Pediatric Nursing - 1 PDF

The Royal Pentagon Review Specialist Inc.
Pediatric Nursing
GROWTH AND DEVELOPMENT

Growing complex phenomenon of a structure or whole
GROWTH
Increase in physical size of a structure or whole
Quantitative
2 parameters
o Weight
Most sensitive measurement for growth
Weight gain:
2x = 5 6 mos.
3x = 1 year
4x = 2 2 years
Height
ESTROGEN responsible for increase in height in female
TESTOSTERONE responsible for the increase in height in male
Stoppage of height coincide with the eruption of the wisdom teeth
- 1/ mo 1 6 mos
- 1.5/ mo 7 12 mos
st
- 50 % - 1 Year
HEIGHT COMPARISON
9 y/o male = female
12 y/o Male < Female
13 y/o Male > Female
DEVELOPMENT
Increase in the skills or capacity to function
Qualitatively
How to measure development
o By simply observing the child doing simple task
o By noting parents description of the childs progress
o Measure by DENVER DEVELOPMENTAL SCREENING TEST (DDST)
MMDST
o Metro Manila Developmental Screening Test
o Philippine Based exam
Main Rated Categories
o LANGUAGE ability to communicate
o PERSONAL/ SOCIAL ability to interact
o FINE MOTOR ADAPTIVE ability to use hand movements
o GROSS MOTOR SKILLS ability to use large body movements
MATURATION
Synonymous with development
Readiness/ learning is effortless
Jomar Anthony D. Maxion, BSN, RN
PLM BSN 2006
Pediatric Nursing
COGNITIVE DEVELOPMENT
Ability to learn and understand from experiences, to acquire and retain knowledge, to
respond to a new situation and to solve problems
LEARNING change of behavior
IQ= [Mental Age/ Chronological Age] x 100
Normal IQ = 90 - 110
GIFTED CHILD > 130 IQ level
BASIC DIVISIONS OF LIFE
Prenatal
o Conception to birth
Infancy
o Neonatal first 28 days
o Formal Infancy 29th 1 year
Early Childhood
o Toddler 1 3 y/o
o Preschool 4 6 y/o
Middle Childhood
o School Age 7 12 y/o
Late Childhood
o Pre adolescent 11 13 y/o
o Adolescent 12 13 y/o to 21
PRINCIPLES OF GROWTH AND DEVELOPMENT
Growth and development is a continuous process (WOMB TO TOMB PRINCIPLE)
begins from conception and ends with death
Not all parts of the body grows at the same time or at the same rate
(ASSYCHRONOUS GROWTH)
Each child is unique
Growth and development occurs in a regular direction reflecting definite and
predictable patterns or trends
o Directional Terms
Cephalocaudal/ Head to Tail
It occurs along bodies long axis in which control over head,
mouth and eye movemens and precedes control over upper
body torso and legs
Proximo Distal/ Centro Distal
Progressing from center of the body to the extremities
Symmetrical/ Each side of the Body
Develop at the same direction at the same time and at the
same rate
Mass Specific
Differentiation SIMPLE TO COMPLEX; BROAD TO
REFINED
o Sequential Trend
Involves a predictable sequence of growth and development to which
the child normally passes
Locomotion
Creeps Stands Walks Run
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Language and Social Skills

Cry coo
Secular Trend
Refers to the worldwide tend of maturing earlier and growing larger as
compared to succeeding generation
BEHAVIOR most comprehensive indicator of developmental stages

o act @ your age
PLAY universal language
A great deal of skills is learned by practice
There is optimum time for initiation of experience or learning
Neonatal reflexes must be lost first before development can proceed
o persistent primitive infantile reflexes is a possible case of cerebral palsy
PATTERNS OF GROWTH AND DEVELOPMENT

Renal digestive circulatory musculoskeletal
o childhood
Brain CNS Neurologic Tissue rapidly grows with in 1 2 years
o Brain achieves its adult proportion @ 5 years
o Rapid growth and development of brain from1 2 years
o Malnutrition may result to Mild Mental Retardation
Lymphatic System (Lymph Nodes)
o Grows rapidly during infancy and childhood
o Provide protection against infection
o TONSIL reach its adult proportion @ 5 years
Reproductive
o Grows rapidly during puberty
RATES OF GROWTH AND DEVELOPMENT
Fetal and Infancy
o Period of most rapid growth and development
o Prone to develop anemia
Toddler
o Period of slow growth and development
Toddler and preschool
o Period of alternating rapid and slow growth and development
School Aged
o Slower growth and development
o Least to develop anemia
Adolescent
o Period of rapid growth
o Secondary prone to anemia
Two Primary Factors Affecting Growth and Development
Heredity
o Race
o Sex
o Intelligence
o Nationality
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Environment
o Quality of Nutrition
o Socio Economic Status
o Health
o Ordinal Position in the family
o Parent Child Relationship
*Universal Principle: F are born < wt. than M by 1 oz.; F are born < lt. than M by 1 in.
THEORIES OF DEVELOPMENT
Developmental Task
A skill or growth responsibility arising at a particular time in the individuals life.
The successful achievement of which will provide a foundation for the
accomplishments of the future tasks
SIGMUND FREUDS PSYCHOSEXUAL THEORY
1856 1939
An Austrian Neurologist
Founder of Psychoanalysis
1st to introduce Personality Development
Phase
Age
Site of
Activities
Gratificati
on
Oral
0 18
Mouth
Biting
Phase
mos.
Crying
Sucking
(enjoyment
and release
of tension)
Anal
19 mos.
Anus
Elimination
Phase
3 yrs.
Retention/
(stage
Defecation of
where
Feces
OC are
develop
ed)
Phallic
Phase
4 6 yrs.
Genital
May show
exhibitionism
Task
Provide oral stimulation even if
baby is place NPO (use
pacifier)CBQ
Never discourage thumb sucking
Help the child achieve bowel and
bladder control even if the child
is hospitalized
Principle of holding on and
letting go
Mother wins or child wins
Child Wins
o Holding on
o Child turns to be
hardheaded, antisocial,
stubborn, unreliable,
irresponsible
Mother Wins
o Letting go
o Child turns to be kind,
obedient, perfectionist
o Meticulous, OCs, reliable,
responsible
Accept the child fondling his own
genetalia as normal area of
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Have or
increase
knowledge of
2 sexes
Latent
Phase
7 12 yrs.
School
aged
Genital
Phase
12 18 yrs
Genitalia
Period of
suppression
No obvious
development,
slower
growth
Childs
energy or
Libido is
diverted into
more
concrete type
of thinking
Achieve
sexual
maturity and
learn to
establish
satisfactory
relationship
with the
opposite sex
Pediatric Nursing
exploration
Divert attention from
masturbation
Answer the childs question
directly
Human sexuality
Help the child achieve (+)
experiences so that hell be
ready to face the conflicts of
adolescents
Give opportunity to relate to

opposite sex
ERIK ERICKSONS STAGES OF PSYCHOSOCIAL THEORY

Former student of Freud
Stresses the importance of culture and society to the development of ones
personality
environment
1. Trust vs. Mistrust
0 18 months
TRUST is the foundation of all psychosocial tasks
Theme: Give and Receive
Trust is developed via
o Satisfying needs of infants on time
o Care must be consistent and adequate
o Give experiences that will add security
Hugs, kisses, touch, eye to eye contact, soft music
2. Autonomy vs. Shame & Doubt
18 mos. to 3 years
Theme: independence and self government
Give opportunity for decision making, offer choices
Encourage the child to make decision rather than judge
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Parents has a moral obligations to set limits

3. Initiative vs. Guilt
4 6 years old
Learns how to do BASIC things
Give opportunity exploring new places and events
Right time for amusement park and zoos
Activity recommended: modeling clay and finger painting
Enhances creativity and imagination and facilitates fine motor
development
4. Industry vs. Inferiority
7 12 years old
Learns how to do things well
Give appropriate short assignments and projects
Unfinished project will develop inferiority
5. Identity vs. Role Confusion
12 18 or 20 years old
Learns who he is or what kind of person he will become by adjusting to new body
image and seeking EMANCIPATION/ freedom from parents
6. Intimacy vs. Isolation
18 25 or 30 years old
Career focus
Looking for a lifetime partner
7. Generativity vs. Stagnation
30 45 years old
8. Ego Integrity vs. Despair
45 years old and above
JEAN PIAGETS STAGES OF COGNITIVE DEVELOPMENT
Reasoning powers
Swiss Psychologist
Genetic Epistemologist
1. Sensorimotor
0 2 years old
Also called Practical Intelligence
o words and symbols are not yet available
o communication through senses
1. Schema 1: Neonatal Reflex
o 1 month
o Early reflexes
2. Schema 2: Primary Circular Reaction
o 1 4 months
o Activities related to body; repetition of behavior
Example: thumbsucking
3. Schema 3: Secondary Circular Behavior
o 4 8 months
o Activities not related to the body
o Discover person and objects permanence
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o Memory traces are present and anticipate familiar events

4. Schema 4: Coordination of Secondary Reaction
o 8 12 months
o Exhibit goal directed behavior
o sense of permanence and separateness
o Play activities: Throw and retrieve
5. Schema 5: Tertiary Circular Reaction
o 12 18 months
o use trial and error to discover characteristic of places and events
o Invention of new means
o capable of space and time perception
6. Schema 6: Invention of New Means thru Mental Coordination
o 18 24 months
o Symbolic representation
o Transitional phase to the pre-operational thought period
2. Pre-operational Thought
1. Pre conceptual Thought
o 2 4 years old
o Concrete, literal, static thinking
o CBQ EGOCENTRIC unable to view anothers viewpoint
o CBQ (-) REVERSIBILITY in every action there is opposite reaction; cause
and effect
o Concept of time is only now and concept of distance is only as far as they can
see
o CBQ ANIMISM consider inanimate object as alive
2. Intuitive Thought
o Beginning of causation
3. Concrete Operational
o 7 12 years old
o SYSTEMATIC REASONING as solution to problems
o Concept of (+) reversibility
o Concept of Conservation constancy despite of transformation
o Activity recommended: Collecting and Classifying
4. Formal Operational
o 12 years old and above
o Period when cognition achieve its final form
o Can solve hypothetical problem with SCIENTIFIC REASONING
o Can deal with past, present and future
o Capable of ABSTRACT, mature thought and formal reasoning
o Activity recommended: talk time; focus on opinions and current events
KOHLBERGS THEORY OF MORAL DEVELOPMENT
Recognized the theory of moral development as considered to closely approximate
cognitive stages of development
Stages of Moral Development
o Infancy
o Premoral
o Amoral
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o
Age
Pediatric Nursing
Pre-religious
Stage
0 3 yrs
4 7 yrs.
4 10 yrs.
10 12
yrs.
Older than
12
Descritption
PRECONVENTIONAL (Level I)
PUNISHMENT/ OBEDIENCE/ ORIENTATION
o Heteronomous morality
o Child does right because PARENT tells him to and to avoid
punishment
INDIVIDUALISM
o Instrumental purpose and exchange
o Carries out action to satisfy own needs rather than society
o Will do something for another if that person does something
for the child
CONVENTIONAL (Level II)
ORIENTATION TO INTERPERSONAL RELATIONS OF
MUTUALITY
o Child follows rules because of need to be a good person in
own eyes and eyes of others
MAINTAINANCE OF SOCIAL ORDER, FIXED RULES AND
AUTHORITY
o Child finds following rules satisfying
o Following rules of authority figures as well as parents in an
effort to keep the system working
POST CONVENTIONAL (Level III)
SOCIAL CONTRACT, UTILITARIAN LAW MAKING
PERSPECTIVE
o Follows standards of society for the good of the people
UNIVERSAL ETHICAL PRINCIPLE ORIENTATION
o Follows internalized standards of conduct
o Only few people achieved this level
o Only saints and holy
DEVELOPMENTAL MILESTONES
Major marker of growth and development
Determines developmental delays
TEETH QUESTIONS
6 mos.
Eruption of first temporary teeth 2 LOWER CENTRAL INCISORS
30 mos.
Temporary teeth complete
20 decidous teeth
POSTERIOR MOLAR --> last to appear
Time to go to Dentist
Begins to brush teeth
3 years
Tooth brushing with minimal supervision
6 years
Tooth brushing alone
Temporary teeth begins to fail
1st permanent teeth 1st MOLAR
Last to appear WISDOM TOOTH
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BOWEL/ BLADDER CONTROL

