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”/mo during 1st 6 months- average increase in ht - 1st year = 50%

stoppage of ht 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 DDST1. Language communication2. personal social-interaction3. fine motor adaptive- ability to use hand movement4. 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 = IQChronological age

Average IQ – 90-100Gifted child- > 130 IQ

Basic Divisions of LifeI. Prenatal stage from conception- birth

II. Period of infancy1. Neonatal- 1st 28 days or 1st 4 weeks of life2. Formal infancy- 29 day – 1 year

III. Early childhood 1. Toddler – 1-3 yrs2. Pre school 4-6 years

IV. Middle childhood1. School age- 7 – 12 yrs

1

V. Late childhood1. Pre adolescent 11 – 13 yrs2. Adolescent 12 - 18 – 21

Principles of G & D 1. G&D is a continuous process-begins form conception- ends in death- womb to tomb principles2. not all parts of the body grow at the same time or at same rate.- asynchronism

Patterns of G&D 1. )renal digestive grows rapidly during childhoodcirculatory musculoskeletal

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 period4. Toddler and preschool- alternating rapid and slow5. 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 – intelligenceS – sexN - nationality

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

B. EnvironmentQ – quality of nutritionS – socio eco. status H – healthO – ordinal pos in family P – parent child relationship

Eldest- skillful in language and social skillsYounger- toilet trained self

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

2

Directional trends- occur in a regular direction reflecting the development of neuromuscular function. These apply to physical, mental, social and emotional development and includes.

a. cephalo-caudal “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. b. proximo- distal “Centro distal” - progressing form center of body to extremities. c. Symmetrical- at side of body develop on same direction at same time at same rate. d. 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.

B. Sequential- involves a predictable sequence of G&D to which the child no9rmally passes. a. locomotion- creep than crawls, sit then stand. b. socio and language skills- solitary games, parallel games

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

5.Behavioral in the most compressive indicator of developmental status. 6. universal language of child- play7. great deal of skill and behavior is learned by practice. Practice makes perfect.9. neonatal reflexes us 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

Theories of G&D Developmental tasks- different form chronological age-skill or growth responsibility arising at a particular time in the individuals life.The successful achievement of which will ------- a foundation for the accomplishments of future tasks.

Theorists 1. Sigmund Freud 1856-1939 Austrian neurologists. Founder of psychoanalysis- offered personality developmentPsychosexual theory

a.) Oral Phase 0-18 months- mouths 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, meticulousOC-anal phase-help child achieve bowel and bladder control even if child is hospitalized.

c.) Phallic- 3-6 yearssite of gratification -genitalsactivity- may show exhibitionism-increase knowledge of a sexes-accept child fondling his/her own genitalia as normal exploration

3

-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.

ERIC ERICKSON- psychoanalysis theory - stresses important of culture and society to the development of ones personality- environment - culture

stages of psychosociala.) trust vs mistrust – 0-18 months .-foundations of all psychosocial task -to give and receive is the psychosocial theme-know to develop trust baby1. satisfy needs on time- breastfeed2. care must be consistent and adequate-both parents- 1st 1 year of life3.) give an experience that will add to security- touch, eye to eye contact, soft music.

b.) Autonomy vs shame and doubt 18-3 years --- independence /self gov’t develop autonomy on toddler1. give an opportunity of decision making like offer choices.2. encourage to make decision rather then judge.3. set limits

c. initiative vs guilt- 4-6 years-learns how to do basic things-let explore new places and events -activity 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 vs role 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 form 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

4

JEAN PIAGET- Swiss psychologists -develop reasoning power

STAGES OF COGNITIVE DEVELOPMENTA-Sensory motor 0-2 yrs-“practical intelligence”- words and symbols not yet available baby communicates through senses and reflexes. (sub div.)

Schema Age Behavior1.) neonate reflex 1 month All reflexes2.) primary circular 1-4 months -Activity related to body

-repetition of behaviorex. thumb sucking

3.) secondary circular reaction 4-8 months -activity not related to body-discover obj and person’s permanence-memory traces present-anticipate familiar events.

Coordination of secondary reaction 8-12 months

-exhibit goal directed behavior-increase of separateness (will search of lost toy, knows mom)

Tertiary circular reaction 12-18 months

-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)

Invention of new means there mental combination

18-24 months

-transitional phase to the pre operational thought period.

