PEDIATRIC NURSING
Developmental Levels
> FREUD (OAPhaLaGe)
> ERIKSON
Trust vs. Mistrust
Autonomy vs. Shame
Initiative vs.guilt
Industry vs. Inferiority
Identity vs. Role confusion
Intimacy vs. Isolation
Generativity vs. Stagnation
Ego Integrity vs. Despair
1. INFANT (0-18 months)
Erikson: Trust vs. Mistrust
- Trust can be develop by consistency
Freud: Oral Phase
- Hemtaxia (satisfy ang mouth)
PLAY (Solitary - Independent Play)
Toys:
● Mobile Toys
● Rattles
● Teething rings
● Music boxes
● Squeeze toys
Criteria(focus on neurosensory development):
consider safety, purpose, goal
Colors that infant only see: White, Black, Red
(immaturity of rods and cones)
- We use colors to stimulate
development kahit 3 colors lang yung
nakikita niya.
Significant Person: mother / mother figure
Fear: stranger anxiety
Hospitalization: oral stimulation and sucking
Surgery: bedside pacifier
Accident / Injury: aspiration (asphyxia) , fall
> NO CONCEPT OF DEATH
2. TODDLER (18 months - 3 years old)
Erikson: Autonomy vs. Shame and Doubt
(Greater sense of self control)
- To build autonomy let the child perform
other tasks that are not hazardous.
Freud: Anal (controlling bladder and bowel)
Signs for Readiness of Bladder and Bowel
Control: Talk, Walk, Sit
Best to train bladder: AM bladder control (1st)
Nighttime bladder control (last)
PLAY: Parallel - “You play, I play”
Toys:
● push and pull toys (development
of gross and fine motors)
Significant Person: Parents
Fear: Separation Anxiety
- How to control? Reassurance (return
when you promise)
Hospitalization: Security object (stuff toy)
Accident / Injury: falls, poisoning, thermal Oedipus Complex - son to mom
burns Electra Complex - daughter to father

How to identify if the burn is r/t abuse or not?
Abuse: nakatago, flinching when touch,
different degrees of healing
Behaviors observed on toddler:
● Negativism - “NO” (give choices and set
limits)
● Temper Tantrums - expression of needs
(time out, find out)
● Egocentrism - inability to distinguish
between one’s own perspective (goods
sign of autonomy)
PLAY: Associative / Cooperative (play together
but no focus on common goal)
Toys:
● Puppets
● Play house
● Doctor-nurse skit
Significant Person: immediate family
Fear : mutilation and castration
Hospitalization: play therapy, puppets, dolls
Accident / Injury: MVA

> DEATH IS REVERSIBLE

Behaviors observed:
● Exploration
● Love to share and imitate adult plays

4. SCHOOL AGE (6-12 y/o)

3. PRESCHOOL (4 - 5 years old)
Erikson: Industry vs. Inferiority
Erikson: Initiative vs. Guilt
Hallmark sign of Industry: good school
Freud: Phallic
performance

Why do preschools masturbate/fondel?

Freud: Latent
- Boredom
- Sexual curiosity
PLAY: Competitive
 Toys: > DEATH IS PERMANENT
● Skipping rope ______________________________________________
● Card games Developmental Milestone
● Scrabble
FINE MOTOR SKILLS - smaller movements
Significant Person: teacher (hands) “proximodistal development”
- Kamay at paa
Fear: doing wrong = cheating - Walang ulo

Hospitalization: simple diagrams / drawings

0 month Reflex grasp

Accident / Injury: MVA 3 months Hands held open

6 months Palmar grasp

> DEATH IS IRREVERSIBLE
disappears

9 months Pincer grasp

10 months Points at objects

11 months Puts object into cup

12 months Throws an object;

able to do 2 blocks
tower

5. ADOLESCENT (12-20 y/o) 12 months 2 blocks

Erikson: Identity vs. Role Confusion 2 years old 5 blocks

2 ½ years old 7 - 8 blocks

Freud: Genital (Puberty - increased libido,
hormones) 3 years old Unbutton shirt

4 years old Button of shirt

PLAY: Foreplay - prelude to intercourse
5 - 6 years old Tie shoelaces
Toys:
● Competitive sports activities
GROSS MOTOR SKILLS - cephalocaudal
development
Significant Person: Peers

