Pediatric Nursing
PEDIATRIC NURSING
Extreme hypothermia shiver/chills increase o2
consumption decresed O2, increased CO2
ACIDOSIS
o
Extreme hypothermia burns brown fat for heat
ketones/fatty acids ACIDOSIS
Management
o
Dry baby immediately after birth (heat loss by
evaporation)
o
Unang Yakap
o
Use heating devices (Radiation)
Gooseneck lamp
Floor lampv uneven distribution, more
contact; prone to burns
Radiant warmer- 18-24 inches away
(safe), even distribution of heat
Drop light
o
Avoid cold draft (convection)
o
Postpone the bath until temperature is stable (6
hours)
o
Use warm water during bathing
o
O-18 years old
THE NEONATES
The Immediate Delivery Room Care
Administrative Order 2009
New Policies and Protocol on Essential Newborn Care
A- airway
B- body temperature
C- certify the birth
D- determine adaptation to extrauterine life- Apgar Score
To reduce childhood mortality in support of the Millennium
Developmental goal #4
2 strategies by the DOH
Unang Yakap
IMCI
Airway
2 possible cause of death when there is no medical
professional to attend the delivery
o
Asphyxiation
o
Aspiration
Asphyxiation
o
Causes
Umbilical cord is clamped no more O2
from the placenta hypoxia
hypercapnia acidosis (more
dangerous) CNS depression can
potentiate death
If cord is not cut- reverse circulation will
Rh Incompatibility.
o
Prevention
Babies must breathe after birth, neonates
breath after birty by crying so stimulate to
cry effectively after bityh
A crying baby is a breathing baby
o
When he is delivered disorientation to space
Suction with the bulb syringe PRN if (with nasal
obstruction/meconium stained amniotic fluid) TO PREVENT
ASPIRATION
o
deep suctioning might
hit carin/hypoxia vagal stimulation arrhythmias
(dec.HR)
o
Meconium stained
(Meconium Aspiration
Syndrome)
Alveoli collapse because meconium is
sticky and cannot be absorbed by the
sinuses
Sepsis since feces goes to the stomach
Use wall suction but use whiffs of oxygen
to allow rest
If the HR drops more than 10bpm, stop
the suctioning
Oxygen can cause blindness (Retrolental Fibroplasia) use
pulse oxymeter on the sole of the foot
Encourage to cry to effectively to maximize lung
expansion assess color (should be pinkish)
Breathes but becomes bluer Transposition of the greater
vessels give prostaglandin and prepare for surgical
intervention
Body Temperature
Physiologic heat loss after birth (37.2 C down to 35.5-36.5 C)
Extreme hypothermia (lower than 35.5) can cause COLD
STRESS causing ACIDOSIS
Prone to cold tress due to extreme hypothermia
University of Santo Tomas
College of Nursing / JSV
Certify
Identification and registration
Identification- can be done by SN
o
Plastic bracelet on foot and crib card not reliable
since it is detached
o
Footprints- more reliable (no longer recommended
because of wrong technique of doing it)
o
Most ideal: DNA/HLA (Human Leukocyte Antigen
Compatibility) less done
Registration- MD, RN
o
Local Civil Registrar (municipio) then NSO for Birth
Certificate
Determine adaptation to Extra-uterine life APGAR Score
APGAR SCORE- Done at 1 minute then at 5 minutes
Criteria
Pulse
Respiration
Activity
Grimace
Assess
Cardiac
rate
Cry
0
Absent
1
<100
Absent
Strong,
regular
Muscle
tone
Limp,
floppy
tone
No
response
Weak,
slow,
irregular
Some
flexion
Some
grimace
Gagging,
crying,
sneezing,
pulls away
from the
stimulus
Pink/Red all
over
CNS,
response
to stimulus,
reflex
irritability
Color
Appearance
Pale/blue
all over
Acrocyanosis
(hands
and feet)
2
>100
Well flexedfetal position
Activity Assessment
Limp, floppy tone- frog like position WARNING
o
Most likely not also breathing
2-3 hours of not breathing - brain
damage
o
Possibly dead
o
Premature
o
Narcotic effect
Pediatric Nursing
Mommy requested for pain killers
twilight delivery
Narcotics (Demerol,
morphine sulfate)
Give NALOXONE- give via endotracheal
tube (narcotic antagonist)
o
Intubation
Some Flexion
o
Drug user mother
watch out for withdrawal symptoms in
baby: seizure (do not breath well)
Well flexed
o
Pull the arms of the baby
baby will go back to
fetal position
Color Assessment
Not so much reliable
Pink- Caucasian
Red- Afro-American
0-3
o
Poor condition
o
Resuscitation needed, goes to ICU
4-6
o
Fair condition but guarded
o
Closer monitoring, baby goes to NICU
7-10
o
Good condition
o
Regular nursery care
*Congenital deffect will not affect APGAR
Phocomelia can have 10/10 score
Abnormality
Implication
Birth weight
3,000 gms
(6.5 lbs.)
2,500-3,500
IUGR
Maternal DM
Birth length
50 cm
19-20 inches
Microcephaly
Macrocephaly
Mental
retardation
Hydrocephal
us
Spina bifida
Chest
Circumferenc
e
Abdominal
Circumferenc
e
31-33cm
31-33
AGA- appropriate for gestational Age
At term
i. 38-40 t0 41 weeks
o
1 year old- same size of chest and abdomen
1.2 Color:
o
Normal: Pinkish or Reddish
o
Gray- septicemia due to intrauterine infection
o
Green- meconium stained due to fetal distress
o
Blue- congenital cyanotic cardiac disease
o
Yellow- pathologic jaundice due to blood
incompatibility (ABO/Rh)
o
o
2.
