NCMA 219 Midterm Exam

topics
Pointers to review:
• ◦ High risk newborn ◦ IUGR/ SGA/ LGA/ Preterm ◦ RDS ◦ MAS ◦ SIDS ◦
Hyperbilirubinemia ◦ Neonatal Sepsis ◦ Necrotizing enterocolitis ◦
G6PD/ Congenital Hypothyroidism ◦ Phenylketonuria ◦ Galactosemia ◦
Tetralogy of Fallot ◦ Rheumatic fever/ RHD ◦ ASD/ VSD/ PDA ◦
Kawasaki Disease ◦ Streptococcal pharyngitis ◦ Tonsillitis ◦ Sickle Cell
anemia/ IDA ◦ CROUP syndrome / LTB/ Epiglottitis
• Premature Infant < 38 weeks gestation
• birth that takes place more than three weeks before the baby's
estimated due date. Occurs before the start of the 37th week of
pregnancy.
• lanugo covers the entire back and face, soles few creases, scrotum
little rugae
• Thin and pinkish skin, plenty of lanugo and relaxed posture
• Postmature infant - > 42 weeks gestation
• a baby delivered after 42 weeks of gestation.
• abundant scalp hair. Visible creases on palms and soles of feet.
Minimal fat deposits
• Absence of lanugo
IUGR

• Small for Gestational Age Infants

• Infant whose rate of intrauterine growth was slowed and whose birth weight
falls below the 10th percentile on the intrauterine growth chart.
• Causes –
• Poor nutrition during pregnancy

• Placental defects and complications

• Teenage pregnancies

• Hypertensive mother
• Priority nursing care in the first few days of life
• Initiation and maintenance of respirations

• Maintenance of hydration and normal glucose - glucose IVF, thermoregulation,

correct IVF rate, breastfeeding every 3-4 hours
• monitor glucose level every 4 hours

• Control of body temperature

• For newborns under radiant warmers – monitor vital signs, keep the newborn
hydrated, assess integrity of the skin.
• Maintaining neutral thermal environment permits the neonate to maintain a
normal core temperature with minimal oxygen consumption.
IUGR and SGA newborn
• Causes
• Age – under 18 or over 35 years of age
• Poor nutrition during pregnancy
• Placental defects – perinatal hypoxia
• Maternal condition – HPN, anemia, DM
Respiratory Distress Syndrome (Hyaline
Membrane Disease)
• refers to a condition of surfactant deficiency and physiologic
immaturity of the thorax.
• Diagnostic exam – X-ray, blood glucose, ABG, Fetal lung maturity
assay ( the fastest)
• diagnostic findings – radiographic findings – diffuse granular pattern
like broken glass appearance on chest x-ray, hypoxemia, increased
carbon dioxide and respiratory acidosis on ABG.
• Medications- artificial surfactant, nitric oxide ( it will dilate
pulmonary bronchus)
Clinical Manifestations of RDS
MAJOR SIGNS:
• Tachypnea 60>
• Flaring nares
• Expiratory grunting,
dyspnea
• Chest Retractions –
sternal and subcostal
• Seesaw respirations
Meconium Aspiration Syndrome
• Is the aspiration of amniotic fluid containing meconium into fetal or
newborn trachea in utero or at first breath.
• Occurs primarily in full-term and post term infants during relaxation
of the anal sphincter and passage of meconium into amniotic fluid
due to intrauterine stress
• assessment – widened anteroposterior diameter of the chest (barrel-
chest), greenish stains on the skin, umbilical cord and nails
• Priority nursing care – assist in tracheal suctioning
Meconium Aspiration Syndrome

