PEDIATRIC NURSING o It undergoes a series

of mitotic divisions
FETUS FORMATION o Becomes a
 How? BLASTOMERE
o Two (2) donors  Blastomere
 Father o Also undergoes a
 XY series of mitotic
 Mother divisions
 XX o Becomes a MORULA
 Morula becomes a
Mother Father BLASTOCYST with a cavity
(XX) (XY)  The Blastocyst with a cavity
egg cell sperm cell is found in the uterus
▼▼▼ sexual ▼▼▼
▼▼▼ intercourse ▼▼▼ Blastocyst Cavity
▼▼▼ ▼▼▼ ▼▼▼▼▼▼ ▼▼▼▼▼▼
▼▼▼ ▼▼▼ Trophoblast Embryoblast
▼▼▼ ▼▼▼ ▼▼▼▼▼▼ ▼▼▼▼▼▼
▼▼▼ Chorion ▼▼▼▼▼▼
fertilization ▼▼▼▼▼▼ ▼▼▼▼▼▼
(egg and sperm cell unite) Placenta ▼▼▼▼▼▼
▼▼▼ ▼▼▼▼▼▼
Forms the zygote ▼▼▼▼▼▼
▼▼▼▼▼▼
Important Concepts! ▼▼▼▼▼▼
 The father determines the sex ▼▼▼▼▼▼
of the child ▼▼▼▼▼▼
 Ampulla of the Fallopian Tube ▼▼▼▼▼▼
o The process of ▼▼▼▼▼▼
fertilization occurs here Amnion
o Egg and sperm cells ▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼E
meet at this area mbryonic Umbilical Umbilical
o It takes three (3) to five Disc Cord Sac
(5) minutes before the ▼▼▼▼▼▼
sperm cell reaches the Most important
ampulla part of the
Amnion
Important Concepts! ▼▼▼▼▼▼
 Zygote Becomes the
o The product of Fetus
fertilization
o It is found in the Other Important Concepts!
ampulla of the  Blastocyst with a Cavity
fallopian tube o The biggest in size
o It is unicellular o This is normally found
in the uterus

1
 o If the blastocyst stays
in the Fallopian Tube, it
lodges in the Isthmus
of the Fallopian Tube
 Isthmus
o Narrowest portion of
the Fallopian Tube
o Is the most common
site of Ectopic
Pregnancy
Important Concepts!
 In normal pregnancy
o Fetus stays for nine
(9) months in the
womb
o Customized in the
intrauterine
environment as it
stays there for nine
(9) months
Intrauterine Environment (9 months)
▼▼▼▼▼▼
▼▼▼▼▼▼
▼▼▼▼▼▼ Second Stage of Labor
▼▼▼▼▼▼ Seven (7) Cardinal
▼▼▼▼▼▼ Movements in Normal
▼▼▼▼▼▼ Spontaneous Delivery
▼▼▼▼▼▼
▼▼▼▼▼▼
Newborn (Extrauterine Environment)
Seven (7) Cardinal Movements of
Labor
 Experienced during Normal
Spontaneous Delivery
o Engagement
o Fetal Descent
o Flexion
o Internal Rotation
o Extension
o External Rotation
o Expulsion
2
Key Concepts!
Importance of Seven Cardinal
Movements of Labor
 Responsible for squeezing the
shoulders and chest of the
newborn
 Remember that the entire
lung of the fetus contains
amniotic fluid
 The lung does not function yet
 When both chest and
shoulder of the baby are
being squeezed, seven (7) to
forty-two (42) ml of amniotic
fluid are removed from the
lungs of the newborn
 This would aid in the
breathing of the baby
 This would make the lung
functional and make the baby
take his or her first breath
Important Concepts!
 In contrast, in Caesarian
Deliveries, the seven (7)
Cardinal Movements of Labor
are not utilized
 There is no mechanism
whereby seven (7) to forty-two
(42) ml of amniotic fluid would
be removed from the baby’s
lungs
 Thus, the priority nursing
diagnosis for a baby born
through Caesarian Section is
Ineffective Airway Clearance
Physiologic Changes that are  Oxygen and Carbon Dioxide
Responsible for making the pass through the placenta
Newborn Breathe for the First
Time Clamping of Umbilical Cord
 Does not allow the passage of
Mother Oxygen from the mother to
▼▼▼▼▼ the fetus
▼▼▼▼▼Placenta  Thus, when the umbilical cord
▼▼▼▼▼ is clamped
▼▼▼ o There is a decrease in
▼▼▼ Clamping of oxygenation of the
▼▼▼ Umbilical Cord newborn
▼▼▼ o There is an increase in
▼▼▼▼▼ carbon dioxide levels in
▼▼▼▼▼ the newborn
▼▼▼▼▼ o When carbon dioxide
Fetus levels increase, the
blood pH level drops
How is Clamping of the Umbilical  Therefore, the following
Cord Done? CHEMICAL STIMULI:
 First Step o Decreased Oxygen
o Clamp is applied at o Increased Carbon
MATERNAL SIDE Dioxide
 Second Step o Decreased Blood pH
o Milk the umbilical cord  Will stimulate the MEDULLA
towards the FETAL OBLONGATA for the newborn
SIDE to BREATHE FOR THE
 Third Step FIRST TIME!!!
o Clamp is applied at
FETAL SIDE Important Concept!
 Upon growing older, both:
Nursing Responsibility o Decrease in Oxygen
 Clamp and Cut the Umbilical levels
Cord o Increase in Carbon
Dioxide levels
Important Concept!  Become respiratory drives
 Upon clamping and cutting of
Umbilical Cord, physiological Intrauterine Environment (9 months)
changes NOW START! This is a RELATIVELY WARMER
ENVIRONMENT
Cutting of Umbilical Cord ▼▼▼▼▼▼
 Decreases oxygenation of the ▼▼▼▼▼▼
newborn ▼▼▼▼▼▼
 Placenta is a structure Newborn (Extrauterine Environment)
responsible for fetal This is a RELATIVELY COOLER
respiration ENVIRONMENT