University of Santo Tomas
College of Nursing / JSV
o
o
o
SGA- decreased
size
LGA- increased in
size
33-35 cm
o
Pathologic Jaundice
If noticed at birth or baby is
less than 24 hours old
Blood incompatibility
Hgb hemolysis bilirubing unconjugated, indirect
not excretable fat soluble
Liver converts bilirubin through
glucoronyltransferase conjugated, direct
excretable water soluble urine and stool
yellow
Why neonates have hemolysis
Neonates have to excrete excess blood
because they are polycythemic (6-8 M
RBC, 55-65% Hct, 16-18 Hgb) because
baby is surviving in low oxygen in
intrauterine
Normal
Head
Preterm- 2nd day until 10th day
Caused by normal
accumulation of bilirubin due to
expected hemolysis after birth
o
Regular Nursery Care
(1) Initial Assessment
1. Take note of life-threatening abnormalities that require
immediate referral
Measurement
Physiologic Jaundice
Term Babies- 3rd day until 7th day
decreased o2
kidneys
stimulate
erythropoietin
increased
RBC
Sluggish blood flow- clot and thrombus formation
Identify when you saw the jaundice (take not also
(2) Eye Care (
)
o
Prevents Opthalmia Neonatorum due to maternal
gonorrhea or chlamydia
o
Done to all babies delivered either CS or NSD after initial
bonding/breastfeeding
o
Broad spectrum antibiotic/povidone iodine eye drops on
the lower conjuctival sac
o
Use half a grain of rice
o
Silver nitrate irritating and conjunctivitis, prevent by rinsing
with isotonic solution
o
Antibiotic: betadine eyedrops (no rinsing, replaced silver
nitrate)
(3) Initial Cord Care
Clamp when no longer pulsating (1-3 minutes)
DO NOT MILK causes hemolysis of blood,
hyperbilirubinemia
A-V-A
1 artery 1 vein- organs may have defects (kidney and heart)
o
1 kidney = kidney agenesis
Choice of food affected (avoid sodium,
preservatives)
No contact sports
Earliest attack of tonsillitis, tooth abcess
go to MD
attacks heart and kidneys
Child can live as long as possible
Prevent Infection
o
Clean with soap and water if soiled
Promote drying
o
Do not use abdominal binders
o
Should fall-off between 7-10 days
o
Teach the mother to fold down the waist band for
air drying
o
Ethyl alcohol (rubbing) - not used
o
Use Betadine when meconium stained
When cord falls off
o
Assess the site
o
When bleeding
Get cotton balls
apply pressure to the
site
If does not stop, check for hemophilia
(4) Vitamin K
Pediatric Nursing
To promote synthesis of prothrombin
Neonates cannot synthesize Vitamin K because of absent
intestinal bacterial flora
Given IM
1 mg IM in thigh muscle- 0.1 cc (Vastus Lateralis)- biggest
muscle mass and most highly developed for AGA (5.5-7.5lbs
or 2500-3500gms/ Intrauterine growth chart 10-90%)
Half a dose for SGA for day of discharge, half when birth
Vitamin K can also be given ORALLY
Avoid using the gluteal muscle (buttocks) because of the
danger of sciatic nerve trauma causing paralysis
o
Use when the child has been walking for at least 1
year
Offer oral Vit K if patients refuses IM
o
o
o
o
(5) Inject Hepatitis B and BCG
BCG intradermal; site may vary
(6) Initial Bath
Done best when vital signs especially temperature is stable/6
hours after birth
Do not remove vernix caseosa
Vernix
o
Waterproof
o
Slippery- prevent friction from ruggae of the
vaginal canal
o
Insulation for the baby- contains heat and moisture
for the baby
o
Keeps baby moist days after birth
o
Desquamation if with little vernix
Oil bath
o
For meconium stained babies to remove vernix
Home Bath
o
Depends on the schedule of the mother
be
flexible
o
Can get a bath anytime
o
Baby is sick
Immediately after feeding
o
NO TUB BATH until cord if off
(7) Rooming In (RA 7600)
Provide Optimum Nutrition: RA 7600 on RoomingIn/Breastfeeding Act of 1992
EO #51: Milk Code of the Philippines
Breastfeeding
o
The best feeding must be done at least 8x/day ON
DEMAND AND EXCLUSIVE
o
Exclusive- ONLY breastmilk
o
On Demand- every time baby wants to
o
Passive natural immunity
Until 1 year
IgA- breastmilk
IgG- placenta
o
If inverted nipple- NOT a contraindication
o
Breast pump
Ideal: put milk in milk bag (with zipper and
calibration)
Practical: ice bag
Label: date and time
First in first out
Put in freezer
Good for 1 year (frozen)
Kept continuously frozen
Do not abruptly heat it
destroys the
immunoglobulins
Use warm water bath
soak it
o
Temporary Contraindication
University of Santo Tomas
College of Nursing / JSV
o
o
If baby is critical
Promote lactation still with
mother
breast pump
Mastitis - discard pumped milk
Absolute Contraindication
Hepatitis, HIV, Active TB, Maternal
substance abuse, surgical Reasons,
injectable breast implant
Parlodel (deladomone)- supress breastmilk
production
Give mother advice on the use of breast milk
substitute:
Type (infant formula only)
Below 12 months
, evaporated
milk, condensed milk, am
- can cause kwashiorkor
Preparation:
Sterilization/boiling
10-15 minutes from boiling point
Feeding Method
Do not prop the feeding bottle
Aspiration
Position
Carry baby while feeding
Burping
Schedule
Give water in between
(8) RA #9288 Newborn Screening Act of 2004
Done to diagnose inborn errors in metabolism that may
cause DEATH or MENTAL RETARDATION
o
Congenital adrenal hyperplasia
Decreased cortisol, severe salt loss
dehydration.
If not treated, death in 9-13
Mx: NaCl supplement (tablet)
Galactosemia
Inability to metabolize galactose in milk
Sx: vomiting, diarrhea, liver damage,
cataract, growth failure and brain
damage
Mx: No animal source/milk/ NO
BREASTFEEDING
Soy Formula Isomil, Nursoy, Prosobee
o
Phenylketonuria
Inability to utilize an essential amino acid
causing mental retardation
Phenylalanine converted to tyrosine
converted to melanin (hyopigmentation)
May go to the brain and cause MR
Mx: special formula lofenalac/phenalac
o
G6PD (Glucose-6-Phosphate Dehydrogenase)
Breakdown of RBC causing anemia
Mx avoid triggers like beans,
naphthalene, sulfas
o
Congenital Hypothyroidism (Cretinism)
Deficiency in thyroid hormones causing
physical, developmental and mental
delay
Mx: Thyroid supplement for life (Synthroid)
Done by heel prick when baby is at least 24 hours old
o
GROWTH AND DEVELOPMENT
Growth
Increase in the number and size of cells
Pediatric Nursing
Measured in terms of quantity
Development
Capacity of functioning or skill
Measured in terms of quality
Milestones
Principles of Growth and Development
1. Unique
o
individualized
o
No 2 person is exactly the same
o
Care plan should be individualized
o
Do not compare children with one another
2. Unified
o
All areas are important
Physical, social, emotional
3. Continuous Process
o
Begins at conception and ends at death
4. Influenced by factors in the environment
o
Pre-natal factors: genetics and pregnancy care
o
Post-natal factors: home, school, city, country
5. Rate of growth varies
o
Rapid stages (growth spurts)
Infancy
Adolescence
o
Slow Periods (growth gaps)
Toddler
Preschool
Schooler
6. Directional
o
Growth
Horizontal and vertical
o
Development
Cephalo-caudal (gross motor)
Proximo-distal (fine motor)
Assessment of Growth
Physiologic weight loss
o
A couple of weeks after birth
o
5-10% of birth weight
o
1st baby check-up- 1 week after birth
For follow-up
Umbilical cord- dried; about to fall-off
Jaundice status
1. Breastfeeding jaundicespresence of pregnanendiole
decreased
gucoronyltransferase jaundice
o
Baby has no longer a supply of growth hormone
from mother stunting of growth
o
Expel meconium and urine, low amount of milk
ingestion dec.weight
o
Days after birth, skin begins to desquamate
o
Newborns tends to sleep and sometimes eat
Regain weight rapidly during infancy and
adolescent stages
Most rapid during infancy and adolescent stage
o
General trends in physical growth during childhood
(hand-outs)
*Computing for expected weight (birth weight is unknown)
Below 1 year: Age in months/2 + 3 or 4 = weight (kg)