Bowel Control
18 months / 1 years
Day Time Bladder Control
2 years
Night Time Bladder Control 3 years
MILESTONES
Infancy
Solitary play
o Consider when choosing a play
Safety
Age appropriateness
Hygiene
Fear: Stranger Anxiety
o Begins: 6 7 months
o Peaks: 8 months
o Diminishes: 9 months
Neonate
Complete head lag
Largely reflex visual fixation for human face
Hands fisted with thumbs in
Cries without tears because lacrimal glands are not fully developed
1 month
Dance reflex disappears
Looks at mobile; follows midline
Alert to sound, regards face
2 months
Holds head up when in prone
Social smile, cries with tears, cooing sound
Closure of posterior fontanel (2-3 months)
Head lag when pulled to sitting position
No longer clinches fist tightly
Follows object past midline
Recognizes parents
3 months
Holds head and chest up when in prone
Holds hands open at rest
Hand regard, follows object past midline
Grasp and tonic neck reflexes are fading
Reaches for familiar people or object
Anticipates feeding
4 months
Head control complete
Turns front to back; needs space to turn
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Laughs aloud; Babbling sound

Babinski Reflex disappears
5 months
Turn both ways (roll over)
Teething rings, handles rattle well
Moro reflex disappears (5 6 months)
Enjoys looking around environment
6 months
Reaches out in the anticipation of being picked- up
Sits with support
Puts feet in mouth in supine position
Eruption of first temporary teeth ( Lower 2 central incisors)
Vowel sounds ah, eh
Uses palmar grasp; handless bottle well
Recognizes strangers
7 months
Transfer objects from hand to hand (6 7 months)
Likes objects that are good sized for transferring
8 months
Sits without support
Peak of stranger anxiety
Plantar reflex disappear (6-8 months)
9 months
Creeps or crawls; need space for creeping
Neat pincer grasp reflex, probes with forefinger
Finger feeds, combine 2 syllables mama & dada
10 months
Pulls self to stand
Understand the word no
Respond to name
Peek a boo, pat a cake, since they can clap
11 months
Cruising, stand with assistance
Walking while holding to his cribs handle
One word other than mama and dada
12 months
Stands alone
Walk with assistance
Drink from cup, cooperates in dressing
Says two words other than mama and dada
Pots & pans, pull toys and nursery rhymes
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Imitates actions, comes when called

Follows one step command and gesture
Uses mature pincer graps, throws objects
Toddlerhood
Parallel Play 2 toddlers playing separately
Provide 2 similar toys for 2 toddlers
Toys
o Squeaky frogs to squeeze
o Waddling ducks to pull
o Trucks to push
o Building blocks
o Pounding peg
Fear: Separation Anxiety
o Begins: 9 months
o Peaks: 18 months
o 3 stages
Protest
Despair
Denial
o Prevent:
Do not prolong goodbye
Say goodbye firmly
Say when youre back
Toddler Characteristic Traits
Negativistic: says no most of the time
Saying no way of developing independence
Limit questions, offer choices
Rigid, ritualistic and stereotyped
Ritualistic way to gain mastery
Temper Tantrums
o Stomping of feet
o Holding breath
o Screaming
o Head banging
o NC: Ignore the behavior
Scaphoid abdomen underveloped abdominal muscle
Physiologic Anorexia food fad, food jag that last for a short period of time due to
the preoccupation to environment
15 Months
Plateau stage
CBQ WALKS ALONE lateness in walking is a sign of mild mental retardation
Puts small pellets into small bottle
Creep upstairs
4 6 words
Scribbles voluntarily with pencil, holds spoon well, seat self in a chair
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18 Months
Height of POSSESIVENESS favorite word MINE
Bowel control achieved
No longer rotates a spoon
Can run and jump in place
Walks up and downstairs holding on to a persons hand or railing, typically places
both feet on one step before advancing
Names one body part
24 months
TERRIBLE TWOS
Turns pages one at a time, removes shoes, pants, etc
Can open doors by turning door knobs, unscrew lids
50 200 words (2 word sentences), knows 5 body parts
Walk upstairs alone, still using feet on the same step at same time
Daytime Bladder Control
CBQ best time to bring the child to dentist: 2 3 years or when temporary teeth is
complete
30 months
Makes simple lines or stroke or crosses with pencil
Can jump down from chair
Knows full name, holds up finger to show age
Copy a circle
CBQ Temporary teeth complete (posterior molar: last to erupt)
CBQ 20 deciduous teeth
CBQ tooth brushing: 2 3 years
36 months
TRUSTING THREES
Tooth brushing with little supervision
Unbutton buttons
Draws a cross, learns how to share
Knows full name and sex
Speaks fluently, 200 900 words
NIGHTIME BLADDER CONTROL achieved
Rides tricycle
Preschoolers
Cooperative play playhouse
Role playing is usual
Fears:
o Castration/ Body Mutilation
o Dark places and witches
o Thunder and lightning
o Ghost
Curious, creative, imaginative and imitative
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Preschoolers Characteristic Traits

Telling tall tales
Imaginary friend way of relieving tension and anxiety
Sibling rivalry jealousy to a newly delivered baby
Regression
o Signs: bedwetting
o Thumbsucking
o Baby talk
o Fetal position
Masturbation
o Sign of boredom
o Divert attention
o Offering toy
4 years old
FURIOUS FOUR
Noisy, aggressive and stormy
Buttons button
Copy square
Catches ball, jumps, skips
Alternates feet going downstairs
CBQ LACES SHOES
Vocabulary of 1500, knows the basic color
Says song or poem from memory
5 years old
FRUSTRATING FIVES
Jumps over low obstacles
Spreads with a knife
Draws 6 part man, copy triangle
Imaginary playmates
2100 words
Identification with same sex
Attachment to opposite sex
School Aged
Competitive Play: Tug of war
Fears
o School Phobia orienting child to his new environment
o Displacement from school
o Death
Significant Person
o Teacher
o Peer of same sex
Stoppage of height coincide with the eruption of wisdom tooth
Prone to fracture: Common Green stick
Mature vision
o 20/200 legal blindness
Theyll Cheat cant afford to lose
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6 years old
Temporary teeth begins to fall, permanent teeth begins to appear (1st: First Molar)
Tooth brushing alone
A year of continuous motion, clumsy moving
1st grade teacher becomes authority figure
o nail biting sign of strict teacher
Beginning interest with God
7 years old
Age of assimilation
Copies a diamond
Enjoys teasing and playing alone
Quieting down phase
8 years old
Expansive age
Smoother movements
Normal homosexual
Loves to collexct objects
Counts backwards
9 years old
Coordination improves
Tells time correctly
Hero worship
Stealing and lying are common
Takes care of body needs completely
Teachers find their group difficult to handle
10 years old
Age of special talents
Write legibly
Ready for competitive games
More considerate and cooperative
Joins organizations
Well mannered with adults and critical with adults
11 12 years old
Pre adolescent
Full of energy and constantly active
Secret languages are common
Share secrets with friends
Sense of humor is present
Social and coopoerative
School Aged Characteristic Traits
Industrious
Modest
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Signs of Sexual Maturity in Female

I ncrease in size of breast and genitalia telarche 1st sign
W idening of hips
A ppearance of pubic axilliary and pubic hair - adrenarche
M enarche last sign
Signs of Sexual Maturity in Male
A ppearance of axilliary and pubic hair
D eepening of voice
D evelopment of muscle
I ncrease in size of penis and scrotum 1st sign
P roduction of viable sperm last sign
Adolescence
Fear
o Acne
o Obesity
o Homosexuality
o Death
o Replacement from friends
Peer of opposite sex significant other
Experiences conflicts between his needs for sexual satisfaction and societal
expectations
Core Concern
o Change of body image
o Acceptance of the opposite sex
Nocturnal Emission: Wet dreams
o Hallmark of adolescence
CBQ distinctive odor due to stimulation of apocrine gland
Testes and scrotum increases until age 17
Sperm is viable by age 17
Breast of female and genitalia increases until age 18
Signs of sexual maturity
Characteristic traits
o Idealistic, rebellious, reformers
o Parent child conflict
o Very conscious with body image
o Peer pressure
Problems
o Vehicular accident
o Smoking
o Alcoholism
o Drug Addiction
o Pre Marital Sex
Concept of Death
6 years old death is reversible
CBQ 7 9 years old personification of death, permanent loss of the corporal life
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IMMEDIATE CARE OF THE NEWBORN

8 PRIORITIES OF THE NEWBORN IN THE FIRST DAYS OF LIFE
1. Initiation and maintenance of respiration
2. Establishment of extrauterine circulation
3. Control of body temperature
4. Intake of adequate nutrition
5. Establishment of waste elimination
6. Prevention of infection
7. Establishment of an infant parent relationship
8. Developmental care that balance rest and stimulation for mental developmental
INITIATION & MAINTENANCE OF RESPIRATION
Alerts!
Expulsion is @ 2nd stage of labor
Most neonatal deaths w/in the first 24 hours is due to INABILITY TO INITIATE
AIRWAY
Lung function begins only after birth
How?
Support head and remove secretion
Proper suctioning with a catheter
o Place babys head to side facilitates drainage
o Suction the mouth first before nose newborns are nose breathers
o Period of 5 10 seconds, should be gentle and quick
Prolonged suctioning can cause hypoxia, laryngospasm and
bradycardia due to vagal nerve stimulation
o Evaluate patency
Cover 1 nostril, if newborn struggles, additional suctioning needed
If not effective requires effective LARYNGOSCOPY to open airway. After deep
suctioning, and ET tube can be inserted and O2 administration by (+) Pressure Bag
and mask with 100% O2 @ 40 60 bpm
Alerts in O2 Administration
No Smoking O2 is combustible
Must be humidified prevent drying of mucosa
Cover the nose and mouth only
Scarring Retina results Retinopathy (O2 overdose)
Meconium Stain never administer O2 with pressure causes atelactasis
ESTABLISHMENT OF EXTRAUTERINE CIRCULATION
Alerts!
Circulation id initiated by LUNG EXPANSION and PULMONARY VENTILATION
Completed by cutting the cord
Assess characteristics of cry
o Normal strong, vigorous, lusty cry
o Hypoglycemia/ Increased ICP high pitched, small cry
o Never stimulate crying before all secretion are remove to prevent aspiration
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Feto Placental Circulation

Placenta O2 carried by vein liver Inferior Vena Cava Right atrium 70%
goes to Foramen Ovale Remaining 30 tricuspid valve right ventricle
pulmonary artery lungs for nutrition vasoconstriction of lung tissue pushes the
blood to DUCTOS VENOSUS supply extremities 2 arteries carry unO2 Blood
back placenta
Ways to facilitate closure of Foramen Ovale
Tangential Footslap
o Cry expands lung pressure from left to right side of the heart
Proper positioning of the Baby
o Right side lying position pressure on left side of heart facilitating closure
Best Position immediately after Birth
CS supine, crib level position
NSD
Structure
Foramen Ovale
Appropriate
Time of
Obliteration
1 year
Complete
Closure
Ductus
Arteriosus
1 month
Ductus Venosus
Umbilical
Arteries
Umbilical Vein
2
2 3 month
W/in 24 hrs
completed 1
month
W/in 24 hrs
completed 1
month
2 3 months
2 3 months
2 3 months
2 3 months
Structure Remaining
Failure to
Close
Fossa Ovalis
Atrial
Septal
Defect
Patent
Ductus
Arteriosus
Ligamentum
Arteriosum
Ligamentum Venosum
Lateral Umbilical Artery
(Intrerior Iliac Artery)
Ligamentum Teres
(Round ligament of the
liver)
Signs of Increased ICP

Abnormal large head
Bulged & tensed fontanel
Projectile Vomiting surest sign of cerebral irritation
Cushing Triad of ICP
o BP
o PR
o RR
High pitched, shrill cry
Dilopia normal in newborns, sign of ICP in older children
CONTROL OF BODY TEMPERATURE/ TEMPERATURE REGULATION
Alerts!
The goal of temperature regulation is to maintain Temperature not less than 97.7 F
or 36.7 C
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Pediatric Nursing
Factors leading to the development of Hypothermia

