermometer is inserted 1 inch

- Don’t force insertion because it may lead to pruritus

- Types of imperforate anus

Atretic– no anal opening, causing failure to pass meconium

Agenetic
- no anal opening, causing failure to pass meconium

- abdominal distention
- foul smelling stool

- vomitus of fecal materials

- respiratory problems

- Management: surgery with temporary colostomy

Membranous

Cardiac Rate 120-160/min

- Irregular

- Radial pulse is absent, if present suspect PDA

Congenital Heart Diseases

*Common in girls: PDA, ASD

*Common in boys: TOGA (transposition of great arteries), Tronchus Arteriosus

*Causes: TOF

Familial
Exposure to rubella (1stmonth for mother)
Failure of heart structure to progress

TWO MAJOR TYPES

Acyanotic Heart Defects

- Left to right shunting

- With increased Pulmonary Blood Flow

Ventricular Septal Defect

- Opening between 2 ventricles
Signs and Symptoms

Systolic murmur at lower border of sternum and no other significant signs

Cardiac catheter reveals oxygen saturation at right side of heart
ECG reveals hypertrophy of right side of heart

Management

Long term antibiotic therapy to prevent development of sub acute bacterial endocarditis
Open heart surgery

Atrial Septal Defect

- Failure of foramen ovale to close

Signs and Symptoms

Systolic murmur at upper border of sternum and no other significant signs

Cardiac catheter reveals increase oxygen saturation at right side of heart
ECG reveals hypertrophy of right side of heart

Endocardial Cushion Defects

- AV canal affecting both tricuspid and mitral valve

Signs and Symptoms

Only confirmed by cardiac catheter

Management

- Open heart surgery

Patent Ductus Arterious

- Failure of ductus arteriosus to close
Signs and Symptoms

Continuous machine like murmur

Prominent radial pulse
Hypertrophy of left ventricle upon ECG

Management

Endomethiacine (prostaglandin inhibitor that facilitate closure of PDA

Ligation of PDA by 3 – 4 years old

WITH DECREASE PULMONARY BLOOD FLOW

Pulmonary Stenosis
- Narrowing of valve of pulmonary artery

Signs and Symptoms

Typical systolic ejection murmur

ECG reveals hypertrophy of right ventricle
S2 sound is widely split

Aortic Stenosis
- Narrowing of valve of aorta

Signs and Symptoms

Left ventricular hypertrophy

Typical murmur

Management
Balloon stenotomy
Surgery (last resort)

Duplication of aortic arch

- Doubling of arch of aorta causing compression to trachea and esophagus

Signs and Symptoms

Dysphagia
Dyspnea

Management

Close heart surgery

Coarctation of the Aorta

- Narrowing of arch of aorta

Signs and Symptoms

Blood pressure in upper extremities is increased

Blood pressure in lower extremities is decreased
Outstanding sign is absent femoral pulse

Management

Take blood pressure in 4 extremities

Close heart surgery

CyanoticHeartDefects
- Right to left shunting

WITH INCREASE PULMONARY BLOOD FLOW

Transposition of Great Arteries
- Situation where aorta is arising from the right ventricle and pulmonary artery of the left ventricle

Signs and Symptoms

Cyanosis after 1stcry (outstanding sign)

Polycythemia (compensatory mechanism to decrease oxygen supply
Prone to thrombus leading to embolism resulting to stroke (complications)

Management

Palliative repair – kashkind procedure

Complete repair – mustard procedure

Total Anomalous Pulmonary Venous Return

- Pulmonary vein enters the right atrium or superior vena cava

Signs and Symptoms

Mixed blood supplying the body (oxygenated and unoxygenated)

Open foramen ovale
Aspleenia(absent spleen)
Mild to moderate cyanosis

Management

Restructuring of the heart

Truncus Arteriosus
- Pulmonary artery and aorta is arising from one common trunk or single vessel with VSD

Management

Positive cyanosis and polycythemia

Restructuring of the heart
Hypoplastic Left Heart Syndrome
- Non functioning left ventricle

Signs and Symptoms

Cyanosis
Polycythemia

Management

Heart transplant

WITH DECREASE PULMONARY BLOOD FLOW

Tricuspid atresia
- Failure of tricuspid valve to open

Signs and Symptoms

Open foramen ovale

Cyanosis

Management

Fontan procedure

Tetralogy Fallot
4 Anomalies Present

Pulmonary stenosis

VSD
Overriding aorta
Right ventricular hypertrophy
Signs and Symptoms

High degree of cyanosis

Polycythemia
- Increase red blood

- Thrombus, embolus, stroke

- Mental retardation

- Clubbing of fingernails (chronic tissue hypoxia) late sign

- X-ray reveals boot shape heart

Severe dyspnea
- Relieved by squatting position

Growth retardation
Tet Spells
- Blue spells, short episode of hypoxia

Management

Morphine – for hypoxic episode

Propranol (Inderal) – decrease heart spasm
Palliative Repair – Blaylock Taussig procedure
Complete Repair – Brock procedure

ACQUIRED HEART DISEASE

Rheumatic heart Disease

- Inflammatory disease following an infection caused by Group-A beta hemolytic streptococcus

(thrives in aerobic environment)
Affected Body Parts

- Musculo skeletal – cardiac muscles and valves

- Integumentary

- CNS

- Aschoff bodies

- Rounded nodules containing of multi nucleated cells and fibroblasts that stays in mineral valve

Signs and Symptoms

MAJOR

MINOR

- Polyarthritis (multi joint pain)

