day 2-3

PEDIATRICS DAY 2

SPINA BIFIDA
Neural Tube defects
¡Folic Acid deficiency (maternal)
¡ Types:
¡ Occulta - not visible
Cystica - portrusion
-Meningocele - posterior ,, sac life portrusion, sac sa likod. laman is
cerebrospinal fluid no nerves or no parts ng spinal cord
-Myelomeningocele - herniation contains the meninges, cerebrospinal fluid and a
porition of the spinal cord. sometimes with nerve roots at the sac. there are times
that the sac leaks.
*obvious at birth

Diagnostics
Ultrasound
¡Fetoscopy
¡Amniocentesis
¡Maternal serum analysis (AFP) - extracting blood from the mother then checks and
analyze if may presence ng specific protein na ineemit ng fetus.

Assessment:
• depends on spinal cord involvement
• visible spinal defect
• flaccid paralysis of legs
• bladder and bowel incontinence

may surgery pero di na mababalik yung function ng nerves ng legs

Management:
¡Surgery - if occulta walang surgery.
⁃ usually 24-48 hrs dapat narrepair or may surgery na if cystica.
especially if naglleak yung sac kasi baka madehydrate, and tumataas risk for
infection
¡Antibiotics
¡Straight catheterization (if may neurogenic bladder, or may problem sa pagihi ang
bladder bawal ang indwelling or foley kasi tumataas risk ng infection) - every 2-4
hours. , enemas (manage neurogenic bowels of the patient) and laxatives
¡Physical therapy - it helps them adjust with regards to their condition.

*usually if occulta, weakness of the legs ang meron.

*some patients use crutches and wheelchairs, it depends

¡Side lying or prone position

¡Reposition frequently - atleast every 2 hours. as long as hindi naka supine.
¡Keep sac moist - if naglleak ang sac, tinatakpan with gauze na sinoak sa sterile
saline solution para di mainfect
¡Avoid contamination of sac area. - iiwas ang urine and feces.
¡ High fiber diet, adequate fluid intake - bowel development, and no constipation

HYDROCEPHALUS
! Imbalanced CSF production and absorption
¡Enlarged ventricles and increase ICP
¡ Communicating or extraventricular hydrocephalus - absorption of csf obstructed
¡ Obstructive or intraventricular hydrocephalus - obstruction to normal absorption
of csf thus always present
¡ Congenital/ Acquired
*CSF is formed in the first and second ventricles of the brain and will pass to the
aquie??? duct then empty out sa spinal cord

Assessment:
¡ ↑ Head circumference (true sa di pa nagffuse ang fontannels), bulging fontanel,
split cranial sutures, prominent scalp veins (dahil lumalaki lalo yung ulo then
makikita lalo yung ugat)
¡ Bossing (mula sa kilay lumalaki)
¡Sunset eyes - parang nakakita ng araw na palubog
¡↑ ICP
⁃ decreased pulse and respi
⁃ increased body temp and bp
⁃ optic atrophy
¡Irritability or lethargic
¡Failure to thrive - affected ang growth and weight.
!High-pitched cry - typical shrilling. matinis ang boses.

Diagnostics:
!Prenatal ultrasound - kahit nasa loob ng tiyan ng nanay
!CT scan
¡MRI
¡Cranial x-ray - makikita na manipis and separated ang sutures
!Transillumination - bright light or flashlight, specialized light na ilalagay sa
skull ng baby while nasa darkened room. makikita na filled of fluid yung ulo ni
baby rather than the solid brain of the patient. mas maliit yung brain.

Surgical Management: - prevent further cerebrospinal fluid na magaccumulate sa ulo

ng patient. kailangan ma reabsorb ng katawan ng baby.
¡ Ventriculoperitoneal (VP) Shunt - may maliit na tube na nakainsert sa brain, tas
yung end nagddrain sa peritoneal cavity ng baby. tas sa cavity na yon dun
narereabsorb. very important na iprevent ang baby na magkainfection. check if
functional ang shunts. if nagmalfunction kasi may infection

malfunctioning shunts:
*look out for onset of vomitting
*severe headache (cry)
*irritable
*some become lethargic - no activity no alert
*sa surgical wound sites, namumula and naglleak ang csf
⁃ if nagmmalfunction ang shunt, remove the shunt tapos another surgery

¡ Ventriculoatrial Shunt - yung dulo from the ventricles, magddrain ng

cerebrospinal fluid sa atrium usually sa right atrium ng heart para sumama sa blood
flow ng patient
Diuretics (diamox, acetazolamide) - para iihi ng patient
Antibiotics