Preterm are born POIKILOTHERMIC (easily adapt the temperature of environment
due to immaturity of thermo regulating center of the body HYPOTHALAMUS)
Inadequate subcutaneous tissues
Newborn are not yet capable of shivering
Newborns are wet
Process of Heat Loss
Evaporation body to air
Conduction body to solid objects (cold compress)
Convection body to a cooler surrounding object (fever, aircon)
Radiation body to a cold subject not in contact with the body (thermal shift)
Effects of Hypothermia (COLD STRESS)
RR first sign of hypothermia
Hypoglycemia due to utilization of glucose
o Normal 45 55 mg/ dl
o Average/ borderline 40 mg/ dl
Metabolic Acidosis due to the catabolism of BROWN FAT (vest-like, best
insulators of newborns) leading to the formation of ketone bodies
High risk for KERNICTERUS (bilirubin in the brain)
Additional fatigue added to already stressful heart
Prevention of Cold Stress
Dry and wrap the newborn
Mechanical measures ( radiant warmer, acrylic sided incubator)
Prevent unecesarry exposure cover areas not being examined
In case of no electricity
o Cover baby with thin foil
o Skin to skin contact human blanket/ kangaroo care
ESTABLISHING ADEQUATE NUTRITION
Breastfeeding
Best time
NSD ASAP
CS after 4 hours
Physiology of Breastmilk Production
Estrogen, Progesterone releases PROLACTIN acts on ACINAR/ ALVEOLI CELLS
produces FOREMILK store in LACTIFEROUS TUBULES/ COLLECTING TUBULES
Sucking stimulates posterior pituitary gland release oxytocin causes Contraction of
smooth muscles of Lactiferous Tubules milk ejection reflex let down reflex
Advantages of Breastfeeding
Economical
Promotes bonding
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Pediatric Nursing
Contains LACTOBACILLUS BIFIDUS interfere the attack of pathogenic bacteria

in the GIT
Helps in early involution of uterus oxytocin causes contraction
Always available
Incidence of breast cancer
Breastfed babies have higher IQ than bottle fed ones
Antibody IgA
Macrophages
Disadvantages of Breastfeeding
No iron
Possibility of transfer of Hepa B, HIV, CMV (13 39% possibility)
Father cant bond with the mother and baby instead, father can sing, suddle, kiss,
put baby to sleep
Alerts!
Freezer good for 6 mos./ dont reheat
Should be stored in a sterile plastic container
Pre Colostrums 6 weeks
Colostrums 3
Stages of Breastmilk
COLOSTRUM
o Present 2 4 days
o Contents
fats
CHO
Immunoglobulin
protein
fat soluble vitamin
minerals
TRANSITIONAL MILK
o Present 4 14 days
o Contents
Lactose
minerals
water soluble vitamins
o Lactose Intolerance deficiency in enzyme
Lactase responsible for digestion of Lactose sour milk/ smelling
of stool
MATURE MILK
o Present 14 days and above
o Contents
Linoleic Acid responsible for the development of brain and
integrity of skin
CHO (Lactose)
Protein (lactabulmin)
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Pediatric Nursing
COWS MILK
fats almost similar to mature milk
Causes constipation
Content
o fats
o CHO add sugar
o CHON casein hard to digest
o Minerals (has traumatic effect to kidneys of babies)
o PHOSPHORUS ( causes inversely proportional effect of Calcium
water to prevent kidney stones
Health Teachings
1. Proper Hygiene
Hand washing, clean areola with cotton and water or NSS
Cleanse the area with CAKE COLOSTRUM
2. Position while Breastfeeding
Upright Sitting (best position)
3. Stimulate and Evaluate Feeding Reflexes
Rooting Reflexes
o Stimulate by touching the side of the cheek or side of flip then the
baby will turn to the syimulus
o Purpose: to look for food
o Disappear by 6th weeks
Sucking Reflexes
o Stimulate the middle part of the lips and the baby will suck
o Disappear by 6 months
Swallowing Reflexes
o When the food touches the posterior part of the tongue, the baby
will automatically swallow
o Never disappears
Extrusion Reflexes
o When food touches anterior part of tounge, it will extrude/ protrude
o Purpose: prevent poisoning
o Disappears @ 4 moths
4. Criteria for effective sucking
Babys mouth is hiked well up @ areola
Mother experiences after pain sign of releasing oxytocin thereby
contracting uterus
The other nipple is also flowing with milk
5. To prevent from crack nipples and initiate proper production of oxytocin
Begin initially for 2 3 mins/ breast
the time 1 min/ breast/ day until it reaches 10 minutes/ breast/ feeding
or 20 min/ feeding
6. For proper emptying and continuous milk production per feeding
Feed the baby at the last breast that you fed him/ her
Problems experience in Breastfeeding
ENGORGEMENT
o Feeling of fullness and tension in the breast (3rd Day)
PLM BSN 2006
o
o
Pediatric Nursing
Breastfeeding mother apply warm compress

Bottle Feeding apply cold compress, wear supportive bra
SORE NIPPLE/ CRACK NIPPLE

o Crack, red, painful nipple
o Causes
Breastfeeding @ one side only
Unhealthy sexual practices
o Management
Breastfed using the unaffected side
Manually express milk @ affected side
Antibiotic (continue breastfeeding)
MASTITIS
o Inflammation of breast
o Causative Agent: STAPHYLOCOCCUS AUREUS
o Management
Avoid wearing lined/ wired bra
o 4 weeks Breast Involution
Contraindications for Breastfeeding

Maternal Conditions
o HIV
o Hepa B
o CMV
o Coumadin/ Warfarin taking moms give heparin instead
Newborn Conditions
o Erythroblastocis Fetalis
o Inborn errors of metabolism
Hydrofetalis
Phenylketonuria
Galactosemia
Tay- Sachs Diseas
ESTABLISHMENT OF WASTE ELIMINATION
GIT Obstructions
Hirshsprung Disease
Imperforate Anus
Meconium Ileus (common with Cystic Fibrosis)
Different Stools
MECONIUM/ PHYSIOLOGIC STOOL
o Blackish green
o Odorless (sterile intestine)
o Normally passed within 24 hours
o Tar like
o Sticky
TRANSITIONAL STOOL
PLM BSN 2006
o
o
o
o
Pediatric Nursing
Present 4 14 days
Green
Loose
Slimy that may appear like diarrhea to the untrained eyes
BREASTFED STOOL
o Golden yellow
o Occur almost nearly after feeding
o With sour milk smell
o Mushy
o Soft
BOTTLEFED STOOL
o Pale yellow
o Hard due to casein
o Formed
o Typically offensive odor
o Seldom passed 2 3 days
INDICATION OF STOOL CHANGES
Light Stool
With jaundice
Bright Green
Under phototherapy
Mucus mixed
Milk Allergy
Clay Colored
Bile Duct Obstruction
Black
GIT Hemorrhage
Blood Flecked
Anal Fissure
Curant Jelly
Intussuception
Fatty, bulky, foul
Suspect malabsorption
smelling/ Steatorrhea
syndrome/ Cystic Fibrosis/
Celiac Disease
Ribbon like
Hirshsprung disease
ASSESSMENT OF WELL BEING

Apgar Scoring
Virginia Apgar
Special Consideration
1st 1 minute determines general coneral condition of the baby
Next 5 Minute determines the capability of the baby to adjust extrauterinely (most
important)
Next 15 minutes optional depndent on the 5 minutes apgar score
Components
A ppearance
P ulse Rate
G rimace
A ctivity
R espiration
Color upon birth is slightly cyanotic

After first cry baby will be pink
Take apical pulse at the lower left nipple
Determines reflex irritability using tangential foot slap and catheter
insertion
To determine the degree of muscle tone
PLM BSN 2006
Pediatric Nursing
Newborns will cry within 30 seconds upon expulsion

ASPHYXIA NEONATORUM failure to cry within 30 seconds because mother received
Demerol
NARCAN antidote of Demerol
APGAR SCORING
Criteria
0
Heart Rate
Absent
Respiratory Effort
Absent
Muscle Tone
Flaccid Extremities
Reflex Irritability
Catheter
No Response
Tangential FS
No Response
Color
Blue / Pale
High score means healthy baby
Score
1
< 100
Slow RR/ Weak
Some reflexes
2
> 100
Good strong cry
Well Flexed
Grimace
Grimace
Acrocyanosis
Cough or sneeze
Cry
Pink
Interpretation
0-3
Severely depressed
Needs CPR
Admission at NICU
4-6
Moderate depression
Additional suctioning
7 10
Good and healthy
CARDIOPULMONARY RESUSCITATION
CPCR cardiopulmonary and cerebral resuscitation
5 minutes of 02 deprivation will cause irreversible brain damage
Priority: Airway, Breathing, Circulation
AIRWAY
Clear the airway
Shake the baby
If no response, call help
Immediately do 1 minute CPR before calling for help
Flat on bed, put a board if the bed is soft
Head tilt chin lift maneuver
No head tilt for suspect of cervical damage
Overextension may cause occlusion
BREATHING
Ventilating the lungs
Check breathlessness
If breathless give 2 breaths
PLM BSN 2006
Pediatric Nursing
If newborn mouth and nose

If child mouth and pinch the nose
Force puff only
Use one way mask to prevent contact with the secretion
CIRCULATION
By cardiac compression
Check if pulseless
Use brachial pulse children
No breath + No pulse CPR
Infant 1 finger breadth below nipple line, 2 finger
1 year old heal of the palm
CPR RATIO
Adult 2:15
Infant 1:5
REPIRATORY EVALUATION (SILVERMAN ANDERSON INDEX)
Criteria
Chest movement
Intercoastal retraction
Xiphoid Retraction
Nares dilatation
Expiratory Grunt
0
Synchronized
No retraction
No retraction
No dilatation
None
Score
1
Long on inspiration
Just visible
Just visible
Minimal
Heard by stet only
2
See-saw
Marked
Marked
Marked
Heard by ear
Low score means Good condition of the baby

Interpretation
0 3 normal, no RDS
4 6 with moderate RDS
7 10 with severe RDS
ASSESSMENT OF GESTATIONAL AGE (Ballard and Dubowitz)
Score
Criteria
Less 36 weeks
37 38 Weeks
Sole creases
Anterior transverse
Occasional 2/3
only
Breast nodule (dm) 2 mm
4 mm (3 5 cm)
Scalp Hair
Fine and fuzzy
Fine and fuzzy
Ear Lobe
Pliable
Some
Testes and
In lower canal,
Some intermediate
Scrotom
covered testes with
rugae
39 weeks and up
Sole cover with
crease
7 mm (>5cm)
Course and silky
Thick
Testes pendulous,
scrotum full,
extensive rugae
PRETERM BABIES
babies delivered after 20 weeks and before 37 weeks
sign of preterm less 36 weeks according to Ballatrd and Dubowitz
plus frog legs or lax position
PLM BSN 2006
Pediatric Nursing
Hypotonic prone to repiratory infection

There is a Scarf Sign elbow passes midline
Square window wrist 90 deg. Angle
Heal to ear sign
Anterior traverse crease
Abundant lanugo
Prominent labia minora and clitoris
POST TERM BABIES

Delivered after 42 weeks
Old mans face classic sign
Desquamation pealing of skin
Long and brittle fingernails
Wide and alert eyes
NEONATES IN THE NURSERY
Nursing Responsibilities upon Receiving the Baby
1. Proper identification
o Foot print of the baby and the thumb mark of the mother
2. Take anthropometrics measurement
o Length
19. 5 21 inches
Ave: 20 inches
47.5 53 cm
Ave: 50 cm.
o Head Circumference
13 14 inches
33 35 cm
Ave: 34 cm
o Chest Circumference
12 13 inches
31 33 cm
Ave: 32 cm
o Abdominal Circumference
12 13 inches
31 33 inches
Ave: 32 cm
3. Bathing the baby
o Give oil Bath
To cleanse the baby and spread the vernix caseosa
2 functions of vernix caseosa
insulator
bacteriostatic
o Full bath is given when cord falls off
o Babies of HIV + mothers will be given a full bath immediately after the birth to
lessen the transmission of HIV
4. Dressing the Umbilical Cord
o Strict asepsis to prevent tetanus neonatorum that is why mothers are given
tetanus toxoid while pregnant
CHN 3 Cleans
Hand
Surface
Cord
o Betadine (Povidone Iodine)
PLM BSN 2006
Pediatric Nursing
Check 3 vessels (AVA)