- Chorea (sydenhanns chores) st. vitus dance, purposeless/involuntary hand and shoulder
movement accompanied by grimace

- Carditis

- Errythema marginatum (macular rash)

- Subcutaneous nodules

- Arthralgia (joint pain)

- Low grade fever

- Increase diagnostic tests

a. Antibody

b. C-reactive protein
c. Erythrocyte Sedimentation Rate

d. Anti-streptolysin O titer (ASO)

Management

- CBR (avoid contact sports)

- Culture and sensitivity (throat swab)

- Antibiotic management (to prevent recurrence)

- Aspirin (anti inflammatory)

- Side Effects: Reye’s Syndrome

- Non recurring encephalopathy accompanied by fatty infiltration of organs such as liver and
brain

RESPIRATION

- Abnormal/diaphragmatic

- Short period of apnea without cyanosis

- Normal apnea of newborn is less than 15 seconds

Respiration Check
New born 40-90

1 year 20-40

2-3 years 20-30

5 years 20-25

10 years 17-22

15 and above 12-20

Breath Sounds Heard on Auscultation

Sound

Characteristics

Vesicular

Bronchovesicular
Bronchial

Rhonchi

Rales

Wheezing

Stridor

Resonance

Hyperresonance

Soft, low pitched, heard over periphery of lungs, inspiration longer than expiration, normal.

Soft, medium-pitched, heard over major bronchi, inspiration equals expiration, normal.
Loud, high-pitched, heard over trachea, expiration longer than inspiration, normal.

Snoring sound made by air moving through mucus in bronchi, normal.

Crackles (like cellophane) made by air moving through fluid in alveoli. Abnormal; denotes
pneumonia or pulmonary edema which is fluid in alveoli.

Whistling on expiration made by air being pushed through narrowed bronchi. Abnormal; seen on
children with asthma or foreign-body obstruction.

Crowing or rooster like sound made by air being pulled through a constricted larynx, Abnormal,
seen in infants with respiratory obstruction.

Loud, low tone, percussion sound over normal lung tissue.

Louder, lower sound than resonance, a percussion sound over hyperinflated lung issue.

RESPIRATORY DISTRESS SYNDROME

- Hyalin membrane disease

- Cause:lack of surfactant

- Common in preterm infants

- Hypoxic

- Formation of hyalin
- Causing atelectasis

Signs and Symptoms

- Definite within 4 hours of life

Increase RR with retractions (early sign)

Expiratory grunting (major sign)
Flaring alae nassi
Xiphoid retractions
Intercoastal retractions
Respiratory acidosis

Management

Keep head elevated

Proper suctioning
- Oxygen administration

- Place on continuous positive airway pressure

- Positive end expiratory pressure (maintain alveoli partially open and prevent collapse)

Monitor skin color, vital signs, ABG

Surfactant replacement and rescue

Laryngotracheobronchitis

- Infection of larynx, trachea and bronchi

Assessment

- Barking cough/croupy cough

- Respiratory acidosis
Laboratory Studies

ABG
Throat culture
CBC

Diagnostic Studies

Chest and neck x-ray (to rule out epiglotitis)

Management

Bronchodilators
Oxygen with increase humidity
Prepare tracheostomy set when necessary

Broncholitis

- Inflammation of bronchioles characterized by production of thick tenacious mucous

Signs and Symptoms

- Cold like/flu like symptoms

- Causative agent: respiratory syncitial virus

- Drug:Ribavirin (anti viral drug)

- End stage epiglotitis (emergency condition or URTI), sudden onset

Management

- Tripod position (leaning forward with tongue protrusion)

- Never use tongue depressor

- Prepare tracheostomy set

- Encircle age

- Mist tent “croup tent”, croupette

- Nursing management

Check edges if properly tucked

Washable plastic material
Avoid toys that cause friction and hairy and furry materials

BLOOD PRESSURE

- 80/46 mmHg after 10 days 100/50

- Normal blood pressure taking begins by 3 years old

Alerts

- BP cuff must cover 50 – 75% (2/3) of upper arm

- To large cuff results to false low BP

- To small cuff results to false high BP

SKIN
- Acrocyanosis (body pink extremities blue)

- Generalized mottling due to the immaturity of the circulatory system

Birthmarks

Mongolian Spots– slate-gray-or-bluish discoloration/patches commonly seen across he sacrum

or buttocks
- Due to increase melanocytes

- Common in asian newborn

- Disappear by 1 year, preschool, 5 years old

Milla– plugged unopened sebaceous gland usually seen as white pinpoint patches on nose,
chin and cheek, disappears by 2 – 4 weeks
Lanugo– fine downy hair
Desquamation– peeling of the newborn skin within 24 hours, common among post term
Stork bites (talengeictasis nevi)– pink patches at the nape of the neck
- Never disappear but is covered by hair

Erythema Toxicum (flea bite rash)– first self limiting rash to appear sporadically and
unpredictably as to time and place.
Harlequin sign– dependent part is pink, independent part is blue (RBC settles down)
Cutis marmorata– transitory motling of neonates skin when exposed to cold
Hemangiomas– vascular tumors of the skin

3 types

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

Strawberry hemangiomas (nevus vasculosus)– dilated capillaries in the entire dermal or

subdermal area continuing to enlarge but disappear after 10 years old.
Cavernous hemangiomas –Consist of communicating network of venules in the subcutaneous
tissue that never disappear with age.
- Dangerous type may lead to internal hemorrhage

Vernix Caseosa – white cheese like substance for lubrication

- Color of vernix is same as amniotic fluid

SKIN COLOR AND THEIR SIGNIFICANCE

Blue– cyanosis/hypoxia

White– edema

Gray– infection

Yellowish– jaundice/carotinemia (increase carotin)

Pale– anemia

Burn Trauma

- is injury to body tissue cause by excessive heat

Assessment

Depth

1st(partial thickness)

Ex. Sunburn

2nd(partial thickness)

Ex. Scalds

3rd(full thickness)

Characteristics

Involves only the superficial epidermis characterized by erythema, dryness and pain

Heals 1 -10 days

Involves the entire epidermis, and portion of dermis characterized by erythema, blistered and
moist from exudates which is extremely painful.