Postop Care:
¡ Keep child flat on bed as prescribed
¡ Observe increase ICP
¡ Monitor for infection or malfunction of shunt
¡ Measure head circumference - daily. para makita if unti unting lumiliit.
¡ MonitorI&O - since may diuretics baka madehydraye
¡ Provide comfort measures
¡ Medications (diuretics, antibiotics or anticonvulsants - magcconvulse usually if
nag increase ang icp)
¡ Toddler (1-3 yo) - Headache and anorexia ; lack of appetite (earliest common
signs of shunt malfunction)
MENINGITIS
⁃ Inflammation of the meninges caused by bacteria or viruses
⁃ ¡ Acquired as a primary or as a result of complications - can be after
spina bifida correction
⁃ ¡ Diagnosis – CSF analysis (increased pressure, cloudiness, high
protein, low glucose)
⁃ increased wbc
⁃ increased protein levels
⁃ decreased glucose
⁃ bacterial
⁃ caused be E.coli or beta hemolytic streptococcus
⁃ less than 2 yrs of life especially at the first month of life
⁃ often causes septicemia, kaya may blood culture to see ano yung present
na bacteria

primary meningitis:
spread via bloodstream

secondary meningitis:
ears, sinuses, trauma, surgery

main pathogens:
neisseria meningitidis
strept. pneunomiae
haemophilus influenzae

¡ N – Nuchal rigidity - naninigas ang leeg

¡ P - Photophobia - sensitive to light
¡ O - Opisthotonos - kind of posture wherein hyperextended yung head and neck
¡ P – Positive: Kernig’s and Brudzinki’s signs - telltale sign of meningitis

kernig's - pahigain tas ifflex yung knee/leg ng 90 degrees tas if nagreklamo ng

pain then positive
brudzinki - if finlex yung head, tas may voluntary reaction and hips and necks then
positive

vomitting
diarrhea
bulging of anterior fontannel
irritability
high pitched cry

Diagnosis:
¡ Clinical diagnosis
¡ CBC - shows elevation of wbc
¡ Lumbar puncture or spinal tap
¡ CSF analysis (protein and increased WBC)
¡ Culture - identify the causative agent that causes the meningitis

if bacterial:
elevation ng protein
low glucose (kinakain ng bacteria ang glucose)

if viral:
normal to low protein
normal glucose level

Management:
¡ R- RESPIRATORY ISOLATION; maintain for at least 24 hours after antibiotics are
initiated and droplet precautions
¡ O- Optimum hydration - usually iv fluids
¡ A- Antibiotics/ anti-virals - usually nagsstart sa broad spectrum antibiotics tas
magchchange if nakuha na or naidentify yung causative agent
¡ D- Dexamethasone (antiinflammatory to reduce risk of seguala???) or decadron,
antipyretics, and analgesics

¡ S- Status: VS and Neuro - cranial nerves and gcs

¡ C- Close contacts of child identification - kasi pede siya makahawa or pano
nalaman sino nakahawa sakanya
¡ A- Assess nutritional status - insert ngt if di nakakakain until keri na mag
orally
¡ M- MonitorI&O

Complications:
• hearing loss
• neurologic deficit
• seizures - phenobarbital
• visual impairment
• behavioral problems - laging galit, irritable, masungit
• others: cn dysfunction, brain abcess, syndrome of inappropriate
antidiuretic hormone (siadh), and death (10-15%)

SEIZURE DISORDER
⁃ ¡Alterations in firing of neurons in brain
⁃ Idiopathic
⁃ ¡Partial seizures
⁃ !Generalized seizures
⁃ involuntary, sudden
⁃ can be accompanied by other disorders
⁃ can be a symptom of an underlying disease

pedeng focal - one side or part of the brain. pero if not treated pedeng maging
generalized

associated with
⁃ birth trauma
⁃ Infection
⁃ ¡ Trauma
⁃ Tumor growth
⁃ Febrile seizure
⁃ brain abcess
⁃ head trauma
⁃ metabolic disorders - like hypoglycemia. hyponatremia, hypernatremia
⁃ babies na jaundiced due to high bilirubin levels
⁃ plain febrile seizure

types:
⁃ febrile seizure
tonic clonic - 15-20 seconds. stiffening muna of the muscles tas involuntary
jerking ng katawan
⁃ recurrent seizures (epilepsy)

can be divided into two

focal - one part/one side
generalized - buong brain.
Management:
Seizure precautions:
• raise and pad side rails - to decrease cause of injury
• place waterproof mattress on bed
• instruct child to swim with companion - kasi baka atakihin ng seizure
• alert caregivers to the need for special precautions
• wear medic alert bracelet

Emergency Treatment for Seizures:

¡ Ensure patency of airways - turn the patient to their side. para if may secretion
maddrain at di papasok sa airway ng patient
¡ Ease the child down to the floor if standing or sitting
¡ Place pillow or folded blanket under the childʼs head
¡ Loosen restrictive clothing
¡ Clear area of any hazards
¡ Turn child to one side
¡ Do not restraint; do not place anything in the mouth - makaharqng sa airway, and
magkainjury ang jaw. baka makagat kayo
¡ Remain with child until full recovery - wag iwan until the patient becomes
conscious. sometimes may sectetions u need suctioning. pede magka accidental fall.
¡ medications (Diazepam, Lorezepam, Phenobarbital)

warning sign - may flash ng light or may naamoy

RENAL PROBLEMS

Glomerulonephritis
¡Inflammation of the glomeruli
¡ Post-streptococcal glomerulonephritis (PSGN)
! preceded by a streptococcal infection
! di nabigyan ng medications
! if untreated ang sore throat
! caused by an antigen antibody complex na naglaunch sa glomerulus

Test:
¡ BUN - tataas ang content.
¡ ESR - elevated, ibigsabihin may inflammation so body
¡ASO titer - anti streponisid .. , previous infection of streptococcus
!Renal ultrasound - enlarged kidneys
¡ Urinalysis - gross hematuria, rbc cast
¡ Azotemia - retention of excess nitrogenous waste
!Creatinine
!Serum electrolytes - imbalance

if nag inflame ang glomerulus, bababa ang filtration, resulting to retention of

sodium, magaattract ng water. causes vasoconstriction, problem of the heart and
renal function

filtration decrease
-
na reterntion
-
increase bp, heart fx, renal fx

S/sx:
D – decrease UO oliguria
A - anorexia - because of inflammation, nababawasan ang appetite
T – tea colored urine - presence of blood in the urine, hematuria
E - edema - due to na retention, results to fluid retention

L - lethargy - sleepy always.

I - irritability - when they wake up
P - pale

tumataba dahil sa fluid accumulation, di pantay ang taba

Management:
¡B – Bed rest
I – I & O
¡D – Diuretics - drug of choice is furosemide (monitor bp)

¡F – Fluid restriction
¡L – Low Na & Protein diet - kidneys ay affected so tumataas ang creatinine dapat
ipababa.
¡A – Antihypertensives
¡W –Weigh daily
¡S – Skin care - due to dehydration

*pede magresume into normal activities if nawala ang hematuria

Nephrotic Syndrome
⁃ abnormal loss of protein
⁃ autoimmune illness
⁃ usually cause is unknown
⁃ walang infection
⁃ may inflammation sa nephrons resulting to:
proteinuria - lalabas sa urine ang proteins
edema
hyperlipidimia - secondary to liver stimulation. decreased volume albumin, so di
nakakapagrelease ng enzymes para mabreak down ang fats ng patient resulting to
increased lipids.

increased permeability allowing to pass so the kidneys can reabsorb the salt and
churva.

S – Shiny skin
A - Anasarca
W- Weight gain

D – Decrease UO
I – Increase BP - hypertensiom
D – Dark foamy urine

⁃ susceptible sila sa infections

Uncomplicated cases - Regular diet; no added salt diet

(+) hypertension or edema - Moderate Na restriction
azotemia (too much nitrogen in the body)h - Protein free diet

diagnostics:
⁃ bun
⁃ creatinine
⁃ urinalysis
⁃ serum cholesterol

Goal
Promote diuretics -
Adequate nutrition - high calories
Prevent infection

D - diuretics
O – oral restriction
C - corticosteroids - immunosupressant kasi so tumataas risk for infection.

goal is to prevent infection

if ordinary nephrotic syndrome, no antibiotics !! unless your patient develops
infection

nursing management:
• antibiotics
• na restriction
• vs, i and o
• fluid restriction
• weight daily - using the same clothes, same time, same weighing scale

continuous pagbibigay ng corticosteriod hindi agad agad dinidiscontinue dapat dahan

daha

Endocrine Problems

Diabetes Mellitus
⁃ Pancreas - unique organ na may both endocrine and exocrine type of
tissue. the islet of langerhans endocrine portion tas yung cells nakascatter sa
exocrine. yung islet cells 1% lang ng total weight ng pancreas
islet cells:
alpha - secretes glucagon
beta - secretes insulin - essential for carbohydrate churvaness, and fats and
protein production. rineregulate ng glucose levels sa katawan. serum glucose passes
through the pancreas if too much glucose ang nagppass or nageexceed, automatic
magiincrease ang production ng insulin. which is normal. when the blood serum
levels are lowered, the production decreases.

