PEDIATRIC NURSING Review (NLE)

PEDIATRIC NURSING Growth and Development Growth- increase in physical size of a structure or whole. -quantitative change. Two parameters of Growth 1. Weight- most sensitive measure of growth, especially low birth rate. Wt doubles 6 months 3x 1yr 4x 2-2 ½ yrs 2. Height- increase by 1 inch/mo during 1st 6 months - average increase in ht - 1st year = 50% *Stoppage of height coincide with eruption of wisdom tooth. Development- increase skills or capability to function -qualitative How to measure development 1. Observe child doing specific task. 2. Role description of child’s progress 3. DDST- Denver development screening test. MMDST (Phil) Metro Manila Developmental Screening Test. DDST measures mental 4 main rated categories of DDST 1. Language communication 2. personal social-interaction 3. fine motor adaptive- ability to use hand movement 4. gross motor skills- large body movement Maturation- same with development “readiness” Cognitive development –ability to learn and understand from experience to acquire and retain knowledge. To respond to a new situation and to solve problems. IQ test- test to determine cognitive development Mental age x 100 = IQ Chronological age Average IQ – 90-100 Gifted child- > 130 IQ

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Basic Divisions of Life I. Prenatal stage from conception- birth II. Period of infancy 1. Neonatal- 1st 28 days or 1st 4 weeks of life 2. Formal infancy- 29 day – 1 year III. Early childhood 1. Toddler – 1-3 yrs 2. Pre school 4-6 years IV. Middle childhood 1. School age- 7 – 12 yrs V. Late childhood 1. Pre adolescent 11 – 13 yrs 2. Adolescent 12 - 18 – 21 Principles of G & D 1. G&D is a continuous process -begins form conception, ends in death - womb to tomb principles 2. not all parts of the body grow at the same time or at same rate. - asynchronism Patterns of G&D 1. Renal , digestive, Circulatory, Muscoskeletal - grows rapidly during childhood 2. Neuromuscular tissue (CNS, brain, S. cord) - grow rapidly 1-2 years of life - brain achieved its adult proportion by 5 years. 3. Lymphatic system- lymph nodes, spleen grows rapidly- infancy and childhood to provide protection -infection - tonsil adult proportion by 5 years 4. Repro organ- grows rapidly at puberty Rates of G&D 1. Fetal and infancy – most rapid G&D 2. Adolescent- rapid G&D 3. Toddler- slow G period 4. Toddler and preschool- alternating rapid and slow 5. School age- slower growth *fetal and infancy- prone to develop anemia 3. Each child is unique 2 primary factors affecting G&D A. Heredity - R – race I – intelligence S – sex N - nationality 2

 

Females are born less in weight than males by 1 oz. Females are born less in length than males by 1 inch

B. Environment Q – Quality of nutrition S – Socio eco. status H – Health O – Ordinal pos in family P – Parent child relationship  

Eldest- skillful in language and social skills Younger- toilet trained self

5. G&D occurs in a regular direction reflecting a definitive and predictable patterns or trends. 

a. b. c. d.

Directional trends- occur in a regular direction reflecting the development of neuromuscular function. These apply to physical, mental, social and emotional development and includes: Cephalocaudal- “head to tail” 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 form center of body to extremities. Symmetrical- at side of body develop on same direction at same time at same rate. Mass specific “differentiation” - child learns form simple operations before complex function of move from a broad general pattern of behavior. To a bore refined pattern. 

Sequential- involves a predictable sequence of G&D to which the child normally passes. a. locomotion- creep than crawls, sit then stand. b. Socio and language skills- solitary games, parallel games 

Secular- worldwide trend of maturing earlier and growing larger as compared to succeeding generations.

6. Behavior is the most compressive indicator of developmental status. 7. Universal language of child --- PLAY 8. Great deal of skill and behavior is learned by practice. Practice makes perfect. 9. Neonatal reflexes must be lost before one can proceed. - plantar reflex should disappear before baby can walk -moro reflex should disappear before baby can roll persistent primitive infantile reflexes- case of cerebral palsy 3

Theories of G&D 1. SIGMUND FREUD (1856-1939) Austrian neurologists. Founder of psychoanalysis Psychosexual theory a.) Oral Phase 0-18 months - mouth- site of gratification -activity of infant- biting, sucking crying. -why do babies suck?- enjoyment and release of tension. -provide oral stimulation even if baby was placed on NPO. -pacifier. -never discourage thumb sucking. b.) ANAL- 18 months-3 years -site of gratification- anus -activity- elimination, retention or defecation of feces make take place - principle of holding on or letting go. -mother wins or child wins -child wins- stubborn, hardheaded anti social. (anak pupu na, child holds pupu, child wins) -mother wins- obedient, kind, perfectionist, meticulous OC-anal phase -help child achieve bowel and bladder control even if child is hospitalized. c.) Phallic- 3-6 years - site of gratification -genitals - activity- may show exhibitionism -increase knowledge of a sexes -accept child fondling his/her own genitalia as normal exploration -answer Childs question directly. Right age to introduce sexuality – preschool d.) Latent- 7-12 years -period of suppression- no obvious development. -Childs libido or energy is diverted to more concrete type of thinking -helps child achieve (+) experience so ready to face conflict of adolescence e.) Genital- 12-18 years -site of gratification -genitals -achieve sexual maturity -learns to establish relationships with opposite sex. -give an opportunity to relate to opposite sex. 2. ERIC ERICKSON- psychoanalysis theory - stresses important of culture and society to the development of ones personality - environment - culture 4

Stages of psychosocial a.) Trust vs Mistrust – 0-18 months. -foundations of all psychosocial task -to give and receive is the psychosocial theme -know to develop trust baby 1. satisfy needs on time - breastfeed 2. care must be consistent and adequate -both parents- 1st 1 year of life 3. give an experience that will add to security- touch, eye to eye contact, soft music. b.) Autonomy vs Shame and doubt 18mos-3 years --- independence /self gov’t develop autonomy on toddler 1. give an opportunity of decision making like offer choices. 2. encourage to make decision rather than judge. 3. set limits c. Initiative vs Guilt- 4-6 years -learns how to do basic things -let explore new places and events -activities recommended- modeling clay, finger painting will enhance imagination and creativity and facilitate fine motor dev’t d. Industry vs Inferiority 7-12 yrs -child learns how to do things well -give short assignments and projects e. Identity vsRole confusion or diffusion 12-18 yrs - learns who he/she is or what kind of person he/ she will become by adjusting to new body image and seeking emancipation form parents -freedom from parents. f. Intimacy vs Isolation 20-40 yrs -looking for a lifetime partner and career focus g. generatively vs stagnation 40- 60 45-65 yrs h. ego integrity vs, despair 60-65 3. JEAN PIAGET- Swiss psychologists -develop reasoning power STAGES OF COGNITIVE DEVELOPMENT A- Sensory motor 0-2 yrs -“practical intelligence”- words and symbols not yet available baby communicates through senses and reflexes.

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(sub div.) Schema 1.) neonate reflex 2.) primary circular

Age 1 month 1-4 months

3.) secondary circular reaction

4-8 months

Coordination of secondary reaction

8-12 months

Tertiary circular reaction

12-18 months

Invention of new means there mental combination

18-24 months

Behavior All reflexes -Activity related to body -repetition of behavior ex. thumb sucking -activity not related to body -discover obj and person’s permanence -memory traces present -anticipate familiar events. -exhibit goal directed behavior -increase of separateness (will search of lost toy, knows mom) -use trial and error to discover places and events -“ invention of new means” -capable of space and time perception (hits fork, spoon on table or drops fork) -transitional phase to the pre operational thought period.

B. Preoperational thought 2-7 years Schema age Preconceptual 2-4 yrs

Initiative

4-7 yrs

Behavior -thinking basically complete literal and static -egocentric- unable to view others interrupt -concept of dying is only now -concept of distance is only as fat as they can see. -concept of amenism inanimate object is alive -not aware of concept of r3eversibility- in every action theories an opposite reaction or cause and effect Beginning of causation

C. Concrete Operational thought 7-12 years 1. able to find solution to everyday problems which systematic reasoning. 2. have concept of reversibility- cause and effect 3. have concept of longer duration – constancy despite of transformation. 4. activity recommended- collecting and classifying 5. stamps stationeries, dolls, rubber band markers. D. Formal Operational thought 12 and up. 1. Cognition achieved its final form 6

2. 3. 4. 5.

can deal with past present and future have abstract and mature thoughts. can find solutions to hypothetical problems with scientific reasoning. activity ------- will sort out opinions and current events.

4. KOHLBERG- recognized the theory of moral dev’t as considered to closely approximate cognitive stages of dev’t -“sabay” with cognitive dev;t Stages of Moral dev’t Infancy – premoral, prereligious, amoral stage AGE Preconventional 2-3 yrs

STAGE Level 1

DESCRIPTION

1

4-7

2

-Punishment/ obedience oriented (heteronymous morality) child does right cause a parent tells him or her to and to avoid punishment -Individualism. Instrumental purpose and exch. Carries out action to satisfy own needs rather than society. -Will do something for another if that person does something for the child.

Conventional 7-10

Level 2 3

10-12

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Postconventional Above 12 yrs

Level III 5 6

-Orientation to interpersonal relations of mutuality. Child followers rules cause of a need to be a “good” person in own eyes and eyes of others. -Maintenance of social order fixed rules and authority. Child finds ff. rules satisfying. Follows rules of authority figures.

-Social contract, utilitarian level making perspectives. Followers standards of society. Universal ethical principle orientation. Follows internalized standards of conduct.