Involves both skin layers, epidermis and dermis/may involve adipose tissue, fascia, muscle and
bone. It appears leathery, white or black and not sensitive to pain since nerve ending had been
destroyed.

Management

First Aid
Put out flames by rolling the child on a blanket
Immerse the burned part on cold water
Remove burned clothing
Cover burn with sterile dressing
Maintenance of a patent airway
Suction as needed
Oxygen administration
ET tube
Tracheostomy
Prevention of Shock and Fluid and Electrolyte Balance
Colloids to expand blood volume
Isotonic saline to replace electrolytes
Dextrose and water provide calories
A booster dose of tetanus toxoid
Relief of pain such as IV analgesic (morphine sulfate)
6.Prevention of wound infection

Cleaning and debriding of wound

Open/close method of wound care
Whirlpool therapy
Skin grafting
Big skin xenograft
Taken from cadaver
Diet
High protein
high calorie

Atopic Dermatitis
- Infantile exema

- Skin disease characterized by maculo vesicular errythematous lesion with weeping and
crusting

- Cause: allergens (main), milk, eggs, citrus juices, tomatoes and wheat

- Characterized by extreme pruritus

- Sign:linear excoriation, lichenified – scaling

Management

- Treat main cause

- Prosorbbee or Isomil (milk)

- Hydrate skin with burrow’s solution

- Prevent infection

- Cut short the nails

Impetigo

- Cause:group A beta hemolytic streptococcus

- Characterized by populo vesicular surrounded by localized errythema becoming purulent and

ooze forming a honey colored crust

- Pediculosis capitis (kuto)

- Give oral penicillin

- AGN complication

Acne
- Self limiting inflammatory disease affects sebaceous glands common in adolescence

- Signs:Comodones (sebum causing white heads)

- Sebum is composed of lipids

Management

- Proper hygeine

- Wash face with soap and water

- Use sulfur soap or mild soap

- Retin A

PALLOR-ANEMIA

Possible cause of Anemia

Early cutting of cord

Bleeding Disorder/blood dyscracia

HEMOPHILIA

- Deficient clotting factor

- X link recessive inheritance

- Sex link

- Excessive bleeding upon cutting of cord or circumcision

- Carrier mother passed to son, when son becomes a father he will pass it to his daughter
Hemophilia A (classic)– deficiency of the coagulation component (Factor VIII)

Hemophilia B(Christmas disease) – deficiency in clotting factor IX

Hemophilia C– deficiency in clotting factor XI

Assessment

- Newly delivered baby receive maternal clotting factor

- Sudden bruising of bumped area

- Continuous bleeding to hemarthrosis

- Bleeding or damage of synovial membrane

Diagnostic Test

- High risk for injury (prevent injury)

- Partial thromboplastin time

Management

- Avoid contact sports

- Significance: determine case before doing any invasive procedure

- No aspirin

- Immobilize and elevate upon injury

- Apply gentle pressure

- Cold compress

- Blood transfusion: cryoprecipitate, fresh frozen plasma

LEUKEMIA

- Group of malignant disease characterized by rapid proliferation of immature WBC

- WBC (soldiers of body)

- Ratio: 500 RBC:1WBC

Classification (depends on affected part)

Lympho – lymphatic system

Myelo – bone marrow

Acute/Blastic – immature cells

Chronic/cystic – mature cells

Acute lymphocytic – common among children

Signs and Symptoms

From the invasion of bone marrow

- Anemia (pallor, fatigue, constipation)

- Bleeding (bruising, petechiae, epistaxis, bleeding in urine, emesis)

- Infection

- Fever

- Poor wound healing

- Bone weakens and causes fracture

From the invasion of organs
- Hepatosplenomegaly

- CNS affectation (headache and signs of increase ICP)

Diagnostic Tests and studies

PBS (peripheral blood smear)– determine immature WBC

CBC– anemia, neutropenia, thrombocytopenia
Lumbar Puncture – place in fetal position without flexion of neck, C position or shrimp position
Bone Marrow Aspiration
- Site for aspiration is the iliac crest

- Put pressure after aspiration

- Place on affected side

Bone Scan – determine bone involvement

CTscan– determine organ involvement

Surgery

Irradiation Chemotherapy
Therapeutic Management

Medications
4 Levels of Chemotherapy

For Induction – achieve remission (main goal)

IV vincristine
L-aspariginase
Oral prednisone
For Sanctuary – treat leukemic cells that has invaded testes and CNS

Methotrexate (intrathecally via CNS/spine)

Cytocin
Arabinoside
Extra irradiation
For Maintenance – continue remission

Oral methotrixate
Oral 6 mercaptopurine
Cytarabine
For Reinduction – treat leukemic cells after relapse occurs