If only 2 vessels is seen suspect that the baby has a kidney
malformation
1 inch above the base of the cord when cutting
But if IV infusion or blood transfusion is going to be given to the
newborn, leave at least 8 inches of the umbilical cord
Umbilical cord is the best site for IV and blood transfusion because it
has no nerve and no pain
OMPHALAGIA bleeding of the cord for more than 30 cc, suspect
hemophilia
The umbilical cord turns black by the 3rd day and falls of 7 10th day
UMBILICAL GRANULATION failure of the cord to fall after 2
weeks without foul odor, bring the baby to the hospital and will be
given Silver Nitrate or will be cauterized
Clean the umbilical cord with saline or 70% alcohol
It should be dry
PATENT URACHUS itf the cord is always moist, suspect a fistula
between the bladder and the umbilicus, do NITRAZINE PAPER TEST
(+ for urine if it turns yellow)
5. Credes Prophylaxis
o Purpose: to prevent opthalmia neonatorum or gonnorheal conjeunctivitis
o If mother has an untreated gonorrhea and passed the baby vaginally
o ERYTHROMYCIN OPTHALMIC OINTMENT drug of choice, inner to outer
canthus
o Before 1989 2 drops of 2% silver nitrate at lower conujunctival sac
o It should be washed immediately after 1 minute to prevent burning
6. Administration of Vitamin K
o Purpose: to prevent hemorrhage related o physiologic hypoprothrobinemia
o Other name
Aquamephyton, Phytomenadone, Konakion
0.5 10.5 mg IM @ vastus lateralis or lateral anterior thigh
o Preterm give 0.5 mg
o Vit. K is synthesized at the intestine
o On the 7th day, there is prothrombin
7. Weight Taking
o Normal Weight
3000 3400 gm
3 3.4 kg
6.5 7.5 lbs
o Arbitrary Lowe Limit 2,500 grams
o Low Birth Weight
< 2,500 g
it is not the same for gestational age
o Small for Gestational Age
Less than the 10th % rank
o Large for Gestational Age
> 90% rank
Macrosomia baby delivered 4,000 g or 4 kilos
Diabetic mother
o Appropriate for Gestational Age
PLM BSN 2006
Pediatric Nursing
Physiologic Weight Loss

5 10% physiologic weight loss 10th days after birth
PHYSICAL EXAMINATION AND DEVIATION FROM THE NORMAL

Important Consideration
If the client is a newborn, cover areas that is not being examined (prevent
hypothermia)
If the client is an infant, he first vital sign to take is the RR because of fear of
stranger will change the normal respiration. Begin from at least intrusive to the
most intrusive procedure.
If the client is a toddler and preschooler, le them handle the instruments like
stethoscope or play syringe. If the client has security blanket (like stuffed toy)
give it to them to lessen anxiety
If the client is a school age and adolescent, explain the procedure and respect
their modesty
Components
Temperature
o Temperature of the newborn is taken rectally
o Rectal temperature taking is done only once to rule out imperforated anus
o Insert thermometer 1 inch inside the anus
Types of Imperforated Anus
No Anal Openning
AtreticAgenetice
o These two is the most dangerous because there is
failure to pass meconium after 24 hours
o There is abdominal distention
o Foul odor breath
o Vomitus of fecal material which might result in
aspiration and casue respiratory problems
o Management: Surgery with temporary colostomy
With anal openning
Stenos
Membranous
Cardiac Rate
o Newborn 120 160 bpm irregular
o Radial pulse of a newborn is normally absent
o If radial pulse is prominent suspect that there is a PDA
o Femoral pulse is normally palpable, if absent suspect Coarctation of Aorta
o
CONGENITAL HEART DISEASE

Common in Boys
o Transposition of the great artery (TOGA)
o Truncus Arteriosus
o Tetralogy of Fallot
Common in Girls
o Patent Ductus Arteriosus
PLM BSN 2006
Pediatric Nursing
Atrio Septal Defect
Causes
o Familial tendency
o Exposure to rubella/ German measles 1st month
o Failure of the Heart Structure to progress
Two Major Types

Acyanotic Heart Defects shunting from left to right
Cyanotic Heart Defects from right to left
Acyanotic Heart Defects with Increase Pulmonary Blood Flow
1. Vetricular Septal Defect
Opening Between 2 ventricles
Signs and symptoms
o Systolic murmur at lower border of the sternum and no other
significant sign
o Cardiac catheterization reveals increase oxygen saturation at the
right side of the heart
o ECG reveals hypertrophy of the right side of the heart
o Only 50% of the oxygenated blood will go to the aorta
Management
o Open heart surgery
o Placing the client on a long tern antibiotic therapy to prevent the
development of sub-acute bacterial endocarditis
o Protect site of catheterization (right femoral vein)
o Avoid flexion of joints
2. Atrial Septal Defect
Failure of the foramen ovale to close
Signs and symptoms
o Systolic murmur at the upper border of the sternum with no
significant sign
o Cardiac catheterization reveals increase oxygen saturation at the
right side of the heart
o 50% of the blood goes to the right atrium
Management
o Open heart surgery
o Placing the client on a long tern antibiotic therapy to prevent the
development of sub-acute bacterial endocarditis
3. Endocardial Cushion Defect
AV canal affecting both the tricuspid and the mitral valve
Signs and symptoms
o Only confirmed by cardiaccatheterization
o Valves are closed
4. Patent Ductus Arteriosus
Failure of the Ductus Arteriosus to close
Signs and symptoms
PLM BSN 2006
Pediatric Nursing
o Prominent radial pulse

o Continuous machinery like murmur
o ECG reveals hypertrophy of the left ventricle
Management
o Indomethacine prostaglandin inhibitor that facilitate closure of
PDA
o Ligation of PDA by 2 4 years old
Acyanotic Heart Defects with Decrease Pulmonary Blood Flow

1. Pulmonary Stenosis
Narrowing of valve of pulmonary artery
Signs and symptoms
o Typical systolic ejection murmur
o S2 sound is widely split
o ECG reveals right ventricular hypertrophy
o Only 50% of the blood goes to the lungs
Management
o Balloon Stenotomy
2. Aortic Stenosis
Narrowing of valve of aorta
Signs and symptoms
o Typical systolic ejection murmur
o Murmur
o ECG reveals right ventricular hypertrophy
o Only 50% of the blood goes to the body
o Angina like symptoms may be present when active
Management
o Balloon stenotomy
3. Duplication of Aortic Arch
Doubling of arch of the aorta causing compression to the trachea and
esophagus
Signs and symptoms
o Dysphagia due to esophageal compression
o Dyspnea due to tracheal compression
o Left ventricular hypertrophy
o Only 50% of the blood goes to the body
Management
o Close heart surgery
4. Coarctation of Aorta
Narrowing of ach of aorta
Outstanding signs
o Absent femoral pulse
o BP is higher on the upper extremities and on the lower
extremities
o Epistaxis
o Lesser blood goes to the lower extremities
PLM BSN 2006
Pediatric Nursing
Management
o Take BP on 4 extremities
o Close hear surgery
Cyanotic Heart Defects with Increase Pulmonary Blood Flow

1. Transposition of Great Arteries
Aorta is arising from the right ventricle while the pulmonary artery is
arising from the left
Signs and symptoms
o Cyanosis after 1st cry
o Polycythemia because of increase production of RBC, a
compensatory mechanism to the oxygen supply to the body, the
blood become viscous
o Polycythemia will lead to:
Thrombuis
Embolus
Stroke (CVA)
o ECG reveals Cardiomegaly
Management
o Palliative repair Rash Kind repair
o Complete repair Mustard repair
2. Total Anomalous Pulmonary Venous Return
Situation wherein pulmonary vein instead of entering the left atrium enters
the right atrium or superior vena cava
Signs and symptoms
o Open foramen ovale
o Mild moderate cyanosis
o Absent spleen
Management
o Restructuring of the heart
3. Truncus Arteriosus
Situation in which pulmonary artery and aorta is arising in one common
trunk or a single vessel with ventricular septal defect
Signs and symptoms
Thrombuis
Embolus
Stroke (CVA)
Management
o Restructuring the heart
PLM BSN 2006
Pediatric Nursing
4. Hypoplastic Left Heart Syndrome

Non functioning left ventricle
Signs and symptoms
Thrombuis
Embolus
Stroke (CVA)
Management
o Heart transplant
Cyanotic Heart Defects with Decrease Pulmonary Blood Flow
1. Tricuspid Atresia
Failure of the tricuspid valve to open
Signs and symptoms
o Open foramen ovale
o Cyanosis
Thrombuis
Embolus
Stroke (CVA)
Management
o Fontan Proledum
2. Tetralogy of Fallot
4 Anomalies Present (PVOR)
o Pulmonary Stenosis
o Ventricular Septal Defect
o Overriding of Aorta
o Right Ventricular Hypertrophy
Signs and symptoms
o High degree of Cyanosis outstanding Sign
Thrombuis
Embolus
Stroke (CVA)
o Severe dyspnea relieved by squatting position because it will
prevent venous return and facilitate maximum lung expansion
Knee chest position in infants
o There is growth retardation
PLM BSN 2006
Pediatric Nursing
TET Spells blue spells or short episode of hypoxia

Syncope faintaing
Mental retardation
Clubbing in fingernails because of tissue hypoxia late and last
sign
o X ray reveal a boot shape heart
Management
o Oxygen therapy
o Morphine sulfate for hypoxic episode
o Propanolol (inderal) decrease heart spasm
o Palliative repair BLT or Blalock Taussig Shunt Procedure
o Complete repair Brock Procedure
o
o
o
o
ACQUIRED HEART DISEASE

Rheumatic Heart Disease
Inflammatory disease following an infection caused by Group A Beta Hemoilytic
Streptococcus
Affected body parts
o Musculoskeletal
o Cardiac muscle
o Integumentary system
o CNS
Tonsillitis due to love of sweets with no oral hygiene serving a good medium for
bacterial growth causing inflammation
Group A Beta Hemolytic Streptococcus will release toxin and enters circulation
Group A Beta Hemolytic Streptococcus is an anaerobic organism and will stay at the
left side of the heart or the mitral valve as an ASCHOFF BODIES
ASCHOFF BODIES round nodules with multi nucleated cell and fibroblast that
stays in the miral valve
Left sided heart failure because of mitral stenosis due to increase in the size of
Aschoff Bodies
Diagnostic Exam: JONES CRITERIA
Major
Minor
Polyarthritis multi joint pain
Low grade fever
Athralgia joint pain
Diagnostic Exams
CHOREA/ Sydenhamms Chorea/
Antibody
St. Vitous Dance involuntary,
C reactive protein
purposeless movement of the hand
ESR
and shoulder accompanied by
Anti Streptolysin Titer
grimacing
Carditis signs of tachycardia
Erythema Marginatum macular
rashes
Subcutaneous nodules
Presence of 2 major or 1 major and 2 minor plus a history of sore throat
will confirm diagnosis
Management
o Bed rest
PLM BSN 2006
o
o
o
o
o
Pediatric Nursing
Avoid contact sports

Throat swab for C & S
Antibiotics purpose is to prevent recurrence
Aspirin Therapy or salicylates act as an anti-inflammatory agent in RHD
Side effect: Reyes Syndrome encephalopathy accompanied by fatty
infiltration of the organs such as the heart and liver
RESPIRATION
Normal Values = 30 60 bpm irregular
Either abdominal or diaphragmatic breathing with short period of apnea without
cyanosis
Normal apnea in newborn is 15 seconds or less
Age
Newborn
1 year old
2 3 years old
5 years old
10 years old
15 and above
Vesicular
Normal
Bronshovesicular
Normal
Bronchial
Normal
Ronchi
Normal
Rales
Abnormal
Wheezing
Abnormal
Stridor
Resonace
Hyper
Resonance
Rate
40 90
20 40
20 30
20 25
18 22
12 20
Breath Sounds Heard on Auscultation