DEVELOPMENTAL MILESTONES -major markers of growth and dev’t 1. Period of infancy- universal language of child-play a.) Play- Infancy- solitary plays -solo, mom interactive -facilitate motor and sensory dev’t -safety- important age appropriate -solitary play- mobile, teeter, music box, rattle 7

b.) fear of infancy- stranger anxiety begin 6-7 months peak 8 months diminishes 9 months 1 month- dance reflex disappears looks at mobile 2 months- holds head up when in prone, social smile, baby coos “doing sound” cry with tears -closure of frontal fontanel 2-3 months head lag when pulled to sitting position. 3 months- holds head and chest up when prone follows obj. past midline grasp and tonic neck reflex fading hand regard (looks at hand) 4 months – turns form front to back head control complete needs space to turn Laugh aloud, bubbling sounds 5 months- turn both ways “roll over” -teething rings -handles rattle well -moro reflex disappears ( 4-5 months) 6 months- reaches out in anticipatory of being picked up -sits with support -uses palmar grasp -eruption of 1st temp teeth 6-8 months 2 lower incisors -say vowel sounds “ah”, “oh” -handles bottle well 7 months- transfer obj. hand to hand -likes obj that are good size 8 months- sits without support -peak of stranger anxiety -planters reflex disappears 8-9 months in prep for walking 9 months - creeps or crawls -neat finger grasp reflex - combine 2 syllables “mama” and “papa” 10. needs space for creeping 10 months – pull self to stand -understands “no” -responds to own name -peak a boo, pat a cake -can clap 11 months- cruisse - stands with assistance 12 months- stand alone take 1st step -walk with assistance 8

-drink from cup, cooperate in dressing -says 2 words mama and dada -pots and pans, pull tay, nursery rhymes 2. Toddler- Parallel play- 2 toddlers playing separately -provide with similar toys -squeaky frog to squeeze -waddling duck to pull -trucks to push-push pull toy -building blocks, pounding peg -toys to ride on -fear- separation anxiety -begin 9 months -peak 18 months 3 phases of separation anxiety (in order) 1. P- protect 2. D- despair 3. D -denial -don’t prolong goodbye -say goodbye firmly to develop trust- say when ul be back

15 months – plateau stage -walks alone - lateness in walking- mild mental retardation -puts small pellets into small bowl -holds spoon well - seats self on chair -creeps up stairs - 4 - 6 words 18 months- height of possessiveness -favorite word- “mine” -bowel control achieved (bowel 1st before bladder) -no longer rotates spoon -can run and jump in place -walks up and down stairs holding railing or persons hand -1-20 words -name, body part -puts both feet on 1 step before advancing. 24 months- terrible two -can open doors by turning door knobs -unscrew lids -can walk upstairs alone –using both feet on same step at same time -50-200 words ( 2 words sentences) -daytime bladder control achieved ( daytime 1st- next nighttime bladder control) 9

30 months or 2 ½ years – makes simple lines or stroke for crosses with a pencil -can jump down from chairs -knows full name - copy a circle -holds up finger to show age temp teeth complete      

post molar- last temp teeth to appear how many deciduous teeth -20 beginning of toothbrush – 2-2 ½ yrs tooth brushing with little assistance 3 yrs tooth brushing alone – 6 yrs right time to bring to dentist- when temp teeth complete

36 months or 3 yrs- trusting 3 - unbutton buttons (unbutton before learn to button) -draw a + - learns how to share -knows full name and sex (gender identity) - speaks fluently -nighttime bladder control -300-900 words -ride a tricycle Characteristic Traits of toddler 1.) negativistic- “NO!” -way to search for independence –limit questions –modify questions to a statement 2.) rigid, ritualistic and stereotype -ritualism- for mastering 3.) Temper tantrums- head banging, screaming, stamping feet, holds breath –ignore behavior 3.) scaffoid abdominal-due to underdeveloped abdominal muscles 4.) physiologic anorexia- due to preoccupation with environment- food jag that last for short period of time 5.) loves rough and tumbling play 6.) loves toilet training- failure of toilet training- unreadiness Clues of toilet readiness: 1.) can stand, squat walk alone 2.) can communicate toilet needs 3.) can maintain dry for 2 hours Pre schoolers- associative or cooperative play 1.) bahay-bahayan – play house 10

2.) role playing 3.) fear-body mutilation or castration fear of dark places witches fear of thunder and lightning fear of ghosts 4years old- furious 4 , noisy, aggressive, stormy -can button buttons -copy a square -jumps and skips -laces shoes -vocabulary 1,500 -knows four basic colors 5 years old- frustrating 5 -copy a triangle -draw a 6 part man -imaginary playmates -2,100 words Character Traits of Pre-schooler: 7.) curious, creative imaginative, imitative 8.) 2. favorite words- why and how 9.) complexes- word identification to parent of same sex and attachment to parent of opposite sex ex. Oedipal complex- boy to mom Electra complex- girl to dad - Cause of incest marital discord - Concept of Death-sleep only Behavior problems Preschool 1. telling tall tales-over imagination 2. imaginary friend- to release tension and anxieties 3. sibling rivalry- jealousy to newly delivered baby. 4. regression- going back to early stage -thumb sucking (should be oral stage only) -baby talk -bed wetting -fetal position 5. masturbation- sign of boredom -divert attention- offer a toy School Age Play- competitive play Ex. Tug of war, track and field, basket ball

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Fear. 1.) school phobia -orient to new environment 2.) displacement from school -teacher and peer of same sex 3. loss of privacy -wants bra 4.) fear of death -7-9yrs death is personified -death- permanent loss of life Significant Development a. boys- prone to bone fracture b. mature vision 20/20 6 years- temp teeth begin to fall perm teeth appear- 1st molar 1st temporary teeth- 5 months 1st permanent teeth- 6 yrs -year of constant motion - clensy mou’t recognize all shapes -1st grade teacher becomes authority figure -nail biting -begin interest in God. 7 yrs- Assimilation age -copy a diamond -enjoys teasing and playing alone -quieting down period 8 yrs- Expansive age -smoother mouth -loves to collect objects -count backwards 9 yrs –coordination improves -tells time correctly -hero worship -stealing and lying are common -takes care of body needs completely -teacher finds this group difficult to handle 10 yrs- age of special talent -writes legibly -ready for competitive games -more considerate and cooperative 12

-joins orgs. -well mannered with adult -critical of adults 11-12 yrs – Pre adolescents -full of energy and constantly active -secret language are common -share with friends secrets -sense of humor present -social and cooperative Character Traits School Age 1. industrious2. modest 3. can’t bear to lose- will cheat 4. love collections- stamps

Signs of sexual maturity GIRLS: I-inc size breast and genitalia (pelarche- 1st sign sexual maturation) W- widening of hips A- appearance axillary, pubic ( adrenarch) M- menarche- last sign sexual maturation for girls BOYS: A-appearance axillary, pubic hair ( 1st sign sexual maturation) D-deepening voice D- development of muscles I--inc in testes and penis size P- production of viable sperm (last sign sexual maturity) Adolescent Fear 1. obesity 2. acne 3. homosexuality 4. death 5. replacement from friends 6. significant person- opposite sex. Significant development 1. experiences conflict bet his needs for sexual satisfaction and societies expectation 2. change of body image and acceptance of opp/sex 3. nocturnal emission – wet dreams 4. distinctive odor- due to stimulation apocrine glands 5. sperm is viable by 17 yrs 13

6. testes & scrotum increase until age 17 7. breast and female genitalia increase until age 18 Personality Traits Adolescents 1. idealistic 2. rebellious 3. reformers 4. conscious with body image 5. adventuresome Problems: 1. vehicular accident 2. smoking 3. alcoholism 4. drug addiction 5. pre marital sex

IMMEDIATE CARE OF NEWBORN 1. 2. 3. 4. 5. 6. 7. 8.

1st days of life initiation and maintenance of respiration establishment of extra uterine circulation control of body temp intake of adequate nourishment establishment of waste elimination prevention of infection establishment of an infant parent relationship dev’t care that balances rest and stimulation or mental dev’t

A.Initiation and maintenance of respiration -2nd stage of labor- initial airway -initiation of airway is a crucial adjustment -most neonatal deaths with in 24 h caused by inability to initiate an airway -lung function begins after birth only How to initiate a/w a.) remove secretions bulb syringe b. ) Catheter Suctioning 1.) place head to side to facilitate drainage 2,) suction mouth 1st before nose -neonates are nasal breathers 3.) period of time -5-10 sec suctioning, gentle and quick prolonged and deep suctioning can lead to hypoxia, laryngo spasm, brady cardia due to stimulation vagal nerve 14

4.) evaluate for patency -cover nostril and baby struggles there’s a need for additional suctioning c. ) If not effective, requires effective laryngoscopy to open a/w. After deep suctioning an endotracheal tube can be inserted and oxygen can be administered by an (+) pressure bag and mask with 100% oxygen at 40-60b/m. Nsg alert: 1. No smoking 2. Always humidify to prevent drying of mucosa 3. Over dosage of oxygen can lead to scarring of retina leading to blindness ( retro lentalfibrolasia or retinopathy of prematurity) 4. When mecomium stained (greenish) never administer oxygen with pressure ( O2 pressure will push mecomium inside) B. Establishing extra uterine circulation - circulation is initiated by lung expansion or pulmo ventilation and completed by cutting of cord.  FETO PLACENTAL CIRCULATION -Placenta(simple diffusion) –oxygenated blood is carried by the umbilical vein- passes liverductus venousus- IVC- RT atrium 70% blood is shunted to foramen ovale- LT atrium mitral valve – LT ventricle- aorta-lower extremities. -Remaining 30%- tricuspid valve- RT ventricle- pulmonary arteries- lungs (for nutrition) (vasoconstriction of lungs pushes blood to ductus arteriousus to aorta to supply upper extremities. SHUNTS-shortcuts Ductus venosus- -shunts from liver to IVF Foramen ovale- shunts bet 2 atrias Ductus arteriosus- from pulmonary artery to aorta

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Decrease PO2, increase PCO2 acidosis