IV vincristine
L-aspariginase
Oral prednisone
Antigout Agents – treat/prevent hyperuricemic nephropathy

Allopurinol (Zyloprim)
Increase fluid intake

Nursing Management

- Assess for common side effects

- Nausea and vomiting

- Administration of anti emetics 30 minutes before chemo and continue until 1 day after

- Check for stomatitis, ulcerations and abscess of oral mucosa

- Oral care (alcohol free mouthwash) no toothbrush

- Diet (soft and bland) according to child’s preference

- Alopecia (temporary side effects)

- Hirsutism

- To parents (always repeat instruction)

HEMOLYTIC DISORDER
Rh Incompatibility
- Mother negative, fetus positive

- 4thbaby affected

- Mother negative, no antigen (no protein factor)

- Erythroblastosis fetalis: hemolysis leading to decrease oxygen carrying capacity with

pathologic jaundice within 24 hours

- Test:Comb’s Test

- Vaccine:Rhogam

- Given to RH negative mother within first 72 hours to destroy fetal RBC therefore preventing
antibody formation

ABO Incompatibility
- Mother is type O, fetus is type A, B, AB

- Most common is O, and A

- Severe O and B

- First pregnancy can be affected

Assessment

- Coomon is hydrops fetalis, edematous on lethal state with pathologic jaundice within 24 hours

Management

Initiation of feeding, temporary suspension of breast feeding to prevent kernikterus

Pregnanediole – delays action of glucorinyl transferace(liver enzyme that converts indirect
bilirubin to direct bilirubin)
Use of Phototherapy
Exchange Transfusion of Rh or ABO affectations that tend to cause continuous decrease in
hemoglobin during the first 6 months because bone marrow fails to produce erythrocytes in
response to continuing hemolysis.

Yellow – Jaundice

Hyperbilirubinemia

- Normal: indirect bilirubin 0 – 3 mg/dl

- More than 12 mg/dl of indirect bilirubin in fullterm

Kernicterus

- Bilirubin encephalopathy more than 20 mg/dl indirect bilirubin in fullterm

- Less than 12 mg/dl in preterm because of immature liver

Physiological Jaundice

- Icterus neonatorum

- 48 – 72 hours
- Expose to sunlight

Pathological Jaundice

- Icterus gravis neonatorum

- Clinical jaundice within 24 hours

Breastfeeding Jaundice

- Pregnaniliol

- 6 – 7 days

Assessment

- Blanching the neonates forehead , nose or sternum

- Yellow skin and sclera

- Light stool

- Dark urine

Management

Phototherapy

- Photo oxidation

- Height of 18 – 20 inches away from baby

Nursing Responsibilities
Cover the eyes – prevent retinal damage
Cover genitals – prevent priapism (painful continuous erection)
Change position – for even exposure to light
Increase fluid intake – to prevent dehydration
Monitor I & O – weigh baby 1 gram:1 cc
Monitor Vital Signs
- Avoid use of lotion or oil because it may result to bronze baby syndrome

HEAD
Structures

Sutures: 3

Fontanels: 12 – 18 months close

Anterior fontanel

- Craniostenosis/craniosinustosis (premature closure of anterior fontanel)

Posterior fontanel

- 1 x 1 cm

- Closes by 2 – 3 months

Microcephaly

- Small/slow growing brain

- Fetal alcohol and HIV positive

Anencephaly

- Absence of cerebral hemisphere

Noticeable Structure of the head

Craniotabes
- Localized softening of cranial bones to 1stborn child due to early lightening
- Ricketts in older children

Caput Succedaneum
- Edema of scalp due to prolonged pressure at birth

- Characteristics

- Present at birth

- Crosses the suture line

- Disappear after 2 – 3 days

Cephalhematoma
- Collection of blood due to rupture of periostial capillaries

- Characterisitcs

- Present after 24 hours

- Never cross the suture line

- Disappear after 4 – 6 weeks

Seborrheic Dermatitis
- Cradle cap

- Scaling, greasy appearing salmon colored patches usually seen on scalp, behind ears and
umbilicus

- Primary cause:improper hygiene

- Management:proper hygiene, apply oil the night before shampooing (use baby oil or coconut
oil)
Hydrocephalus
- Collection of CSF

2 types

Communicating – extra ventricular hydrocephalus

Non communicating – intra ventricular hydrocephalus also called obstructive

Signs and Symptoms

- Sign of increase ICP

- Sign of frontal bossing (prominent forehead)

- Prominent scalp vein

- Sunset eyes

Therapeutic Management

- Place client in low semi fowlers position (30o)

- Osmotic diuretic

- Diamox (Acetazolamide) to decrease CSF production

- Seizure precaution

- Surgery (AV shunt, VP shunt)

- Shave just before surgery

- Place in side lying position on non operated side

- Monitor for good drainage

- Sunken fontanel is a good sign

- Mental retardation depend on extent of hydrocephalus

SENSES
Sense of Sight (Eyes)
Sclera– light blue becomes dirty white

Pupils – round and adult size

Coloboma – part of iris is missing

Congenital cataract – whiteness and opacity (caused by german measles)
Cornea– round and adult size, larger in congenital glaucoma