Preoperational thought 2-7 years

Schema age BehaviorPreconceptual 2-4

yrs-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

Initiative 4-7 yrs

Beginning of causation

Concrete Operational thought 7-12 years1. able to find solution to everyday problems which systematic reasoning. 2. have concept of reversibility- cause and effect 3. have concept of longer uation – constancy despite of transformation.4. 4. activity recommended- collecting and classifying 5. –stamps stationeries, dolls, rubber band markers.

Formal Operational thought 12 and up.1. Cognition achieved its final form2. can deal with past present and future3. have abstract and mature thoughts.4. can find solutions to hypothetical problems with scientific reasoning.5. activity ------- will sort out opinions and current events.

5

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’tInfancy – premoral, prereligious, amoral stage

AGE STAGE DESCRIPTIONPre-conventional Level 12-3 yrs 1 -Punishment/ obedience oriented (heteronymous morality) child does

right cause a parent tells him or her to and to avoid punishment4-7 2 -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 Level7-10 3 -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.

10-12 4 -Maintenance of social order fixed rules and authority. Child finds ff. rules satisfying. Follows rules of authority figures.

Post-conventional Level IIIAbove 12 yrs 5 -Social contract, utilitarian level making perspectives. Followers

standards of society.6 Universal ethical principle orientation. Follows internalized standards

of conduct.

E. DEV’T MILESTONES-major markers of growth and dev’t1. 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

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 pronefollows obj. past midlinegrasp and tonic neck reflex fading hand regard (looks at hand)

4 months – turns form front to back head control completeneeds space to turnLaugh aloud, bubbling sounds

5 months- turn both ways “roll over”-teething rings-handles rattle well

6

-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”- 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-drink from cup, cooperate in dressing-says 2 words mama and dada-pots and pans, pull tay, nursery rhymes

Toddler- parallel play - 2 toddlers playing separately -provide with similar toys-squeaky frog to squeezewaddling duck to pull trucks to push-push pull toy building blocks, pounding peg toys to ride onfear- separation anxietybegin 9 monthspeak 18 months

3 phases of separation anxiety (in order)1. P- protect2. d despair3. d- denial

-don’t prolong goodbye-say goodbye firmly to develop trust- say when ul be back

7

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 possessivenessfavorite word- “mine”bowel control achieved (bowel 1st before bladder)-no longer rotates spoon-can run and jump in placewalks 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)

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 toddlernegativistic- “NO!” -way to search for independence

–limit questions–modify questions to a statement

2.) rigid, ritualistic and stereotyperitualism- for mastering

3.)Temper tantrums- head banging, screaming, stamping feet, holds breath –ignore behavior

8

scaffoid abdominal-due to underdeveloped abdominal muscles physiologic anorexia- due to preoccupation with environment- food jag that last for short period of time loves rough and tumbling playloves toilet training- failure of toilet training- unreadiness

Clues of toilet readiness:1.) can stand, squat walk alone2.) can communicate toilet needs3.) can maintain dry for 2 hours

Pre schoolers- associative or cooperative play1.) bahay-bahayan – play house2.) role playing3.) fear-body mutilation or castration

fear of dark places witchesfear of thunder and lightningfear of ghosts

Milestones4years 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:1.) curious, creative imaginative, imitative2.) 2. favorite words- why and how3.) complexes- word identification to parent of same sex and attachment to parent of

opposite sexex. Oedipal complex- boy to mom Electra complex- girl to dad

Cause of incest marital discord

Death-sleep only

Behavior problems Preschool

1. telling tall tales-over imagination2. 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

9

School AgePlay- competitive playEx. Tug of war, track and field, basket ball

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 Developmenta. boys- prone to bone fractureb. mature vision 20/20

6 years- temp teeth begin to fallperm teeth appear- 1st molar1st temp teeth- 5 months1st perm teeth- 6 yrs-yr of constant motionclensy mou’trecognize 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-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

10

-sense of humor present-social and cooperative

Character Traits School Age1. industrious-2. modest3. can’t bear to lose- will cheat4. love collections- stamps

Signs of sexual maturityGIRLS:I-inc size breast and genitalia (pelarche- 1st sign sexual mat.W- widening of hipsA- appearance axillary, pubic ( adrenarch)M- menarche- last sign sexual mat. Girls

BOYS:A-appearance axillary, pubic hair ( 1st sign sexual mat)D-deepening voiceD- development of musclesI--inc in testes and penis sizeP- prod of viable sperm ( last sign sexual maturity)

Adolescent Fear

1. obesity2. acne3. homosexuality4. death5. replacement from friends 6. significant person- opp sex.