Will cause 1st breath /cry of baby

Decrease pulmo artery pressure

Increase PO2

Closure of ductus arteriosus

Decrease blood flow

Closure of ductus venosus & AVA

Increase pressure to Lt side of heart

Closure of foramen ovale

What will sustain 1st breath- decreased artery pressure What will initiate lung circulation-lung expansion What will complete circulation- cutting of cord * 2 way to facilitate closure of foramen ovale a.) Tangential Footstep- slap foot of baby -never stimulate baby to cry if secretions not fully drained to prevent aspiration -check characteristic of cry normal cry- strong, vigorous and lusty cry cri-du-chat syndrome-chromosomal obliteration cat like cry b.) proper position -right side lying pos. -will increase pressure on left and foramen ovale will close -Foramen Ovale and Ductus arteriosus will begin to close within 24h

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Obliteration-complete closure Structure F. Ovale Ductus Arteriosus Ductus Venosus Umbilical artery Umbilical vein

Appropriate time of obliteration 1yr

Structure remaining

Failure to close

Fossa Ovalis

1 month

Ligamentum Arteriosum

Atrial Septal Defect Patent ductus arteriosus

2 months

Ligamentum venosum

2-3 months

1.) lateral umb. Ligament 2.) interior iliac artery -ligamentum teres ( round ligament of liver)

2-3 months

Position of infant immediately after birth: NSD-trendelenberg/ T position for drainage contraindication of trendelenberg position - increase ICP CS- supine or crib level position Signs of increased ICP 1.) abnormally large head 2.) bulging and tense fontanel 3.) increase BP and widening pulse pressure 4.) Decreased RR, decreased PR 5.) projective vomiting- sure sign of cerebral irritation 6.) high deviation – diplopia – sign of ICP older child 4-6 months- normal eye deviation >6 months- lazy eyes 7.) High pitch shrill cry-late sign of ICP

#3 & #4 are Cushings triad of ICP

C. Temp Regulation - goal in temp regulation is to maintain it not less than 97.7% F (36.5 C) - maintenance of temp is crucial on preterm and SGA (small for gestational age) babies prone to hypothermia or cold stress A. factors leading to dev’t of HYPOTHERMIA 1. preterms are born poi kilo thermic- cold blooded 2. babies easily adapt to temp of environment due to immaturity of thermo regulating system of body. Hypothalamus 3. inadequate SQ tissue 4. baby is not capable of shivering 5. babies are born wet

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PROCESS OF HEAT LOSS 1. evaporationbody to air (TSB) 2. conductionbody to cold solid object (cold compress) 3. convectionbody to cooler surrounding air (aircon) 4. radiationbody to cold object not in contact with body earliest sign of hypothermia- increase in RR Effects of Hypothermia ( Cold stress) 1.) Hypoglycemia- 45-55 mg/dl normal 50- borderline 2.) met acidosis- catabolism of brown fats (best insulator of newborns body) will form ketones 3.) high risk for kernicterus- bilirubin in brain leading to cerebral palsy 4.) additional fatigue to allergy stressful heart To Prevent Hypothermia 1. dry and wrap baby 2. mechanical pressure – radiant warmer i. pre-heated first isolette (or square acrylic sided incubator) 3. prevent an necessary exposure – cover baby 4. cover baby with tin foil or plastic 5. embrace the baby- kangaroo care D. Establish Adequate Nutritional Intake CS- breastfeeding after 4 hours NSD- breastfeeding asap Physiology breast milk production As you deliver baby, decrease Estrogen, decrease Progesterone- -Anterior Posterior Gland (APG) releases prolactin – acts on acinar cells (or alveoli) – produce foremilk – stored in lactiferous tubules ( or collecting tubules) where breast milk is produced – alveoli postpit.gland Sucking- PPG – oxytocin – contraction of lactiferous tubules - milk ejection reflex- let down reflex. Advantages of Breastfeeding 1. Economical 2. Always available 3. Breastfed babies have higher IQ than bottle fed babies. 4. It facilitates rapid involution 5. Decrease incidence of breast cancer. 6. Has antibodies- IgA 7. Has lactobacillius bifidus- interferes with attack of pathogenic bacteria in GIT 8. Has macrophages 18

Store milk- plastic storage container Store milk – good for 6 months from freezer- put rm temp. don’t heat Disadvantages: 1. Possibility of transfer HEP B, HIV, cytomegalo virus. 2. No iron 3. Father can’t feed & bond as well Stages of Breastmilk: 1. Colostrum- 2-4 days present content: decrease fats, increase IgA, dec CHO, dec CHON, inc minerals, inc fat soluble minerals 2. Transitional milk- 4 – 14 days content: inc lactose, inc water soluble vit., inc minerals 3. Mature milk- 14 & up content: inc fats (linoleic acid) – resp for devt of brain & integrity of skin inc CHO- lactose – easily digested, baby not constipated. - resp of sour milk smelling odor of stool. Lactose intolerance- deficiency of enzyme LACTASE that digest LACTOSE Decrease CHON- lactalbumin Cows milk – inc fatsDec CHO Inc CHON – casing- has curd that’s hard to digest. Inc minerals–traumatic effect on kidneys of babies. Can trigger stone formation. Inc phosphorus Health Teachings: 1. Proper hygiene- proper hand washing Care of breast - cotton balls with lukewarm water Caked colostrum- dry milk on breast 2. Best position in breastfeeding – upright sitting -avoid tension! 3. Stimulate & evaluate feeding reflexes a.) Rooting reflex- by touching the side of lips/cheeks then baby will turn to stimulus. Disappear by 6 weeks- by 6 weeks baby can focus. Reflex will be gone - Purpose rooting- to look for food. b.) Sucking – when you touch middle of lips then baby will suck - Disappears by 6 months - When not stimulated sucking will stop. c.) Swallowing- when food touches posterior of tongue then it will be automatically swallowed d.) Extrusion/ Protrusion reflex -when food touches anterior portion of tongue then food will be extruded. Purpose: to prevent from poisoning Disappear by 4 months & baby can already spit out by 4 months.

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Criteria Effective Sucking a.) Baby’s mouth is hiked up to areola b.) Mom experiences after pain. c.) Other nipple is also flowing with milk. To prevent from crack nipples & initiate proper production of oxytocin. - begin 2-3 min at @ breast ( 5 – 7 min other authors) to initiate production of oxytocin - increase 1 min/ day – until reaching 10 mins @ breast or 20 mins/ feeding. For proper emptying & continuous milk production / feeding -feed baby on last breast that you feed her with, alternately ( if not emptied - mastitis) Problems experienced in Breastfeeding : 3RD day changes in breast post partum a.)Engorged- feeling of fullness & tension in breast. - sometimes accompanied by fever known as MILK FEVER. Mgt:

Warm compress- for breastfeeding mom Cold compress – for bottle feeding & wear supportive bra. When is involution of breast- 4 weeks b.) Sore nipple – cracked with painful nipple Mgt: 1.) exposure to air – remove bra & wear dress, if not, expose to 20 Watt bulb avoid wearing plastic liner bra - will create moisture, cotton only c.) Mastitis- inflammation of breast : staphylococcus aureus Factors: 1. Improper breast emptying 2. Unhealthy sexual practices -contraindicated for breast feeding - manually express inflamed breast feed on unaffected breast - give antibiotics – can still feed on unaffected breast Contra Indications in Breast Feeding: Maternal Conditions: 1. HIV CMV Hepa B Coumadin Newborn Condition - Inborn errors of metabolism 1.Erythrobastosis Fetalis – Rh incompatibility Hydrops Fetalis Phenylketonuria Galactosemia Tay Sachs disease 20

F. Establish of waste elimination A. Diff stools 1. Meconium - physiologic stool - black green, sticky, tar like, odorless (Sterile intestine) will pass with in 24 – 36 hrs -failure to pass mecomium after 24h- GIT obstruction ex. Hirschsprungs disease imperforate anus mecomium ileus – due to Cystic Fibrosis 2. Transitional stool - green loose & shiny, like diarrhea to the untrained eye 3. Breastfed stool - golden yellow, soft, mushy with sour milk smell, frequently passed - recur every feeding 4. Bottlefed stool – - pale yellow, formed hard with typical offensive odor, seldom passed, 2–3 x/day - with food added -brown & odorous Jaundice baby – light stool Under phototherapy – bright green Mucus mixed with stool - milk allergy Clay colored stool – obstruction to bile duct Chalk clay stool – after barium enema Black stool – GIT bleeding (melena) Blood flecked stool anal fissure. Currant jelly stool – instussusection Ribbon like stool – hirschsprung disease Steatorrhea stool – fatty, bulky foul smelling odor stool - malabasorption syndrome ( celiac disease or cystic fibrosis) Cult blood – stool exam III Assessment for Well–being APGAR SCORE – Dr. Virginia Apgar Special Considerations: 1st 1 min – determine general condition of baby Next 5 min- determine baby’s capabilities to adjust extra uterinely Next 15 min – dependent on the 5 min A- appearance- color – slightly cyanotic after 1st cry baby becomes pink. P- pulse rate – apical pulse – left lower nipple G- grimace – reflex irritability- tangential foot slap, catheter insertion A – activity – degree of flexion or muscle tone R – respiration Baby cry – within 30 secs 21

Failure to cry after 30 secs – asphyxia near the neatorum Resp. depression – due mom given Demerol. Administer Naloxone

APGAR Scoring Chart: 0 -absent -absent - flaccid extremities

HR Resp effort Muscle tone Reflex irritability Catheter - no response Tangential Footslap - NR Color - blue/pale

1 100 -good strong cry - well flexed

- grimace - grimace - acrocyanosis (body- pink extremities-blue)

- cough, sneeze - cry - pinkish

APGAR result 0 – 3 = severely depressed, need CPR, admission NICU 4 – 6 = moderately depressed, needs add’l suctioning & O2 7 - 10 =good/ healthy CPR – cardio pulmonary resuscitation or CPR Cardio pulmonary cerebral resuscitation (CPCR) 5 min no O2 – irreversible brain damage 1. shake, no resp, call for help 2. flat on head 3. head tilt chin lift maneuver except spinal cord injury over extension may occlude airway Breathing ( ventilating the lungs) 1. check for breathlessness - if breathless, give 2 breaths- ambu bag > 1 yr old- mouth to mouth, pinch nose < 1 yr – mouth to nose force – different between baby & child infant – puff Circulation Check for pulslessness :carotid- adult Brachial – infants CPR – breathless/pulseless Compression – inf – 1 finger breath below nipple line or 2 finger breaths or thumb CPR inf 1:5 22