both have the ability to increase production as a response of the pancreas

diabetes type 1
⁃ problems sa insulin production
⁃ insulin dependent
⁃ deficiency sa production ng insulin
⁃ ¡ Characterized by destruction of pancreatic islet beta cells, which
fail to secrete insulin
⁃ ¡ Onset in childhood and adolescence, but it can occur at any age
⁃ ¡ Juvenile onset DM
diabetes type 2
⁃ insulin independent
⁃ may insulin na is being produced kaya lang di nagiging effective kaya
di nammaximize ang insulin ng patient. nagpproduce yung pancreas pero di enough
⁃ ¡ Arises because of insulin resistance in which the
⁃ body fails to use insulin properly combined with relative insulin
deficiency
⁃ ¡ Onset usually after age of 45
⁃ ¡ Adult onset DM

⁃ di mammetabolize yung glucose

⁃ if di pumasok yung glucose sa cells magkakaron ng intra cellular
hunger, feeling di kumain so magugutom. issend sa brain ng patient na gutom siya
 ⁃ causes polyphagia - increased appetite hence kain ng kain
⁃ tataas ang number ng glucose, magccause ng hyperglycemia
⁃ pedeng magkaviscosity sa blood , lalapot. babagal ang blood
circulation. maaaffect ang kidneys then resulting to poor filtration of kidneys and
it will attract fluid. laging iihi ang patient, that causes polyuria.
⁃ intracellular thirst din, mauuhaw. inom ng inom. poor blood circulation
because of the viscosity so may poor wound healing. bumabagal ang clotting ng
blood. yung tinatravel nung magccause para magheal yung sugat di nakakarating sa
sugat

The 3 P's
Polyuria
Polydipsia
Polyphagia

check the blood glucose of the patient (normal 70-110 mg/dL)

increased - hyperglycemia

if mataas ang sugar:

⁃ mainit ang pakiramdam pero di pinagpapawisan

hot and dry

hypoglycemia:
cold and clammny
⁃ nanlalambot

type 1 - bigay insulin

type 2 - oral hypoglycemics

Management:
¡A- administer insulin - no same spot. can cause lipotrophy. 1 cm - 1 inch apart.
!B-blood glucose monitoring
!C- complications - watch out for signs of deiabteic ketoacidosis. ketones. fruity
odor. can become comatose, or death. // retinopathy, nephropathy, neuropathy -
numbing of fingers, or peripheral areas
¡D- diet - iwas sa carbs, small frequent feedings.
¡E- exercise - helps in the metabolism of carbs.
¡F-follow up
¡G-give sweets

GASTROINTESTINAL PROBLEMS

Pyloric Stenosis
⁃ narrowing of the pyloric sphincter at the outlet of the stomach
⁃ unknown cause but can be hereditary
⁃ progressive hypertrophy and hyperplasia
⁃ the muscles grows twice in size, that leads to obstruction of pyloric
sphincter
⁃ destruction,

¡P - projectile vomiting
¡Y - young as ages 4 to 6 weeks
¡L - lose weight, dehydration signs - poor skin turgor, pangangalumata sunken eyes
¡O - olive shaped mass - upper right quadrant of the abdomen
¡R - Ramstedt/ pyloromyotomy - surgical managemwnt. to remove the specific stenosis
¡I – IV fluids - for hydration
¡C – care of wound (Collodion) - bawal maexpose sa feces and urine
Hirschsprung Disease
⁃ congenital aganglionic megacplon
⁃ failure to pass meconium by 24 hours
⁃ 6-12 months of age
⁃ constiption

¡M - meconium (-)
¡E - enema (Barium) - xray, may iniintroduce sa colon ng patient at tinitignan san
obstruction
¡G - give stool softener - due to constipation
¡A - aganglionic - absence of ganglion cells

6-12 months:
¡C - chronic constipation - pag tinry ilabas sa enema odorous siya
!O- odorous - mabaho
¡L - like ribbon (stool)
!O - operation 2 step type of repair :
temporary colostomy
pull through - end to end anastomosis
!N - no rectal temp - due to the peristaltic movement of the colon of the patient

Serious complication: enterocolitis

Treatment: relieve constipation

PEDIATRIC DAY 3

HEMATOLOGIC PROBLEMS

IDA (Iron Deficiency Anemia)

⁃ ¡Iron stores are depleted, resulting in a decreased supply of iron for
the manufacture of hemoglobin in RBCs
⁃ ¡Results from blood loss, increased metabolic demands, syndromes of GI
malabsorption (di naabsorb yung iron sa body), dietary inadequacy