Above 1 year: Age in years x 2 +8 = weight (kg)
- weight for height
o
Height in cm 100 = weight in kg
Less 10% for Orientals Filipinos
*Computing for number of teeth
Age in months 6
Assessment of Development
University of Santo Tomas
College of Nursing / JSV
DDST- Denver Developmental Screen Test
MMDST- Metro Manila Developmental Screen Test
o
Phoebe Williams
4 areas assessed (read handouts)
o
Fine motor- skills done by the small muscles (hands)
0,3,6,9
o
Gross Motor- skills done by the large hands (body,
torso)
2,4,6,8
o
Language
o
Interpersonal Social
0
2
4
6
8
10
12
14 15
0
3
6
9
12
Cephalo caudal
Cry
Head lag no head control
Cradle hold
Support head
Begins to have head control
Lifts head on prone
Full head control
Lifts head and chest
Sits with support
Sits without support
Sits alone
Stands with support
Stands without support
Walks with support
Walks alone
Proximo distal
Strong grasp reflex
Grasp reflex gone
Hand-regard hands are held open
Plays with hand
Beginning communication between brain & hand
Palmar grasp
Can hold bottle with 2 hands
Pincer grasp
Thumb and finger to hold objects
Put things in and out of container
*Games Children Play
Criteria for picking toys
o
Safety
o
Based on their developmental age
o
Must have a function or a purpose
Infants
o
Can play
o
o
Play with their BODY SENSES (sight, hearing, touch)
o
Solitary play/games
o
Toys
Mobiles
Rattles
Teething rings
Music boxes
Squeeze toys
o
3-4 monthsToddlers
o
share
- possessive; cannot
Pediatric Nursing
o
o
o
o
o
What is mine is mine, what is yours is mine
Parallel Games;
Loves to play BESIDE another child but must have
each a toy
Must promote walking or talking
Toys: Promote skills of walking-push and pull toys,
talking- toy telephone, coordination- blocks
o
Pre-schoolers
o
Loves to share and imitate adults in their play
o
Role Play; stage of make believe
o
Cooperative/Associative Games
o
Do not typecast toys
o
Toys: Role playing games, play school, play house,
doctor-nurse kit
School-Age
o
Must have a winner at the end of the game
o
Competitive Games
o
Toys: Card games, scrabble, hopscotch, skipping
rope
Theories in Development
*Milestones are not affected by gender/sex
Relationships
Formation of developmental tasks (positive and negative)
foundation of our personalities
There is a body that is most important in each stage of our
lives
That is what the person will use in their relationship which lays
down the foundation for the developmental tasks which
then develops their personality
Trust vs. Mistrust and Oral Stage (Infants)
Mom and Baby
Love trust know see
Lust is the foundation of all relationship
Baby used the mouth to get attention of mother through
crying mommy will be known as the one who tends to the
baby baby will trust mommy LOVE
baby will develop trust
If unanswered mistrust
o
Oral frustrations
o
Oral fixation
o
Oral residuals: Excessive thumb sucking, nail biting,
over talkativeness, overeating, chain smoking,
alcoholism, drug addiction
o
Why unanswered busy, unwanted, ignoran9
The infant receives stimulation and pleasure through his
mouth. Answering their cry (needs) helps develop trust
Nurses must watch out for fixation in patients which rests the
GI system due to medical condition
o
Use non-nutritive sucking (pacifier) to replace oral
need
o
Remove if it already pacified
o
Pacifier would not cause buckteeth as long as the
teeth is still milkteeth
o
Do not improvise
Autonomy vs. Shame and Doubt and Anal Stage (Toddlers)
Finds pleasure in controlling his eliminatory function
Toilet training begins: Right place
Important facts about toilet training
University of Santo Tomas
College of Nursing / JSV
o
o
Recommended to be started at 18 months with
bowel first
Spinal cord fully coated myelin sheath
Most important factor is READINESS
Physical- neurologic system readiness;
Can feel the urge
Psychological- please the mother
Completed by 4 years
Feeling of INDEPENDENCE develops through bowel training
You can never feel dependent if you are insecure
Narcissistic
Child feels he can do whatever he wants, can feel the urge
Behaviors to observe:
o
- set limits/ offer acceptable
choices
o
Ritualistic or stereotype behavior
To feel secure
o
Temper tantrums
Ignore the behavior
Frustrations because of the needs and the
wants
Time-out- 1 minute for each year of life
Initiative vs. Guilt and Phallic Stage (Preschool)
Oedipal/Electra Phase
o
Child turns toward the parent of opposite sex,
usually resolved toward the end of this period
How to resolve Oedipal/Electra
o
Negate
Unresolved Electra complex: Querida
Initiative develops if the child is allowed the freedom to
initiate small activities and is appreciated for it
Behaviors to observe:
o
Very curio
?
o
Asks many questions (300-400/day)
o
Exhibits interest in sex (gender) difference
o
Touches/Explores their body
o
Exhibits fear of bodily injury
o
Very imaginative- engages in fantasy play
To solve the conflict (anxiety)
o
Fondle their genital
o
Exhibitionists
o
To seek revenge for the penis: Hit a person with it
(Rapists)
What to do
o
divert (alam na napansin)
o
You IGNORE
In social situations, tell him to go to his
room = provide privacy
o
When you give injection, cover it
o
Magical thinking kissing of wounds, non living
things are alive
Industry vs. Inferiority and Latency Stage (Schooler)
Calmest stage in sexual development -latency
The sexual drive (libido) is controlled and repressed interest
on same sex only (normal homosexuals)
Heroism crush of opposite sex, usually older
Industry develops if the child is permitted to do things by
himself and praised for the results
ACHIEVEMENT ORIENTED YEARS
Wants to prove their BEST in school
Identity vs. Role Confusion and Genital Stage (Adolescent)
Resurgence of sexual drives
Develops relationships with members of the opposite sex
Identity develops when there is feeling of belongingness and
acceptance by others
Pediatric Nursing
Behaviors to observe:
o
Undergoes bodily changes corresponding to
puberty
o
Moody and unpredictable
o
Attempts to make decision for himself
o
Makes long-range plans for the future (career
plans)
Puberty
o
First change in BOTH sexes:
Increased height and weight (2nd period
of growth spurts)
Female: widening of the pelvis
(ovoid)
Male: broadening of the chest
and shoulders
o
Physical changes in the female in order of
appearance:
Development of the breast buds
(thelarche)
Growth of pubic and axillary hair
(pubarche, adrenarche)
Menstruation (menarche)- usually
unovulatory
Average 10 ½ to 15 y/o
Regular menstruation and
ovulation- 6-14 months after
menarche
o
Physical changes in the male in order of
appearance:
Increase in the size of the genitalia
(scrotum)
Growth of pubic, axillary, facial and leg
hair
Voice changes
Production of spermatozoa (nocturnal
emission)
o
No Menstrual Cycle
Ovarian agenesis
Polycystic ovary
Hypothyroidism
o
No wet dreams
Cryptorchidism
Sx: Orchidopexy
ABNORMAL PEDIA
THE RISK NEONATES
Pre-ecclampsia
might lead to abruption placenta
baby must be delivered
Preterm- most common risk newborn
PRETERM
Born before the 38th week or before completing 37 weeks of
gestation regardless of he birth weight
38 weeks = 37 weeks and 7 days
Physiologic Handicaps
Expected handicaps for preterm because of immature
organs
1. Respiratory Distress
Immature alveoli with less amount of surfactant
Problems: atelectasis, prolong apnea (more than 20 secs),
cyanosis, asphyxia
Symptoms
o
Nasal flaring- because they are
o
o
Fast breathing more than 60
Chest indrawing
University of Santo Tomas
College of Nursing / JSV
Grunting- most accurate sign umuungol
like a near collapsed lungs upon expiration)
Suction first the mouth newborns are obligate nasal
breathers
If the nose is suctioned first
stimulation of pharyngeal reflex
aspiration of secretions