Fear: Body Image Disturbance 0 month Head lag

2 months Lifts head

Hospitalization: Privacy
4 months Full head control
Accident/ Injury: Sexual Abuse, Substance
Abuse, Suicide, Sports Injures 5 months Roll over
 2 ½ years old Knows first name

6 months Sit with support 3 years old Word sentences ;

900 words
7 months Foot to mouth

8 months Sit without support GROWTH PRINCIPLES

Physiologic weight loss → 5 - 10% weight loss
- length → 50% increase by 1 year
9 months Crawl
Pathologic weight loss = >10% of the ideal
10 months Stand with support body weight → sign of Inorganic Failure to
Thrive (hindi na-a-absorb properly ang vitamins
11 months Cruising
and minerals ng bata)
12 months Stand without
support Physiologic Jaundice - common among infant
→ occurs after 24 hours “sunlight”

14 - 15 months Walk Pathologic Jaundice - occurs within 24 hours

(sign of complication) “phototherapy” (cover
eyes and gonads)

3 years old Ride a tricycle

6 months: 2x the weight
BEQ: Acc. to Denver Classification 50% of 12 months: 3x the weight
children can walk by 1 year old 24 months: 4x the weight

SPEECH
4 years old Birth length doubled

0 month Child may smile 2 years old Child achieve 50% of

adult hand
1 -2 months Coos
18 months Child throw over
2 months Social smile hand

2- 4 months Laughs ; makes 2 years old Speak 2-3 word

consonant sounds sentences

6 months Imitative sounds 4 years old Child use scissors

8 - 9 months Pronounces syllables

BEQ: Common physiologic problems among
(da-da)
adolescents contributing to their low
12 months Says 4 - 5 words self-esteem?
- Acne / Body Odor
2 years old First phrase ; 300
words
PRIORITY: Hygiene
NUTRITION PRINCIPLES - noticeable during crying periods
- disappear at age of 2
0 - 6 months exclusive
2. NEVUS FLAMMEUS (Port Wine Stain)
breastfeeding
- capillary angioma directly below
4 months IRON store epidermis
INCREASES - benign capillary malformations
- Nonelevated, sharply demarcated, red
6 months supplementary to purple, dense are of capillaries
feeding (cereal → - common in FACE
fruits → vegetables) - no fading in time (may require surgery)

> Transition of food 3. NEVUS VASCULOSUS (Strawberry Mark)

is one food at a time: - capillary hemangioma (most common)
5 -7 days ; 1 - 2 tsp - overgrowth of capillary blood vessels
- raised, clearly delineated, dark red
12 months introduce egg (1st
rough surface
yolk - most nutritious
- Head region
→ 2nd egg white
- Disappear 7 - 9
=allergy)
4. MONGOLIAN SPOTS (Slate Gray Nevi)
Feeding Problems: - bluish or black pigmentation on lumbar
dorsal area and buttocks
- gradually fade during 1st and 2nd years
Infancy Aspiration
of life
Toddler Physiologic Anorexia - common in Asian and dark-skinned
(NEGATIVISM) individuals
- disappear 2 - 5
Preschool Picky eaters; food
fade
______________________________________________
School Zero calorie intake REFLEXES
(junkfoods)

Adolescence Anorexia Nervosa Rooting - stroke chin head will follow

(eating disorder)
Sucking - touch roof of mouth, baby will
begin to suck
______________________________________________
BIRTHMARKS (NEONATE) - disappears 3 to 4 months

Tonic neck - extend

1. TELANGIECTATIC NEVI (Stork Bites)
- pale pink on red, flat, dilated capillaries Palmar grasp - stroke hands then close
- eyelids, nose, lower occipital bone, nape
of neck - disappear 6 months
- blanches easily
 ● no vernix and lanugo
Startle reflex - disappear 4 months
● long hair and nails
Moro reflex - disappear 6 months ● alert look

Babinski reflex - stroke legs form “J”

- normal up to 2 years
- Abnormal >2 years still present
- (+) fanning
= normal for infant
= abnormal for adult (can be
impending sign of neurologic
disorder)
Step reflex - sumasayaw if held upright
- walking or dance reflex
- disappear 5 to 6 months
Associated problems:
● Hypoxia (O2)
● Hypoglycemia (glucose water)
● Fetal distress (check HT)
● Meconium aspiration (suction)
● Meconium staining (IV antibiotic ;
Gentamycin)
______________________________________________
PEDIATRIC DISORDERS