ASSESSMENT:
¡ Pallor
¡ Weakness and fatigue - mabilis mapagod at mahingal
¡ Irritability
! bumabagal ang learning, cognitively. slow mag isip

MANAGEMENT:
¡ ↑ oral intake of iron
¡ Diet (High in Iron) - green leafy vegetables
¡ Iron supplements as prescribed - b vitamins
¡ Liquid iron prep stains
¡ Side effects of iron therapy
⁃ discoloration of stool
⁃ if iron supplements were taken on an empty stomach, maauupset yung
stomach, or macconstipate (drink more water and eat foods high in fiber)

Aplastic Anemia
¡ A deficiency of circulating erythrocytes resulting from the arrested development
of RBCs within the blood marrow
¡ Causes: exposure to toxic agents (household chemicals), viruses, infection,
autoimmune disorders, allergic states
! definitive diagnosis: BMA bone marror aspiration
⁃ placed under anesthesia
 ⁃ pelvic bone, tas may binabaoon na equipment sa buto then magaaspirate
ng bone marrow

ASSESSMENT:
¡ Pancytopenia
⁃ decreased rbc (anemia)
⁃ decreased wbc (leukopenia)
⁃ decreased platelets (thrombocytopenia)
¡Petechiae, purpura, bleeding, pallor, weakness, tachycardia, and fatigue
⁃ due to low count of platelets & rbc

CLINICAL MANIFESTATIONS
¡ Lack of RBC
¡ Pallor, lethargy, tachycardia and shortness of breath (on exertion)
¡ Lack of WBC
¡ Recurrent infections
¡ Lack of platelets
¡ Abnormal bleeding, petechiae, and bruising

MANAGEMENT:
¡ Blood Transfusion - whole blood
¡ Splenectomy
¡ Corticosteroids - antiinflammatory, immune suppressive effect
¡ Immunosuppressive therapy - immunoglobulins
¡ Bone marrow transplantation
¡ Medic-alert bracelet - because the patient is prone to diff infections

*bawal masyadong aggressive na activity

Sicke Cell Disease

¡ Hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin
(HgbS)
¡ HgbS – sensitive to changes in oxygen content of RBC (kumokonti yung laman na
oxygen para magcirculate sa katawan)
¡ Sickling response – reversible under adequate oxygenation (nagpunta sa place na
kulang ang oxygen)
¡ Sickle cell crises – vaso-occlusive crisis, splenic sequestration, plastic crisis

sickle - crescent moon shape

ASSESSMENT:
¡Vaso-occlusive crisis
- Most common type
- Caused by blood stasis with (because of the shape) clumping of cells in
microcirculation, ischemia and infarction (magrreact ang inflammatory responses)
hence fever and pain
- Fever, pain and tissue engorgement (namamaga)
- blood vessels lang

¡ Splenic sequestration
- Pooling of blood in the SPLEEN
- Profound anemia, hypovolemia and shock

¡ Aplastic crisis
- Causes: ↓production & ↑ destruction of RBCs, viral infection, depletion of
folic acid
- Anemia and pallor
 - madali buhay - hemolysis. naddestroy ang rbc, lalabnaw ang dugo ng patient.
bababa ang immune system. viral infection.

MANAGEMENT:
¡ O2 and BT
¡ Analgesics
¡ Adequate hydration ( oral fluids/ IVF)
¡ Comfortable position (extension of extremities no more than 30 degrees) - if
masyadong flexed babara dun yung sickle cells sa area na yon. magkakaron ng poor
blood circulation
¡ Avoid strain on painful joints (sa joints nagcclump kasi ang sickle cells so
usually para di mastrain is bed rest yung patient)
¡ High calorie, high protein diet with folic acid supplementation (okay lang iron
supplements pero bawal overload ang iron)
¡ Antibiotics
¡ Monitor signs of increasing anemia and prevent shock (pallor, decreased vs
changes of the patient )

Beta Thalassemia Major

• cooley's anemia
• autosomal recessive disorder (weak genes ni nanay + week genes ni tatay
= combine)
• reduced production of one of the globin chains in the synthesis of the
hemoglobin
• most commonly seen sa mediterranean descent - highest incidence
⁃ greek
⁃ somewhere in the middle of europe

Assessment
• severe anemia
• pallor
• failure to thrive
• hepatosplenomegaly
• microcytic, hypochromic rbcs - immature

Management:
• folic acid administration (vit b9)
• bt - packed rbc
• monitor iron overload
• chelation therapy with deferoxamine (for iron overload) - antidote for
iron overload
• genetic counseling