Symptoms or respiratory distress not visible immediately after
birth
Body temperature- a more immediate problem (within 1
minute might have hypothermia)
Management:
o
Assist MD in inserting ET
Neonatologist
Serve as an accessible route for
administration of surfactants
o
Artificial surfactant given via ET
(Survanta/Liquivent)
o
Give O2 by CPAP (Continuous Positive Airway
Pressure)/ventilator
o
Prolonged ventilator
Might develop bronchopulmonary
dysplasia
P. aeroginosa
o
Monitor pulse oximeter (danger of retinopathy of
prematurity/ retrolental fibroplasia)
O2 not greater than40%
o
On NPO during respiratory distress
o
Good urine output = good cardiac output
1-1.5 cc/kgbw/hour
o
2. Regulation of Body Temperature
Immature hypothalamus
Less amount of subcutaneous tissue
Poikilothermia- can go very high low (dependent on the
environment) due to immature hypothalamus
Management:
o
o
Put in incubator- provides neutral temperature
o
KMC- Kangaroo Mother Care
3. Nutritional Difficulties
Prone to aspiration/ gastric distention
Hypoglycemia
Causes
o
Poor suck and gag must not be removed
o
Uncoordinated swallowing must not be removed
o
Small gastric capacity
Management
o
Gavage (OGT) feeding inserted at the mouth
Orogastric feeding
Breastmilk or formula
Special preemie formula (25 cal/oz)
O-lac, Pre-Nan
Similac Special Care
o
Small frequent feeding
o
If observed to be sucking
refer
preemie nipple
(shorter, smaller, opening is cross-cut)
o
Upright position during feeding
o
Right Lateral position after feeding
Promote gastric emptying
4. Hematologic Difficulties
Immature liver function (no glucoronyl transferase)
Jaundice due to indirect bilirubin due to hemolysis, liver
cannot convert
Problem:
o
Early and prolong jaundice
o
Prone to kernicterus
o
Bleeding
Pediatric Nursing
Photoisomerization more skin exposed
Management
o
Phototherapy as ordered
Phototherapy
o
Maximum exposure except the eyes and genitals
Increase in temperature vascular
engorgement priapism (continuous
erection of the penis)
Cover eyes to prevent loss of moisture
o
Regular turning to all sides: front back, side to side
every 30 mins
o
Check temperature regularly
o
Promote feeding and hydration
Prevent dehydration
Promote faster elimination of bilirubin
o
Promote bonding/breastfeeding if allowed
o
Breast feeding jaundice - mas matagal mawala
pag breastfed (prenanendiole decreases
glucoronyl transferase)
o
Physiologic jaundice is normal after 1 day; if not
maternal antibody destroys
o
Bilirubin can go to the brain causing kernicterus
(pre-term only)
5. Low Resistance to Infection
Most common cause of death
Immature immune system
Problem: Sepsis neonatorum (nosocomial infection)
Management
o
Note for signs of infection
Fever- not a sign for preterm (immature
hypothalamus)
Hypothermia- sign for preterm
Poor feeding
o
Strict compliance with Nursery aseptic protocol
o
Antibiotics as ordered
A risk because of immature liver (post
antibiotic hepatitis)
POST MATURE INFANT
Born more than 42 weeks in gestation
Problem: placental degeneration causing decreased uteroplacental perfusion
Manifestations
o
Long but thin
o
Dry cracking skin
o
No vernix and lanugo
o
Long hair and nails
o
Alert look
o
Possible IUFD
o
Associated Problems
o
Hypoxia due to placental insufficiency
o
Hypoglycemia due to decrease glycogen
o
Fetal distress
Restlessness of the baby- earliest sign
o
Seizure disorders
might develop cerebral palsy
o
Cold stress due to less subcutaneous fats
o
Meconium aspiration
Due to respiratory distress
Infection
o
Polycythemia causing hyperbilirubinemia
Not critical for kernicterus
Phototherapy but not as long as that of a
preterm
DRUG A
Unborn child is passively addicted to the drug
University of Santo Tomas
College of Nursing / JSV
Neonates are born SGA and may show signs of withdrawal
12-24 hours after birth
Manifestations of Withdrawals
o
GIT Irritability
Earliest
Diarrhea hypokalemia, dehydration
Regurgitation
Vomiting
Anorexia
o
CNS Irritability: Tremors, Irritability, High-pitched cry,
Restlessness, Seizures
Management
o
Environmental modulation to decrease external
stimuli (NICU)
Placed in incubator for sound incubation
o
Providing adequate nutrition and hydration (IV line)
o
Drug Therapy
Phenobarbital- anticonvulsant
Chlorpromazine (Thorazine)- CNS
depressant/ antipsychotic
Diazepam- muscle relaxant
o
Seizure Precaution
Airway is maintained give whiffs of O2
Do not suction while having a seizure
Refer mother to social service of the
hospital
can go to rehab
FETAL ALCOHOL SYNDROME (FAS)
Facial Features
o
Hypoplastic maxilla
o
Hypoplasticphiltrum
o
Short palpebral fissures
o
Thin upper lips
Neurologic Symptoms
o
Microcephaly
o
Mental retardation
Growth
o
Prenatal growth retardation (SGA)
o
Persistent postnatal growth lag
Irritability and Hyperactivity, restlessness
No withdrawal
BABY OF DIABETIC MOTHER
Mommy with diabetes decreased insulin increased
glucose in blood blood goes to baby 1 glucose supply
for baby increased production of insulin intrauterine
hyperinsulinism more glucose absorption macrosomia
(above 4000gm) uterine stretch reach maximum point
contractions preterm delivery, fractured clavicle
(greenstick fracture) after birth hypoglycemia
Baby may be diabetic in the future
Macrosomic Baby
o
Large shoulders (broad) bigger than head
Management
o
While fracture is healing
hold figure 8 to facilitate
fracture healing
o
Monitor signs and symptoms of hypoglycemia
Restlessness
Tremors
Irritability
o
Monitor blood glucose level (CBG)
Can be done on great toe
40-60 mg/dl; 2-3 mmol (normal)
1 mmol = 20 mg/dl
o
If CBG lower than 40 mg/dl give glucose (D50W
in a vial) as ordered; bolus
BLOOD INCOMPATIBILITY
Pediatric Nursing
ABO/RH (erythroblastosis fetalis)
Orientals- 99% have Rh (+) (D antigen)
Rh (-) = no Rh factor (D antigen); can only receive (-)
Rh (+) = can receive blood from Rh (+) and (-)
Mother
Rh negative
Rh positive
Type A
Type B
Type O
Type AB
Baby
Rh positive
No problem
Type B
Type A
Type A or B
No problem any blood
type
Uteroplacental barrier prevents blood of baby and mother
to mix
Through pinocytosis, antibodies cross membrane
(Mother (-) and Baby (+)First baby not affected birth of
placenta
production of antibody (anti-Rh (+))
second pregnancy
uteroplacental barrier allows antibodies to cross
membrane
hemolysis
Manifestations:
o
Jaundiced/ Alive but with pathologic jaundice
Management:
o
Exchange transfusion remove blood
o
o
o
replacement with fresh whole blood (Rh
Negative)
Di napwede Rh (+) because of the
presence of antibodies
Mother cannot donate because
antibodies came from her
PREVENTION is the best intervention
If mommy and baby are not compatible:
After 1st baby,
(baby)
determines presence of maternal
If mother is not compatible with baby and
RhIg (RHOGAM) is given
to mother within 72 hours after delivery or abortion
of an incompatible fetus
o
EXCHANGE TRANSFUSION
o
Can be given during pregnancy
___________________________________________________
o
NEONATES WITH CONGENITAL DEFECTS
CONGENITAL HEART DISEASE
All congenital conditions are risky
1st trimester- most critical period for the mother
Overall cause of the problem: mixing/shunting of
oxygenated and unoxygenated blood
Acyanotic
o
Left Side shunt going to the right
o
Aorta does not get unoxygenated blood
Cyanotic
o
Right shunt going to the left
o
Aorta gets unoxygenated blood systemic
circulation Decreased O2 saturation
ACYANOTIC
Left to right side shunt
CYANOTIC
Right to left side shunt
Aorta does not get
unoxygenated blood
Aorta gets unoxygenated
blood
1. Ventricular Septal Defect
2. Atrial Septal Defect
3. Patent DuctusArteriosus
4. Coarcation of Aorta
5. Pulmonary Stenosis
6. Aortic Stenosis
1. Tetrallogy of Fallot
2. Transposition of the Great
Vessels
3. Tricuspid Atresia
T= cyanotic!