BEQ: Reflex that will prevent baby from

poisoning?
- Extrusion reflex
______________________________________________

RISK NEONATES

1. PREMATURE (<37 weeks)

S/Sx:
● Thin, shiny, pink / red skin, little scalp
hair but lots of lanugo
● Nasal flaring, fast breathing, chest
indrawing / grunting

MGT:
● ET tube
● O2 via CPAP
● Incubator
● Gavage
● Surfactant

2. POSTMATURE (40 - 42 wks)

- decrease placental viability

S/Sx:
● long but thin, dry cracking skin
Placenta → liver (umbilical vein) then it will 2. ATRIAL SEPTAL DEFECT
shunts to → ductus venosus then it will enter - Acyanotic HD
—> inferior vena cava → right atrium (2 - Main Problem: Pulmonary Congestion
pathways: 70% Foramen Ovale other 30% Right (backflow from the left to the lungs)
Ventricle
3. PATENT DUCTUS ARTERIOSUS
Carries oxygenated blood from the placenta? - failure of the ductus arteriosus to close
= umbilical vein
Hallmark signs: Machinery like murmur
Carries unoxygenated blood from the placenta? (+) radial pulse
= umbilical artery
N: (-) radial pulse
LEFT SIDE OF HEART - greater pressure
4. COARCTATION OF AORTA
What causes the ductus arteriosus, foramen
ovale, ductus venosus (heart valves) to close? S/Sx:
= first cry of baby ● Cold legs and feet
● Pale skin
● Irritability
CARDIOVASCULAR DISORDERS ● Heavy sweating
● Difficult breathing
Congenital Heart Disease ● Difficulty feeding
- viral illness (CMV, GMV)
- maternal age >40 Hallmark sign: absent femoral pulse
- maternal DM
- UNKNOWN Mgt: check BP on all 4 extremities
INCREASE - UE
Acyanotic Heart Defect —Pulmonary DECREASE - LE
Congestion → CHF
Treatment: Balloon Dilation / Balloon
Cyanotic Heart Defect - cyanosis Angioplasty (dilate the small aorta)
- direct from the right side - no passage
to lungs for oxygenated → direct to left –
S/Sx. of Acyanotic heart disease:
1. VENTRICULAR SEPTAL DEFECT
Normal Infant:
> Radial = absent (if present - sign of
PDA)
> Femoral = present (if absent - sign
of COA)

● SOB
● Fatigue
 ● Swelling of legs, feet, abdomen Goal of Mgt: Prevent pulmonary congestion /
● Frequent lung infxn Digoxin (check HT ; digoxin toxicity =
● Stroke bradycardia)
● Heart palpitations / skipped beats Enalapril (for peripheral vasodilation)
● Heart murmur, whooshing sound that
can be heard through stethoscope =
APPROPRIATE AGE RANGE = HEART RATE
ASD
● Absent femoral pulse Newborn 100-160
- BP is increased = Upper
0-5 mos 90-150
- BP is low; lower extremities = COA
● Cold legs and feet = COA 6-12 mos 80-140

DIAGNOSTIC AND MANAGEMENT FOR 1-3 yo 80-130

ACYANOTIC HEART DEFECTS
3-5 yo 80-120

Chest Radiography 6-10 yo 70-110

Echocardiography
Cardiac Catheterization 11-14 yo 60-105

15-20 yo 60-100
Mgt.
● check for puncture site (bleeding) Adults 50-80
● Thrombus formation
● Distal pulses
● Check for HPN
APPROPRIATE AGE RANGE =
● Bradycardia
RESPIRATORY RATE
● Fluctuating BP
● Retroperitoneal bleeding Newborn 30-50
● Grey’s turner's sign (flank bruising)
0-5 mos 25-40
Surgeries: 6-12 mos 20-30

1. Open Heart Surgery 1-3 yo 20-30

- induce hypothermia = decrease BMR and O2
3-5 yo 20-30
demand
- Heart - lung bypass machine 6-10 yo 15-30
- Cardioplegia - high cold potassium
- Done: 6 mos - 2 years 11-14 yo 12-20