Soft, low pitched, heard over periphery of lungs, aspiration is longer
than expiration
Soft, medium pitched heard over major bronchi, inspiration equals
expiration
Loud, high pitched, heard over the trachea, expiration is longer than
inspiration
Snoring sound made by air moving through mucus in bronchi
Crackles (like Celophane) made by air moving through fluid in alveoli

Denotes pneumonia, fluid in the lungs or pulmonary edema
Whistling on expiration made by air being pushed through narrowed
bronchi
Denotes children with asthma or foreign body airway obstruction
Crowing or roster like sound made by air being pulled through a
constricted larynx
Indicative of Respiratory Obstruction
Loud, low tone, percussion sound over normal lung tissue
Louder, lower sound than resonance, percussion sound over
hyperinflated lung tissue
1. RESPIRATORY DISTRESS SYNDROME

Lack of surfactant within 24 hours of life
Aka Hyalin Membrane Disease
Common in preterm babies
The alveoli cannot expand properly
Signs and symptoms
o Present within 4 hours of life
PLM BSN 2006
Pediatric Nursing
o Using the Silverman Anderson Scoring to determine RDS

o RR with retraction (1st sign of RDS)
o Expiratory Grunting (major sign)
o Xiphoid retraction
o Flaring nasal flares
o Cyanosis
o Respiratory acidosis
Management
o Head elevated
o Proper suctioning
o O2 administration with humidity
o Client placed on
CPAP Continuous Positive Airway Pressure
PEEP Positive End Expiratory Pressure
Purpose id to maintain the alveoli partially open and
prevent alveolar collapse
o Monitor for acidosis
o Surfactant replacement
2. LARYNGOTRACHEO BRONCHITIS (LTB)
Most common form of croup
Viral infection of the larynx, trachea and bronchi
Signs and symptoms
o BARKING or CROUPY COUGH outstanding sign
o Inspiratory Stridor
o Respiratory acidosis
o Cyanosis
o Death
Diagnostic Exams
o Throat swab for c & s
o ABG
o Chest and x-ray to ruyle out epiglotitis
Management
o Racemic Epinephrine bronchodilator
o Humidified Oxygen
3. BRONCHIOLITIS
Inflammation of the bronchioles characterized by production of tenacious
mucus
FLU LIKE SYMPTOMS outstanding sign
RR
Causative Agent: Respiratory Syncitial Virus
Drug: Antiviral Ribavirin
LTB and Bronchiolitis ends with Epiglotitis
4. EPIGLOTITIS
Inflammation of the epiglotitis
Sudden onset
The child always assume the tripod position
PLM BSN 2006
Pediatric Nursing
Less than 18 months cannot cough must be placed on mist tent or Croup
tie make sure that the edges are tucked in
o Provide washable plastic toys or materials
o Avoid toys that crate friction
o Avoid toys that are hairy or furry
Blood Pressure
Newborn 80 46 mmHg
After 10 days 100/ 50 mmHg
BP taking begins by 3 years old
SKIN
If cyanotic after the first cry suspect Transposition of the Great Arteries
1. Acrocyanosis body is pink, extremities are blue
2. Generalized Mottling due to the immaturity of the circulatory system
3. Birthmarks
a. Mongolian Spots
Slate grya or bluish discoloration/ patches commonly seen across the
sacrum or buttock
Related to melanocyte which is common in Asian newborn
Usually disappear by 1 5 years old (preschool)
b. Milia
Plugged or unopened sebaceous glands usually seen as a white
pinpoint patches at the nose, chin and cheeks and will disappear by 2
4 weeks
c. Lanugu
Fine downy hair which is common in preterm
d. Desquamation
Peeling of the newborns skin within 24 hours characterized by
extreme dryness that begin in the sole and palm, common in post
term babies
e. Stork Bites (Talengeiclasis Nevi)
Pink patches at the nape, never disappears
f. Erythema Toxicum (Flea Bite Rash)
First self limiting rash to appear sporadically and unpredictably as to
time and place
g. Harlequin Sign
Dependent part is pink, independent part is blue because of the
immaturity of circulation, the RBC settles down
h. Cutis Memorata
Transitory motlling of the neonates skin when exposed to cold
i. Hemangiomas
Vascular tumors of the skin
Types:
o Nevus Flammeus/ Port Wine Stain
PLM BSN 2006
Pediatric Nursing
j.
Macular purple or dark red lesions usually seen on

the face or thigh, disappears and be removed
surgically
Nevus Vasculosus/ Strawberry Hemangioma
Dilated capillary in the entire dermal or subdermal
area continuing to enlarge but disappear after 10
years old
Cavenous Hemangiomas
Consist of communicating network of venules in the
subcutaneous tissue that never disappear with age
Vernix Caseosa
White cream cheese like substance that serves as skin lubricant
SKIN COLOR AND THEIR SIGNIFICANCE

1. Blue cyanosis , hypoxia
2. White edema
3. Gray infection
4. Yellow jaundice or carotinemia
5. Pale anemia
Burn Trauma
Injury to body tissues caused by excessive heat
Characteristic
1st Degree
Involves only the superficial epidermis characterized by erethema,
Partial Thickness
dryness and pain
Ex: Sunburn heals by regeneration in 1 10 weeks
2nd Degree
Involves the entire epidermis, and portion of the dermis,
Partial Thickness
characterized by erythema, blistered and moist from exudates
which is extremely painful
Ex: Scalds
3rd Degree
Involves skin layers, epidermis and dermis, may involve adipose
Full Thickness
tissue, fascia, muscle and bone. It appears to be leathery, white or
black, not sensitive to pain since nerve ending had been
destroyed
Ex: Lava Burn
Management:
First Aid
o Put out the flames by rolling the child on a blanket
o Immerse the burned part on cold water
o Removed burned clothing (sterile material)
o Cover burned part with sterile dressing
Maintainance of patent airway
o Suction PRN
o O2 administration with humidity
o Endotracheal Intubation
o Tracheostomy
Prevention of shock and flued and electrolyte imbalances
o Colloids to expand blood volume
o Isotonic saline to replace electrolyte
PLM BSN 2006
Pediatric Nursing
o Dextrose in water to provide calories

Booster dose of Tetanus Toxoid
Relief pain such as IV analgesic (morphine sulfate)
Prevention of wound infection
o Cleaning and debriding the wound
o Open or close method of wound care
o Whirl pool therapy
Skin grafting
o 3rd degree burn
o get skin from buttocks or pig skin (xenograft) or from frozen cadaver
Diet CHON and calories
Atopic Dermatitis
Skin disease characterized by papulo-vesicular eruthematous lesions with weeping
and crusting
Usually caused by food allergen
o Milk
o Eggs
o Citrus Juice
o Tomatoes
o Wheat
Signs and symptoms
o Extremely pruritus outstanding sign
o Linear excoriation
o Crusty
o Lichenification dry and shinny, scaly white skin
Management
o Avoid allergens
o Prosobes/ Isomil hypoallergenic milk
o Prevent infection by proper handwashing, cut the fingernails
o Hydrate with a burrows solution
o Topical steroid 1% hydrocortisone cream
Impetigo
Skin disease caused by Group A Beta Hemolytic Sreptococcuscharacterized by
papulovesicular lesions surrounded by localized erythema becoming purulent and
ooze forming honey colored crust
Before the development, the baby should always been exposed to Pediculosis Capitis
(kuto)
Management
o Proper handwashing
o Treated with antibiotic
Complication: AGN
Acne
Self limiting inflammatory disease involving sebaceous gland, common in adolescents
Comadones composed o sebum that is mainly causing white heads
Sebum composed of lipids
PLM BSN 2006
Pediatric Nursing
Management
o Proper handwashing wild mild soap (sulfur soap) and water, leave for 5 10
minutes or use tretenoin or Retin A anti acne
Anemia/ Pallor
Caused by
o Early cutting of the cord
o Bleeding disorders/ blood dyscarias
BLEEDING DISORDERS/ BLOOD DYSCARIAS
Hemophilia
Sex linked (X) Recessive disorders
The mother is the carrier
The son is affected
The father transmits to daughter
Deficiency in clotting factor
o Hemophilia A factor 8 classic hemophilia
o Hemophilia B Factor 9 Christmas disease
o Hemophilia C Factor 11
OMPHALAGIA earliest sign
o >300 cc loss of blood during cutting of the cord
the maternal clotting factor is present in the new born that is why there is a delayed
diagnosis of hemophilia
in toddlers sudden bruising
HEMARTHROSIS major sign repeated bleeding, bleeding of the synovial
membrane
Diagnostic exam: PTT
Nursing Diagnosis: High Risk for Injury
Goal: Prevention of injury
Health Teaching
o Avoid contact sports
o Determine the case before doing any invasive procedure
In immunization change the needle into a smaller one
o In case of fracture/ injury
Immobilize and elevate
o Cold compress
o Gentle pressure
o Blood transfusion of cryoprecipitate
Leukemia
Group of malignant disease characterized by rapid proliferation of immature RBC
Ratio is 500 RBC : 1 WBC
The client is immunocompromised
Classification of Leukemia
o Lympho affects the lymphatic system
o Myelo affects the bone marrow
o Acute/ Blastic affects the immature cells
o Chronic/ cystic affects the mature cells
PLM BSN 2006
Pediatric Nursing
Acute Lymphocytic Leukemia

Most common in children
Increase immature WBC
Signs and Symptoms
a. Infection
i. Fever
ii. Poor wound healing
b. Bone weakness and causes fractures
c. Signs of bleeding
i. Blood in the urine
ii. Emesis
iii. Petechiae
iv. Epistaxis
d. Signs of anemia
i.Pallor
ii. Body malaise
iii. constipation
e. Invasion of the organs
i. Hepatomegaly abdominal pain
ii. Spleenomegaly
2. Diagnostic examinations
a. Peripheral Blood Smear reveals immature WBC
b. CBC reveals anemia and thrombocytopenia; neutropenia
c. Lumbar Puncture
i. To determine CNS involvement
ii. Fetal position without flexion of the neck because it will cause airway
obstruction
iii. C position or shrimp position
d. Bone Marrow Aspiration
i. Determines the presence of blast cells
ii. Site of bone marrow aspiration iliac Crest post op : prevent
hemorrhage
iii. Lie on affected site
e. Bone Scan determines the degree of bone involvement
f. CT Scan determine the degree of organ involvement
3. Management Triad
a. Surgery
b. Irradiation
c. Chemotherapy
d. Bone marrow transplant
4. 4 Levels of Chemotherapy
a. Induction
i. To achieve remission
ii. Drugs
IV Vincristine
L Asparagine
Oral Prednisone
b. Sanctuary
i. To treat the leukemic cells that has invaded the testes and CNS
ii. Drugs
intrathecal methotrexate via spine
PLM BSN 2006
Pediatric Nursing
cytocine
arabinase
steroids
irradiation
c. Maintainance
i. To continue remission
ii. Drugs
oral methotrexate
oral 6-mecaptopurine
cytarabine
d. Reinduction
i. Give anti-gout agent To
ii. To treat leukemic cells after relapse occurse
iii. Treat hyperurecemic neuropathy
Alopurinol or zylo[rene
5. Nursing Management
a. Assess for common side effects of chemotherapy nausea and vomiting
b. Assess for stomatitis ulceration and abcess of oral mucosa
i. Oral care
ii. Alcohol free mouthwash
iii. Cotton piedgets
c. Diet give food acoording to childs preference
d. Alopecia temporary side effect of chemotherapy
HEMOLYTIC DISORDERS
Rh Incompatibility
Rh = monkey foreign body
Mother (-) no antigen; no protein factor
Fetus (+), Father (+) has antigen and protein factor
4th baby is severely affected
Erythroblastocis Fetalis
o hemolysis/ destruction of RBC leading to O2 carrying capacity leading to
IUGR with pathologic jaundice w/in 24 hours
ALERT! Baby is small and yellowish
Management
o RHOGAM
Vaccine given to Rh(-) mothers within the first 24 hours or within 72 hours
Given once
If pregnancy was aborted and the mother udergo D & C, RHOGAM must
be given w/in 24 hours, if not given within 24 hours, mother will produce
antibody
Action: destroys RBC preventing antibody formation
Diagnostic Test Coombs Test
ABO Incompatibility
Mother Type O; Fetus Type A most common
Mother Type O; Fetus Type B most severe
Hydrops Fetalis
PLM BSN 2006
Pediatric Nursing
o Common in abo incompatibility