Adults 2:15 Assessment tool determines respiration of baby Silvermann Anderson Index Respiration Evaluation – lowest score – best Criteria 0 1 Chest movement synchronized Lag on respiration Intercostal retraction No retraction Just visible Xiphoid retraction None Just visible Nares dilatation None Minimal Expiratory grunt None Heard on stet only

2 See - saw Marked Marked Marked Heard on naked ear

Interpretation result: 0 -3 – normal, no RDS 4 – 6 – moderate RDS 7 – 10 – severe RDS Assessment of Gestational Age -Ballards & Dobowitz Findings Less 36 weeks (Preterm) Sole creases Anterior transverse crease only Breast nodules 2mm Scalp hair Fine & fuzzy Ear lobe Pliable Testes and testes in lower canal Scrotum Scrotum – small few rugae

37 - 38 Occasional creases 2/3 in 4mm or 3.5 mm Fine & fuzzy Some cartilage Some intermediate

39 and up Covered with creases > 5 or 7mm Coarse & silky Thick cartilage Testes pendulus Scrotum full extensive rugae

Signs of Preterm Babies Born after 20 weeks, after 37 weeks -frog leg or laxed positon -hypotonic muscle tone- prone resp problem -scarf sign – elbow passes midline pos. - square window wrist – 90 degree angle of wrist - heal to ear signabundant lanugoSigns of Post term babies: > 42 weeks - classic sign – old man’s face - desquamation – peeling of skin - long brittle finger nails - wide & alert eyes 23

Neonates in Nursery Nsg responsibility upon receiving baby- proper identification - foot printing, affixing mother thumb print - take anthropometic measurement normal length- 19.5 – 21 inch or 47.5 – 53.75cm, average 50 cm head circumference 33- 35 cm or 13 – 14 “ Hydrocephalus - >14” Chest 31 – 33 cm or 12 – 13” Abd 31 – 33 cm or 12 – 13” Bathing - oil bath – initial - to cleanse baby & spread vernix caseosa Fx of vernix caseosa 1. insulator 2. bacterio- static Babies of HIV + mom – immediately give full bath to lessen transmission of HIV - 13 – 39% possibly of transmission of HIV Full bath – safely given when cord fall Dressing the Umbilical Cord – strict asepsis to prevent tetanus 3 cleans in community 1. clean hand 2. clean cord 3. clean surface betadine or povidone iodine – to clean cord - check AVA, then draw 3 vessel cord - If 2 vessel cord- suspect kidney malformation - leave about 1” of cord - if BT or IV infusion – leave 8” of cord best access - no nerve - check cord every 15 min for 1st 6 hrs – bleeding .> 30 cc of blood bleeding of cord – Omphalagia – suspect hemophilia Cord turns black on 3rd day & fall 7 – 10 days Faiture to fall after 2 weeks- Umbilical granulation Mgt: silver nitrate or catheterization - clean with normal saline solution not alcohol - don’t use bigkis – air - persistent moisture-urine, suspect patent uracus – fistula bet bladder and normal umbilicus Dx: nitrazine paper test – yellow – urine mgt: surgery

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Credes Prophylaxis – Dr. Crede -prevent opthalmia neonatorum or gonorrheal conjunctivitis - how transmitted – mom with gonorrhea drug: erythromycin ophthalmic ointment- inner to outer Vit-K – to prevent hemorrhage R/T physiologic hypoprothrombinemia - Aquamephyton, phytomenadione or konakion - .5 – 1.5 ml IM, vastus lateral or lateral ant thigh - 5 ml preterm baby Vit K – synthesized by normal flora of intestine Vit K – meds is synthetic due intestine is sterile Weight:

Normal wt 3.000 – 3400 gms/ 3 – 3.4 kg / 6.5 -

7.5 lbs

Arbitrary lower limit 2500 gm Low birth wt baby delivered < 2500g Small for gestational age (SGA) < 10th % rank or born small Large for gestational age > 90th % rank or macrosomia >4000 g Appropriate for GA – within 2 standard deviation of mean Physiologic wt loss – 5 – 10% wt loss few days after birth Small GA < (less) 10 Large GA > (more) 90 Physical Exam and Deviations fr Normal 1. if client is new born, cover areas not being examined 2. if client is infant – the 1st yr of life - get VS – take RR 1st - begin fr least intrusive to the most intrusive area 3. if client is a toddler and preschool, let them handle an instrument like: - play syringe or stet, security blanket – favorite article. Let baby hold it. 4. Explain procedure and respect their modesty - school age and adolescent V/S: Temp: rectal- newborn – to rule out imperforate anus - take it once only, 1 inch insertion Imperforate anus 1. atretic – no anal opening 2. agenetic – no anal opening 3. stenos – has opening 4. membranous – has opening Earliest sign: 1. no mecomium 2. abd destention 25

3. foul odor breath 4. vomitous of fecal matter 5. can aspirate – resp problem Mgt: Surgery with temporary colostomy Cardiac rate: 120 – 160 bpm newborn Apical pulse – left lower nipple Radial pulse – normally absent. If present PDA Femoral pulse – normal present. If absent- COA - coartation of aorta

CONGENITAL HEART DISEASES Common in girls – PDA, ASD atrial septal Common in boys – TOGA ( transportation of great arteries) TA – tronchus arteriosus TOF – tetralogy of fallot Causes: 1. familial 2. exposure to rubella – 1st month 3. failure of strucute to progress Acyanotic L to R Cyanotic R to L I.

ACYANOTIC HEART DISEASE - L to R A.Ventricular septal defect - opening between 2 ventricles S&Sx 1. systolic murmurs at lower border of sternum and no other significant sign - cardiac catheterization reveals increased o2 saturation @ R side of heart - ECG reveals hypertrophy of R side of heart Nsg Care: Cardiac catheterization: site – Rt femoral vein 1. NPO 6 hrs before procedure 2. protect site of catheterization. Avoid flexion of joints proximal to site. 3. assess for complication – infection, thrombus formation – check pedal pulses (dorsalis pedis) Mgt. 1.) long term antibiotic – to prevent subacute bacterial endocarditis 2.) open heart surgery-

26

B. ASD – failure of foramen ovale to close S&SX 1. systolic murmur @ upper border of sternum 2. result of cardiac catheterization & ECG same with VSD Mgt: open heart surgery C. Endocardial cushion defects - atrium ventricular (AV) - affects both tricuspid and mitral valve Dx – confirmed by cardiac catheterization Mgt: - open heart surgery Antibiotics to prevent subacute bacterial endocarditis D. PATENT DUCTUS ARTERIOSUS- failure of ductus arteriosus to close - should close within 24 h -complete close – 1 month S&Sx 1. continuous machinery like murmurs 2. prominent radial pulse 3. ECG- hypertrophy Left ventricle Drug: 1. endomethazine – prostaglandin inhibitor - facilitate closing of PDA 2. ligation of PDA by 3-4 yo 3. thoracotomy procedure- nakadapa child D. Pulmunary Stenosis- narrowing of valve of pulmo artery S &Sx: 1.) typical systolic ejection murmur 2. S2 sound widely split 3. ECG- Lt ventricular hypertrophy E. Aortic Stenosis – narrowing of valve of aorta S & Sx: 1. inactive, sx sme with angina 2. typical murmur 3. rough systolic sound and thrill 4. ECG- Left ventricular hypertrophy Mgt Pulmo Stenosis & Aortic Stenosis 1.) balloon stenostomy 2.) surgery Duplication of Aortic Arch- doubling of arch of aorta causing compression to trachea and esophagus S&Sx : 1. dysphagia 2. dyspnea 3. left ventricular hypertrophy Mgt: - close heart surgery E. Coartation of Aorta – narrowing of arch of aorta Outstanding Sx : absent femoral pulse BP increased on upper extremities and decreased on lower extremities 27

ECG – hypertrophy Lft ventricle Mgt: close heart surgery CYANOTIC HEART DEFECTS R to L 1. Transportation of Great Arteries (TOGA) - aorta arising from Rt ventricle pulmo artery arising form Lt ventricle Outstanding Sx: 1. cyanosis after 1st cry (due no exygenation) 2. polycythemia – increased RBC =compensatory due to O2 supply=viscous blood =thrombus = embolus = stroke 3. ECG – cardiomegaly Cardiac cath – decreased O2 saturation Palliative repair – rashkind procedure Complete repair – mustard repair 2.) Total Anomalous Pulmonary venous return – pulmo vein instead of entering Lt atrium, enters Rt atrium or SVC Increased pressure on Rt so blood goes to Lft Outstanding Sx: Open foramen ovale Mild to moderate cyanosis Polycythemia = thrombus = embolus = stroke asplenia- absent spleen Mgt: restructuring of heart 3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 1 single vessel or common trunk with VSD S & Sx 1. cyanosis 2. polycythemia – thrombus = embolus = stroke Mgt: Heart transplant 4.) Hypoplastic Left heart syndrome – non fx Left ventricle 1. cynosis 2. polycythemia – throm, emb, stroke Mgt: heart transplant 5.) Tricuspid atresia – failure of tricuspid valve to open S&SX: open foramen ovale (R to L shunting – goes to Lt atrium) cynosis, polycythemia Mgt: fontan procedure – open tricuspid valve 6.) Tetralogy of Fallot P – pulmonary stenosis V – ventricular SD O – overriding or dextroposition of aorta 28

R – Rt ventricular hypertrophy S &Sx: 1. 2. 3. 4.