Significant dev’t 1. experiences conflict bet his needs for sexual satisfaction and societies expectation2. change of body image and acceptance of opp/sex3. nocturnal emission – wet dreams4. distinctive odor- due to stimulation apocrine glands 5. sperm is viable by 17 yrs6. testes & scrotum increase until age 177. breast and female genitalia increase until age 18

Personality Traits Adolescents1. idealistic2. rebellious3. reformers4. conscious with body image5. adventuresome

Problems:1. vehicular accident2. smoking3. alcoholism4. drug addiction5. pre marital sex

11

IMMEDIATE CARE OF NEWBORN 1st days of life

1. initiation and maintenance of respiration2. establishment of extra uterine circulation3. control of body temp4. intake of adequate nourishment5. establishment of waste elimination6. prevention of infection7. establishment of an infant parent relationship8. dev’t care that balances rest and stimulation or mental dev’t

1.) Initiation and maintenance of respiration 2nd stage of labor- initial airway-initiation of a /w is a crucial adjustment-most neonatal deaths with in 24 h caused by inability to initiate a/w -lung function begins after birth only

How to initiate a/w a.) remove secretions bulb syringe

B. Catheter Suctioning1.) place head to side to facilitate drainage 2,) suction mouth 1 st before nose

-neonates are nasal breathers3.) period of time

-5-10 sec suctioning, gentle and quickprolonged and deep suctioning can lead to hypoxia, laryngo spasm, brady cardia due to stimulation vagal nerve

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 smoking2. Always humidify to prevent drying of mucosa3. 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)

2.) 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 liver-ductus 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.

12

SHUNTS-shortcutsDuctus venosus- -shunts from liver to IVF Foramen ovale- shunts bet 2 atriasDuctus arteriosus- from pulmonary artery to aorta

What will sustain 1st breath- decreased artery pressureWhat will initiate lung circulation-lung expansionWhat will complete circulation- cutting of cord

4.) 2 way to facilitate closure of foramen ovalea.) Tangential Footstep- slap foot of baby

-never stimulate baby to cry if secretions not fully drained to prevent aspiration -check characteristic of crynormal cry- strong, vigorous and lusty crycri-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

Decrease PO2, increase PCO2 acidosis

Will cause 1st breath /cry of baby

Decrease pulmo artery pressure

Increase PO2 Decrease blood flow

Increase pressure to Lt side of heart

Closure of ductus

arteriosus

Closure of ductus venosus

& AVA

Closure of foramen ovale

13

Obliteration-complete closure

Structure Appropriate time of obliteration

Structure remaining Failure to close

F. Ovale 1yr Fossa Ovalis Atrial Septal DefectDuctus Arteriosus

1 month Ligamentum Arteriosum Patent ductus arteriosus

Ductus Venosus

2 months Ligamentum venosum

Umbilical artery

2-3 months 1.) lateral umb. Ligament2.) interior iliac artery

Umbilical vein 2-3 months -ligamentum teres ( round ligament of liver)

Position of infant immediately after birth:NSD-trendelenberg/ T position for drainagecontraindication of trendelenberg position - increase ICPCS- supine or crib level position

Signs of increased ICP1.) abnormally large head2.) bulging and tense fontanel3.) increase BP and widening pulse pressure #3 & #4 are Cushings triad of 4.) Decreased RR, decreased PR ICP5.) projective vomiting- sure sign of cerebral irritation6.) 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

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 HYPOTHERMIA1. preterms are born poi kilo thermic- cold blooded- babies easily adapt to temp of environment due to immaturity of thermo regulating system of

body. Hypothalamus2. inadequate SQ tissue3. baby is not capable of shivering4. babies are born wet

PROCESS OF HEAT LOSS1. evaporation- body to air (TSB)2. conduction- body to cold solid object (cold compress)3. convection- body to cooler surrounding air (aircon)4. radiation- body 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- borderline2.) met acidosis- catabolism of brown fats (best insulator of newborns body) will form ketones3.) high risk for kernicterus- bilirubin in brain leading to cerebral palsy4.) additional fatigue to allergy stressful heart

14

To Prevent Hypothermia1. dry and wrap baby2. mechanical pressure – radiant warmer

i. pre-heated first isolette (or square acrylic sided incubator) 3. prevent an necessary exposure – cover baby4. cover baby with tin foil or plastic5. embrace the baby- kangaroo care

A. Establish Adequate Nutritional Intake

CS- breastfeeding after 4 hoursNSD- breastfeeding asap

Physiology breast milk productionAs 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 post-pit.gland

Sucking- PPG – oxytocin – contraction of lactiferous tubules - milk ejection reflex- let down reflex.