NURSING CARE:
• Suctioning – oropharyngeal and tracheal
• O2 support (Severe: Extracorporeal
membrane oxygenation)
• Exogenous surfactant administration
• IV fluid administration
• Administer systemic antibiotics as
prescribed
• Ampicillin
• Gentamycin
• Amikacin
Sepsis
• Early onset - occurs less than 3 days after birth
• Caused by maternal infection
• Late onset - occurs on the 4th up to 7th days after birth
• Nosocomial infection
Clinical Manifestation
• Pallor, cyanosis, or
mottling
• Hypotension
• Tachycardia
• Irregular respirations
• Jaundice
• Dehydration
• Temperature instability
• Blood culture
• Urine and blood culture
and CSF analysis
• CBC – WBC increased
• ESR and C-reactive
protein - increased
Hyperbilirubinemia
• refers to an excessive level of accumulated bilirubin in the blood and
is characterized by jaundice.
• Pathologic jaundice - Jaundice in the first 24 hours of life
• Physiologic jaundice - Jaundice after 24 hours of life
• Complications - Kernicterus
• Management – Phototherapy
• Nsg care –
• cover the eyes and genitalia,
• check skin turgor for hydration,
• turn the infant every 2 hours
• Instruct the mother to continue breastfeeding every 2-4 hours
• Sudden unexpected death of any infant younger than 1
year of age
• Death usually occurs during sleep – “CRIB Death”
• Most common cause of death in children ages 1 months
to 1 year
• Peak: 2-4 mos., 90% before 6th mos.
 NURSING MANAGEMENT
• Teach parents how to
minimize the risk of SIDS
• Avoid smoking during and after
pregnancy
• Encourage supine position or
side-lying position
• Causes:
• Co-sleeping
• Soft beddings
• Use of pillows, blankets on the
crib
• Maternal smoking
Necrotizing
enterocolitis
• An acute inflammatory disease
of the bowel
• Preterm neonates manifesting
abdominal distention and
vomiting.
• Signs:
• Poor feeding
• Distended abdomen
• Blood in the stool
• Vomiting
• Apnea
Necrotizing Enterocolitis
• Nursing Management
• Assessing patient for presence of abdominal distention
• Reporting to the doctor any episodes of gastric residuals
• Placing the patient on NPO as per doctor’s order if symptoms of NEC is
observed
Newborn Screening
• Congenital hypothyroidism
• Phenylketonuria
• G6PD Deficiency
Newborn Screening - procedure to determine if the newborn
infant has a heritable congenital metabolic disorder
Congenital Hypothyroidism
Results from the absence or lack of development of thyroid gland causing
absence or lack of thyroxine needed for metabolism and growth of the
body and the brain.
s/s – short stature, macroglossia, delayed closure of the fontanelles,
hypotonia
Management - medication will be needed throughout the child’s lifetime
Administration of thyroid hormone will prevent problems.
if managed early it will not cause mental retardation
Medication – Synthroid – taken in the morning. Report signs of tremors
(toxicity)
• Phenylketonuria
• Deficiency or absence of enzyme needed to metabolize essential
amino acid like phenylalanine
• Diagnostic test – Guthrie test
• If managed early it will prevent mental retardation or cognitive
impairment.
• The goal of treatment - meeting the child’s nutritional needs for
optimal growth.
• If untreated – results to FTT, absence of adequate melanin
pigmentation, unpredictable and erratic behavior
• G6PD Deficiency