Test of blindness

AGE

COMMON TEST

1. Newborn

2. Infant and children

3. 3yr – school age

4. School Age – Adult

- General appearance

- See 10 – 12 inches

- Doll’s eye testdone on 10th day

- Glabellars test blink reflex

- General appearance

- Ability to follow object past midline

- Pre school

- E charttest for stereosis or depth of perception

- Allen cards for visual acuity

- Ishiharas plates for color blindness

- Cover testing for strabismus, eye deviation

- Snellen’s test

RETINOBLASTOMA
- Malignant tumor of retina

- Red painful eye often accompanied by glaucoma (pathognomonic sign: cat’s eye reflex)

- Management:enucleation

Senses of Smell (Nose)

- Flaring or alae nasi (RDS)

- Pale with creases nasal membrane, chronic rhinitis

- Inflamed: infection

- Cocaine abuse:

- No hair

- Ulceration with abscess at the nasal mucosa

- Perforation of nasal septum

- Epistaxis:

- Nose bleed

- Sit upright with head tilted forward

- Cold compress

- Apply pressure

- Give epinephrine

Sense of Hearing (Ears)

- First to develop and last sense to disappear

- Properly aligned to outer canthus of eye

1.Kidney Malformation

- Low set ears

- Renal agenesis

- Unilateral/bilateral

- Oligohydramnios (sign of renal agenesis in utero)

- Failure to fade 24 hours

- Kidney transplant

2.Chromosomal Aberrations

- More than 35 years

Nondisjunction
Trisomy 21
- Down syndrome

- Extra chromosome 21

- 47 XX + 21 or 47 XY + 21

- Cause: advance paternal age

- Mongolian slant in eyes

- Low set ears

- Broad flat nose

- Protruding tongue

- Puppy’s neck
- Hypotonic (respiratory problem unable to cough out)

- Simian crease (single transverse line of palm)

- Educable

Trisomy 18
Trisomy 13
Turners
Klinefilters Syndrome

Deletion Abnormalities
Cri-du-chat Syndrome
Fragile X Syndrome

Translocation Abnormalities
Balance Translocation Carrier
Unbalanced Translocation Syndrome

Others
Mosaicism – a situation wherein the nondisjunction of chromosomes occurs during the mitotic
cell division after fertilization resulting to different cells contains different numbers of
chromosomes.
Isochromosomes – a situation wherein the chromosomes instead of dividing vertically it divides
horizontally resulting to chromosomal mismatch.

OTITIS MEDIA

- Inflammation of middle ear, common in children due to wider and shorter eustachian tube

- Common with cleft lip and palate

- Bottle propping, may also result to dental caries

- Otoscopic: bulging tympanic membrane and absence of light reflex

- Observe for passage of milky, purulent and foul smelling odor discharge
- Observe for URTI

Management

- Side lying on affected side to facilitate drainage

- Supportive care (TSB, antipyretic)

- Massive dosage of antibiotic (may lead to bacterial meningitis)

- Apply ear ointment

below 3 years down and back

above 3 years up and back
- Mucolytics to shrink mucous

- Myringotomy:surgical procedure done by making a slight incision of the tympanic membrane

- Place client on the operated side

- To prevent permanent hearing loss

Mouth and Tongue

Bells Palsy
- Facial nerve paralysis

- VII cranial nerve injury

- Related to forcep delivery

Signs and Symptoms

- Continuous drooling of saliva

- Inability to open 1 eye and close other eye

Management

- Artificial tears
- Refer to PT (self limiting)

TEF/TEA
- Tracheo Esophageal Fistula. Tracheo Esophageal Atresia

- No connection between esophagus and stomach

- 4 C’s:coughing, choking, cyanosis, continuous drooling

- Emergency surgery

Epstein Pearls
- White glistening cyst usually seen on palate or gums related to hypercalcemia

Natal Tooth
- Tooth at moment of birth related to hypervitaminosis (rootless)

Neonatal Tooth
- Tooth within 28 days

Oral Trush
- Oral moniliasis, white cheese/curd like patches that coats mouth and tongue

- Treat with anti fungal (Nistatin/Mycostatin)

Anodontia
- No eruption of temporary teeth

Kawasaki Disease
- Common in Japan

- Mucocutaneous lymph node syndrome

- Drug of choice: Aspirin, Salicylates

Criteria for diagnosis of Kawasaki Disease

Fever lasting more than 5 days

Bilateral Conjunctivitis
Change of lips and oral cavity
Dry, red, fissure lips
Strawberry tongue
Diffuse erythema of mucous membrane
Changes of peripheral extremities
Erythema of the palms and sole
Indurative edema of the hands and feet
Membranous desquamation from fingertips
Polymorphous rash (primarily on trunk)
Acute nonpurulent swelling of cervical lymph node to > 1.5 cm in diameter

Cleft Lip

- Failure of the median maxillary nasal processes to fuse by 5 – 8 weeks of pregnancy

- Common in boys

- Can be unilateral or bilateral

Cleft Palate

- Failure of the palate to fuse by 9 – 12 weeks of pregnancy

- Common in girls

Signs and Symptoms

Evident at birth
Ultrasound/3 dimensional UTZ
Milk escape to the nostril
Common URTI (otitis, cholic)

Therapeutic Management

- Surgery

- Cleft lip: cheiloplasty done as early as 1 – 3 months to save sucking reflex

- Cleft palate: uranoplasty done 4 – 6 months to save speech

Nursing Responsibility (Pre Op)

- Emotional support

- Proper nutrition

- Use Rubber tipped medicine dropper

- Prevention of cholic

Feed upright position

Burp twice
Prone position/on abdomen
- Orient parents to feeding technique

Cleft Lip

- Use rubber tipped syringe

Cleft Palate

- Use paper cup, plastic cup, soup spoon

- Use elbow restraints (pre op)