Leukemia
¡ Most frequent type of childhood cancer
¡ Peak: 3-5 years
¡ Proliferation (rapid increase) of abnormal WBCs that do not mature beyond the
blast phase
¡ Blast cells – infiltrate other organs (liver, spleen, lymph tissue)
¡ Causes: environmental (virus), familial/ genetic, Host factors

*4 ang types ng leukemia pero usually sa bata is 2

Acute Lymphocytic leukemia (ALL)

¡ 80-85%
¡ Acute
¡ 75% chance of surviving

Acute Myelogenous leukemia (AML)

¡ Includes granulocytic and monocytic types
¡ 60-80% will obtain remission
¡ 30-40% cure rate
⁃ unexplained bruising
⁃ paleness of skin
⁃ petechiae (rashes)

ASSESSMENT:
¡ Anemia, weakness, pallor, dyspnea - dahil bumaba ang rbc
¡ Bleeding, petechiae, spontaneous bleeding, ecchymoses
¡ Infection, fever, malaise
¡ Enlarged lymph node
¡ Enlarged spleen and liver
Diagnostics: Blood studies, BMA

STAGES OF TREATMENT:
1. Induction
– Goal:To remove bulk of tumor
– Methods: Surgery, radiotherapy, chemotherapy, BM transplant
– Effects: often the most intensive phase
– Side effects: potentially life threatening
2. Consolidation
– Goal:To eliminate any remaining malignant cells
– Methods:Chemotherapy/radiotherapy
– Side effects: will still be evident
3. Maintenance
– Goal:To keep the child disease free
– Methods:Chemotherapy
– Phase may last several years
4. Observation
– Goal:To monitor the child at intervals for evidence of recurrent disease and
complications of treatment
– Methods: treatment is complete
– Child may continue in this stage indefinitely

LATE EFFECTS OF TREATMENT:

¡ Impaired growth and development and CNS damage
¡ Impaired pubertal development
¡ Development of secondary malignancy
¡ Psychologic problems related to living with a life- threatening disease and
complex treatment regimen

NURSING INTERVENTION:
¡ Help child cope with intrusive procedures
• Provide information (developmental level and emotional readiness)
• Explain procedures, purpose, and how it will feel.
• Allow child to manipulate equipment
• Allow child some control in situations
¡ Positioning, selecting injection site
¡ Support child and parents
• Acknowledge feelings and allow them to express it
• Frequent clinical conference and always tell the truth.
• Refer to support groups
¡ Support child during painful procedures ¡ Administer sedation as ordered
¡ Minimize side effects of treatment
• Skin breakdown - lotion, to prevent dryness of the skin especially if
nagrradiation therapy. washing with warm water without soap. wag tanggalin marks ng
radiation. avoid topical agents na may alcohol, bawal heating pads or hot water
bottle. di makakatanggal ng pain ng patient, dadagdag lang sa problem ng skin ng
patient
• Bone marrow suppression - promote rest, avoid big crowds. monitor temp. avoid
using aspirin due to the blood thinning component kasi nawawala ang clotting factor
that could cause bleeding. avoid sharp objects. make sure all activities would be
safe for the patient
• Nausea and vomiting - antiemetics half an hour before chemo. light meal before
chemo. iv fluids.
• Alopecia - inform the patient and the patient's family before the start of chemo.
advise cut the hair short first. advise not to go directly under the sunlight, wala
na kasing protection ang ulo ng pasyente. possibility of dehydration and maiinitan
ang brain that could have problems.
• Nutrition deficits
• Developmental delay

Hemophilia
¡ X-linked recessive trait
¡ Hemophilia A – deficiency of Factor VIII
¡ Hemophilia B – Deficiency of Factor IX
¡ Males inherit hemophilia from their mothers while females inherit the carrier
status from their fathers

ASSESSMENT:
¡Prolonged bleeding after minor injury At birth after cutting cord
!Following circumcision
!Following IM immunization
!Increased bruising as child learns to crawl and walk
!Abnormal bleeding in response to trauma
!Joint bleeding (hemarthrosis) – pain, tenderness, swelling, limited ROM
¡ Tendency to bruise easily
¡ Prolonged PTT - partial thrombin time
¡ Normal BP, PT (prothrombin time), platelet count

MANAGEMENT:
¡Administration of Fact VIII concentrate/ cryoprecipitate
-Thaw slowly; gently rotate bottle; infuse immediately (deteriorates at room
temperature)
!Monitor for bleeding and joint pains (immobilize extremity)
!Asses neurologic status (risk of intracranial hemorrhage) - cranial nerves, LOC,
gcs
!Monitor urine (hematuria)
¡ Control bleeding (immobilization, elevation, application of ice(vasoconstriction)
;apply pressure for 15 minutes for superficial bleeding)
¡ Instruct parents (activities)
¡ Avoid contact sports