o Newborn is edematous, on lethal state, accompanied by pathologic jaundice
w/in 24 hours
Difference from Rh Incompatibility
o First pregnancy is affected
o NB is yellow and edematous
Management
o Initiation of breastfeeding, then temporary suspension of breastfeeding after 4
days ( breastfeeding realeses prenanediole causing kernicterus)
o Pregnanediole delays actions of Glucoonyl transferase ( liver enzyme that
converts indirect bilirubin into direct bilirubin)
Indirect bilirubin
Fat soluble
Cant be excreted by kidneys
Causes hyperbilirubenemia causing jaundice
Direct Bilirubin
Water soluble
Can be excreted by the kidneys
o Use phototherapy
o Exchange transfusion for Rh and ABO affectations that tend to casue a
continuous decrease in hemoglobin during the first 6 months because the
bone marrow fails to produce erythrocytes in reponse to the continuous
hemolysis
Hyperbilirubenemia
More than 12mg of indirect bilirubin among full terms
Normal Indirect Bilirubin Level: 0 3 mg/dl
Kernicterus/ Bilirubin Encephalopathy
Irreversible brain damage
> 20 mg/dl of indirect bilirubin among full terms
> 12 mg/ dl of indirect bilirubin among preterm because of immaturity
Physiologic Jaundice
Normal
Within 48 72 hours
Mx:
Expose to early morning
sunlight
Pathologic Jaundice
Within 24 hours
Yellow upon birth
Breastfeeding Jaundice
Within 6th 7th day
Due to glucoronyl
transferase
Possible Rh/ ABO

incompatibility
Assessment of Jaundice
blanching of forehead, nose and sternum
yellow skin, sclera
light stool
dark urine
Management
Phototherapy/ Photooxygenation
o Nursing Responsibilities
Cover the eyes prevents retinal damage
PLM BSN 2006
Pediatric Nursing
Height of light from baby 18 20 inches

Increase Fluid intake
Cover genetalia prevent priapism ( painful continuous erection
Change position
Avoid lotion and oils
Monitor I&O best way is to weigh the baby
Monitor VS
Bronze Baby Syndrome

Transient bronze discoloration of the skin
Minor side effect of phototherapy
HEAD
of its legth
Structures
o sutures
o fontanels
anterior/ bregma 3 x 4 12 18 mos
posterior/ lambda - 1 x 1 2 3 mos
Noticeable structures of the Head
o Craniotabes
Localized softening of the cranial bone common to first bone chiold due
to early lightening
If present in older children; sign of rickets or Vit. D deficiency
o Seborrheic dermatitis/ Cradle Cap
Scaling, greasing, appearing salmon colored patches
Usually seen at the scalp, behind ears and umbilicus
Usually caused by improper hygiene
Management
Application of baby oil the night before shampooing the child
o Caput Succedaneum
Edema of the scalp due to prolonged pressure at birth
Present at birth
Crosses the suture line
Disappears 2 3 days
Disappears without treatment
o Cephalhematoma
Collection of blood due to rupture of capillaries of poriosteal capillaries
Present after 24 hours
Does not cross the suture line
Disappears after 4 6 weeks
Disappears without treatment
o Hydrocephalus
Excessive accumulation of CSF
Types
Communicating/ extraventricula hydrocephalus
No-communication/ intraventricular hydrocephalus/ obstructive
hydrocephalus caused by tumor
Signs and symproms
PLM BSN 2006
Pediatric Nursing
Signs of increased ICP

o Diplopia eye deviation @ 6th mos and above
o Management
Low semi fowlers (30 degrees) best position
Frontal bossing 9 prominent forehead)
Sunset eyes
Prominent scalp vein
Therapeutic management
Osmotic Diuretic
o Mannitol
o Diamox / acetazolamide
Seizure precautions
Surgery Shunting
o AV Shunt - atrioventricular
o VP shunt ventriculoperitonial most common
Best time to shave the head just before the surgery prevent
infection
Post VP Shunt management
Position sidelying on non-operated side ( applicable to all
eyes and head surgeries)
Sign of good shunting sunken fontanel
Sign of blocked shunting bulging fontanel
Catheter is changed as the child is growing
Child with BP shunt is prone to infection
SENSES
Sense of Sight
Sclera
o Normal light blue
o Later Color dirty white
Pupils
o Normal round and adult size
o Coloboma key hole pupils part of the iris is missing
o Congenital N Cataract whiteness/ opacity of the lens
Cornea
o Normal round and adult size
o Congenital Glaucoma larger than normal
Test for Blindness
Age
Newborn
Can see @ a
distance of 10 12
inches
with
visual
acuity of 20/200 to 20/
800
Infant and children
Common Test
General appearance
Check ability to follow object pass midline
DOLLS EYE TEST done at approximately 10th day
GLADELLAR TEST test for blink reflex, not blinking is a
sign of blindness
ALLENS CARD test for visual acuity
- familiar pictures are flashed 20 ft away from the
child
PLM BSN 2006
3 years old School age

School age adult
Pediatric Nursing
ISHIARA PLATE test for color blindness

Cover testing test for strabismus
Snellens test
RETINOBLASTOMA
malignant tumor of the eye
signs and symptoms
o cats eye reflex (whitish glow of pupil)
o red, painful eye usually accompanied by glaucoma
Management
o Surgery innucleation - removal of the eyeball
o Irradiation
o Therapy
SENSE OF SMELL
Normal nasal membrane - pinkish
Check for sense of smell
Check for nasal flaring
Sign of Cocaine User
Ulceration and abscess of nasal mucosa
Absence of hair
Epistaxis
Nose bleeding
Management
o Position, upright, sitting, head trilted, slightly forward
o Gentle pressure
o Cold compress
o Epinephrine last resort
SENSE OF HEARING
Normal should be aligned with the outer canthus of the eye
Low Set Ears is a sign of
o Kidney malformation
Renal agenesis
Absence of kidney
o Chromosomal Abnormalities
Due to advance maternal age - >35y/o
Types
o Nondisjunction (uneven divison)
Trisomy 21
Down Syndrome
Most common type
PLM BSN 2006
Pediatric Nursing
Extra chromosome 21
47xx + 21/ 47xy + 21
can be related to advance paternal age
signs and symptoms
o broad nose
o protruding tongue
o low- set ears
o puppys neck
o hypotonia prone to URTI
o simian crease single traverse line in palm
o mental retardation ranging from educable to
institutionalization
Trisomy 18
Has 3 numbers of 18 chromosomes
Severely cognitively impaire SGA
Low set ears, small jaw, CHD, index finger crosses over the
other fingers, rounded soles of feet
Trisomy 13
Pataus syndrome
Extra chromosome 13
Severely cognitively impaired
Signs and symptoms
o Microcephaly
o Micropthalmia
o Cleft-lip and palate
o Low-set ears
o VSD
o Do not survive
Turners
Gonadal Dysgenesia
One functional x chromosome
Short in stature
Neck appear to be webbed and short
COA and kidney problems
Only 1 streak (nonfunctional) gonads
Secondary sex characteristic does not develop except for pubic
hair
Lack ovarian function sterility
Cognitively challenged but mostly normal intelligence
Klinefelters syndrome
Males with a XXY chromosome pattern
@ puberty child has poorly developed secondary characteristics
and small testes that produces ineffective sperm
boys tend to develop Gynecomastia
o Deletion Abnormalities
Cri du chat Syndrome
Result of a short arm on chromosome 5
Cats cry
PLM BSN 2006
Pediatric Nursing
Small head, wide set eyes, downward slant to the palbepral

fissure of the eyes
Severe cognitive impairment
Fragile X Syndrome
X linked pattern
One arm of x chromosome is weakened
Most common cause of cognitive impairment in boys
Before puberty, boys typically have maladaptive behavior like
hyperactivity and autism
Large head, long face with high forehead, prominent lower jaw,
large protruding ears
o Translocation abnormalities
Balance translocation Carrier
Unbalanced Translocation Syndrome
o Others
Mosaicism
A situation wherein the nondisjunction of chromosome occurs
during mitotic cell division after fertilization resulting to different
cells contains different numbers of chromosome
Isochromosomes
A situation wherein the chromosome instead of dividing
vertically it divides horizontally resulting to chromosomal
mismatch
Otitis Media
Inflammation of the middle ear
Common to children due to wider and shorter Eustachian tube
Predisposing factors
o Bottle propping
o Cleft lip/ palate
Signs and symptoms
o During otoscopic exam, reveals bulging tympanic membrane
o Observe for passage of purulent, foul smeeling odor discharge
Management
o Positioning sidelying on the affected side
o Supportive care
Medical management
o Massive dosage of antibiotics
o Mucolytics
o Ear drops
< 3 y/o down and back
>3 y/o up and back
o Surgery
Myringectomy slight incision of tympanic membrane to prevent
hearing loss
Side effect bacterial meningitis
MOUTH AND TONGUE

Check for symmetry
PLM BSN 2006
Pediatric Nursing
Bells palsy/ Facial Nerve Paralysis

7th CN injury
usually related to forceps delivery
risk for URTI
Signs and symptoms
o Continuous drooling of saliva
o Inability to open one eye and close the other
Management
o Artificial tear
o Self limiting
o Refer to PT for rehabilitation
TEF/ TEA
No connection between esophagus and stomach
There is a blind pouch
Hydramnios earliest sign intrauterine
Signs and symptoms
o Coughing
o Chocking
o Cyanosis
o Continuous drooling
Management
o Emergency surgery
Epstein Pearls
White glistening cyst
Usually seen on palate, gum
Related to hypercalcemia
Natal Tooth
Tooth at the moment of birth
Related to hypervitaminosis
Management
o Manual extraction if rootless
Neonatal Tooth
Appearance of tooth within 28 days of life
Oral Thrush
White cheese-like, curd like patches
Usually seen in mouth and on toingue
Causative agent C. Albicans fungi
Management
o Do not remove can cause wound
o Wash with cold, bottled water
o Medical Mycostatin/ Nystatin
PLM BSN 2006
Pediatric Nursing
Kawasaki Disease
Discovered in Korea
Strawberry tongue
Common in asian countries
Criteria for diagnosis
o Fever lasting for more than 5 days
o Bilateral conjunctivitis
o Changes in lips and oral cavity
Dry red fissure lips
Strawberry tongue
Diffuse erythema of mucos membrane
o Changes in the peripheral extremities
Erythema on the palms and soles
Erythema on the hands and feet
Membranous desquamation from fingertips
o Polymorphous rash (primarily at trunk)
o Acute non purulent sweeling of the cervical lymph nodes to > 1.5 cm in
diameter
Drug of Choice : ASPIRIN
Cleft Lip
Failure of the median maxillary nasal process to fuse
Common to boys
Surgery cheiloplasty
o Done w/in 1 3 months
o To save sucking reflex
Signs and symptoms
o Evident at birth
o Milk from nostrils spills
o Cold is common
o Frequent URTI and otitis media
Post cheilo sidelying
Nutrition use rubber tip syringe
Cleft Palate
Failure of the palate to fuse
Common to girls
Surgery Uranoplasty
o Done w/in 4 6 months
o To save speech
Signs and symptoms
o Evident at birth
o Milk from nostrils spills
o Cold is common
o Frequent URTI and otitis media
Post cheilo prone
Nutrition use paper cup/ plastic cup/ soup spoon
Condition to consider for suspension of operation
PLM BSN 2006
Pediatric Nursing
If child has a cold/ nasopharyngitis may lead to general septicemia