Advantages of Breastfeeding1. Economical2. Always available3. Breastfed babies have higher IQ than bottle fed babies.4. It facilitates rapid involution5. Decrease incidence of breast cancer.6. Has antibodies- IgA7. Has lactobacillius bifidus- interferes with attack of pathogenic bacteria in GIT8. Has macrophages

Store milk- plastic storage containerStore 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 iron3. 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 dayscontent: inc lactose, inc water soluble vit., inc minerals

3. Mature milk- 14 & upcontent: 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 LACTOSEDecrease CHON- lactalbumin

Cows milk – inc fats- Dec 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

15

Caked colostrum- dry milk on breast2. 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.

Criteria Effective Suckinga.) Baby’s mouth is hiked up to areolab.) 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 partuma.)Engorged- feeling of fullness & tension in breast. - sometimes accompanied by fever known as MILK FEVER.

Mgt: Warm compress- for breastfeeding momCold compress – for bottle feeding & wear supportive bra.

When is involution of breast- 4 weeks

b.) Sore nipple – cracked with painful nippleMgt: 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 aureusFactors:1. Improper breast emptying2. 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 metabolismErythrobastosis Fetalis – Rh incompatibility

16

Hydrops FetalisPhenylketonuriaGalactosemiaTay Sachs disease

5. Establish of waste eliminationA. Diff stools1. Meconium - physiologic stool- black green, sticky, tar like, odorless (Sterile intestine)

will pass with in 24 – 36 hrsfailure 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 stoolUnder phototherapy – bright greenMucus mixed with stool - milk allergyClay colored stool – obstruction to bile ductChalk clay stool – after barium enemaBlack stool – GIT bleeding (melena)Blood flecked stool - anal fissure. Currant jelly stool – instussusectionRibbon like stool – hirschsprung diseaseSteatorrhea stool – fatty, bulky foul smelling odor stool

- malabasorption syndrome ( celiac disease or cystic fibrosis)Cult blood – stool exam

III Assessment for Well–beingAPGAR SCORE – Dr. Virginia ApgarSpecial Considerations: 1st 1 min – determine general condition of baby

Next 5 min- determine baby’s capabilities to adjust extra uterinelyNext 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 toneR – respiration

Baby cry – within 30 secsFailure to cry after 30 secs – asphyxia near the neatorum

Resp. depression – due mom given Demerol. Administer Naloxone

17

APGAR Scoring Chart:

0 1 2HR -absent <100 >100Resp effort -absent - slow, irreg,

weak-good strong cry

Muscle tone - flaccid extremities - some flexion - well flexedReflex irritabilityCatheter - no response - grimace - cough, sneezeTangential Footslap - NR - grimace - cryColor - blue/pale - acrocyanosis

(body- pink extremities-blue)

- pinkish

APGAR result0 – 3 = severely depressed, need CPR, admission NICU4 – 6 = moderately depressed, needs add’l suctioning & O27 - 10 =good/ healthy

CPR – cardio pulmonary resuscitation or CPRCardio pulmonary cerebral resuscitation (CPCR)

5 min no O2 – irreversible brain damage1. shake, no resp, call for help2. flat on head3. 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 & childinfant – puff

Circulation Check for pulslessness :carotid- adult

Brachial – infantsCPR – breathless/pulseless Compression – inf – 1 finger breath below nipple line or 2 finger breaths or thumb

CPR inf 1:5Adults 2:15

Assessment tool determines respiration of baby Silvermann Anderson Index

Respiration Evaluation – lowest score – bestCriteria 0 1 2

Chest movement synchronized Lag on respiration See - sawIntercostal retraction No retraction Just visible MarkedXiphoid retraction None Just visible Marked Nares dilatation None Minimal MarkedExpiratory grunt None Heard on stet only Heard on naked ear

Interpretation result:0 -3 – normal, no RDS

18

4 – 6 – moderate RDS7 – 10 – severe RDS

Assessment of Gestational Age -Ballards & Dobowitz

Findings Less 36 weeks (Preterm) 37 - 38 39 and upSole creases Anterior transverse crease

onlyOccasional creases 2/3 in

Covered with creases

Breast nodules 2mm 4mm or 3.5 mm > 5 or 7mmScalp hair Fine & fuzzy Fine & fuzzy Coarse & silkyEar lobe Pliable Some cartilage Thick cartilage Testes and Scrotum

testes in lower canalScrotum – small few rugae

Some intermediate Testes pendulus Scrotum full extensive rugae

Signs of Preterm BabiesBorn 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 sign- abundant lanugo-