Rt ventricular hypertrophy high degree of cyanosis polycythemia severe dyspnea – squatting position – relief , inhibit venous return facilitate lung expansion. 5. growth retardation – due no O2 6. tet spell or blue spells- short episodes of hypoxia 7. syncope 8. clubbing of fingernails – due to chronic tissue hypoxia 9. mental retardation – due decreased O2 in brain 10. boot shaped heart – x-ray Mgt: 1. O2 2. no valsalva maneuver , fiber diet laxative 3. morphine – hypoxia 4. propranolol – decrease heart spasms 5. palliative repair – BLT blalock taussig procedure Brock procedure – complete procedure

ACQUIRED HEART DSE 1. RHD Rheumatic Heart Disease - inflammation disease ff an infection acquired by group A Beta hemolytic strepto coccus Affected body – cardiac muscles and valves , musculoskeletal , CNS, Integumentary  Sorethroat before RHD  Aschoff – rounded nodules with nucleated cells and fibroblasts – stays and occludes mitral valve. Jones Criteria Major 1. polyarthritis – multi joint pain 2. chorea – sydenhamms chores or st. vetaus dance-purposeless involuntary hand and shoulder with grimace 3. carditis – tachycardia erythema marginatum - macular rashes SQ nodules

Minor 1. arthralgia – joint pain 2. low grade fever

3. all lab results increase antibody “ C reactive protein “ erythrocyte sedimentation rate “ anti streptolysin o titer (ASO) 29

Criteria:Presence of 2 major, or 1 major and 2 minor + history of sore throat will confirm the dx. Nsg Care: 1. CBR 2. throat swab – culture and sensitivity 3. antibiotic mgt – to prevent recurrence 4. aspirin – anti-inflammatory. Low grade fever – don’t give aspirin. S/E of aspirin: - Reyes syndrome – encephalopathy- fatty infiltration of organs such as liver and brain Respiration Newborn resp – 30-60 cpm, irregular abd or diaphramatic with short period of apnea without cyanosis. < 15 secs – normal apnea –newborn Resp Check Newborn – 40 – 90 1 yr - 20 – 40 2-3yr 20 – 30 5 yrs 20 – 25 10 yrs 17 – 22 15 & above 12- 20 BREATH SOUNDS HEARD DURING ASCULTATION: 1.) VESICULAR – soft, low pitched, heard over periphery of lungs, inspiration longer then expiration -Normal 2.) BRONCHOVESICULAR- soft, medium pitched, heard over major bronchi, inspiration equals exp. Normal 3.) BRONCHIAL SOUNDS- loud high pitched, heard over trachea, expiration longer than inspiration. Normal 4.) RHONCHI – snoring sound made by air moving through mucus in bronchi. Normal 5.) RALES-or crackles – like cellophane – made by air moving through fluid in alveoli. Abnormal- asthma, foreign body obstruction. 6.) WHEEZING- whistling on expiration made by air being pushed through narrowed bronchi .Abnormal – asthma, foreign body obstruction 7.)STRIDOR- crowing or ropster life sound – air being pulled through a constricted larynx. Abnormal – resp obstruction Asthma- pathognomonic sign – expiratory wheezing Pet – fish. Sport – swimming Drugs – amynophylline – monitor bp, may lead to hypotension

30

Laryngo Tracheo Bronchitis LTB - inspiratory stridor – pathognomonic sign RDS respiratory dist synd or hyaline membrane dis Cause- lack of surfactant – for lung expansion Hypotonia, Post surgery, Common to preterm Fibrine hyaline Sx – definite with in 1st of life Increase RR with retraction Inspiratory grunting – pathognomonic 7 – 10 severe RDS (silvermenn Anderson index) cyanosis due to atelectasis Mgt: 1. surfactant replacement and rescue 2. pos- head elevated 3. proper suctioning 4. o2 with increase humidity- to prevent drying of mucosa 5. monitor V/S skin color , ABG 6. CPAP- continuous + a/w pressure 7. PEEP - + end expiratory pressure Purpose of #6-7- to maintain alveoli partially open and alveoli collapse LARYNGOTRACHEOBRONCHITIS LTB – most common Creup -viral infection of larynx, trachea & bronchi outstanding sx - croupy cough or barking pathognomonic - stridor - labored resp - resp acidosis - end stage – death Lab: 1. ABG 2. neck and throat culture 3. dx- neck x-ray to rule out epiglotitis Nsg Mgt: 1. bronchodilators 2.increase o2 with humidity 3. prepair tracheostomy set BRONCHOLITIS- Inflammation of bronchioles – tenatious mucus Causative agaent – RSV - Resp sincytial viruses Sx: flu like sx Increased RR Drug: Antiviral – Ribavirin End stage – epiglotitis 31

EPIGLOTITIS - infl of epiglottis - emer. Condition of URTI Sx: sudden onset Tripod position – leaning forward with tongue protrusion - never use tongue depressor prepare tracheotomy set < 5 yo – unable to cough out, put on mist tent (humidifier o2) or croupe tie Nsg Care: check edges tucked on mist tent Provide washable plastic material No toys with friction due O2 on No hairy toys – due moist environment medium for bacterial growth BP – 80/46 mmHg newborn BP after 10 days- 100/50 BP taking begins by 3 yo COA – take BP on 4 extremities SKIN: Acrocyanosis BIRTHMARKS: 1. Mongolian spots – stale gray or bluish discoloration patches commonly seen across the sacrum or buttocks due to accumulation of melanocytes. Disappear by 1 yr old 2. MIlla – plugged or unopened sebaceous gland . white pin point patches on nose, chin or cheek. 3. Lanugo – fine, downy hair – common preterm 4. Desquamation – peeling of newborn, extreme dryness that begin sole and palm. 5. Stork bites (Talengeictasi nevi) – pink patches nape of neck  hair will grow as child grows old 6. Erythema Toxicum – (flea bite rash)- 1st self limiting rash appear sporadically & unpredictably as to time & place. 7. Harlequin sign – dependent part is pink, independent part is blue (side lying – bottom part is dependent pink) 8. Cutis Marmorato – transitory mottling of neonates skin when exposed to cold. 9. Hemangiomas – vascular tumors of the skin 3 types Hemangiomas a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can be removed surgically b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. Enlarges, disappears at 10 yo. c.) Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear with age. - MOST DANGERIOUS – intestinal hemorrhage Skin color blue – cyanosis or hypoxia White – edema 32

Grey – inf Yellow – jaundice , carotene Vernix Caseosa – white cheese like for lubrication, insulator BURN TRAUMA – injury to body tissue caused by excessive heat. INFANT ANTERIOR POSTERIOR Head 9.5 9.5 Neck 1 1 Upper arm 2 2 Lower arm 1.5 1.5 Hand 13 1.25 Trunk 13 Back 13 Genital 1 @ buttocks 2.5@ Thigh 2.75 2.75 Leg 2.5 2.5 foot 1.75 1.75

DEPTH 1st degree – 2nd degree –  rd 3 degree –   Mgt: 1.) 1st aid

5-9 yo Ant Post 6.5 6.5 1 1 2 2 1.5 1.5 1.25 1.25 13 13 1 2.5 @ 4 4 3 3 1.75 1.75

partial thickness – superficial epidermis - erythema, dryness, PAIN -sunburn, heals by regeneration from 1 – 10 days epidermis & dermis- erythema, blisters, moist, extremely painful scalds full thickness- epidermis, dermis, adipose tissue, fascia, muscle & bone lethargy, white or black, not painful – nerve endings destroyed ex. lava burns

a.) put out flames by rolling child on blanket b.) immerse burned part on cold H2o c.) remove burned clothing of with sterile material d.) cover burn with sterile dressing

2.) a/w a.) suction PRN, o2 with increased humidity b.) endotracheal intubation c.) tracheostomy 3.) Preventiuon of shock & F&E imbalance a. colloids to expand bld volume b. isotonic saline to replace electrolytes c. dextrose & H2o to provide calories 4.) Tetanus toxoid booster 5.) Relief of pain – IV analgesic MORPHINE SO4 – needed for 2nd degree – very painful 33

6.) 1st defense of body – intact skin prevention of wound infection a.) cleaning & debriding of wound b.) open or close method of wound care c.) whirlpool therapy – drum with solution 7.) skin grafting – 3rd degree – thigh or buttocks (autograft), pigs/ animals – xenograft frozen cadaver – hallow graft 8,) diet – increase CHON, increase calories. ATOPIC DERMATITIS- infantile eczema (galis) Papulo vesicular erythematus lesions with weeping & crusting Cause – food allergies: milk, citrus juice, eggs, tomatoes, wheat Sx: extreme pruritus, linear excoriation, weeping crusting; scaly shiny and white – lechenification Goal of care: decrease pruritus – avoid food allergens Diet: Prosobi or Isomil Hydrate skin, borow solution 1% hydrocortisone cream Prevent infection – proper handwahsing, trim nails IMPETIGO- skin disease. Causative agent – grp A beta Hemolytic streptococcus - papulovesicular surrounded by localized erythema –becomes purulent , oozes a honey colored crust Pediculosiscapitis –“KUTO” - Mgt: proper hygiene – wash soap and H2o, oral penicillin – bactroban ointment Can lead to acute glomerulonephritis AGN ACNE- adolescent problem - self limiting infl dis – sebaceous gland comedones – sebum causing white heads - sebum- lipids causing acne bulgaris Mgt: - proper hygiene- mild soap or sulfur soap- antibacterial retin A or tretinoi

ANEMIA-pallor Causes: 1.)early cutting of cord – preterm – cut umb cord ASAP fullterm – cut umb cord when pulsation stops 2.) Bleeding disorders – blood dyscrasias HEMOPHILIA – deficiency of clotting factor. X linked recessive – inherited If mom – carrier, son – affected If father carrier- transmitted to daughter Hemophilia A – deficiency of coagulation component factor 8 34