Idiopathix Thrombocytopenic Purpura

• increased destruction of platelets with resultant platelet count less
than 100,000/mm3
• petechiae and ecchymoses of skin
• exact mechanism unknown
• often preceeded by a viral illness
• spleen not enlarged unlike for aplastic anemia and etc

Assessment:
• petechiae
• ecchymosis
• blood in body secretions, mucus membrane bleeding, nosebleeds
diagnostic tests:
• platelet count decreases
• low hematocrit

Management:
• steroids and immunosuppressants
• platelet transfusion
• surgery: splenectomy
• control bleeding
• prevent bruising
• protect from infection
• measure norma circumference of extremities for baseline (because of
inflammation)
• administer meds krally, rectally or iv (bawal IM)
• avoid aspirin
• provide client teaching and discharge planning
⁃ pad crib and play pen
⁃ soft tous
⁃ protective headgear (toddler)
⁃ soft toothbrush
⁃ avoid contact sports

MUSCULOSKETELETQL

Cerebral Palsy
¡ Upper motor neuron impairment that results in motor dysfunction
Risk Factors:
¡ Prenatal conditions
¡ Perinatal and birth difficulties
⁃ prolonged anoxia
⁃ cerebral anomalies that caused rupture sa blood vessels ng utak
¡ Infection or trauma during infancy
ETIOLOGY:
¡ Developmental anomalies
¡ Infections
¡ Cerebral anoxia

Types:
¡ Pyramidal or Spastic (40%)
¡ Extrapyramidal
⁃ Dyskinetic or athetoid (30%)
⁃ Ataxic (10%)
⁃ Mixed (10%)
Diagnostics
¡ Developmental screening
¡ EEG
¡ Neuroimaging studies (CT scan, MRI)
¡ Cytogenic studies and metabolic studies

Management:
¡ Baclofen (Lioresal) pump - treat spasticity/spasm of the skeletal muscle of the
patient. muscle relaxant
¡ Oral muscle relaxants
¡ Botulinum toxin A (Botox) - spasticity of the lower extremities
¡ Antiepileptics - for those patients na with seizures

¡ Braces or splints and special appliances - to help them ambulate/immobilize

¡ ROM exercises - physical therapy
¡ Artificial urinary sphincter - esp with children with incontinence
¡ Neurosurgery or Orthopedic surgery

Nursing Management:
¡ High-calorie diet - kasi mas mabilis metabolism nila
¡ Assist with locomotion, communication, and educational opportunities
¡ Perform ROM exercises
¡ Plan activities that involve gross and fine motor skills
¡ Provide safe environment
¡ Health teaching (medications, physical rehabilitation, and seizure management)
¡ Refer family to community agencies that will enhance child’s quality of life

Scoliosis
• laterql curvature of spine
• most common in adolescent girls
• familial pattern: associated with other neuromusculqr condition
• idiopathic

assessment:
• failure of curve to straighten when child bends forward with knees
straight qnd arms hanging down towards feet
• uneven bra strap marks
• uneven rib cage, hips, shoulders
• x-ray: reveals curvature

management:
• stretching exercises - mild
• moderate - milwaukee brace - worn 23 hrs/day for 3 yrs; adjusted every
3 mo ths
• plaster jacket vest
• surgery: spinal fusion

nursing care:
• teach/encourage exercises
• care of milwaukee brace
⁃ 23hrs a day
⁃ monitor pressure points
⁃ promote positive body image with brace
• cast care
⁃ assist with modifying clothing for immobilization devices
⁃ adjust diet with decreased activity
• discharge instructions:
⁃ exercise
⁃ cast care
• correct body mechanics
• alternative education for long term hospitalization
• availability of community agencies
• diet as tolerated

Congenital Hip Dysplasia/Dislocation

⁃ nadisolace head ng femur sa acetabulum
⁃ usually present at birth pero di agad naddiagnosis
⁃ familiar disorder so can be genetic
⁃ more frequently seen sa girls than males 7:1
⁃ baka daw dahil sa fetal position nung nasa uterus
⁃ head of the femur is cartilagenous at birth
Assessment:
• maybe unilateral or bilateral
 • limitation of abduction (cannot spread legs)
• ortolani's click
⁃ observe if under 4 weeks of age
⁃ with anninfant supine, bend knees and plane thumb on bent knees,
fingers at hip joint
⁃ bring femur 90 degrees to hip, then abduct
⁃ audible click - dislocation
• galeazzi's tests
⁃ with infant on back, bend knees
⁃ shortening of femur
⁃ asymmetry of gluteal and thigh folds
⁃ when lying on abdomen, buttocs of affected side will be flat
• trendelenburg test (if child can walk)
⁃ have child stand on affected leg only
⁃ pelvis will dip on normal side as child attempts to stay erect