Signs of Post term babies:> 42 weeks- classic sign – old man’s face- desquamation – peeling of skin- long brittle finger nails- wide & alert eyes

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 cmhead 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 caseosaFx of vernix caseosa

1. insulator2. 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 community1. clean hand2. clean cord3. clean surface

19

betadine or povidone iodine – to clean cordcheck 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 bloodbleeding 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

Credes Prophylaxis – Dr. Crede-prevent opthalmia neonatorum or gonorrheal conjunctivitis- how transmitted – mom with gonorrheadrug: erythromycin ophthalmic ointment- inner to outer

silver nitrate (used before) – 2 drops lower conjunctiva (not used now)

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 gmLow birth wt baby delivered < 2500gSmall for gestational age (SGA) < 10th % rank or born smallLarge for gestational age > 90th % rank or macrosomia >4000 gAppropriate for GA – within 2 standard deviation of mean Physiologic wt loss – 5 – 10% wt loss few days after birth

Small GA < (less) 10Large 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 area3. 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 anus1. atretic – no anal opening

20

2. agenetic – no anal opening3. stenos – has opening4. membranous – has opening

Earliest sign: 1. no mecomium2. abd destention3. foul odor breath4. vomitous of fecal matter5. can aspirate – resp problem

Mgt:Surgery with temporary colostomy

Cardiac rate: 120 – 160 bpm newborn Apical pulse – left lower nippleRadial pulse – normally absent. If present PDAFemoral pulse – normal present. If absent- COA - coartation of aorta

Congenital Heart DseCommon in girls – PDA, ASD atrial septal Common in boys – TOGA ( transportation of great arteries)

TA – tronchus arteriosus TOF – tetralogy of fallot

Causes: 1. familial2. exposure to rubella – 1st month 3. failure of strucute to progress

acyanotic L to Rcyanotic R – L

Acyanotic heart defects L to R1. ventricular septal defect - opening between 2 ventricles

S&Sx 1. systolic murmurs at lower border of sternum and no other significant sign 2. cardiac catheterization reveals increased o2 saturation @ R side of heart3. ECG reveals hypertrophy of R side of heart

Nsg Care:Cardiac catheterization: site – Rt femoral vein

1. NPO 6 hrs before procedure2. 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 endocarditis2.) open heart surgery-

2.) ASD – failure of foramen ovale to closeS&SX

1. systolic murmur @ upper border of sternum 2. result of cardiac catheterization & ECG same with VSD

Mgt: open heart surgery3.) endocardial cushion defects - atrium ventricular (AV) - affects both tricuspid and mitral valve

Dx – confirmed by cardiac catheterizationMgt: - open heart surgery

21

Antibiotics to prevent subacute bacterial endocarditis

4.) PDA - 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 PDA2. ligation of PDA by 3-4 yo3. thoracotomy procedure- nakadapa child

5.)Pulmunary Stenosis- narrowing of valve of pulmo arteryS &Sx: 1.) typical systolic ejection murmur

2. S2 sound widely split3. ECG- Lt ventricular hypertrophy

6.)Aortic Stenosis – narrowing of valve of aortaS & Sx: 1. inactive, sx sme with angina

2. typical murmur3. rough systolic sound and thrill4. ECG- Left ventricular hypertrophy

cardiac catheterization- Mgt Pulmo Stenosis & Aortic Stenosis

1.) balloon stenostomy2.) 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 hypertrophyMgt: - close heart surgery

8.) Coartation of Aorta – narrowing of arch of aorta outstanding Sx : absent femoral pulse

BP increased on upper extremities and decreased on lower extremities 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 saturationPalliative repair – rashkind procedure Complete repair – mustard repair

2.) Total Anomalous Pulmonary venous return – pulmo vein instead of entering Lt atrium, enters Rt atrium or SVCIncreased pressure on Rt so blood goes to Lft

Outstanding Sx: Open foramen ovale Mild to moderate cyanosis

Polycythemia = thrombus = embolus = stroke

22

asplenia- absent spleen Mgt: restructuring of heart

3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 1 single vessel or common trunk with VSDS & Sx 1. cyanosis

2. polycythemia – thrombus = embolus = stroke

Mgt: Heart transplant

4.) Hypoplastic Left heart syndrome – non fx Left ventricle1. cynosis2. polycythemia – throm, emb, strokeMgt: heart transplant

5.) Tricuspid atresia – failure of tricuspid valve to openS&SX: open foramen ovale