3
Important Concept! oxygen levels in the
 First task of the newborn upon newborn’s blood
birth is to ADJUST TO  Increased carbon dioxide
EXTRAUTERINE levels in the newborn’s blood
ENVIRONMENT  Abrupt changes in the
external temperature
Important Concepts!
 Abrupt changes in Difference between FETAL
temperature, like the CIRCULATION and PULMONARY
following: SYSTEMIC CIRCULATION
o Warmer intrauterine
environment Pulmonary Systemic Circulation
o Cooler extrauterine
environment Lungs
 Causes ▼▼▼
stimulation of Pulmonary Vein
RECEPTORS in ▼▼▼
the SKIN Left Atrium
 This would, in turn, stimulate ▼▼▼
the MEDULLA OBLONGATA Left Ventricle
and cause the BABY TO ▼▼▼
BREATHE FOR THE FIRST Aorta
TIME!!! ▼▼▼▼▼▼▼▼▼▼▼
 These are called the ▼▼▼ ▼▼▼
THERMAL STIMULI!!! ▼▼▼ ▼▼▼
Upper Lower
Key Concept! Extremities Extremities
 Pain is NOT NECESSARY for ▼▼▼ ▼▼▼
the newborn to breathe for the ▼▼▼ ▼▼▼
first time. Superior Inferior
 Therefore, spanking the Vena Cava Vena Cava
newborn immediately upon ▼▼▼▼▼▼▼▼▼▼▼
birth is no longer practiced Right Atrium
▼▼▼
Key Concepts! Right Ventricle
 Therefore, CHEMICAL and ▼▼▼
THERMAL STIMULI are Pulmonary Artery
responsible for making the ▼▼▼
baby breathe for the first time! Back to the Lungs

Important Concepts! Important Concepts!

The following factors that make the  Arteries
baby breathe for the first time are: o Carry both oxygenated
 Stimulation of the medulla and deoxygenated
oblongata due to decreased blood

4
 o However, they carry o A hole between right
more oxygenated blood and left atrium
 Veins  Ductus Arteriosus
o Carry both oxygenated o An artery that connects
and deoxygenated pulmonary artery and
blood aorta
o However, they carry
more deoxygenated
blood
Fetal Circulation (continued from
FETAL CIRCULATION left side of page)