- So baby can easily adjust post op

Post Op Nursing Care

- Maintenance of airway

- Side lying (cheiloplasty)

- Prone (uranoplasty)

- Facilitate drainage

- Monitor for developing RDS

- Proper nutrition

- NPO 4 hours post op

- Check for colds or nasopharyngitis

- May cause septicemia

- Begin with clear liquid

- Observe for signs of hemorrhage (frequent swallowing)

- Usually happens 6 – 7 days post op

- Protect site of operation

- Maintain integrity of logan bar

Half strength hydrogen peroxide and saline

Prevent baby from crying
Prevent cholic
Check for wet diaper

Neck
- Check for symmetry

Congenital Torticolis
- Wry neck

- Birth injury of sternocleidomastoid muscle due to excessive traction during cephalic delivery

- Management:

- Passive stretching exercises daily

- Surgery (last)

- Complication is scoliosis

Congenital Cretinism (congenital hypothyroidism) – absence or non functioning thyroid glands

Signs and Symptoms

Change in sucking (early sign)

Change in crying
Sleep excessively due to decrease metabolism
Constipation
Moon face baby
Mental retardation (late sign)

Diagnostic Exam

- Radio active iodine uptake

- Protein bound iodine

- radio immuno assay test

Reasons for delayed diagnosis

- Thyroid glands are covered by sternocleidomastoid

- Baby receive maternal thyroxine

- Sleep 16 – 20 hours a day

Management

- Synthroid (synthetic thyroid)

- Sodium Levothyroxine (given lifetime)

Chest
- Check for symmetry

- Breast produces witch milk a transparent fluid related to hormone changes

Abdomen
- Inspection, Auscultation, Palpation, Percussion

Diaphragmatic hernia
- Protrusion of stomach contents through a defect in the diaphragm due to failure of
pleuroperitoneal canal to close

Signs and Symptoms

Sunken abdomen
Signs of RDS
Related to shunting

Management

- CPAP (continuous positive airway pressure)

- Diaphragmatic repair within 24 hours

Ompalocele
- Protrusion of stomach contents between junction of abdominal wall and umbilicus
- Small: surgery

- Large:

- Suspension of surgery

- Wrap with sterile wet dressing

- Apply silver sulfadiazine ointment to prevent infection

GASTROINTESTINAL SYSTEM

1.Functions

Assists in maintaining fluid and electrolyte and acid/base balance

Processes and absorbs nutrients to maintain metabolism and support growth and development
Excrete waste products from the digestive system
Recommended Daily Allowance
Calories: 120 calories per kilo body weight per day (360 – 380 calories)
Fluids: 16 – 20 cc per kilo body weight
Protein: 2.2 grams per kilo body weight

Supplementary Feeding
- 4 – 6 months

Principles

Solid food is offered to the following sequence

- Cereals: rich in iron (because at 6 months iron is completely catabolized)

- Fruits

- Vegetables

- Meat

Begin with small quantities

Finger food is deferred by 6 months
Soft table food/modified family menu by 1 year
Dilute fruit juices (6 months)
- Ratio:1 oz. fruit to 4 oz. water

- Never give half cooked egg, may cause gastroenteritis/salmoneliosis diarrhea

- Avoid giving honey cause infant botulism

- Offer new food 1 at a time with interval of 4 – 7 days to determine food allergies

Major concepts of fluid and electrolyte balance

Distribution of body fluid

- Total body fluids comprises of 65 – 85% body weight among infants and children

- Fluids are greater ECF compartment among infants and children (prone to dehydration)

5.Acid-base balance

Dependent on the following

Chemical buffers
Renal and respiratory system involvement
Dilution of strong acids and bases on blood

Imbalance of acid

Respiratory acidosis
- Carbonic acid excess

- Hypoventilation

- Asthma

- Pneumonia

- Emphysema
- Laryngo tracheo bronchitis

- RDS

Respiratory alkalosis
- Carbonic acid deficit

- Hyperventilation

- Fever

- Encephalitis

Metabolic acidosis
- Carbonate deficit

- Diarrhea

- Severe malnutrition

- Dehydration

- Celiac crisis

Metabolic alkalosis
- Carbonate excess

- Uncontrolled vomiting

- Gastric lavage

- NGT aspiration

- Pyloric stenosis
Conditions that produce fluids and electrolytes imbalance
Vomiting
- Forceful expulsion of stomach contents

Signs and Symptoms

Nausea
Dizziness
Abdominal cramping
Flushing of face
Teary eyes

Assessment

- Amount

- Frequency

- Force (projectile:IC, pyloric stenosis)

Management

Banana

Rice, cereal

Apple sauce

Toast

Diarrhea
- Exaggerated excretion of intestinal content
Acute diarrhea are associated with the following
Gastroenteritis, caused by salmoneliosis (half cooked egg)
Antibiotic use
Dietary indescretions
CNSD (Chronic Non Specific Diarrhea)
Food intolerance
Carbohydrates and Protein malabsorption
Excessive fluid intake

Assessment

- Frequency

- Consistency

- Appearance of green color stool

Complications

Dehydration

Mild – 5% weight loss

Moderate – 10% weight loss
Severe – 15% weight loss

Signs of dehydration

Tachycardia
Tachypnea
Hypotension
Increase temperature
Sunken fontanel and eyeballs
Poor skin turgor/dry skin and mucous membrane
Absence of tears
Scanty urine (mark oliguria sign of severe dehydration)