15-20 yo 12-30
2. Closed Heart Surgery
- Indomethacin - prostaglandin inhibitor → PDA Adults 16-20

Cardiac Catheterization - COA (rule of 10: 10 ______________________________________________

wks; 10 lbs)
CYANOTIC HEART DEFECTS MGT:
● Decreased O2
1. TRANSPOSITION OF GREAT VESSELS ● Propranolol
● Monitor high Hgb , HCT
Aorta - right (N: Left) ● Positioning during attacks (squatting /
Pulmonary artery - left (N: Right) knee chest)
● Morphine to decrease catecholamines
Other issues can arise as well: PDA, VSD, ASD (decrease anxiety - vascular dilation)

> may nakaopen pa where oxygen still comes

from

Persistent cyanosi (decreased oxygenation)

Hypoxia despite O2 Therapy

Mgt.
● Prostaglandin E1 - keep DA open
ACQUIRED HEART DISEASE
● Corrective Heart surgery “ARTERIAL
- Affect connective tissue
SWITCH (JATENE PROCEDURE)”
- Autoimmune

Rule of 10: 10 wks, 10 lbs.

MAJOR MINOR
2. TETRALOGY OF FALLOT
● Joint ● CPR
involvement increased
4 Hallmark Signs: ● O looks like ● Arthralgia
● Ventricular Septal Defect heart = ● Elevated ESR
● Pulmonary Stenosis MYOCARDITI ● Prolonged
● Overriding of the Aorta S PR interva
● Right Ventricular Hypertrophy ● Nodules, ● Anamnesis
subcutaneous of
● Erythema Rheumatism
S/Sx:
marginatum ● Leukocytosis
● Tet spells (cyanosis during eating / ● Sydeham’s
crying) chorea
● Exertional dyspnea
● Polycythemia (increased RBC, HCT)
DOC: Penicillin / Amoxicillin
(increased blood viscosity)
X Tetra = high risk for resistance

Patho: Chronic Hypoxia → CVA

2 major = + RHD
1 major + 2 minor = + RHD
● Stunted physical growth and delayed
development
● Clubbing of fingers (chronic hypoxia)
 Surgery: Uranoplasty (within 4-6 months to
save speech)

Post-op: PRONE
> check for frequent swallowing (6-7 days after
surgery = bleeding)

Protect Incision: Elbow restraint

Feeding: Sippy cup / plastic cup
KAWASAKI DISEASE
- Strawberry tongue
Future problem:
- UNKNOWN
● Speech defect
● Decreased social acceptance
DOC: Aspirin, IVG

3. PYLORIC STENOSIS
Main Issue: Weakening of BV
- Hypertrophy of muscles of pylorus
______________________________________________
causing narrowing and obstruction
GASTROINTESTINAL PROBLEMS

Cause: UNKNOWN
1. CLEFT LIP
- failure of median maxillary nasal
S/Sx:
process to fuse by 5-8 wks
● Projectile vomiting
● Abdominal distention
Cause: Multifactorial
Males
Dx:
● String sign - olive shaped mass on
Surgery: Cheiloplasty (1-3 months)
palpation
- save sucking reflex
- String sign of KANTOUR seen
when barium swallow is
Post-Op: SUPINE
performed
● UTZ, X-RAY
Logan Bar - ½ strength hydrogen peroxide and
saline solution
Surgery: Fredet-Ramstedt Procedure
- decrease sucking / minimize crying
(pyloromyotomy with pyloroplasty) → surgeon
cuts through the muscle fibers of enlarged
BEQ: What is used to feed pt. with cleft lip?
pyloric muscle to widen the opening to the
- Rubber tipped syringe
intestine.
- Dropper

Post-Op: MIO, Small frequent feeding, burp

2. CLEFT PALATE
frequently
- failed palate to fuse by 9-12 wks

Cause: Hypervitaminosis A / Vit. A deficiency

Females
4. INTUSSUSCEPTION Diet: avoid high , increase caloric and protein,
- invagination or telescoping of position low fiber (preop)
of bowel to another
6. IMPERFORATED ANUS
Common site: ilio-cecal junction - embryonic abnormality