Placenta Right Atrium

▼▼▼▼ ▼▼▼▼▼▼▼▼▼▼▼
▼▼▼▼ Maternal blood and Fetal ▼▼▼ ▼▼▼
▼▼▼▼ blood do not cross though ▼▼▼ ▼▼▼
▼▼▼▼ the placenta to prevent Rh Foramen Right
▼▼▼▼ incompatibility Ovale Ventricle
▼▼▼▼ ▼▼▼ ▼▼▼
▼▼▼▼ Anti-bodies, O2 and CO2 ▼▼▼ ▼▼▼
▼▼▼▼ are substances that cross Left Pulmonary
▼▼▼▼ the placenta Atrium Artery
▼▼▼▼ ▼▼▼ ▼▼▼
▼▼▼▼ ▼▼▼ ▼▼▼
Umbilical Vein Left Ductus
(contains more oxygenated blood) Ventricle Arteriosus
▼▼▼▼ ▼▼▼ ▼▼▼
▼▼▼▼ ▼▼▼▼▼▼▼▼▼▼▼
Ductus Venosus Aorta
(contains more oxygenated blood) ▼▼▼
▼▼▼▼ ▼▼▼
▼▼▼▼ ▼▼▼
Hepatic Vein ▼▼▼
▼▼▼▼ Organs
▼▼▼▼ (Systemic Circulation)
Inferior Vena Cava ▼▼▼
▼▼▼▼ ▼▼▼
▼▼▼▼ Umbilical Artery
Right Atrium ▼▼▼
(continued on right side of page) Placenta

Important Concepts! Important Concept!

Three (3) Additional Fetal Structures  The purpose of the following
in the Fetal Blood Circulation structures:
 Ductus Venosus o Foramen Ovale
 Foramen Ovale o Ductus Arteriosus

5
 o Is to bypass the lungs Key Concepts!
 Rationale  Upon closure of the Foramen
o Because fetal Ovale, blood in the Right
circulation already Atrium GOES TO THE RIGHT
carries oxygen VENTRICLE

How does Fetal Circulation  Thus, when clamping and

Change to Pulmonary Systemic cutting of the umbilical cord
Circulation? occurs, the baby BREATHES
FOR THE FIRST TIME
 This is facilitated by
physiologic changes, which  When the baby breathes for
starts when the nurse cuts or the first time, there will be:
clamps the umbilical cord o INCREASED OXYGEN
LEVELS in the lungs of
 Clamping and cutting of the the baby and;
umbilical cord causes o DECREASED
INCREASED SYSTEMIC PULMONARY
VASCULAR RESISTANCE RESISTANCE in the
lungs of the baby
 Increased Systemic Vascular
Resistance causes  Therefore, increased oxygen
INCREASED PRESSURE IN levels and decreased
THE LEFT ATRIUM pulmonary resistance results
into the CLOSURE OF THE
 Increased pressure in the Left DUCTUS ARTERIOSUS
Atrium brings about
CLOSURE OF THE
FORAMEN OVALE

Clamping and Cutting of the Clamping and Cutting of the

Umbilical Cord Umbilical Cord
▼▼▼ ▼▼▼
Increased SVR Increased Oxygen Levels in the
(Systemic Vascular Resistance) lungs
▼▼▼ ▼▼▼
Increased pressure in the Decreased Pulmonary Vascular
Left Atrium Resistance
▼▼▼ ▼▼▼
Closure of the Foramen Ovale Closure of the Foramen Ovale

Important Concept! Important Concept!

 Clamping and Cutting of the  Clamping and Cutting of the
Umbilical Cord also causes Umbilical Cord also causes
CLOSURE OF THE CLOSURE OF THE DUCTUS
FORAMEN OVALE ARTERIOSUS