Weight loss
Prolonged capillary refill time

Management

Acute – NPO to rest bowel, IV infusion

Potassium Chloride – check if baby can void because it can lead to hyperkalemia leading to
cardiac arrest
Sodium Bicarbonate – metabolic acidosis, administered slowly to prevent cardiac arrest

Gastric Motility Disorder

Hirschprungs Disease
- Congenital gagnlionic mega colon

- Absence of gagliion cells for peristalsis

Assessment

Neonatal Period
- Failure to pass meconium after 24 hours

Early Childhood
Ribbon like stool
Constipation
Diarrhea
Foul smelling stool

Signs and Symptoms

- Foul odor breath with stool

- Vomitus of fecal materials

Management
- NGT feeding

- Surgery

Temporary colostomy (at 2 -3 months)

Anastomosis and pull through procedure
- Diet:high calorie and low residue (spaghetti and chicken)

Diagnostic Procedures

Barium Enema – reveals the narrowed portion of the bowel

Rectal Biopsy
Abdominal x-ray – reveals dilated loops on intestine
Rectal manometry – reveals failure of intestinal sphincter to relax
Therapeutic Management and Nursing Care

Gastroesohageal Reflux (GER)

- Chalasiapresence of stomach contents in esophagus

Assessment Findings

Chronic vomiting
Failure to thrive syndrome (organic)
Esophageal bleeding manifested by

Effects and complication

- Esophagitis

- Aspiration

- Carcinoma

Diagnostic procedures
Barium Esophogram
Esophageal Manometry – reveals lower esophageal sphincter pressure
Intraesophageal pH content – reveals pH of distal esophagus

Medications

Cholinergics
Betanicole (Urecholine) - to increase esophageal tone and peristaltic activity
Metochlopromide (Reglan)– to decrease esophageal pressure by relaxing pyloric and duodenal
segments increasing peristalsis without stimulating secretion
Histamine receptor antagonist (Ranitidine/Zantac)– to decrease gastric acidity and pepsin
secretion
Antacid (Maalox)– to neutralize gastric acid between feedings

Management

Administration of thickened feeding with cereal to prevent vomiting

Feed slowly
Burp often every 1 oz.
Position: below 9 months place in prone with head of mattress slightly elevated on a 30O angle
Surgery: fundoplication

Obstructive Disorders
Pyloric Stenosis
- Hypertrophy of pylorus muscle causing narrowing and obstruction

Assessment

Projectile vomiting
Nursing Alerts:

- Vomiting is an initial symptom of upper GI obstruction

- Vomitus of upper GI can be blood tinged not bile streaked

- Vomitus of lower GI is bilous

- Projectile vomiting is either a sign of ICP or GI obstruction

- Abdominal distention is the major symptom of lower GIT obstruction

Failure to gain weight

Palpate olive shape mass

Peristaltic wave visible from left to right across epigastrium

Diagnostic Procedures

ABG – metabolic alkalosis

Serum electrolyte: increase Na and K, decrease chloride
Ultrasound
X-ray of upper abdomen with barium swallow reveals string sign

Therapeutic Management

- Surgery: pyloromyotomy

Intussusception
- Telescoping of one portion of the bowel to another

- Complication of peritonitis

Signs and Symptoms

- Acute paroxysmal abdominal pain

- Vomiting

- Curant jelly stool

- Sausage shape mass

Diagnostic test

- X-ray with barium enema reveal staircase sign

Management

- Hypostatic reduction with barium enema

Inborn Errors of Metabolism

- Deficient liver enzyme

Phenylketeinuria
- Deficiency of liver PHT (Phenylalanine Hydroylase Transferase)

- No tyrosine, melanin, tyroxine – basal metabolism

Signs and Symptoms

- Fair skin

- Blonde hair

- Blue eyes

- Accumulation of phenyl pyrobic acid in the blood

- Musty or mousy odor urine

- Atopic dermatitis

- Seizure

- Mental retardation
Diagnostic Tests

Guthrie test

Management

- Low phenylalanine indefinitely

- No food rich in protein (chicken, eggs, meat, legumes, peanut)

- Lofenalac

Celiac Disease
- 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)

Assessment

Early signs
Diarrhea; failure to regain weight ff diarrheal episodes
Constipation
Vomiting
Abdominal Pain
Steatorrhea
Late signs
Behavioral changes: irritability and apathy
Muscle wasting and loss of subconscious fats (protuberant abdomen)
Celiac Crisis
Exaggerated form of vomiting (emergency condition)
Diagnostic Procedures

Laboratory Studies: Stool Analysis

Serum antigliadin and antireticulin antibodies – presence indicates disorder
Sweat test – to rule out cystic fibrosis
Therapeutic Management

Vitamin supplements
Mineral supplements
Steroids

Poisoning
- Common among toddlers

Principles

Determine the substance taken, assess LOC

Unless the poison was corrosive, caustic (strong alkali such as LYE) or a hydrocarbon, vomiting
is the most effective way to remove the poison from the body
Syrup of ipecac– oral emetic to cause vomiting after drug over dose or poisoning
15 ml to adolescent, school age and pre school
10 ml to infant
Universal antidote– charcoal, milk of magnesia, and burned toast
Never administer the charcoalbefore ipecac
Antidote for Acetaminophen poisoning. Acetylsysteine (Mucomyst)
For caustic poison
Prepare tracheostomy set
Kerosine (use mineral oil to coat the intestine to prevent absorption)
Give vinegar to neutralize acid (for muriatic acid ingestion)