(R to L shunting – goes to Lt atrium) cynosis, polycythemia

Mgt: fontan procedure – open tricuspid valve

6.) Tetralogy of FallotP – pulmonary stenosisV – ventricular SDO – overriding or dextroposition of aortaR – Rt ventricular hypertrophy

S &Sx: 1. Rt ventricular hypertrophy 2. high degree of cyanosis3. polycythemia4. severe dyspnea – squatting position – relief , inhibit venous return facilitate lung expansion. 5. growth retardation – due no O26. tet spell or blue spells- short episodes of hypoxia7. syncope8. clubbing of fingernails – due to chronic tissue hypoxia9. mental retardation – due decreased O2 in brain 10. boot shaped heart – x-ray

Mgt: 1. O2 2. no valsalva maneuver , fiber diet laxative3. morphine – hypoxia4. propranolol – decrease heart spasms5. 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.

23

Jones Criteria

Major Minor1. polyarthritis – multi joint pain 1. arthralgia – joint pain2. chorea – sydenhamms chores or st. vetaus dance-purposeless involuntary hand and shoulder with grimace

2. low grade fever

3. carditis – tachycardia erythema marginatum - macular rashes SQ nodules

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

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

RespirationNewborn resp – 30-60 cpm, irregular abd or diaphramatic with short period of apnea without cyanosis.< 15 secs – normal apnea –newborn

Resp CheckNewborn – 40 – 901 yr - 20 – 40 2-3yr 20 – 30 5 yrs 20 – 2510 yrs 17 – 2215 & 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

24

Asthma- pathognomonic sign – expiratory wheezing Pet – fish. Sport – swimming Drugs – amynophylline – monitor bp, may lead to hypotension

Laryngo Tracheo Bronchitis LTB - inspiratory stridor – pathognomonic sign

RDS respiratory dist synd or hyaline membrane disCause- lack of surfactant – for lung expansion

Hypotonia, Post surgery, Common to preterm

Fibrine hyaline Sx – definite with in 1st of life

Increase RR with retractionInspiratory 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 suctioning4. o2 with increase humidity- to prevent drying of mucosa 5. monitor V/S skin color , ABG

6. CPAP- continuous + a/w pressure7. PEEP - + end expiratory pressurePurpose of #6-7- to maintain alveoli partially open and alveoli collapse

LARYNGOTRACHEOBRONCHITISLTB – most common Creup -viral infection of larynx, trachea & bronchioutstanding sx - croupy cough or barking pathognomonic - stridor- labored resp - resp acidosis- end stage – death

Lab:1. ABG 2. neck and throat culture3. 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 virusesSx: flu like sx Increased RRDrug: Antiviral – Ribavirin End stage – epiglotitis

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

25

< 5 yo – unable to cough out, put on mist tent (humidifier o2) or croupe tieNsg 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 yoCOA – take BP on 4 extremities

SKIN: AcrocyanosisBIRTHMARKS:

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 Hemangiomasa.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can be removed surgicallyb.) 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 Grey – infYellow – jaundice , carotene

Vernix Caseosa – white cheese like for lubrication, insulator

BURN TRAUMA – injury to body tissue caused by excessive heat.

INFANT 5-9 yoANTERIOR POSTERIOR Ant Post

Head 9.5 9.5 6.5 6.5Neck 1 1 1 1Upper arm 2 2 2 2Lower arm 1.5 1.5 1.5 1.5Hand 13 1.25 1.25 1.25Trunk 13 13Back 13 13Genital 1 1@ buttocks 2.5@ 2.5 @Thigh 2.75 2.75 4 4Leg 2.5 2.5 3 3foot 1.75 1.75 1.75 1.75

26

DEPTH1st degree – partial thickness – superficial epidermis - erythema, dryness, PAIN

-sunburn, heals by regeneration from 1 – 10 days 2nd degree – epidermis & dermis- erythema, blisters, moist, extremely painful

scalds3rd degree – full thickness- epidermis, dermis, adipose tissue, fascia, muscle & bone

lethargy, white or black, not painful – nerve endings destroyed ex. lava burns

Mgt: 1.) 1st aid 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 intubationc.) 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 painful6.) 1st defense of body – intact skin prevention of wound infection

a.) cleaning & debriding of woundb.) open or close method of wound carec.) whirlpool therapy – drum with solution

7.) skin grafting – 3rd degree – thigh or buttocks (autograft), pigs/ animals – xenograftfrozen 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

27

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 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 Dx- increase 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 healingc.) bone weakness & causes fracture

signs of bleeding a.) petecchiae-small, round, flat, dark red spot b.) epistaxisc.) 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:1. PBS- peripheral blood smear – determine immature RBC 2. CBC – determine anemia, leukocytosis, thrombocytopenia neutropenia