6
Key Concepts!!!
 Upon closure of the Ductus
Arteriosus, blood GOES TO
THE LUNGS
 Normally, the Ductus
Arteriosus takes about fifteen
(15) minutes to twelve (12)
hours to close
Congenital Heart Diseases
 Atrial Septal Defect
o Failure of the Foramen
Ovale to close
 Patent Ductus Arteriosus
o Failure of the Ductus
Arteriosus to close
Normal Physiological Changes in
the Newborn related to the Renal
System
Important Concepts!!!
 All structural organs MUST
BE PRESENT AT BIRTH in a
normal newborn
 These ORGANS are
IMMATURE and CANNOT
FULLY FUNCTION
 When these organs REACH
THE AGE OF ONE (1) YEAR,
they ATTAIN MATURITY
Important Concepts!!!
 The function of the kidney is
to filter the blood
 The urinary bladder is made
up of smooth muscle
 Distention of the smooth
muscle causes contraction
 In adults, two hundred fifty
milliliters (250 ml) of urine is
7
needed in the urinary bladder
to create an URGE TO VOID
 In adults, six hundred
milliliters (600 ml) of urine is
needed in the urinary bladder
for it to contract
Important Concepts in the
Urination of the Newborn!!!
 In the newborn, only fifteen
milliliters (15 ml) of urine in
the bladder is needed to
create an URGE TO VOID
 Therefore, newborns have
more FREQUENT VOIDING
relative to adults
 Normally, the newborn voids
up to twenty times (20x) in a
day!!!
Characteristics of Urine in the
Newborn
Normal Newborn Urine is
 Colorless
 Odorless
 Sterile (applies to the first
void)
Important Concepts!!!
 Newborns should void within
the FIRST TWENTY-FOUR
(24) HOURS, maximum is
FORTY-EIGHT (48) HOURS
 If voiding does not occur
within twenty-four (24) to
forty-eight (48) hours, the
possible problems are:
o Obstruction
o Abnormal positioning of
the urethral opening
  Normally the urethral opening Hirsprung’s

is at the tip of the glans penis Disease
 Aganglionic
Conditions wherein the Urethal Megacolon
Opening is not on the tip of the  Meconium becomes
Glans Penis: transitional stool if the
 Epispadia newborn is fed with either
o Urethral opening is on breast milk or formula milk
the dorsal side of the
glans penis Difference in Characteristics of
 Hypospadia Stool of Infants given Breast
o Urethral opening is on Milk and of Infants given
the ventral side of the Formula Milk
glans penis
Stool Breast Formula
Key Concept! Characteristic Milk Milk
Color Yellow to Pale or
 Patients with epispadia and Golden Light Yellow
hypospadia CANNOT to Light
UNDERGO CIRCUMCISION Brown
Rationale: Odor Sour milk More Foul
 Because prepuce or foreskin odor or
Offensive
are used in the repair of both odor
epispadia and hypospadia Consistency Pasty or Much Finer
Scrambled- appearance
Gastrointestinal System of the egg
Newborn appearance
 Considered sterile at birth
 Contains NO BACTERIA Important Concept!
 Normal odor of stool of adults
Important Concepts! is AROMATIC!!!
Meconium  Bacteria (E. coli) gives the
 This is the first stool of the adult stool its foul odor
newborn
 This is considered as Blood and Circulatory System of
STERILE the Newborn
 Normally greenish black
 Normally viscous Cyanosis
 Should be present in the first  Bluish discoloration of the skin
twenty-four (24) to forty-eight
(48) hours Key Concept!
o Defecation must occur  MAIN REASON for the
within this period occurrence of cyanosis is
o If not, possible INCREASED LEVELS OF
problems are: UNOXYGENATED BLOOD
 Imperforate and NOT THE DECREASED
anus LEVELS OF OXYGENATED
BLOOD!!!

8
Hema / Hepa Concepts in the Important Concepts!!!
Newborn  In the liver, glucoronyl
 Red Blood Cells of the transferase converts indirect
Newborn are IMMATURE bilirubin to direct bilirubin
 Hemoglobin of the Newborn is
IMMATURE  Since the liver of the newborn
 The Liver of the Newborn is is immature, there are
IMMATURE decreased levels of glucoronyl
transferase
Important Concepts!!!
 Normal lifespan of RBC / Hgb  Thus, indirect bilirubin is NOT
is ninety (90) to one hundred CONVERTED to direct
twenty (120) days bilirubin

 Due to the immaturity of the  Therefore, there would be

RBC and the Hemoglobin, INCREASED LEVELS OF
there is INCREASED RATE INDIRECT BILIRUBIN IN THE
OF HEMOLYSIS BODY OF THE NEWBORN
and this leads to
Hemolysis of RBC PHYSIOLOGIC JAUNDICE
(hemoglobin separates into two
components)  Two (2) Factors Responsible
Heme Globin for Physiologic Jaundice in
▼▼▼ ▼▼▼ Newborns
Fe (Iron) Protein o Increased RATE of
▼▼▼ ▼▼▼ HEMOLYSIS
Increased Amino Acids o Decreased LEVELS of
levels of GLUCORONYL
Indirect Bilirubin TRANSFERASE
(yellowish color)
Cannot be excreted Key Concepts!
in urine because it  If jaundice appears in the
is not water-soluble FIRST TWENTY-FOUR (24)
▼▼▼ HOURS after birth, it is
▼▼▼ Converted by considered as PATHOLOGIC
▼▼▼ Glucoronyl transferase JAUNDICE (due to biliary
▼▼▼ into atresia)
▼▼▼
Direct Bilirubin  If jaundice appears on the
Can be excreted SECOND (2nd) to the
in the urine th
SEVENTH (7 ) DAY of life, it
(water-soluble) is considered as
PHYSIOLOGIC JAUNDICE