ACYANOTIC HEART DEFECTS
Congestion of cardiac chamber
heart compensates by
increasing heart rate
CHF
Left Sided Failure and Right
Sided Failure
A-anim
B- breathing (CC)
C- CHF (complication)
D- interventions
Left Sided Failure (lung related symptoms):
o
Earlier to recognize
o
Respiratory Symptoms: Dyspnea, Productive cough
(pink frothy sputum), Rales/crackles
Right Sided Failure: Systemic Symptoms, Distended neck
veins, Pedal edema, Ascites, Hepatomegaly
CC: Early: Pulmonary Symptoms - Dyspnea (refuses to suck),
Fast breathing, Moist cough, Rales/crackles
DX:
o
Chest x-ray
Pulmonary edema and cardiomegaly
o
Echocardiography
Identifies type and size of defect
o
Cardiac Catheterization
Identifies pressure inside the heart
(beginning CHF)
Identifies need for surgery
Best rest, apply pressure dressing, assess
for pedal pulsation (the used leg will have
a weaker pulsation on the first 4 hours, if
no pulsation, possible thrombus
embolectomy, heparin)
Corrective Surgery:
o
If in failure and defect is large (no possible
spontaneous closure)
o
There is possibility of spontaneous closure
Open Heart Surgery
o
Defect is inside the heart/risky since it involves
stopping the heart
o
Procedure:
Induction of asystole (cardioplegia)
Induction of hypothermia
Use of bypass machine (ECMO)
Extracorporeal Membrane Oxygenator
Induction of hyperkalemia bradycardia
Closed Heart Surgery
o
Defect is outside the heard
Induction of hypothermia
Medical/Nursing Management:
o
Drugs:
Digoxin
Diuretics
o
Diet - Low sodium, low cholesterol
o
Decrease cardiac demand
o
Decrease occurrence of infection
Objective #1: Prevent CHF
o
Improve Cardiac Output
University of Santo Tomas
College of Nursing / JSV
Pediatric Nursing
Cardiac Glycoside (Digoxin)
Increase strength of contraction
Given before meals- so you can
assess for toxicity (first sign of
toxicity is GI symptoms)
Hold if slow CR
o 1y/o lower than 100
o 1-5 y/o lower than 80
o 6-10 y/o lower than 70
o 11 and up lower than 60
12 hours interval
o
Prevent Sodium Retention and Promote Elimination
of Excess Fluids
Diuretics- Furosemide (Lasix)
Given during acute stage of CHF
Not a maintenance drug
ACE Inhibitors- Captopril/Enalapril
Prevent sodium and water
retention
1-1.5 ml/kg BW/hour
o
Low sodium intake
Low Sodium Formula- Lonalac
Clarification on solids allowed
Not all salty foods are rich in sodium!
Enough salt to taste but no more added
during eating
Tocino, soda,
Objective #2: Decrease Oxygen Demand
o
Cluster nursing care
o
Quiet play activity - toys that can be played in bed
o
Decrease stress and anxiety level
Limit crying
Course your interventions through the
mother
o
Small frequent feeding
Objective #3: Prevent Respiratory Infections
o
Because of pulmonary edema
o
Vitamin C - for non-asthmatics- vitamin C is an
allergen
o
Promote Immunization
1. ATRIAL SEPTAL DEFECT
Increased amount of blood in the right atria
overstretching effect of the myocardium (compensation)
heart pumps faster (increased HR) will eventually decrease
contraction (exhaustion)
decreased cardiac output
systemic effects (CHF)
May close by itself
Congestive heart failuredecreased
o
Same manifestions
Kidney symptoms most dangerous
Congenital heart failure digoxin, diuretics
o
No aspirin in children since the cause it not an
infarct
o
No NTG
o
No statins
2. VENTRICULAR SEPTAL DEFECT
Blood from left ventricle goes to right
congestion of right
ventricle
hypertrophy
overstretch
compensation
exhaustion
decreased CO
CHF
3. PATENT DUCTUS ARTERIOSUS
Fetal structure
Should have closed at birth ligamentum arteriosum
More pressure in the aorta
blood goes to pulmonary
artery right ventricle hypertrophy
University of Santo Tomas
College of Nursing / JSV
Can be managed by meds (may not need surgery)
Management:
o
Indomethacin- prostaglandin inhibitor
4. COARCATION OF THE AORTA
Constriction of the descending part aorta
blood goes
back left ventricle
hypertrophy
Greater BP on the upper part of the body
Hypotension in the lower part of the body
5. AORTIC STENOSIS
Constriction of the aorta
increased blood in the left
ventricle
6. PULMONIC STENOSIS
Constriction of the pulmonary artery
increased blood in
right ventricle
CYANOTIC HEART DEFECTS
o
o
C- central cyanosis
C- clubbing of fingers
o
o
C- clots (thrombus)
C- cerebral thrombosis (CVA)
o
P- propanolol
o
P- penicillin
o
P- phlebotomy
o
P- promote fluids
o
P- promote rest
o
P- polycythemia (monitor)
1. TRANSPOSITION OF THE GREAT VESSELS
Right ventricle
aorta
Left ventricle
pulmonary artery
Pure unoxygenated blood is delivered into the systemic
circulation; symptoms may be seen on delivery room table
More favorable if with septal defect (ductus arteriosus) less
symptomatic
Sx:
o
Persistent cyanosis in spite of vigorous crying
(central oxygen)
o
Hypoxia in spite of O2 therapy
Management
o
Palliative - Emergency Balloon Septostomy
Followed by corrective Open Heart
Surgery (Miller-Rashkind Procedure)
o
Prostaglandin- open ductus arteriosus temporarily
2. TETRALLOGY OF FALLOT
D- displaced aorta
R- right ventricular hypertrophy
O- opening in the septum (VSD)
P- pulmonary artery stenosis
More pressure in the right side of the heart because of
pulmonary stenosis right to left shunting blood goes to
the displaced aorta (center) delivery of mixed
unoxygenated blood to the systemic circulation
Symptoms usually seen when child is more active because
of increased oxygen demand
o
Exertional dyspnea with central cyanosis
o
(hypercyanotic state)
relieved Squatting
Delaying of venous return decreased
pressure in the right ventricle relieve of
symptoms
Knee chest position in babies
o
Clubbing of fingers due to peripheral hypoxia
Shamrock test
Due to peripheral hypoxia, additional
capillaries are formed (collateral
circulation is made)
o
Polycythemia due to chronic hypoxia
Pediatric Nursing
Can cause sluggish circulation
formation o clots and thrombus lodge
in cerebral circulation cerebral infarct
Prevented by phlebotomy
o
Stunted physical growth and delayed
development
Management:
o
Palliative: Close Heart
Goal: increase amount of blod going to
the lungs
Blalock Taussig (goal: increase
amound going to lungs,
anastomoses subclavian), Potts,
Glenn Shunt, Waterson side to
side anastomosis; not preferred
since it may causes a weak wall
which is prone to aneurysm
o
Corrective Open Heart
o
Nsg Mgt.
Decrease demand for oxygen
Cluster nursing care
Allay anxiety
Quiet play activity
Small frequent feeding
Propanolol (Inderal)
Dilation of blood vessels
Propanolol Penicillin
Prophylactic antibiotic for
bacterial endocarditis; lung
filters
Monitor Hgb and Hct count- detects early
polycythemia
Assist in phlebotomy as needed to be
done
Viscous blood is remove and
replaced by plasma
Increase fluids/Maintain IVF line as
necessary
Juicy fruits, Sherbets, Soup, Iced
candy
Positioning during attacks squat, kneechest- infants, give O2
Monitor activity tolerance/LOC
___________________________________________________
NEURAL TUBE DEFECTS
Cause: inadequate intake of FOLIC ACID during pregnancy
Not enough folic acid
Posterior lamina is missing or absent
contents went out
85% of children with neural tube defects
develop
HYDROCEPHALUS
Drugs, radiation
Sources of Folic acid
o
Green leafy vegetables
o
Nuts
o
Legumes
o
Brown rice
o
Strawberries
Spina Bifida Oculta- hidden; no sac
o
Usually not visible externally
o
Dimple at sacral area
o
With hair
o
No intervention necessary
Cystica- with sac
o
Intervention is necessary
o
Meningocele- consist of sac-like cyst of meninges
filled with spinal fluid
University of Santo Tomas
College of Nursing / JSV
Meningomyelocele- protrusion of a sac-like cyst
containing meninges, spinal fluid and spinal cord
with its nerves. Paralysis of lower extremities.