28

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 CHEMOTHERAPHY1. induction – goal of tx; to achieve remission meds: IV vincristine

L- agpariginase Oral predinisone

2. Sanctuary- treat leukemic cells that invaded testes & CNSgive: methotrixate- adm intrathecally via CNS or spinecytocine, 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:Alopecia – altered body image Hirsutism – hair

-give emotional support to parents

ABO incompatibility – Most common incompatibility – ( mom) O – ( fetus) AMost severe incompatibility (Mom) O– (Fetus) BCan affect 1st pregnancy

29

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 palsy-

Physiologic 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 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 fontanelHydrocephalus – ant fontanel open after 18 mos Microcephaly – small growing brain due- alcohol & HIV momAnencepahly – 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 birth2. crosses suture lines 3. disappear after 2-3 days

30

Cephalhematoma- collection of blood due to rapture of pericostal capillaries Char :

1. present after 24 h2. 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 hygieneMgt:

1. proper hygiene2. put oil night before shampoo - baby oil

Hydrocephalus – excessive accumulation of CSF1. communicating – extra ventricular hydrocephalus2. 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 - - prominent skull vein - sunset eyes

Mgt: position to lessen ICP – low semi-fowlers 30 degree angleAdminister- osmotic diuretic Mannitol/ Osmitrol , Diamex- AzetamDecrease 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 pupilwhiteness & opacity of lens congenital cataract cornea – round & adult size

large – congenital glaucoma

Test for blindness common tests1. 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

31

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 - 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 : oligohydramniossign in newborn: 2 vessel cordfailure to void within 24 h

Mgt: kidney transplant

32

Chromosomal aberrations : -advance maternal age 1. non disjunction – uneven division

Trisomy 21 - down syndrome - extra chromosome 47xx + 21 - related to advance paternal age

Sx: Mongolian slantBroad flat nose Protruding neck Puppy’s neck Hypotonic – prone to resp problemSimean 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 – maleTurner – 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: Otitis1. 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)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.

33

1. Continuous drooling saliva 2. inability to open , eye & close either eye

Mgt:Refer to PTTEF (Tracheoesophageal Fistula)-TEA- no connection bet esophagus and stomach

Outstanding Sx – Coughing Choking Continuous droolingCyanosis

Mgt:Emergency surgery

Epstein pearl – white glistering cyst at palate & gums related to hypercalcemia

HypervitaminosisNatal 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 cmDrug: aspirin Can lead to MI

LIPS- symmetrical 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 mom2. proper nutrition

34

3. prevent colic feed – upright seating or prone posburp 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)- prone2. 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

traps microorganism- prevent baby form crying for pain- analgesic

NECK- 1.) 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 earlyDx:

1. PPI-protein 2. radioimmunoassay test 3. radioactive iodine uptake

35

Mgt: synthroid – sodium Levothyrosine -synthetic thyroid given lifetime- check pulse rate before giving synthroid - tachycardia – Sx of hyperthyroidism

CHEST 1. symmetry 2. breast - transparent fluid coming out from newborn related to hormonal changes- 3. chest has retroactive – RDS4. sternum sunken – pectus excavation

ABDOMEN (in order)1. inspection I2. Auscultation A3. percussion P4. 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 abd2. Sx of RDS3. 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 mosSupplementary feeding given – 4 mos.

a.) solid food offered to ff sequence!1. cereals – rich in iron2. 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

36

e.) dilute fruit juices – 6 mosf.) never give half cooked eggs – usually causes of salmoneliosisg.) 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 buffersb. 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. nausea2. dizziness 3. facial flushing 4. abd cramping

assess: amt, freq, forceprojectile vomiting= increase ICP or pyloric stenosis

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

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

37

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 weight losstachypnea sunken fontanel & eyeballs scanty urinehypotension absence of tears

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 megacolonAganglionic – absence of ganglion cells needed for peristalis

Earliest sign 1. failure to pass mecomium after 24h2. abd distension 3. vomitus of fecal material early childhood – ribbon like stool

foul smelling stool constipationsdiarrhea

Dx: 1. Barium enema – reveals narrowed portion of bowel 2. Rectal Biopsy – reveals absence of ganglionic cells3. abd x-ray – reveals dilated loops on intestine 4. 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 RefluxChalasia – presence of stomach contents to esophagus Will lead to esophagitis complication – aspiration pneumonia

38

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 pressure3. intra esophageal pH content – reveals pH of distal esophagus.