• Lack of enzyme resulting to premature destruction of RBC leading to
hemolytic anemia
• Without G6PD, RBC’s undergo HEMOLYSIS when exposed to oxidative
stress.
• Symptoms – jaundice,. Dark colored urine, back pain, anemia
• Complications – severe anemia, hyperbilirubinemia
• Management – avoid food, drugs, chemicals that cause oxidative
stress
Heart Disorders
• Congenital Heart Disorders
• ASD
• VSD
• PDA
• TOF
• Acquired Heart Disease
• Rheumatic Heart Dse,
• Kawasaki Heart Dse
a. Defects with blood flow -
Increased Pulmonary blood flow
• Atrial Septal Defect - a hole in the wall (septum) that divides the upper chambers (atria) of the heart. Failure
of the foramen ovale to close.
• Left to right shunting – acyanotic
• Dacron patch – for large ASD
• Complications – activity intolerance, risk for infection, decrease cardiac output, excess fluid volume
• Ventricular Septal Defect - a hole in the wall (septum) that separates the two lower chambers (ventricles) of
the heart.
• Left to right shunting – increased pulmonary blood flow - acyanotic
• a loud, holosystolic murmur.
• Nursing Diagnosis – Ineffective tissue perfusion related to left heart dilation from increased pulmonary
blood flow
• Patent Ductus Arteriosus - a normal fetal connection between the aorta and the pulmonary artery does not
close as it should after birth.
• Left to right shunting – increased pulmonary blood flow - acyanotic
• Machinery-like murmur
• Medication - Indomethacin
Decreased pulmonary blood flow
• Tetralogy of Fallot
• combination of four congenital heart defects.
• right to left shunt through ventricular septal defect
• ventricular septal defect (VSD) (major),
• pulmonary stenosis (major),
• a misplaced aorta (minor) and
• a thickened right ventricular wall (right ventricular hypertrophy) (minor).
• Increasing cyanosis when crying or activity
• Presence of hyper cyanotic spells or tet spells (place the child in knee-chest
position during tet spells)
• Management – Blalock-Taussig shunt - creates anastomosis of the subclavian
artery to the pulmonary artery.
• Acquired Heart Disorders
• Kawasaki Disease
• Rheumatic Heart Disease
Rheumatic • Inflammatory disease occurs after Group A
Beta-hemolytic streptococcal throat infection
Heart
• Has history of strep throat infection within the
Disease last month
• Self-limiting
• Affects joints, skin, brain, serious surfaces,
and heart
 Diagnostic approach: Modified Jones Criteria
• 2 major or 1 major + 2 minor manifestations + strep infection
• MAJOR
• Carditis – tachycardia out of proportion to degree of fever
• Cardiomegaly, murmur, muffled heart sounds
• Polyarthritis
• Arthritis is reversible and migrates, especially in large joints (knees, elbow, hips, shoulders,
wrists)
• Swollen, hot, red, painful joints, after 1-2 days à affects different joints
• Should continue salicylates ( analgesics ) – anti inflammatory, analgesic
- Activity intolerance
• Erythma marginatum – rash
Transitory, non pruritic
Trunk and proximal portion of extremities
Red macule with clear center wavy, well-dermacated border
• Subcutaneous nodules
Small nontender nodules
Bony prominences – hands, feet, elbows, scalp, scapulae, vertebrae
Persistent indefinitely after onset of the disease and resolve with no resulting damage
 Diagnostic approach: Modified
Jones Criteria