S/Sx: Initial: absence of meconium

● Spasmodic abdominal pain
● Blood with mucus (currant jelly stool) Surgery: Anoplasty → perform temporary
● Sausage shaped mass Colostomy → after anoplasty
● Bile stained vomitus
When to take down colostomy? Toilet training
MGT: - After 12 months and before 18 months
● Hydrostatic reduction
● Anastomosis & pull thru procedure 7. CELIAC DISEASE
- intolerance to gluten
5. HIRSCHSPRUNG'S DISEASE
- aganglionic innervation (absence of Common gluten food:
ganglion cells) ● Barley
- Ganglion cells (responsible for ● Rye
peristalsis) ● Oats
● Wheat
S/Sx:
Initial: absence of meconium within 24 hrs Assessment:
● Constipation ● Steatorrhea
● Ribbon like stool ● Vomiting
● Abdominal distention of fecaloid mucus ● Anorexia
● Weight loss ● Abdominal pain
● Pellet like stool ● Anemia
● Muscle wasting
Dx: Rectal biopsy (absence of ganglion) ;
barium enema Dx: Stool Analysis

Surgery: Endorectal pull-through procedure Confirmatory: Serum Antiglidian Test (+)

(SWENSON PROCEDURE) → ganglionic
segment is resected down to sigmoid colon
and rectum and anastomosis is performed
between the normal colon and low rectum.
Nsg Intervention:
● Laxative
● Bowel irrigation
● Manual extraction
antiglidian antibodies
Intervention:
● Gluten free diet for life
● Mineral and Vitamin supplements
Support Group: Celiac Sprue Association
______________________________________________
NEUROLOGIC DISORDERS 2. HYDROCEPHALUS

1. Neural Tube Defects (Spina Bifida)

- deficiency in folic acid

Test: Alpha fetoprotein

S/Sx:
● Flaccid paralysis
● Altered elimination Causes:
● Neck and Head rigidity ● Tumor
● Hemorrhage
MGT: ● infection or trauma
Overall objective: prevent infxn, pressure, and
injury to outpouching Types:
● Communicating - increased volume of
Spina Bifida Occulta Tuft of hair CSF
dimpling ● Noncommunicating - obstruction,
disturbance in the flow of CSF
Spina bifida with CSF
meningocele
S and Sx:
Mgt: fetal surgery
-Increased ICP
Spinia bifida with CSF + spinal cord -Sunset eyes
myelomeningocele -Frontal bossing
-Dilated scalp veins
Interventions: -MACEWEN's sign = crack pot sign at the
Position: PRONE junction
Feeding: hold the baby -Increased head circumference
Cover: Sterile gauze moisten NSS
Laxative: monitor sign of infxn: Nuchal Rigidity INFANT:
Normal length- 19.5 - 21 inch or 47.5 - 53.75cm,
average 50 cm

Normal head circumference 33- 35 cm or 13-

14"

Hydrocephalus ->14"

Chest 31 - 33 cm or 12- 13"

Abd 3x 33 cm or 12 - 13"
Nsg Care:
-Sidelying
-Measure head circumference
⁃Prevent increased ICP (early signs:
restlessness, apprehension, tachycardia)
-Administer - osmotic diuretic Mannitol/
Osmitrol
Surgery: Ventriculoperitoneal Shunt (catheter
inserted to enlarged ventricles)
Preop:
-Monitor I and O
-Reposition head frequently
-Abnormal motor performance
-Stiff rigid arms and legs
-Delayed developmental milestone
-Persistent infantile reflexes
-Abnormal posturing
- Seizure
Nursing Interventions:
Goal: Early detection and prompt tx
-Assess child's developmental level
-Mobilizing devices
-Encourage communication and interaction
-Provide safety- high risk for fall and pressure
ulcer

Postop:
-Position: flat on bed (to prevent abrupt CSF
drainage thereby
preventing headache)
-Monitor: shunt malfunction and increased ICP
-Shunt Problems= Increased ICP

INFANT: high pitched shrill cry

TODDLER: loss of appetite
OLDER CHILDREN- altered level of
consciousness

3. CEREBRAL PALSY

Pyramidal Tracts includes:

● Corticospinal Tract - cerebral cortex -
spine
● Corticobulbar Tract - cerebral cortex -
brain stem

Assessment:
-feeding difficulties