Hemophilia B –or christmas disease, deficiency of clotting factor 9 Hemophilia C – deficiency of clotting factor 11 Assessment: - umphalagia – earliest sign - newborn receive maternal clotting factor - newborn growing – sudden bruising on bump area- marks earliest sign - continuous bleeding – hematrosis – damage or bleeding synovial membrane Dx test : PTT. Partial thromboplastin time – reveals deficiency in clotting factor Long Term Goal- prevention of injury Nsg Dxincrease risk of injury HT: avoid contact sport, swimming only, don’t stop immunization – just change gauge of needle Falls – immobilized , elevate affected part, apply pressure-not more then 10 min cold compress -determine case before doing invasive procedure LEUKEMIA- grp of malignant disease - rapid proliferation of immature WBC - WBC – protection from infection, soldiers of body Classification : 1. Lympho – affects lymphatic system 2. Myelo – affects bone marrow 3. acute / blastic- affects immature cells 4. chronic/ cystic- affects mature cells MOST COMMON CANCER – (ALL) – Acute Lymphocytic Leukemia S&Sx: 1. from invasion of bone marrow signs of infection a.) fever b.) poor wound healing c.) bone weakness & causes fracture signs of bleeding a.) petecchiae-small, round, flat, dark red spot b.) epistaxis c.) blood in urine/ emesis signs of anemia a.) pallor , body malaise , constipation 2. from invasion of body organ- hepato spenomegaly – abd pain , CNS affectation, increase ICP Dx Tests: 35

1. PBS- peripheral blood smear – determine immature RBC 2. CBC – determine anemia, leukocytosis, thrombocytopenia neutropenia 3. lumbar puncture (LP) – determine CNS involvement. Before LP, fetal pos.- avoid flexion of neck – will cause a/w obstruction.“C” position or shrimp position only. 4. bone marrow aspiration – determine blast cells, - common site- iliac crest - post BMA s/effect – bleeding - apply pressure. Put pt on affected side to prevent hemorrhage 5. Bone scan – determine bone involvement 6. CT scan – determine organ involvement Therapeutic Mgt: TRIAD: 1. surgery 2. irradiation 3. chemotheraphy Focus Nsg Care: prevent infection 4 LEVELS OF CHEMOTHERAPHY 1. induction – goal of tx; to achieve remission meds: IV vincristine L- agpariginase Oral predinisone 2. Sanctuary- treat leukemic cells that invaded testes & CNS give: methotrixate- adm intrathecally via CNS or spine cytocine, Arabinoside, steroids with irradiation 3. maintenance- to continue remission give: oral methotrisate – check WBC -adm of methotrisate – do weekly WBC check 4. Reinductin – treat leukemic cells after relapse occurs. Meds – same as induction - give antigout agents: allopurinol or Zyloprim- treat or prevent hyperurecemic nephropathy. Nsg mgt:

Outstanding nsg dx: alteration in nutrition less body requirement. Based on Maslow’s heirarchy S/Effect of Chemotherapy 1. N/V – adm antiemetic drugs 30 mins before chemo until 1 day after chemo 2. Ulcerations / stomatitis / abscess of oral mucosa- (alteration nutrition less body req) - oral care – alcohol free mouthwash , betadine mouthwash - don’t brush – use cotton pledgets - topical xylocaine before meals diet- soft, bland diet according to child’s preference Temporary S/E of chemo: 36

Alopecia – altered body image Hirsutism – hair -give emotional support to parents ABO incompatibility – Most common incompatibility – ( mom) O – ( fetus) A Most severe incompatibility (Mom) O– (Fetus) B Can affect 1st pregnancy Hydrops (h20) Fetalis – edematous on lethal state with pathologic jaundice Within 24 h Mgt: 1. initiate breastfeeding to get colostrum 2. Temp suspension of breastfeeding - content breast milk pregnanedioles – that delays action of glucoronil transferees liver enzymes converts in direct bilirubin to become direct bilirubin 3. Needs phototherapy 4. needs exchange therapy Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term Normal – 0-3 mg/dL - bilirubin encephalopathy - Kemicterus - > 20 mg/dL among full term & >12 mg /dl of indirect – preterm =can lead to cerebral palsyPhysiologic jaundice – jaundice within 48 -72 h (2-3 days) expose morning sunlight Pathologic Jaundice – within 24h. Jaundice during delivery. Breastfeeding jaundice – caused by pregnanediole Assessment of Jaudice : 1. Blanching neonates forehead, nose or sternum - yellow skin & sclera - color of stool – light stool - color of urine – dark urine Mgt: Phototheraphy – photo oxygenation Nsg Resp: 1. cover eyes – prevent retinal damage 2. cover genitals – prevent priapism – painful continuous erection 3. change position regularly – even exposed to light 4. increase fld intake – due prone to dehydration 5. monitor I&O – weigh baby 37

6. monitor V/S – avoid use of oil or lotion due- heat at phototherapy = bronze baby syndrome-transient S/E of phototherapy weigh diaper 1gm = 1cc Head – largest part of baby ¼ of its length Craniostenosis or craniosinustosis – premature closing of fontanel Hydrocephalus – ant fontanel open after 18 mos Microcephaly – small growing brain due- alcohol & HIV mom Anencepahly – absence of cerebral hemisphere Craniotabes – localized softening cranial bone. Common – 1st born child -due early lightening (2 weeks prior to EDD) Rickets of Vit B deficiency – soft cranial bone in older children Caput Succedaneum – edema of scalp due prolonged pressure at birth Char: 1. present at birth 2. crosses suture lines 3. disappear after 2-3 days Cephalhematoma- collection of blood due to rapture of pericostal capillaries Char : 1. present after 24 h 2. never cross suture line 3. disappear after 4-6 weeks 4. monitor for developing jaundice Seborrheic Dermatitis – ‘craddle cap” Scaling, greasy appearing salmon colored patches – seen on scalp behind ears and umbilicus Cause: - improper hygiene Mgt: 1. proper hygiene 2. put oil night before shampoo - baby oil Hydrocephalus – excessive accumulation of CSF 1. communicating – extra ventricular hydrocephalus 2. non-communicating- intraventricular hydrocephalus or obstructive hydrocephalus due to tumor obstruction Sx – ICP – abnormally large head, bulging fontanel - cushings triad - high pitched cry older child – diplopia – eye deviation, projectile vomiting - fontanel bossing – prominent forehead 38

Mgt:

- prominent skull vein sunset eyes position to lessen ICP – low semi-fowlers 30 degree angle Administer- osmotic diuretic Mannitol/ Osmitrol , Diamex- Azetam Decrease CSF production Shunting – AV shunt or Vp shunt (ventriculoperitoneal shunt) Shave hair – in OR – to prevent growth of micro org.

Nsg Care: 1.) post VP shunt – side lying on non operated site - to prevent increase ICP monitor for good drainage - sign – sunken fontanel bulging fontanel – blocked shunt change fontanel as child is growing SENSES EYES: Assessment 1. check for symmetry 2. sclera – normal color – light blue then become dirty white pupil – round- adult size coloboma- part of iris is missing sign: key hole pupil whiteness & opacity of lens congenital cataract cornea – round & adult size large – congenital glaucoma Test for blindness common tests 1. newborn – general appearance - can only see 10 – 12 “ - visual acuity 20 /200 to 20/ 800 Doll’s eyes test- test for blindness - done 10th day - pupil goes opposite to direction when head is moved Globellars test – test for blink reflex. Points near nose – baby should blink 2. Infant & children - appearance - ability to follow object past midline 3. 3 yrs – school age - general appearance Allen cards – test for visual acuity. Show picture 20 ft away Ishiharas plates – test for color blindness Prechool E chart - test for stereopsi of depth perception Cover testing test – cover 1 eye for 10 – 15 min. Then remove. Test for strabismus 4. School age – adult 39

- general appearance - snellens test Retinobastoma – malignant tumor of retina Outstanding sign : oat’s eye reflex-whitish glow of pupil - red painful eye - blindness surgery – Enucliation – removal of eyeball put artificial aye NOSE: 1. flaring alenase – case of RDS 2. cyanosis at rest – choanal atresia - post nares obstructed with bone or membrane Sx: 1. resistance during catheter insertion 2. emer. Surgery within 24 h normal color nasal membrane – pinkish rhinitis – presence of creases & pale check sense of smell – blindfold – smell Hair in nose – cilia Adolescent no hair with ulceration of nasal mucosa suspect cocaine user Epistasis – nosebleed - sit upright, head slightly forward to facilitate drainage - cold compress , apply gentle pressure, epinephrine most developed sense of newborn – sense of touch 1st sense to develop & last to disappear – hearing EARS: 1. Properly aligned with outer cantus of eyes low set ear – kidney malformation ex. Renal aginesis – absence of kidney sign in uterus : oligohydramnios sign in newborn: 2 vessel cord failure to void within 24 h Mgt:

kidney transplant

Chromosomal aberrations : -advance maternal age 1. non disjunction – uneven division Trisomy 21 - down syndrome - extra chromosome 47xx + 21 - related to advance paternal age Sx: 40

Mongolian slant Broad flat nose Protruding neck Puppy’s neck Hypotonic – prone to resp problem Simean crease – single transverse line on palm. Trisomy 18 – “endvard syndrome” Trisomy 13- patau syndrome Turner – Monosomy of X synd. - 45x0 - affected girls - signs evident during puberty - has poorly developed 2dary sexual char. - Sterile Klinefelters Syndrome- has male genitalia - 47 XXY - poorly devt secpndary sexual characteristics - no deepening of voice -small testes, penis -sterile Klinefelter – Calvin Kline – male Turner – Tina Turner – female Otitis Media – inflammation of middle ear. Common children due to wider & shorter Eustachian tube Causes 1.) bottle propping 2.) Cleft lip/ cleft palate – Sx: Otitis 1. bulging tympanic membrane, color – pearly gray 2. absence light reflex 3. observe for passage of milky, purulent foul smelling odor discharge 4. observe for URTI Nsg Care: 1. position side lying on affected aside – to facilitate drainage 2. supportive care- bedrest, increase fld intake Med Mgt: 1. Massive dosage antibiotic Complication – bacterial meningitis 2. Apply ear ointment School age – up and down < 3 yo – down & back > 3 yo – up & back Small child – down & back ( no age) 41

surgery (to prevent permanent hearing loss)– otitis media – myringotmy with tympanostomy tube post surgery – position affected side for drainage both – put ear plug if tympanous tube falls – healed na Bells Palsy- facial nerve #7 paralysis R/T forcep delivery Sx. 1. Continuous drooling saliva 2. inability to open , eye & close either eye Mgt: Refer to PT TEF (Tracheoesophageal Fistula)-TEA- no connection bet esophagus and stomach Outstanding Sx –