• MAJOR
• St. Vitus Dance – The Fifth Manifestation (Sydenham’s Chorea)
• St. Vitus Dance(aka, chorea) reflects CNS involvement
• Definition: Chorea refers to sudden, aimless movements of
extremities, involuntary facial grimaces, speech disturbances,
emotional lability and muscle weakness
• MINOR
• Arthralgia
• Fever
• Increased ESR
• Increased CRP
 TREATMENT
• Prevention of RHD
• Antibiotics - acute phase of rheumatic fever
• Treatment of streptococcal tonsillitis / pharyngitis
• Penicillin G – IM x 1 ( drug of choice)
• Penicillin V – oral x 10 days
• Erythromycin (if allergic to above) – oral x 10 days
Rheumatic Heart Disease (RHD)

• Most common
complication of RF
• Damage to valves –
valvular heart disease
KAWASAKI DISEASE

• Mucocutaneous LN
syndrome
• Acute systemic
vasculitis
• < 5 y/o (Peak:
toddlers)
• Self limiting but
20% children
without treatment
develop cardiac
disease
• Etiology: unknown
• Area involved: CVS
• Initially: Inflammation arterioles, venules, capilliaries à
formation coronary artery aneurysm
• Death: result of coronary thrombosis or severe scar formation
& stenosis of main coronary artery
• Myocardial infarction from thrombosis
• No specific diagnostic test
• IRRITABILITY – hallmark of Kawasaki Disease
• Persists in 2 weeks
 • Treatment
• Intravenous Immune
globulin (IVIG)
KAWASAKI infusion - 10-12 hours
(7-10 days from onset)
DISEASE • Diphenhydramine –
reduce risk for allergic
reaction to IVIG
• Aspirin
Respiratory /Hematologic Disorders
• Tonsillopharyngitis
• Iron Deficiency Anemia
• Sickle-cell anemia
 • Group A b-hemolytic
streptococci infection
(GABHS)
• Strep throat
• Risk for serious
complications:
– Acute Rheumatic
fever
– Inflammatory
disease of joints,
heart, CNS
– Acute
ACUTE Glomerulonephritis
(AGN)
STREPTOCOCCAL
PHARYNGITIS
 Nursing Care Management:
• Analgesics (acetaminophen, ibuprofen)
• Remain in bed
• Antipyretic for fever.
• Cold or warm compress
• Fluid intake
• Warm saline gargles
• Avoid sharing drinking or eating utensils
• Antibiotic full compliance. Complete the course of
antibiotics to prevent rheumatic fever. (10 days antibiotic
treatment)
• Advise to discard toothbrush after 24 hours of taking
antibiotics
TONSILLITIS • An infection or inflammation (hypertrophy)
of the palatine tonsils
 • Inflammation
Clinical • Palatine --- Kissing tonsils = no
Manifestation passage of food & air
• Adenoid --- no air passage =
mouth breather >>> dry
oropharynx >>> impaired smell
& taste, voice nasal muffled
quality --- OM/ hearing impaired
 • Self-limiting & Treatment is
symptomatic (Viral)
• Antibiotics (Bacterial infection)
• Drug of choice: amoxicillin
Surgical Treatment :
Therapeutic • TONSILLECTOMY
Management – Recurrent peritonsillar abscess,
airway obstruction, with febrile
convulsions, tissue pathology
• ADENOIDECTOMY
 • Soft to liquid diet
• Cool mist humidifier – soothes inflamed
mucous membrane
• Cool water, crushed ice, Ice chips
• Allow the child to have diluted juice after
Nursing Care the procedure - Avoid red juices, citrus,
milk, ice cream
Management • Opioids – acetaminophen
Post •
•
Avoid routine suctioning and coughing
Place the child on the abdomen until fully
tonsillectomy •
wake.
NPO until fully alert and no signs of
hemorrhage
• WOF: Continuous swallowing – notify
MD
Treatment:
• Cool mist vaporizer at night
• Corticosteroids
– Dexamethasone IM - 0.6mg/kg single dose or 0.15mg/kg
– Budesonide nebulized - 2mg
• Nursing management
– Allow the parents to stay in the bedside – The
parent’s presence will reduce anxiety and ease
the child's respiratory efforts.
– Do not use tongue depressor to examine the throat - it will
cause complete obstruction.
Priority nursing action if the child is sitting
in frog like position, drooling and agitated –
nitify the doctor and prepare for
tracheostomy.
Iron Deficiency Anemia
• Most common type of anemia and
nutritional deficiency in children
• Preterm infants – at risk due to reduced
fetal iron supply
• Children 12-36 months: at risk due to
cow’s milk intake ( poor source of iron) and
not eating adequate amount of iron-
containing food
• Adolescents – at risk due to rapid growth
rate combined with poor eating habits,
menses, obesity, or strenuous activities
Assessment Findings
• Clinical manifestations
• Clinical manifestations are related to a reduction in the amount of oxygen
available to tissues.
• Major signs
• Pale skin - pallor
• Fatigue
• Muscle weakness
etiology
• Iron deficiency due to impaired iron absorption
• Chronic diarrhea
• Lactose intolerance
• Inflammatory bowel diseases
• Gastric alkalinity
• Presence of phosphates
Family education
• Administering liquid iron prerations will turn the stool tarry green
color.
• Use straw in giving PO – can discolor the teeth
• The iron should be given in two divided doses between meals.
• Breast milk or iron-fortified formula should be used for the first
12 months.
• Management
• Nutrition - Red meat, eggs, oatmeal, and dried fruit
• Ferrous sulfate – advise the patient the stool will appear black.
Sickle-cell Anemia

• One of a group of diseases collectively termed

hemoglobinopathies in which normal adult hgb is partly or
completely replaced by abnormal sickle hgb (HbS).
• Autosomal recessive disorder (inherited)
• Each sibling has a 25% chance of having SCA

• Causes occlusion of small blood vessels, ischemia, and

damage to affected organs
• RBCs change from round to sickle or crescent shaped
• Increased RBC destruction
• Assessment Findings -

• Clinical manifestations
• Enlarged spleen from congestion with sickled cells
• Enlarged and tender liver from blood stasis
• Hematuria
• Enuresis
• Bone weakness
• Dactylitis (symmetric swelling of the hands and feet)
Management
• Rest to minimize energy expenditure and to improve
oxygen utilization
• Hydration through oral and IV therapy
• Electrolyte replacement because hypoxia results in
metabolic acidosis, which also promotes sickling
• Analgesia for the severe pain from vaso-occlusion
• Blood replacement to treat anemia and to reduce the
viscosity of the sickled blood
• Antibiotics to treat any existing infection.
• Immunosuppressive therapy treatment for aplastic
anemia