Clubbed foot-talipes equinovarum.
o
Encephalocele- herniation of the brain and
meninges through a defect in the skull - most
dangerous
o
How to assess:
Observe for movement of the lower
extremities, apply pain
With movement- meningocele
(+) talipesequinovarus (clubfoot)meningomyelocele
Overall objectives of nursing care:
o
Protect the sac against pressure, injury and
infection
Intervention:
o
Surgical closure preferred within 24-48 hours after
birth to prevent local infection and trauma to the
exposed tissues
o
Prone position
o
During feeding
pressure on the sac
o
o
No problem with breastfeeding
o
Cover the sac with sterile gause with plain NSS
keep moisture to prevent cracks
HYDROCEPHALUS
o
Hydrocephalus
enlarged ventricles
brain
pushed against the cranium
increased pressure
baby still has fontanels, can expand
able to
accommodate the swelling
o
May be caused by a tumor
o
Complication of encephalitis
o
Bulb-shaped head, Sunset eyes, Distended scalp
veins
o
High pitched cry, Increased ICP
o
Give morphine to decrease pain
Interventions:
o
Position side-lying (especially if opisthotonic)
o
Assessment of signs of increased ICP: measure
HCOD (head circumference of the day)
o
Measures to prevent increased ICP
Surgical Management:
o
Ventriculostomy - to relieve pressure
o
Insertion of shunt to bypass the point of obstruction
(ventriculoperitoneal shunt)
So CSF can be recycled
Drainage of CSF in the peritoneum
CSF
reabsorbed by the blood vessels
o
Shunt Revision- based on the length of the tube
inserted in the body (scheduled)
o
Obstruction of catheter (unscheduled shunt
revision)
Increased ICP
o
Medications are not effective
o
In adults, permanent shunting is done with:
Removal of brain lesions
Clipping of aneurysms
Post-op Nursing Care of Shunt Insertion:
o
Routine post-op VS monitoring
o
Position: FLAT on the unoperative side to prevent
pressure on the shunt valve and too rapid drainage
and reduction of CSF that may cause subdural
hematoma
o
Do not carry the infant
o
Monitor for increased ICP
o
Observe for abdominal distention (peritonitis or
abdominal ileus)
o
Pediatric Nursing
___________________________________________________
GIT PROBLEMS
A lot of GIT problems are HEREDITARY
1. CLEFT LIP AND CLEFT PALATE
Can cause problems with airway
More common in males
Cleft palate- speech, defects in ear, hearing problem
SURGERY is a PRIORITY
Will have coping problems as they grow up
Surgery
o
Cheiloplasty/Z-plasty
Cleft Lip Repair
Usually done 3 times
Not un urgent procedure, not life
threatening
Delayed until they are no longer surgically
at risk
o
Rule of 10 (way of determining surgical risk)
10 lbs.
10 gms of Hgb (at least)
Less than 10,000 WBC
At least 10 weeks old (2 ½ months)
Rarely used because if other
perimeters are ok, surgery can
proceed
Pre-op:
o
Feeding technique: dropper used with SAP; drop at
side
o
pressure
Post-op:
o
Position: NEVER ON PRONE (No head control)
o
Prevent tension on the suture lines: LOGANS to hold
suture in splace
Anticipate needs to lessen crying
Use of arm restraint
Restraint removed every 2 hours; need
consent
Clean suture lines after feeding
2. CLEFT PALATE
Surgery
o
Uranoplasty/Palatoplasty
Done before speech development begins
Cannot be done in the same time with
cheiloplasty (kontra yung care plan)
Post-op
o
SHOULD BE DONE ON PRONE
To promote natural drainage of secretions
o
Observe for bleeding
Frequent swallowing
o
Use ELBOW RESTRAINT
To protect suture lines
Prevents flexion of the arms
o
Feeding device post-op
Drink from cups
NEVER USE STRAW, nipple
Big spoon for solids
No breastfeeding
ESSR enlarge nipple, suck (give time),
swallow (give time), rest
o
Speech Rehabilitation/Hearing Test nasal twang
3. ATRESIA OF THE ESOPHAGUS
No connection between the upper and lower segment of
the esophagus
University of Santo Tomas
College of Nursing / JSV
Manifestations
o
Drooling of mucus after birth
o
Mother with polyhydramnios
4. TRACHEOESOPHAGEAL FISTULA
Fistula between esophagus and trachea
Problems:
o
Aspiration
Possible cause of death
o
Nutrition
Manifestations
o
Observe reaction of baby to feeding
o
COUGHING
CHOKING
CYANOSIS
Dx:
o
NGT- coiling
o
X-ray
o
Ultrasound
Management:
o
Surgery ASAP
Pre-op:
o
Prevent aspiration
Suctioning
Strict NPO
o
Promote nutrition
Gastrostomy feeding
TPN as ordered (check blood sugar)
Check for patency of the tube
Flush with small amount of h2o
If hyperglycemic
refer to MD
give
insulin as ordered
5. CHALASIA / GASTROESOPHAGEAL REFLUX (GER)
Caused by immaturity of the cardiac sphincter
Symptoms
o
Frequent reflux of stomach content right after
feeding
o
No precipitating factors
Mgt. Self-limiting (resolves as the child gets older)
Proper feeding technique
o
Small frequent feedings
o
Thickened formula / breast milk
o
Upright position during feeding
o
Burp frequently during feeding
o
Right lateral semi-upright position after feeding
Medical management:
o
Metoclopramide (Reglan) to increase Lower
esophageal sphincter tone and to stimulate upper
GI tract motility.
o
Ranitidine (Zantac) to inhibit gastric secretions
o
Surgery: Nissen Fundoplication
6. PYLORIC STENOSIS
Caused by hypertrophy of the muscles of the pyloric
sphincter
NOT HEREDITARY
Gradual hypertrophy of muscles of pyloric sphincter
accumulation of food in stomach increased pressure
vomiting f & e imbalance hypokalemia alkalosis
Manifestations
o
Hours after they eat abdomen is distended
o
Positive peristaltic wave (waterbed)
o
Projectile vomiting (yellow, acidic, sour smell)
Milk (curdles)
o
Dehydration
o
Metabolic alkalosis
o
Hypokalemia
Pediatric Nursing
o
o
Weight loss
Palpable olive-shaped mass in RUQ
Palpatory technique is least reliable
o
Barium Swallow
X-ray
String Sign
Dx
Dx:
Congenital Aganglionic Megacolon
Ganglion cells- nerve supply, nerve cells
Absence of parasympathetic nerve supply (ganglion cells)
on the large intestines
Part affected constricts
4 segments of large intestine
o
Ascending
o
Transverse
o
Descending
o
Recto-sigmoid
If large intestines is full of contents
reverse peristalsis
small intestine absorb the toxins
stomach breaks down
fecal matter
Manifestations:
o
Early (nursery)
Delayed meconium
o
Late
Constipation (stool is very hard, quality!)
Ribbon-like/pellet-like stool early signs
University of Santo Tomas
College of Nursing / JSV
Pre-op:
o
Promote elimination
Regular colonic irrigation
Palliative COLOSTOMY
o
Promote nutrition
High calorie
High protein
Vitamins
Low in residue no fiber!