Coughing Choking Continuous drooling Cyanosis

Mgt: Emergency surgery Epstein pearl – white glistering cyst at palate & gums related to hypercalcemia Hypervitaminosis Natal tooth – tooth at birth. Move with gauze Neonatal tooth – tooth within 28days of life Moniliasis – oral candidiasis - white cheese like, curd like patches that coats tongue - oral thrush - Nsg Care – don’t remove, wash with cold boiled H2o Meds – nystatin / Mysnastatin – antifungal Kawasaki Dse--strawberry tongue - originated in Korea - Dr. Kawasaki discovered it - common in Japan - “mucocutaneous Lymphnode Syndrome” Sx: -persistent fever – 5 days -strawberry tongue , -desquamation of palm & sole - lymph adenopathy > 1.5 cm Drug: aspirin Can lead to MI LIPS- symmetrical 42

Cleft lip – failure of median maxillary nasal process to fuse by 5-8 wks of pregnancy - common to boys - unilateral Cleft Palate- Failed palate to fuse by 9 – 12 wks of pregnancy - common to girls - unilateral or bilateral Sx: 1. evident at birth 2. milk escapes to nostril during feeding 3. frequent colic & otitis media or URTI Mgt: 1. Surgery cleft lip repair – Cheiloplasty =done 1-3 months to save sucking reflex (lost in 6 months ) Cleft Palate- uranoplasty = done 4-6 months to save speech Pre op care 1. emotional support especially to mom 2. proper nutrition 3. prevent colic feed – upright seating or prone pos burp frequently 2x at middle and after feeding-lower to upper tap 4. orient parents to type of feeding rubber tipped syringe – cheiloplasty paper cup/ soup spoon/ plastic cup – urano plasty 5. apply restraints – elbow restraints so baby can adjust post op Condition that warrants suspension of operation - colds & pharyngitis = can lead to generalized infection – septicemia Post Op Nsg Care : 1. airway – positon post cheilopasty – side lying for drainage post uranoplasty (tonsillectomy)- prone 2. assess for RDS sx bleeding 3. assess for bleeding – freq swallowing. 6-7 days after surgery – bleeding 4. proper nutrition - clear liquids- ( gelatin except red or brown color due may mask bleeding) - ( popsicle- not ice cream) full liquid soft diet regular diet 5. Maintain integrity of suture line such as: Logan bar – wash ½ strength Hydrogen Peroxide & saline solution- Bubbling effect 43

traps microorganism - prevent baby form crying for pain- analgesic

NECK1.) check symmetry Congenital torticolis- “ wryneck”-burn injury of sternocleidomsstoid muscle during delivery – due to excessive traction at cephalic delivery Mgt: passive stretching exercise , Surgery Complication – scoliosis THYROID gland – for basal metabolism Congenial cretinism – absence or non functioning thyroid glands reasons for delaying dx: 1. Thyroid glands covered by sternocleidomastoid muscles in newborn 2. baby received maternal thyroxine 3. baby sleeps 16 – 20 h a day earliest sign: 1. change in crying 2. change in sucking 3. sleep excessively 4. constipation 5. edema – moon face late sign 1. mental retardation prognosis : mental retardation preventable when Dx is early Dx: 1. PPI-protein 2. radioimmunoassay test 3. radioactive iodine uptake Mgt: synthroid – sodium Levothyrosine -synthetic thyroid given lifetime - check pulse rate before giving synthroid - tachycardia – Sx of hyperthyroidism CHEST 1. 2. 3. 4.

symmetry breast - transparent fluid coming out from newborn related to hormonal changeschest has retroactive – RDS sternum sunken – pectus excavation

ABDOMEN (in order) 1. inspection I 44

2. Auscultation A 3. percussion P 4. Palpation P = Will change bowel sounds, so do last Normal contour of abd – slightly protruding Sunken abd- diaphramatic hernia – protrusion of stomach content through a defective diaphragm due to failure of puroperitoneal canal to close. Sx: 1. sunken abd 2. Sx of RDS 3. R to L shunting Mgt: Emergency surgery within 24h Omphalocele – protrusion of stomach contents in between junction of abd wall and umbilicus. Mgt- very small surgery If large – suspension surgery Nsg Mgt: protect sac- sterile wet dressing Gastrochisis – absence of abd wall Nsg Mgt: sterile wet dressing Fx of GIT 1. assists in maintaining F&E & acid base balance 2. Processes & absorbs nutrients to maintain metabolism & support G & D 3. excrete waste products from digestive process Recommended Daily Allowance Calories : 120 cal / Kbw/day (kilo body wt) 360 – 380 cal/ day CHON_ 2.2g /Kbw/day Principles in Supplementary Feeding Supplementary Feeding usually – 6 mos Supplementary feeding given – 4 mos. a.) solid food offered to ff sequence! 1. cereals – rich in iron 2. fruits 3. veg 4. meat b.) begin with small quantities c,) finger foods – offered 6 months d.) soft table food – “modified family menu” given 1 yr 45

e.) dilute fruit juices – 6 mos f.) never give half cooked eggs – usually causes of salmoneliosis g.) don’t give honey – infant botulism h.) offered new food one at a time – interval of 4 – 7days or 1 week – determines food allergens Total Body Fluids- comprises 65 - 85% of body wt of infants & children Where fluids are greater in infants Extracellular fld – prone to develop dehydration Acid Base Balance dependent on the ff: a. chemical buffers b. renal & resp system involvement c. dilution of strong acids and bases in bld Resp Acidosis – carbonic acid excess - hypoventilation - RDS - COPD - Laryngotracheobronchitis (LTB) Resp Alkalosis – carbonic acid deficit - hyperventilation - fever - encephalopathy Met. Acidosis – base HCO3 deficit - diarrhea - severe dehydration - malnutrition - ciliac crisis Met Alkalosis – base HCO3 excess - uncontrolled vomiting - NGT aspiration - Gastric lavage PROBLEMS LEADIING TO F&E IMBALANCE 1. vomiting – forceful expulsion of stomach content Sx: 1. nausea 2. dizziness 3. facial flushing 4. abd cramping assess:

amt, freq, force projectile vomiting= increase ICP or pyloric stenosis

Mgt:

BRAT diet - banana, rice – cereal, apple sauce, toast

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2. Diarrhea – exaggerated excretion of intestinal contents Types: Acute diarrhea – related to gastroenteritis, salmoneliosis - dietary indiscretions - antibiotic use Chronic non specific diarrhea Cause: 1. food intolerance 2. excessive fld intake 3. CHO, CHON malabsorption Assess: freq, consistency, appearance of given colored stool. Best criteria to determine diarrhea : consistency Complication = dehydration Mild dehydration 5% wt loss Moderate dehydration 10% wt loss Severe dehydration 15 % wt loss Earliest sx of dehydration tachycardia increase temp tachypnea sunken fontanel & eyeballs hypotension absence of tears

weight loss scanty urine

Severe dehydration: Oliguria , Prolonged capillary refill time Mgt: Acute – NPO ( rest the bowel ) - with fluid replacement – IV - prone to Hypokalemia – give K chloride before adm of K chloride – check if baby can void, if cant void – hypokalemia Drug: Na HCO3 – adm slowly to prevent cardiac overload

Gastric Motility Disorder: HIRSCHPRUNGS DISEASE – congenital aganglionic megacolon Aganglionic – absence of ganglion cells needed for peristalis Earliest sign 1. failure to pass mecomium after 24h 2. abd distension 3. vomitus of fecal material early childhood – ribbon like stool foul smelling stool 47

constipations diarrhea Dx: 1. 2. 3. 4.

Barium enema – reveals narrowed portion of bowel Rectal Biopsy – reveals absence of ganglionic cells abd x-ray – reveals dilated loops on intestine rectal manometry – revels failure of intestine sphincter to relax

Therapeutic Mgt/Nsg care 1. NGT feeding – measure tube fr nose to ear to midline of xyphoid & umbilicus 2. surgery a.) temp colostomy b.) anastomosis & pull through procedure Diet: Increase CHON, increase calories , decrease residue – pasta GER- Gastroesophageal Reflux Chalasia – presence of stomach contents to esophagus Will lead to esophagitis complication – aspiration pneumonia Esophageal cancer Assessment : 1. chronic vomiting 2. faiture to thrive syndrome 3. organic – organ affected 4. melena or hematemesis – esophageal bleeding Dx procedure 1. barium esophogram – reveals reflux 2. esophageal manometry – reveals lower esophageal sphincter pressure 3. intra esophageal pH content – reveals pH of distal esophagus. Meds of GERD Anti-cholinergic a.) Betanicol ( urecholine) – increase esophageal tone & peristaltic activity b.) Metachloporomide (Reglam) – decrease esophageal pressure by relaxing pyloric & duodenal segments - increase peristalsis without stimulating secretions c.) H2 Histamine Receptor Antagonist – decrease gastric acidity & pepsin secretion - Zimetidine, Ranitidine (Zantac) – take 30 min before meals d.) antacid – neutralizes gastric acid between feedings - Maalox Surgery: Nissen funduplication : Chronic vomiting – - thickened feeding with baby cereals - effective if without vomiting - feed slowly, burp often every 1 ounce - positioning < 9 months – infant sit with infant supine 48