Lead Poisoning

- Destroy RBC functioning

- Resulting to hypochromic mycrocytic anemia

- Leading to kidney destruction

- That leads to accumulation of amonia

- Then encephalitis

Assessment

Beginning symptoms of lethargy

Impulsive and
As lead increases, severe encephalophaty with seizures and permanent mental retardation

Diagnostic Procedure

Blood Smear
Abdominal X-ray
Long bones

Management

- 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

Alerts

Female

- Pseudo menstration

- Slight bleeding related to hormonal changes

- Rape
- Tearing of forchet

- Concerned with child’s care

- Wound follow different stages of healing

- Identical wound

- Report to authorities within 48 hours (barangay captain, bantay bata)

- Shape of pubic hair is inverted triangle

Male

- Check testes (undescended)

- Cryptorchidism common in preterms and management is orchidopexy

- Warm room and hand

- Check for arch of urine

- Hydrocele: fluid filled scrotum (translumination reveal a glowing sign)

- Phimosis:tight foreskin (balanitis infection of glans penis)

- Varicocele:veins in scrotum is increased

Epispadias – meastus is located dorsal (above glans penis)

Hypospadias – meatus is located ventral (below glans penis)

Chordee – fibrous band causing penis to curve downward

Renal Disorder
Causes

Assessment Findings

Treatment

Nursing Care

1. Nephrotic Syndrome

2. AGN

- Infectious
- Autoimmune Grp. A beta hemolytic streptococcus

- Anasarca (general body edema)

- Massive proteinuria

- No hematuria

- Serum lipid increase

- Fatigue

- Normal or low BP

- Primary peripheral periorbital edema

- Moderate proteinuria

- Gross hematuria (smoky urine)

- Serum potassium increased

- Fatigue

- Increase BP

- Steroid (Prednisone)

- Diuretics (Lasix)
- Anti hypertensive hydralasine (appresoline)

- Hypertensive encephalopathy (complication anemia)

- Iron infusion

- Monitor hydration status (weight everyday with same clothing)

- Decrease sodium, normal protein

- Increase potassium intake (beef broth)

- Monitor weight

- Monitor BP

- Neurologic status

- Increase iron

- Decrease potassium

- Decrease sodium
Back
- Check for symmetry and flatness

Spina bifida Occulta

- Failure of posterior laminae of vertebrae to fuse

- Signs and Symptoms:dimpling at lower back

- Abnormal tuffs of hair

Spina bifida Cystica

- With sac

Types

Meningocele – protrusion of CSF and meninges

Myelomeningocele– protrusion of CSF, meninges and spinal cord
Encephalocele – cranial meningocele or myelomeningocele

Common Complication

- Common problem is rupture of sac (place wet sterile dressing and place in prone position)

- Infection

- Urinary and fecal incontinence

- Paralysis of lower extremities

- Hydrocephalus (CNS complication)

- Always check for a wet diaper

Treatment

- Surgery to prevent infection

Scoliosis
- Lateral curvature of spine common in school age and adolescent

- Uneven hemline

- S shape back

- When bending 1 hip is higher and 1 shoulder prominent

Management

Conservative
Exercise
Avoid obesity
Preventive
Milwaukee brace worn 23 hours a day
Corrective
Surgery – insertion of Harrington rod (post op do log rolling or move as 1 unit)

Extremities
Digits
Syndactyly – webbing of digits (ginger like foot) congenital
Polydactyly – extra digit
Olidactyly – lacking digit
Amelia – total absence of extremities

Pocomelia– absence of distal part of extremities

- Both are caused by talidomides

Erb-duchennse paralysis/Brachial Plexus injury/Brachial palsy

- Birth injury due to lateral and excessive traction during a breech delivery
Signs and Symptoms

- Inability to abduct arm from shoulder, rotate arm externally and supinate forearm

- Absence/asymmetrical moro reflex

Management

- Abduct from shoulder with elbow flexed

III.Congenital Hip Dislocation

- The head of femur is outside acetabulum

Types

Subluxated – most common type

Dislocated

Signs and Symptoms

Shortening of the affected leg

Asymmetrical gluteal fold
Limited movement (early sign)
Positive ortolani’s sign – clicking sound during abduction
When able towalk the child limps (late sign)

Management

Triple the diaper

Carry a stride
Frejka Splint
Pavlik Harness
Hip Spica Cast

Talipes
- Club foot

Types

Equinos – plantar flexion (horse foot)

Calcaneous or Dorsiflexion – the heel is held lower than the foot/the anterior portion of foot is
flexed towards the anterior leg
Varus – foot turns in
Valgus– foot turns out
- Common combination is talipes equino varus andtalipes calcaneo valgus

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.

Crossed extension reflex– when the sole of foot is stimulated by a sharp object, it causes the
foot to rise and the other foot extend (test for spinal cord integrity)

Truck Incurvation reflex– while in prone position and the paravertical area is stimulated, it
causes flexion of the trunk and swing his pelvis toward the touch.

Landau reflex –while prone position and the trunk is being supported, the baby exhibit some
muscle tone (test for muscle tone and present by 6 – 9 months)

Parachute reaction – while on ventral suspension with the sudden change of equilibrium, it
causes extension of the hands and legs (present by 6 – 9 months)

Babinski reflex– when the sole of foot is stimulated by an inverted “J”, it causes fanning of toes
(disappear by 2 months but may persist up to 2 years)