Small frequent feeding if with distention
Corrective Surgery:
o
Endorectal Pull-Through Procedures
more difficult
7. INTUSSUSCEPTION
Hyperactive portion of the small intestine
telescopes/invaginates into the lumen of another
Most common in infants
Manifestations
o
Bile stained vomiting (green, bitter) since it comes
small intestines
o
Blood vessels caught between the layers
decreased blood supply necrosis bleeds
currant jelly stools (blood with mucus in the stool)
o
Appendix might burst perforation peritonitis
o
Sausage-shaped mass
o
Spasmodic abdominal pain
Management:
o
Barium Hydrostatic Reduction Technique
GI tract is a hollow organ difficult to
visualize a hollow organ without contrast
(enema can low)
Used as TREATMENT reduce the
telescoping with barium given under
pressure (enema can high increase
pressure)
Surgery
o
When barium hydrostatic reduction technique is
not successful push barium out, reduce the
telescoping with barium given under pressure
o
Prevent perforation and peritonitis
8.
Rectal Biopsy
Barium enema to determine extent
tail!
o
Surgery
o
Fredet-Ramstedt Procedure
Pyloromyotomy with pyroplasty
Pre-op
o
Correct existing fluid and electrolyte imbalance
IVF for dehydration/KCL for hypokalemia
and alkalosis
o
Correct nutritional imbalance
Thickened formula/TPN PRN
Rice cereal (cerelac)
Denser, heavier
to vomit
Abdominal distention with possible
fecaloid vomitus
Weight loss
9. IMPERFORATE ANUS
More common in girls
Manifestations:
o
Absence of meconium
o
Unable to insert rectal thermometer
o
If female: meconium passes via vagina (rectovaginal fistula)
o
If male: meconium passes through urinary bladder greenish urine (recto-vesical fistula); violates sterility
of urinary bladder
Management:
o
Step 1: Colostomy in the nursery (Palliative)
o
Step 2: Before 1 year old (10 months)
Corrective Surgery: Anoplasty/ Pullthrough procedure
Must heal first before closing colostomy
Must delayed to allow the child to feel
the urge
o
After 6 months
Closure of colostomy
o
May be prone to fecal spillage; problem with
control since only internal sphincter is present
o
Avoid foods with easy transit; dairy products
o
Sharts=ipot
___________________________________________________
KIDNEY PROBLEMS
1.
A
CC: abdominal mass
Pre-op:
o
Avoid pressure over the mass
Do not put on prone position
Do not wear tight waist band
Do not vigorously scrubbing the body
Do not palpate
Manifestations: vague, weight loss
Management:
o
Nephrectomy followed by chemotherapy
NEPHRITIS
Cause
Sx
Caused by GABHS
- Hematuria
- Hypertension
- Periorbital edema
(local)
NEPHROSIS/NEPHROTIC
SYNDROME
Unknown cause (auto-immune)
- Proteinuria
- Hypoproteinemia
- Decreased plasma osmotic
pressure fluid shifting
edema ascites,
Pediatric Nursing
anasarca hypovolemia
hypotension
- Hyperlipidemia secondary to
Dx
Mgt
- Increased BUN
- Increased
creatinine
- Increased ASO
titer (NV: 0-200 IU)
- RBC in the urine
- Renal biopsy
- CBR in acute
stage
- Anti-HTN
- Diuretics
- Antibiotics (does
not respond to
penicillin)
- Decreased Na,
decreased CHON
(variable) if
increased
creatinine
- Skin Care
- Additional pillows
for periorbital
edema
mechanism to increase protein
- Protein in the urine
- Decreased serum protein
Ambulate as tolerated
Bed sore precautions
Diuretics
Steroids (Prednisone) can lead
to bloated effect
- High CHON, Low Na, Low fat
diet
- Skin care
-
PEDIATRIC RESPIRATORY CONDITIONS
1. THROAT PROBLEMS: PHARYNGITIS/TONSILITIS
Caused by GABHS
Manifestations:
o
Kissing tonsils
Airway obstruction
Can t be removed if it is inflamed because tonsils are highly
vascular
NO emergency tonsillectomy
Wait till infection is over and swelling is controlled
Management:
o
If (+) GABHS
Antibiotic (penicillin/ erythromycin if with
allergy)
o
Health center: Cotrimoxazole/ Amoxycillin
o
Soft to liquid diet in small frequent feeding
o
Comfort measures:
Safe throat remedies: Calamansi, ginger,
tamarind, breastmilk
Calamansi- not given if with tonsillitis
Warm saline gargle
Antipyretic PRN (NO ASA)
(Acetaminophen) (Biogesic, Tempra,
Tylenol, Calpol)
Gastric upset (earliest)
Tinnitus (few days after intake)
Bleeding (prolonged use)
o
o
Less than 12 years old
Viral infection
Surgery
o
2 criteria: big tonsil which causes dyspnea,
collection of pus, recurrent inflammation 3 times a
year or more
o
Tonsillectomy when on preschool (not in
infants/toddler); planned required surgery; no
incision
Pre-op:
University of Santo Tomas
College of Nursing / JSV
o
Check dental (loose teeth) and bleeding status
(bleeding disorder) - prevent aspiration
Post-op:
o
Prone or Lateral position while asleep
Promote natural drainage of secretion
o
Observe for bleeding
Frequent swallowing and restlessness
o
If bleeding provide kidney basin spit blood
o
Prevent bleeding
Ice collar- vasoconstriction on the are
and decreasing pain
Avoid suctioning, throat clearing
Avoid valsava maneuver- frozen
osteorized papaya
o
Diet resumes once fully awake and can swallow
COLD, CLEAR, NON-IRRITATING
Cool water, ice cold apple juice, frozen
gelatin, suck on frozen popsicle, sherbet
Ice cream NOT ADVISABLE, if given, make
sure child drinks lots of cold water after
Iced cold ginger ale
Then SOFT diet then DAT
No red colored juices
2. SPASMODIC CROUP/LARYNGOTRACHEOBRONCHITIS (LTB)
Etiology: Virus
Manifestations
o
Hoarseness of voice
o
Cough-brassy spasmodic seal like sound,
sucessively
o
Inspiratory stridor
o
Fever
o
Unconsciousness
o
Laryngospasm respiratory distress
Management:
o
Supportive Care
Prevent coughing causing laryngospasm
and respiratory distress
Avoid respiratory irritants and sudden
temperature changes
Feed and hydrate with aspiration
precaution
Decrease demand for oxygen
Administer high humidity with MIST
THERAPY during attacks
Bring child inside steamy
bathroom for 15 minutes
pakulo, ilagay
sa plangana, towel to inhale
Cool mist vaporizer (steam
inhalation)
3. BRONCHIAL ASTHMA
Asthma in children is only acute
Only bronchioles are affected
Condition can be reversed
If chronic
may reach alveoli later on in life
EMPHYSEMA
2 Kinds of Asthma:
o
Extrinsic Asthma- allergen from the outside (food,
environment)
Foods rich in protein, iodine
Foods with artificial colors
Foods with preservatives
o
Intrinsic Asthma- idiopathic/ innert on the patient
Stress
Anxiety
Mechanisms responsible for symptoms:
o
Bronchospasm
o
Inflammation and edema of the airways
Pediatric Nursing
o
Accumulation of tenacious secretions
Complications: ACIDOSIS
Management
o
Allergen control
Skin testing followed by Hyposensitization
(for 3 years)
Supportive Management during exacerbation
o
Administer bronchodilators/ aerosol
o
IVF for hydration and drugs (aminophylline, steroids