> 9 months – prone with head of mattress slightly elevated 30 degree angle OBSTRUCTIVE DISORDERS A. PYLORIC STENOSIS – hypertrophy of muscles of pylorus causing narrowing & obstruction. 1.) outstanding Sx- projectile vomiting - vomiting is an initial sx of upper GI obstruction - vomitus of upper GI can be blood tinged not bile streaked. (with blood) - vomitus of lower GI is bilous ( with pupu) - projectile vomiting – increase ICP or GI obstruction - abd distension – major sx of lower GIT obst 2.) met alk 3.) failure to gain wt 4.) olive shaped mass – on palpation 5.)serum electrolyte – increase Na & K, decrease chloride 6.) ultrasound 7.) x ray of upper abd with barium swallow reveal “string sign” Mgt: 1. Pyleromyotomy 2. Fredet Ramstedt procedure INSTUSSUSCEPTION- invagination or telescoping of position of bowel to another Common site – ilio-secal junction Prone pt: person who eats fat Complication – peritonitis – emergency Sx: 1.) persistent paroxysmal abd pain 2.) vomiting 3.) currant jelly stool- dye bleeding & inflammation - palpate sausage shaped mass Mgt: 1.) Hydrostatic reduction with barium enema 2.) Anastomosis & pull thru procedura

Inborn Errors of Metabolism- deficient liver enzymes PHENYLKETONURIA (PKU) – deficiency of liver enzymes (PHT) Phenylalaninehydroxylase Transferase – liver enzyme that converts CHON to amino acid 9 amino acids: valine isolensine tryptophase lysine phenylalanine Thyronine – decrease malanine production 49

1.) fair complexion 2.) blond hair 3.) blue eyes Thyroxine – decrease basal metabolism - accumulation of Phenyl Pyruvic acid 4.) Atopic dermatitis 5.) musty / mousy odor urine 6.) seizure – mental retardation Test – GUTHRIE TEST – specimen – blood - preparation increase CHON intake - test if CHON will convert to amino acid specimen and urine mixed with pheric chloride, presence of green spots at diaper a sign of PKU DIET: Low phenylalanine diet- food contraindicated- meats, chicken, milk, legumes, cheese, peanuts Give Lofenalac- milk with synthetic protein Galactosemia – deficiency of liver enzyme - GUPT – Galactose Urovil Phosphatetranferase - Converts galactose to phosphate tranferace glucose Galactose – will destroy brain cells if untreated – death within 3 days Dx: Beutler test – get blood -done after 1st feeding presence of glucose in blood – sign of galactosemia galactose free diet lifetime neutramigen – milk formula CELIAC DISEASE – gluten enteropathy Common gluten food: Intolerance to food with brow B- barley R- rye O- oat W- wheat

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Gluten – glutamine ( normal absorption)

Gliadin ( toxic to epithelial cells of villi of intestines, effects is malabsorption syndrome)

Malabsorption

CHON & CHO peripheral edema & malnutrition

Fats

Vit D calcium

Vit K

Iron folic acid

Inadequate blood

coagulation Steatorrhea

Osteomalasia

Bleedin

anemia

gg

Early Sx: 1. diarrhea – failure to gain wt ff diarrheal episodes 2. constipation 3. vomiting Late Sx: 1. abd pain – protruberant abd even if with muscle wasting 2. steatorrhea Celiac Crisis- exaggerated vomiting with bowel inflammation Dx: 1. lab studies – stool analysis 2. serum antiglyadin – confirmatory of disease gluten free diet – lifetime all BROW – not allowed ok – rice & corn Mgt: 1. vitamin supplements 2. mineral supplements 3. steroids

POISONING- common in toddlers. (falls- common to infant) 1. determine substance taken, assess LOC 51

2. unless poison is corrosive, caustic (strong alkali such as lye) or a hydrocarbon, vomiting is the most effective way to remove poison. - Give syrup 1 pecac to induce vomiting 3. 1 pecac – oral emetic - 15 ml – adolescent, school age & pre school - 10 ml to infant 4. UNIVERSAL ANTIDOTE- charcoal, milk of magnesia & burned toast 5. Never adm charcoal before 1 pecac 6. antidote for acetaminophen poisoning – acetylsysterine ( mucomyst) 7. caustic poisoning ( muriatic acid ) neutralize acid by giving vinegar . Don’t vomit prepare tracheostomy set 8. Gas- mineral oil will coat intestine Lead poisoning Lead = Destroy RBC functioning = Hypochornic Microcytic Anemia = Destroy kidney functioning Accumulation of anemia = Encepalopathy Sx: 1. beginning sx of lethargy 2. impulsiveness, learning difficulties 3. as lead increases, severe encepalopathy with seizure and permanent mental retardation Dx: 1. 2. 3. Mgt: 1. 2.

Blood smear abd x ray long bones remove child from source if > 20 ug/dL – need chelation therapy = binds with led & excreted by kidney =nephrotoxic

Amogenital Female: Pseudomenstration slight bleeding on vagina related to hormonal changes Tearing of fourchette with blood – rape/ child abuse Rape- Report within 48 h Shape pubic hair in inverted triangle ( female) Male: Undescended testes – cyrptorchidism -common to preterm surgery – orchidopexy assess scrotum- warm room & hands

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baby – pee within 24 h -check for arch of urination Epispadias- urinary meatus located dorsal or above glans penis Hypospadias- urinary meauts loc ventral or below glans penis Hypospadias with chordee- fibrous band causing penis to curb downward Mgt: Surgery Phimosis- tight foreskin Balanitis-infection of glands penis – due smegma Mgt: Circusicion Hydroseal – fld filled scrotum Tst of Dx: Transillumination with use of flashlight - glowing sign Varicoseal – enlarged vein of epididimis ( girls- vulvular varicosities)

Renal Disorder NEPHROTIC SYNDROME

Cause infectious

AGN ( acute Glomerulo Nephritis)

Autoimmune Grp A beta hemolytic streptococcus

3A’s; AGN, autoimmune, Grp A

Sx 1. Anasarca- gen edema 2. massive protenuria 3. microscopic or no hematuria 4. serum CHON decreased 5. serum lipid increased 6. fatigue 7. normal or decreased BP 1. (PPP) primary peripheral periobital edema 2. moderate protenuria 3. gross hematuria ( smokey urine)

Tx Prednisone Diuretic

NSG CARE Focus of care: monitor edema - weigh daily Diet: Increase CHON Increase K- OJ, beef broth, banana Decrease Na

1. anti HPN drug - hydralazine or apresoline 2. iron

1. weigh daily 2. monitor BP & neurologiuc status 3. Diet: decrease K, decrease Na

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4. serum K increased 5. fatigue 6. increase BP Complication : 1. hypersensive encephalopathy 2. anemia BACK- check for flatness & symmetry Open Neural Tube Defect- decreased Folic Acid intake SPINA BIFIDA OCCULTA- failure of post laminae of vertebrae to fuse Sx: dimpling of back , Abnormal tufts of hair SPINA BIFIDA CYSTICA- failure of post laminae of vertebrae to fuse with a sac Types: 1. Meningocele – protrusion of CSF & Meninges 2. Myelomeningocele – protrusion of CSF & Meninges & spinal cord ( most dangerous) 3. Encephalocele ( CNS complication – hydrocephalus) – cranial meningocele or myelomeningocele Most common problem - rupture of sac - prone pos - sterile wet dressing Most common complication - infection Myelomeningocele – genitourinary complication- urinary & fecal incontinence Nsg care: always check diaper Orthopedic complication – paralysis of lower extremities Surgery to prevent infection Post op – prone position SCOLIOSIS- lateral curvature of the spine 2 types: 1. structural – rye neck 2. postural – improper posture Dx: 1. uneven hemline 2. bend forward- 1 hip higher 1 shoulder blade more prominent Nsg care: 1. conservative – avoid obesity, exercise 2. preventive – Milwaukee brace - worn 23 h a day 54

3. corrective surgery – insert Harrington rod post op- how to move log rolling- move client as 1 unit EXTREMITIES: check # of digits = 20 1. syndactyly – webbing of digits 2. polydactyly – extra digits 3. olidactyly – lack of digits 4. Amelia – total absence of digits 5. pocoamelia- absence of distal part of extremities ErQ duchennes – paralysis- brachial plexus injury or brachial palsy - birth injury caused by lateral & excessive traction during a breech injury Sx: 1. unable to abduct arms from shoulders, rotate arm externally or supinate forearm 2. absence or asymetrical moro reflex Mgt: 1. abduct arm from shoulders with elbow flex. CONGENITAL HIP DISLOCATION – head of femur is outside acetabulum Types; 1. subluxated – most common type 2. dislocated Sx: 1. shortening of affected leg 2. asymmetrical gluteal fold 3. limited movement – earliest sx 4. (+) ortolanis sign – abnormal clicking sound 5. when able to walk – child limps – late sx- trendelenburg sign Goal of Mgt: Facilitate abduction Mgt. 1. triple diaper 2. carry baby astride 3. Frejka splint 4. Pavlik harness 5. Hip Spica Cast TALIPES – “clubfoot” a.) Equinos – plantar flexion – horsefoot b.) Calcaneous – dorsiflexion – heal lower that foot anterior posterior of foot flexed towards anterior leg c.) Varus- foot turns in d.) Valgus- foot turns out 55

Equino varus- most common Assessment: 1. Straighten legs & flexing them at midline pos Mgt: 1. Corrective shoe- Dennis brown shoe, spica cast Fx: of cast – - to immobilize - bone alignment - prevent muscle spasm lead pencil – mark area to be amputated cold H20 – hasten setting process hot H20- slow setting process After cast application – how to move pt: - use open palm not fingers- fingers will cause indention - dry cast – natural air not blower - priority check : neurovascular check C- circulation M- motion S- sensation Cast – with bleeding - mask with ball pen edge of blood to know if bleeding is on going sign cast is dry = resonant sound, cast cold to touch -do petaline – making rough surface of cast smooth CRUTCHES Fx: To maintain balance - To support weakened leg Principles in crutches - wt of body on palm! - Brachial pulsing – if wt of body in axila - Do palm exercise- squeeze ball Different crutch Gaits: 1. Swing Through 2. Swing to - no weight bearing are allowed into lower ext 3. Three point Gait - wt bearing is allowed in 1 ext 4. Four point gait 5. Two point Gait - wt bearing allowed in 2 lower ext

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