Meds of GERDAnti-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 > 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 alk3.) failure to gain wt4.) olive shaped mass – on palpation 5.)serum electrolyte – increase Na & K, decrease chloride 6.) ultrasound7.) 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 anotherCommon 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

39

- 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 tryptophaselysine phenylalanine

Thyronine – decrease malanine production 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 urinemixed with pheric chloride, presence of green spots at diaper a sign of PKUDIET: 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- ryeO- oatW- wheat

40

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 inflammationDx:

1. lab studies – stool analysis2. serum antiglyadin – confirmatory of disease

gluten free diet – lifetime all BROW – not allowedok – rice & corn

Mgt:1. vitamin supplements2. mineral supplements3. steroids

POISONING- common in toddlers. (falls- common to infant)1. determine substance taken, assess LOC2. 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 vomiting3. 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

Gluten – glutamine ( normal absorption)

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

Malabsorption

Fats CHON & CHO peripheral edema & malnutrition

Vit D calcium Vit K Iron folic acid

Inadequate blood coagulation

Steatorrhea Osteomalasia Bleedingg

anemia

41

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 poisoningLead = Destroy RBC functioning = Hypochornic Microcytic Anemia = Destroy kidney functioning Accumulation of anemia = Encepalopathy

Sx:1. beginning sx of lethargy 2. impulsiveness, learning difficulties3. as lead increases, severe encepalopathy with seizure and permanent mental retardation

Dx:1. Blood smear 2. abd x ray 3. long bones

Mgt:1. remove child from source 2. 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 hShape pubic hair in inverted triangle ( female)

Male:Undescended testes – cyrptorchidism -common to preterm surgery – orchidopexy assess scrotum- warm room & hands

baby – pee within 24 h -check for arch of urination Epispadias- urinary meatus located dorsal or above glans penisHypospadias- urinary meauts loc ventral or below glans penis

Hypospadias with chordee- fibrous band causing penis to curb downward

Mgt: Surgery

Phimosis- tight foreskinBalanitis-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)

42

Renal Disorder Cause Sx Tx NSG CARENEPHROTIC SYNDROME

infectious 1. Anasarca- gen edema

2. massive protenuria 3. microscopic or no

hematuria4. serum CHON

decreased 5. serum lipid

increased6. fatigue7. normal or

decreased BP

Prednisone Diuretic

Focus of care: monitor edema

- weigh daily

Diet:Increase CHONIncrease K- OJ, beef broth, bananaDecrease Na

AGN ( acute Glomerulo Nephritis)

3A’s; AGN,autoimmune, Grp A

Autoimmune Grp A beta hemolytic streptococcus

1. (PPP) primary peripheral periobital edema

2. moderate protenuria

3. gross hematuria ( smokey urine)

4. serum K increased5. fatigue6. increase BPComplication :1. hypersensive

encephalopathy 2. anemia

1. anti HPN drug - hydralazine or apresoline2. iron

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

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 diaperOrthopedic complication – paralysis of lower extremities Surgery to prevent infection Post op – prone position

SCOLIOSIS- lateral curvature of the spine 2 types:1. structural – rye neck2. postural – improper posture

43

Dx:1. uneven hemline2. bend forward- 1 hip higher

1 shoulder blade more prominentNsg care:1. conservative – avoid obesity, exercise 2. preventive – Milwaukee brace - worn 23 h a day 3. corrective surgery – insert Harrington rod

post op- how to move log rolling- move client as 1 unit

EXTREMITIES:check # of digits = 201. syndactyly – webbing of digits 2. polydactyly – extra digits3. olidactyly – lack of digits4. Amelia – total absence of digits5. 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 type2. dislocated

Sx:1. shortening of affected leg 2. asymmetrical gluteal fold3. limited movement – earliest sx4. (+) ortolanis sign – abnormal clicking sound5. when able to walk – child limps – late sx- trendelenburg sign

Goal of Mgt:Facilitate abduction Mgt.

1. triple diaper2. carry baby astride 3. Frejka splint4. Pavlik harness5. Hip Spica Cast

TALIPES – “clubfoot” a.) Equinos – plantar flexion – horsefoot b.) Calcaneous – dorsiflexion – heal lower that foot anterior posterior of foot flexed towards anterior

legc.) Varus- foot turns in d.) Valgus- foot turns out

Equino varus- most common

Assessment:1. Straighten legs & flexing them at midline pos

44

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 gait5. Two point Gait- wt bearing allowed in 2 lower ext

45