for status asthmaticus
o
Position Upright Orthopneic
o
Allay anxiety
o
Promote oral fluids with aspiration precaution
Limit milk
Avoid vitamin C- allergen
o
Promote breathing exercises (purse-lip breathing)
Swimming
4. EPIGLOTTITIS
Air is obstructed
Cause: hemoophilus influenza
Sx: Drooling, dysphonia, dysphagia, child sits upright leaning
forward with chin thrust out (Tripod/sniffing position)
Management
o
Hospitalization ASAP
o
Do not insert anything into the mouth
o
Prepare tracheostomy set at bedside
o
IVF for hydration and antibiotic (Cephalosporin) for
7-10 days
o
Corticosteroid PRN to decrease inflammation
o
Prevention by immunization: H Influenza type B
(Hib) vaccine
Dx
o
Lateral Neck X-Ray
5. PEDIATRIC ASTHMA
PEDIATRIC ASTHMA
Acute
Affects bronchial area only
Good prognosis/Reversible
Cure is possible
ADULT ASTHMA
Chronic (as seen in COPD)
Irreversible
No cure
Remission and
exacerbation
Same causes:
Extrinsic Asthma triggers that produced symptoms (easy to
control)
Intrinsic Asthma caused by the person itself ex. stress, anxiety
Mechanisms responsible for symptoms:
1. Bronchospasm
2. Inflammation and edema of the airwats
3. Accumulation of tenacious secretions
Death due to RESPIRATORY ACIDOSIS
Allergologist
Allergen control skin testing
followed by hyposensitization (for 3
years) to increase tolerance
Mx during Exacerbation
*Administer bronchodilators/aerosol
*IVF drugs (aminophylline, steroids)
*Position: orthopneic position
*Allay anxiety
* Promote oral fluids with aspiration
precaution limit milk, avoid vit C
* Promote breathing exercise (purse
lip breathing)
Status asthmaticus do not respond
to treatment; given steroids
6. RHEUMATIC FEVER
Complication of -strepto infection
Jones Criteria Assessment
Manifestations:
o
Migratory polyarthritis joint pains
o
Chorea (St.Vitus Dance) involuntary jerks/
misconstrued as mannerisms
o
Erythema marginatum rashes on the trunk
o
Subcutaneous nodules on the extensor side
o
Carditis - endocarditis covers the chambers and
forms the valves
o
Mitral valve stenosis
Dx:
o
Jones Criteria plus ASO titer = rheumatic fever
Normal value of ASO (Anti-streptolysin O)
= 0-200 IU
o
Echocardiography if with valve damage (Mitral
valve: stenosis/insufficiency) = rheumatic heart
disease
Management:
o
OBJ 1: Decrease demand from the weakened
heart
CBR/Modify lifestyle after discharge
Cluster care
o
OBJ 2: Prevent further cardiac damage (RHD)
Meds: Penicillin IM once a month for 3-5
days/ASA/Steroids
EMLA patch: lidocaine; numbs the part to
be injected
o
OBJ 3: Safety precaution for chorea
7. KAWASAKI DISEASE
Mucocutaneous lymph node syndrome; fatal and rare
Etiology: unknown
Manifestations:
o
Fever unresponsive to antibiotic, conjunctival
inflammation, strawberry tongue, erythema of
palms and soles with peeling, cervical
lymphadenopathy
o
Most dangerous when coronary artery is involved;
aneurysm formation and risk for rupture
Management:
o
High dose of IV GAMMA GLOBULIN
o
Aspirin
o
Monitor cardiac status. Assess for symptoms of CHF
o
Monitor I&O
o
Comfort measures: skin and mouth care
o
Promote adequate rest
HEMATOLOGIC PROBLEMS
*Aplastic anemia- occupation (rad tech)
1. IRON DEFICIENCY ANEMIA
Above 6 months- at risk for anemia
o
Iron from mother has been used up and due to
overfeeding of milk
Adolescent- due to weight reduction diet and heavy
menstrual loss
University of Santo Tomas
College of Nursing / JSV
Pediatric Nursing
Management
o
Introduction of supplementary/ complementary
feedings at 6 months (one at a time only to rule-out
allergy)
o
Iron rich foods:
Cereals
LUGAW
Potato, Egg yolk
DO NOT GIVE EGG WHITE UNTIL
BABY IS ABOVE 1 YEAR OLD
(ALLERGY)
Dark green leafy vegetable; the darker
the leaves, the higher the iron content
Dark meat (organ meat), beef liver
Iron fortified milk preparation
Supplemental iron preparation (FeSO4)
with Vitamin C
Tell mother that stool turns black
prevents
absorption of iron
Use straw, brush teeth and
tongue
2. HEMOPHILIA
Deficient in Factor VIII (Antihemophilic Factor)
Pattern of transmission is X-linked
Transmitted as X-linked from carrier MOM to AFFECTED SON
(symptomatic)
Daughter gets it as a trait from carrier mom (asymptomatic)
Affected son gives it to daughters as a trait only
Affected sons will have all normal sons
Xa
X
X
X aX
XX
y
X ay
Xy
Xa
X
Xa
Xa Xa
Xa X
y
X ay
Xy
*Impossible to happen
Early Symptom
o
Prolonged bleeding from the umbilical cord
o
Early petechiae
Late Symptoms
o
Easy bruising
o
Easy epistaxis and gum bleeding
o
Hemarthrosis- bleeding in between the ball joints
(pain and swelling)
Given morphine, tramadol, demerol
o
Intracranial hemorrhage major cause of death
Management
o
Medical: Transfusion of Factor VIII, cryoprecipitate,
platelet concentrate
o
Vasopressin (ADH) activates clotting factors
o
Prevent bleeding (avoid trauma)
contact sports
Soft bristled tooth brush
No aspirin
o
Can undergo circumcision, removal of teeth
as
long as Factor VII is ok
o
P- protect (protective devices)
o
R- rest (immobilize)
o
I- ice (vasoconstriction)
o
C- compress (apply pressure)
o
E- elevate (above the heart)
o
S- support (parents, MDs, RNs, dentist, PT, nutritionist,
psychiatric, etc.)
3. LEUKEMIA
Most common form of childhood cancer
University of Santo Tomas
College of Nursing / JSV
Malignant disease of the bone marrow and the lymphatic
system
Imature WBC (lymphoblasts)
increased formation of
lymphoblasts
cancer
Immature WBC not capable of phagocytosis is formed
Lymphocytic
Lymphoblasts from
lymphatic system
Most common in pediatrics
Good prognosis
Myelocytic
Lymphoblasts from myeloid stem cell
(which becomes RBCs, WBCs,
Platelets)
Common in adults
Poor prognosis (6 months- 2 yrs)
3 Primary consequences:
o
Infection, Anemia, Bleeding tendencies
Manifestations: Bone pain
Earliest sx: Intractable infection
Dx:
o
Peripheral blood smear
o
Bone Marrow biopsy (more definitive)
Lumbar puncture
To determine CNS involvement
o
Position: Prone in children
o
Site: Iliac crest
Management (4 phases)
o
Remission Induction
IV (systemic chemotherapy)
Protective isolation
o
CNS Prophylactic/ Sanctuary Therapy
Intrathecal chemotherapy
Sanctuary therapy
o
Intensification/ Consolidation Therapy
Regular systemic and intrethecal chemo
Hairfall
o
Maintenance Therapy combining drug regiment
with periodic CBC, CXR, Lumbar tap
o
2 years of remission is considered cure!
Most ideal: BONE MARROW TRANSPLANT (Most Ideal)
o
Difficult to find a compatible match
o
Should be HLA compatible (Human leukocyte
antigen)
Below 5 years old
o
Death is a form of a sleep; Reversible
o
From fairy tales
6-9 years old
o
Death is a person;reversible
o
Grim Reaper, Bogeyman, Devil monster,
Above 9 years old
o
End of life on earth; Irreversible