management:
• goal: to enlarge and deepn the socket or acetabulum
• early treatment: positioning the hip in abduction with the head of the
femur in the acetabulum and maintin position for several months
• pavlik harness
• traction and casting (hip spics cast)
• surgery

nursing management:
• maintain proper positioning; keep leg abducted
⁃ use triple diaperibg
⁃ use frejka pillow splint (jumper like suit)
⁃ place infant on abdomen with legs in frog paoition
• use immobilization devices (strollers)
• provide adequate nutrition - diet that is age appropriate
• provide sensory stimulation
• client teaching and discharge planning

Clubfoot (Talipes)
• abnormal rotation of foot and ankle
⁃ varus - inward rotation
⁃ valgus - outward rotation
⁃ calcaneus - upward rotation
⁃ equinus - donward rotation
• most common - talipes equinovarus (95%)

assessment:
• foot is fixed in deformed manner

management:
• exercises
• successive casting - weekly cast changes
• dennis browne splint (bar shoe)
• surgery (tenotomy - removal of ligaments s paa) and casting

ponseti method?? ano meron sau ewan di ko maalala

nursing care:
• perform exercises as ordered
• provide cast care
• child learning to walk - prevent from trying to stand; apply restraint
if necessary
 • provide diversional activities
• provide skin care
• client teaching regarding regular cast changes

MOUTH AND THROAT PROBLEMS

Tonsillitis and Adenoiditis

Assessment:
• Persistent or recurrent sore throat
• enlarged bright red tonsils; with exudates at times
• dysphagia
• mouth breathing; unpleasant mouth odor
• fever; cough

managements;
• antibiotics - to treat infectiion
• surgical
⁃ tonsillectomy or adenoidectomy

preop management:
• assess:
⁃ presence of infection
⁃ bleeding and clotting studies
⁃ loose teeth
• prepare:
⁃ for a sore throat
⁃ throat culture

postop management:
• position - side lying para sa draining of the secretion
• suction equipment availability
• monitor signs of hemorrhage - frequent swallowing
• may give ice chips and apply ice collar
• provide clear, cool, non citrus and non carbonated drinks
• avoid milk products
• avoid red liquids or dark colored foods
• discourage coughing or clearing of throa

Cleft Lip and Cleft Palate

• one in every one thousand birth
• multifactorial
• common among children with chromosomal abnormalities
• results from failure of the embryonic structures of the face to unite
• may occur separately or combined
• single unilateral or bilateral cleft from lip through the soft palate
• interferes with capacity to meet oxygenation and nutrritional needs
• seriously hampers normal bonding process with parents
• usually yung pregnant mother nagssteroids

assessment:
• facial abnormality visible at birth
• cleft lip or palate or both, uni or bi
• difficulty sucking
• inability to form airtight seal around d nipple
• formula/milk escapes through nose in infants with cleft palate
• predispose to infection
• diffuclty swallonh
• abdominal distension related to excessive ingestion of air
management:
• team approach (otolaryngolist, audiologist, pediatrician, dentist,
orthodontist, speech therapisy)
• surgical correction:
⁃ palatoplasty
⁃ chelloplastu
• early correction - prevent speech defects (CP)

Cheiloplasty RULE OF 10
preop management:
• feed in upright position
• burp frequently
• press cleft lip tigether with fingers - encourages sucking and
strengthen muscles
• use rubber tipped syringe/ dropper onto one side of mouth (unable to
suck)
• give water to wash away formula in palate area
• small, frequent feedings
• provide emotional support to parents

post op management
• maintain patent airway - kasi prone to inflammation
• observe for frequent swallowing
• do not place in prone position or with pressure on cheeks (logan bow)
• avoid tension and straining on suture lines:
⁃ prevent crying
⁃ keep child comfortable and contented
⁃ use soft elbow restraint
• keep suture line clean (after feeding - saline, peroxide, or water to
remove crusts)
• pain relief

Palatoplasty
⁃ 6 mos to 18 mos
pre op management
• prepare parents to care for child after surgery
• instruct concerning feeding methods and positioning

post op
• side lying
• suction available at bedside
• prevent injury or trauma on suture line
• use cups only for liquids no bottles
• avoid straws, utensils, popsicle sticks, chewing gem
• provide soft toys
• use elbow and wrist restraints
• liquid diet initially then soft diet
• give water after feeding to clean suture line
• hold and cuddle