General management
Maintainance of patent airway
Proper nutrition
o NPO 4 hours post op
o Clear liquid
Popsicle except red and brown in color
Flavore gelatin
No ice cream
Observe for bleeding
o Frequent swallowing
Protect suture lines specially LOGAN BAR
o Clean using hydrogen peroxide, bubbles traps microorganism, more bubbles
more microorganism trapped
o Prevent crying by attending to needs
Therapeutic Management
Emotional support
Proper Nutrition
Cleft lip nipple (long tip, made by silicon)
Prevent Colic
o Burp frequently
o One at the middle of the feeding
o Another at the end of the feeding
o Upright sitting position
o Pat at the back lower to upper
o Prone position
o Right sidelying position facilitates gastric emptying
Educate parents
Apply elbow restraints so the baby can easily adjust post op
NECK
Check for symmetry
Congenital Torticollis/ Wry neck
Birth injury of sternocleidomastoid due to excessive traction during cephalic delivery
A case of incompetence to the one giving birth
Management
o Passive stretching
o Exercise daily
o Surgery
Complication
o Scoliosis
Congenital Critinism/ Congenital Hypothyroidism
Absence or non functioning thyroid gland
Causes
o Due to delayed diagnosis, thyroid is covered by sternocleidomastoid muscle
PLM BSN 2006
Pediatric Nursing
o Hypothyroidism
o Thyroid dysgenesis (absence of thyroid)
o Baby receive maternal thyroxine
Earliest Signs and Symptoms
o Change in sucking
o Change in crying
o Excessive sleeping (16-20 hours/ day)
o Constipation
o Edema moon faced baby
o Mental retardation late sign
Diagnostic Test
o Radioimmunoassay Test
o Protein bounbd iodine
Treatment
o Synthroid / sodium levothyroxine for life
CHEST
Witch Milk
Transparent
Liquid coming out from newborns breast related to hormonal changes
ABDOMEN
Abdominal Assessment
Inspection
Ausculation
Percussion
Palpation
Diaphragmatic Hernia
Protrusion of stomach contents through a defect in diaphragm due to failure of
pleuroperitoneal canal to close
Signs and Symptoms
o Sunken abdomen
o Signs of RDS
o Right to left Shunting
Treatment diaphragmatic repair w/in 24 hours
Omphalocele
Protrusion of stomach content between the the junction of abdominal wall and
umbilicus
If small surgery
If large suspend surgery
Apply wet dressing
GASTROINTESTINAL SYSTEM
PLM BSN 2006
Pediatric Nursing
Functions
o Assist in maintaining fluid and electrolytes and acid and base balance
o Processes and absorbs nutrients to maintain and support growth and
development
o Excrete wasted products from the digestive process
Supplementary Feeding
Begin 4 6 months
As early as 4 months
Usually at 6 months
Principles
o Solid food are often according to the following sequence
Cereals rich in iron
Fruits
Vegetables
Meat
o Begin with small quantities
o Finger food are offered @ 6 months
o Soft table food is offered @ 1 year
o Diluted citrus/ fruit juices @ 6 months
o Offer new food one at a time with an interval of 4 7 days or 1 week
o Never offer half cooked egg may lead to gastroenteritis/ salmoneliosis
Major Concepts of Fluid and Electrolyte Balance
Distribution of Body Fluids
o Fluids are greater in ECF in infant and children
o Newborns are candidate for dehydration
o Total Body fluid is 65 85% of their body weight in infants and children
Acid Base Imbalance
Depending upon the following
o Chemical buffers
o Renal and respiratory system involvement
o Dilution of strong acids and bases in blood
Imbalance of Acid
o Respiratory Acidosis
Carbonic acid excess
LTB RDS
Hypoventilation COPD
o Respiratory Alkalosis
Carbonic acid deficit
Hyperventilation
Fever, encephalitis
o Metabolic Acidosis
Base bicarbonate deficit
Diarrhea
Severe malnutrition and dehydration
celiac
o Metabolic Alkalosis
Base bicarbonate excess due to uncontrolled vomiting
PLM BSN 2006
Pediatric Nursing
NGT aspiration
Gastric lavage
Pyloric stenosis
Conditions that Produce Fluids and Electrolyte Imbalance

Vomiting
Forceful expulsion of stomach content
Signs and symptoms
o Nausea
o Abdominal crumping
o Flushing of face
o Watery eyes
Assessment
o Frequency
o Forces
Projectile increase ICP/ Pyloric stenosis
Non projectile
Alerts
o Vomiting is an initial symptom of GI Obstruction
o Vomitus of upper GI can be blood tinged but bot bile streaked
o Vomitus of lower GI is bilous
o Projectile vomiting is ewither a sign of increased ICP or GI Obstruction
o Abdominal distention is the major symptom of lower GIT obstruction
Management
o Banana
o Rice cereal
o Apple sauce
o Toast
Diarrhea
Exaggerated excretion of intestinal contents
Acute diarrhea is associated with the following
o Gastroenteritis/ salmonelliasis
o Antibiotic use penicillin, tetracycline
o Dietary indigestion
Chronic non specific diarrhea
o Food intolerance
o CHO/ CHON malabsorption
o Excessive fluid intake
Assessment
o Frequemcy
o Consistency (best criteria)
o Appearance of green colored stool
Complications
o Mild dehydration 5% weight loss
o Moderate dehydration 10% weight loss
o Severe dehydration 15% weight loss
Signs of dehydration
o Tachycardia earliest sign
PLM BSN 2006
Pediatric Nursing
o Tachypnea
o Hypontension
o Increase temp
o Sunken fontanel
o Sunken eyeball
o Poor skin turgor
o Absence of tears
o Scanty urine
o Oliguria severe dehy=dration
o Weight loss
o Prolonged capillary refill time
Management
o NPO
o IV infusion
o KCl given by doctors
Assess child for ability to void before giving KCl may lead to
hyperkalemnia
Normal K Value 3.5 5.5
o Order Na Bicarbonate, administer slowly to prevent cardiac overload
Gastric Motility Disorders
Hirschprungs Disease/ Congenital Aganglionic Megacolon
Absence of ganglion cells needed for peristalsis
Assessment
o Neonatal Period
Abdominal distention
Failure to pass meconium within 24 hours
o Early childhood
Ribbon like stool
Constipation
Foul smelling stool
Diarrhea
Vomitus of fecal materials
Diagnostic Procedures
o Barium enema reveals narrowed portion of the bowel
o Rectal biopsy reveals absence of ganglion cells
o Abdominal x- ray reveals dilated loops on intestines
o Rectal manometry reveals failure of intestinal sphincter to relax
Therapeutic Management
o NGT Feeding
NGT Measurement
Infant nose-ears middle of xiphoid process and umbilicus
Adult nose ears xiphoid process
o Surgery
Temporary colostomy
Anastomosis and pull through procedure
o Diet
Increase CHON
Increase Calorie
PLM BSN 2006
Pediatric Nursing
residue diet pasta foods

no raisin/ prunes
Gastroesophageal Reflux
presence of stomach content on esophagus
Assessment
o chronic vomiting
o failure to thrive syndrome organic
o esophageal bleeding manifested by melena and hematemesis
Complications
o esophagitis
o aspiration pneumonia
o esophageal cancer
Diagnostic Procedure
o barium esophogram
o esophageal manometry reveals lower esophageal pressure
o intraesophageal pH content reveals pH of distal esophagus
Medications
o anticholinergics
bathanechol/ urecholine
esophageal tone and peristaltic activity
Methachlopromide (Reglan)
esophageal pressure by relaxing pyloric and duodenal
segments
peristalsis without stimulating secretions
H2 Blocker/ histamine Receptor Antagonist
gastric acidity and pepsin secretion
Maalox/ Cimetidine (Tagamet)/ Ranitidine (Zantac)
Neutralizes gastric acid between feedings
Surgery: Nissen Fundoplication
Diet
o Thickened feeding with rice cereal prevents vomiting
o Feed slowly
o Burp often every 1 oz
o Positioning
< 9 mos infant sit/ infant supine
> 9 mos prone with head on mattres slightly elevated on a 30 angle
Obstructive Disorders
Pyloric Stenosis
hypertrophy of the muscle of pylorus causing narrowing and obstruction
Assessment
o Projectile vomiting
o Failure to gain weight
o Metabolic alkalosis
o Peristaltic wave visible from left to right across epigastrum
o Palpation of olived shaped mass
o ABG
PLM BSN 2006
Pediatric Nursing
o Serum Electrolyte - Na and K, Cl

o Ultrasound
o X-ray of upper abdomen with barium swallow
Management
o Pyloromyotomy/ Fredet Ramstedt Operation
Intussusception
Telescoping or invagination of one portion of the bowel into the other
Peritonitis danger of intussusception
Emergency for URT epiglotitis
Emergency for GIT peritonitis
Signs and symptoms
o Acute paroxysmal abdominal pain
o Currant jelly stool caused by inflammation and bleeding
o Sausage shaped mass
Non congenital
Caused by fast eating and positioning
Management
o Hydrostatic reduction with barium enema
o Surgery Anastomosis
Inborn Errors of Digestion
Phenylketonuria/ PKU
Deficiency of the liver in Phenyalanine Hydroxylase Transferase (PHT)
PHT is a liver enzyme that coverts protein into amino acid
9 Essential Amino Acids
o Tyrosine / phenylalanine
o Histidine
o Isoleucine
o Leucine
o Lysine
o Methionine/ cysteine
o Threonine
o Tryptophan
o Valine
Tyrosine or Phenylalanine responsible for the melanin production
Signs and Symptoms
o Fair complexion
o Blond hair
o Blue eyes
o Infantile eczema
o Mousy/ musty odor urine
o Seizure due to Phenyl Pyruvic Acid goes to brain
o Mental retardation
Guthrie Test
o Specimen Blood
o Preparation Increase Fluid Intake
Management
o Diet
PLM BSN 2006
Pediatric Nursing
phenylalanine diet indefinitely

Chicken, meat, peanuts, milk, legumes, cheese contraindicated
Lofenalac special formula
Celiac Disease/ Malabsorption Syndrome; Gluten Induced Enteropathy

Sensitivity or immunologic response to protein
Assessment
o Early signs
Diarrhea, failure to regain weight following diarrheal episode
Constipation
Vomiting
Abdominal pain
Steatorhea
o Late signs
Behavioral changes: irritability and apathy
Muscle wasting and loss of subcutaneous fats
o Celiac Crisis
Development of infection by a child having a celiac disease
Acute vomiting and diarrhea
o Stool analysis
o Serum antiglandin and antireticulin antibodies
o Sweat test
Therapeutic management
o Vitamin supplements
o Mineral supplements
o Steroid
Poisoning
Common accident in toddlers poisoning
Common accident in infants falls
Principles
o Determine the substance taken and assess LOC
o Unless poisoning was corrosive, caustic (strong alkali, such as lye) or
hydrocarbon, vomiting is the most effective way to remove the poison from
the body
Strong acid poisoning give weak acid to neutralize strong acid
o Syrup of ipecac oral antiemetic to cause vomiting after drug overdose or
poisoning
15 ml adolescent, school age and preschool
10 ml infant
o Universal Antidote
Activated charcoal
Milk of magnesia
Burned toast
Charcoal absorbs toxic substance
o Never administer the charcoal before ipecac because giving charcoal first will
absorb the effect of ipecac
PLM BSN 2006
Pediatric Nursing
Antidote for acetaminophen poisoning : Acetylcysteine (mucomyst)

Kerosine/ Gasoline poisoning: Give mineral oil to coat the intestine and
prevent poison absorption
Tracheostomy set will be at bed side
o
o
Lead Poisoning
Pencil, paint, crayon Lead
Destruction of RBC Functioning
hyupochromic Microcytic Anemia
Destroys Kidney Function
Accumulation of ammonia
Leading to Encephalitis (Late stage)
Severe mental retardation

Assessment
o Beginning symptoms of lethargy
o Impulsiveness and learning difficulty
o As lead , severe encephalopathy with seizure and permanent mental
retardation
Diagnostic procedure
o Blood smear
o Abdominal x-ray
o Lone bone
Management
o Chelation binds with the lead and excreted via kidneys
o Ca EDTA/ BAL/ Dimercapro
Nephrotoxic
ANOGENITAL
Female
Pseudomenstruation
o Slight vaginal bleeding related to hormonal changes
Rape/ Child Abuse
o If the client came with a laceration and bleeding at the perineum
o Report rape within 48 hours
o Preschool are proneto rape because of their innocence
o CBQ Report rape cases to barangay chairman first or bantay bata
Male
Cryptochirdism
o Undecended testes or empty scrotum or ectopic testes
Common in preterm babies
Testes is palpable at lower quadrant
Surgery: Orchioprexy
PLM BSN 2006
Pediatric Nursing
Preop warm the room and hands
Epispadias
o Urinary meatus is located at the dorsal or above the glans penis
Hypospadias
o Urinary meatus is located at the ventral or below the glans penis
o Hypospadias is usually accompanied by Chordee ( A fibrous band causing
penis to curved downward)
o Both are manage by surgery
Phimosis
o Tight foreskin
o This will cause infection
o Circumcision as management
Hydrocele
o Fluid filled scrotum
o Flashlight/ transillumination test to determine
Varicocele
o Enlarged vein opf the epididymis
RENAL DISORDERS
Renal
Disorder
Nephrotic
Syndrome
Causes
Acute
Glomerul
onephritis
Autoimmun
e
Group A
beta
hemolytic
streptyococ
cus
Infection
Assessment
Findings
Anasarca
Massive proteinuria
Microscopic or no
hematuria
serum CHON
serum lipid
Normal or BP
Fatigue
Primary pheripheral
perioprbital edema
Moderate Proteinuria
Goss hematuria
(smokey urine)
serum K
Fatigue
HPN
Treatment
Nursing Care
Prednisone
Skin Care
Weigh the client saily
with the same clothing
CHON(Normal Diet)
Na
K
AntiHPN
Hydralazine
Apresoline
Monitor weight
Skin Care
Monitor BP and
neurologic status
K
Fe
Na
Complication
Hypertensive
Encephalopat
hy
BACK
Check for flatness and symmetry of the back
Spina Bifida Occulta
Failure of the posterior lamina or vertebral to fuse
Sampling of the lower back
Abnormal tufts of hair
Spina Bifida Cystica
PLM BSN 2006
Pediatric Nursing
With Sac
Types
o Meningocele protrusion of CSF and Meninges
o Myelomeningocele CSF, Meninges and Spinal cord
o Ecephacele
cranial meningocele - CSF and meninges
Myelomeningocele - brain, CSF , meninges
Common Complication
o Infection
o Rupture of Sac
Treatment
o Surgery to prevent infection: post op prone position
Scoliosis
Lateral curvature of the spine, common in school age because of heavy bags
Uneven hemline
Tell the child to bend forward, one hip higher than athe other and one shoulder is
most prominent
Types
o Structural
o Postural
Management
o Conserbvative
Exercise
Avoid obesity
o Preventive
Milwaukee Braces worn 23 hours a day
o Corrective: Surgery
EXTREMITIES
Count the number of digits
Digits
Syndactyl webbing of the digits (foot ginger like foot)
Polydactyl extra digits
Olidactyl lacks digits
Erb Duchennse Paralysis/ Brachial Plexus Injury
Birth injury of breech delivery
Signs
o Inabiluity to abduct the arm fronm the shoulder, rotate the arm extremely and
supinate the forearm
o Assymetrical oor absence of moro reflex
Management
o Abduct the arm from the shoulder with the elbow flexed
Congenital Hip Dislocation
Congenital hip dysplacia
PLM BSN 2006
Pediatric Nursing
When the head of the femus is outside the scetabulum

2 types
o subluxated most common
o dislocated
Signs and Symptoms
o Shortening of the affected leg
o Assymetrical gluteal fold
o Limited movement earliest sign
o + ortolanis sign abnormal clicking of during abduction
o when able to walk the child limps (Trendelenburg sign) late sign
Management facilitate abduction
o Triple the diaper
o Carry the baby
o Frejka Splint
o Pavlik Harness
o Hip Spica Cast
Talipes
Club foot
4 types
o Equinos plantar rotation/ horse foot (most common)
o Calcenuous dorsiflexion/ the heel is held lower than the foot/ the anterior
portion of the foot is flexed towards the anterior leg
o Varus foot turns in
o Valgus foot turns out
Assessment
o Make a habit of straightening the legs and flying it to the midline position
Management
o Corrective shoes : Dennis Brown Shoes
o Spica Cast
For immobilization
Maintain bone alignment
Prevent muscle spasm
If there is a blood mark on the cast mark a pen to determine
whether there is a hemorrhage
Neurobvascular check
Circulation
Motion
Sensation
CRUTCHES
Wait is on the palm not the axilla
Exercise squeeze ball
Different Crutches and Gait
Swing Through
Advance both crutches
Lift both feet/ swing forward/ land feet in front of crutches
PLM BSN 2006
Pediatric Nursing

Lift both feet/ swing forward/ land feet in front of crutches
Swing To
Lift both feet/ swing forward/ land feet next to crutches
Lift both feet/ swing forward/ land feet next to crutches
Three point gait
Advance left foot and both crutches
Advance right foot
Advance left foot and both crutches
Advance right foot
Four Point Gait
Advance right crutch
Advance left foot
Advance left crutch
Advance right crutch
Two Point Gait
Advance left foot and right crutch
Advance right foot and left crutch
Advance left foot and right crutch
Advance right foot and left crutch
Other Crutch Maneuvering Technique
To Sit Down
Grasp the crutches at the hand pieces for control
Bend forward slightly while assuming a sitting position
Place the affected leg forward to prevent weight bearing and flexion
To Stand Up
Move forward to the edge of the chair with the strog leg slightly under the seat
Place both crutches in the hand on the side of the affected extremity
Push down on the hand piece while raising the body to a standing position
To Go Downstairs
Walk forward as far as possible to the step
Advance the crutches to the lower step. The weaker leg is advanced first and then
the stronger leg. In this way, the stronger extremity shares the work of raising and
lowering the patients body weight with the arms
To Go Upstairs
Advance the stronger leg first up to the next step
Then advance the crutches and the weaker extremity ( strong legs goes up first and
comes down last.)
PLM BSN 2006
Pediatric Nursing
A memory device for the patient is UP WITH THE GOOD, DOWN WITH THE BAD
WALKER
A walker provides more support than cane andf crutches
The patient is taught to ambulate with a walker as follows
o Patient must hold the walker on the hand grips for stability
o Lift the walker, placing it in front of you while leaning your body slightly
forward
o Walk into the walker, supporting your body weight on your hands while
advancing the weaker leg, permitting partial weight bearing or non weight
bearing leg as prescribed
o Balance yourself on your feet
o Lift the walker and place it in front of you again and continue the pattern of
walking.
CANE
Used to help patient walk with greater balance and support and to relieve the
pressure on the weight bearing joints by redistributing the weight.
Quad Cane (four footed cane) is hold on the hand of affected extremity.
METHODS OF TRANSFERRING A PATIENT FROM THE BED TO A WHEELCHAIR
Weight bearing transfe4r from bed to chair. The patient stands up, pivots his back is
opposite the new seat and sits down.
(Left) Non weight bearing transfer from chair to bed. (Right) With legs braced.
(Left) Non weight bearing transfer combined method. (Right) Non weight bearing
transfer, pull up method.
THERAPEUTIC EXERCISE
Exercise
Description
Passive
carried out by the
therapist or the nurse
without assistance
from the patient
Active Assistance
Carried out by the

patient with the
assistance of the
therapist or the nurse
Purpose
To retain as much
joint range of motion
as possible
To maintain
circulation
To encourage
normal muscle
function
Action
Stabiolize the
proximal joinyt, and
support the distal
part. Move the joint
smoothly, slowly and
gently through its full
rang of motion
Avoid producing
pain.
Support the distal
part and encourage
the patient to take
the joint actively
through its ROM.
PLM BSN 2006
Pediatric Nursing
Active
Accomplished by the
patient without
assistance, activities
include turning from
side to side and from
back to abdomen
and moving up and
down in bed
To increase muscle
strength
Resistive
An ective exercise
carried out by the
patient working
against the
resistance produced
by either manual or
mechanical means
To provide
resistance to
increase muscle
power
Isometric/ Muscle
Setting
Alternately
contracting and
relaxing a muscle
while keeping the
part in fixed position;
performed by the
patient
To maintain strength
when a joint is
immobilized
Give no more
assistance than is
necessary to
accomplish the
action. Short periods
of activity should be
followed by adequate
rest periods.
When possible,
active exercise
should be performed
against gravity. The
joint is moved
through full ROM
without assistance.
(make sure that the
patient does not
substitute another
joint movement for
the one intended)
The patient moves
the joint through its
ROM while the
therapist resist
slightly at first and
the progressively
increasing
resistance.
Sandbagws and
weights can be used
and are applied at
the distal point of the
joint involved. The
movement should be
performed smoothly.
Contract or tighten
the muscle as much
as possible without
moving the joint.
Hold for several
seconds, and then
let go and relax.
Breath deeply.
TRACTION
Use to reduce dislocation
PLM BSN 2006
Pediatric Nursing
Principles of Traction
The client should be in dorsal or supine position
For every traction, there is always a counter traction
Line of pull should be in line with deformity
For traction to be effective it must be continuous
Weight must be freely hanging
Types of Traction
Straight traction weight of the body serves as counter pull
Skin traction applied directly to the skin
o Bryants Traction
use to immobilize for < 2 years old at a 90 angle with buttocks off the
bed
o Bucks extension
For > 2 years old
Halo traction immobilize the spine
Skeletal traction
o Nursing responsibilities
Assess for circulatory and neurology impairment
It can lead to HPN
Be careful to carry out nursing functions by not moving the weights
AUTOIMMUNE SYSTEM
Types of Immunity
o Passive Natural
Developed via exposure to a disease
o Active Natural
Transplacental transfer, IgA from breastmilk
o Passive Artificial
Vaccination
o Active Artificial
Anti Rabies Serum
NEUROMUSCULAR SYSTEM
Reflexes
Blink reflex
Rapid eye closure when strong light is shown to protect the eyes; never disappears
Palmar Grasp Reflex
When a solid object is placed on the palm then the baby will grasp the object
To cling to the mother for safety
Disappears at 3 months
Step in/ Walk in Place Reflex/ Dance Reflex
Neonate placed on a vertical position with their feet touching on hard surface will
take a few quick alternating steps
PLM BSN 2006
Pediatric Nursing
Placing reflex almost the same with the dance reflex except that is when you are
touching the anterior surface of newborns leg
Plantar Grasp Reflex
When an object touches the sole of the newborns foot at the base of his toes, the
toes grasp in the same manner as the fingers do
Disappears @ 8 9 months in preparation for walking
Tonic Neck Reflex/ Fencing/ Boxing reflex
When the newborn lies on its bact, their heads usually turns to one side, the arm and
the leg on the side to which the head turns extend to the opposite arm and legs
contract
Moro Reflex/ Startle Reflex
With a loud voice or by a jarring the base of the crib, the baby will assume a c
position
Test for neurologic integrity
Magnet Reflex
When there is pressure at the sole of the foot, the baby pushes back against the
pressure
Crossed extension Reflex
While supine and the sole of the foot is stimulated by a sharp object, it causes the
foot to raise and the other foot to extend
Test for spinal nerve integrity
Trunk Incurvation Reflex/ Galant Reflex
While in prone position and the parabvertebral area is stimulated, it causes flexion of
the trunk and swing his pelvis towards the touch
Landau reflex
While the infant is placed on a vertical position with the hand underneath supporting
the trunk the baby exhibit some muscle tone
Present at 3 months
Test for muscle tone
Parachute Reflex
When the infant is placed on a vertical suspension with the change in equilibrium, it
causes the extension of the hands and legs
Present at 6 9 months
Babinski Reflex
When the sole of the foot is stimulated by inverted j, it causes fanning of the toes
Disappears by 2 months but may persist till 2 years old
PLM BSN 2006

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GROWTH AND DEVELOPMENT

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

Language and Social Skills

BEHAVIOR most comprehensive indicator of developmental stages

PATTERNS OF GROWTH AND DEVELOPMENT

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

Give opportunity to relate to

ERIK ERICKSONS STAGES OF PSYCHOSOCIAL THEORY

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

Parents has a moral obligations to set limits

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

o Memory traces are present and anticipate familiar events

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

BOWEL/ BLADDER CONTROL

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

Laughs aloud; Babbling sound

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

Imitates actions, comes when called

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

Preschoolers Characteristic Traits

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

Signs of Sexual Maturity in Female

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

IMMEDIATE CARE OF THE NEWBORN

Jomar Anthony D. Maxion, BSN, RN

PLM BSN 2006

The Royal Pentagon Review Specialist Inc.

Feto Placental Circulation