9
Blood Volume in the Newborn o Immunoglobulin A
 Normal is 80 – 110 ml / kg BW  Received
through breast-
Average blood volume in the feeding
Newborn  Found in breast
 300 ml milk and in the
colostrums
Important Concept
 Erythrocyte levels in the Types of Immunity
newborn is INCREASED  Natural Immunity
 This is an effect of fetal  Artificial Immunity
circulation
Types of Natural Immunity
Immune System of the Newborn  Natural Active Immunity
 First Line of Defense  Natural Passive Immunity
o Skin
o Mucous Membrane Natural Active Immunity
 Second Line of Defense  Client is exposed to antigen
o Immunoglobulins or  Infection or antigen is
Anti-bodies introduced into the body
o IgG  Own body produces the
o Immunoglobulin G antibodies
 The only
immunoglobulin Natural Passive Immunity
that CAN  Client is not exposed to
CROSS THE antigen
PLACENTA (this  Infection or antigen is not
occurs on the introduced into the body
ninth (9th)  Body does not produce the
month) antibodies
 Acquired by full-  There is no infection
term babies  Client receives antibodies
 Pre-term babies from the mother
DO NOT  Examples of Natural Passive
RECEIVE IgG, Immunity
therefore, they o Immunoglobulin A
are PRONE TO o Immunoglobulin G
INFECTION
o IgM Types of Artificial Immuity
o Immunoglobulin M  Artificial Active Immunity
 Synthesized by  Artificial Passive Immunity
the fetus at
twenty (20) Artificial Active Immunity
weeks of  No infection
gestation  Client is exposed to weak
o IgA antigen

10
  Examples are immunizations  Usually PRESENT AT BIRTH
like OPV, BCG, etc.  If Moro Reflex is ABSENT by
 Body produces its own the first month of life, this is
antibodies considered ABNORMAL
o This is indicative of
Artificial Passive Immunity deafness or hearing
 No infection problems
 Client is NOT EXPOSED to  Disappears at about three (3)
weak antigen to four (4) months
 Antibodies are given through
immunization EXTRUSION REFLEX
 Example is DPT  Important in terms of feeding
and weaning
REFLEXES  Should disappear at about
 Also called Primitive three (3) to four (4) months
Movements  It must disappear about one
 Presence of reflexes are (1) month before introduction
considered NORMAL in of semi-solid foods
infants  Therefore, the BEST TIME to
 Presence of reflexes indicate INTRODUCE SEMI-SOLID
IMMATURITY OF THE FOODS is around FOUR (4)
NERVOUS SYSTEM TO FIVE (5) MONTHS

Nervous System STEPPING OR DANCING REFLEX

(Immature at Birth to First Year of  Dorsiflexion of the foot when it
Life) is placed on a flat surface
▼▼▼  Disappears in about three (3)
Presence of Reflexes to four (4) months
▼▼▼
Nervous System becomes MATURE ROOTING REFLEX
at ONE YEAR of AGE  Disappears in about three (3)
(Reflexes DISAPPEAR) to four (4) months
▼▼▼
▼▼▼ DOLL’S EYE
▼▼▼ Growth and Development  Disappears when fixation is
▼▼▼ developed
▼▼▼
Purposeful Movements are BLINKING REFLEX
PRESENT  This reflex does not disappear

MORO REFLEX COUGHING REFLEX

 Also called:  This reflex does not disappear
o Startle Reflex
o Parachute Reflex SNEEZING REFLEX
 This is elicited when the baby  This reflex does not disappear
is distracted by LOUD NOISE

11
SUCKING REFLEX GROWTH AND DEVELOPMENT
 This reflex does not disappear DURING THE FIRST YEAR OF
INFANCY BASED ON
BABINSKI REFLEX CEPHALOCAUDAL PATTERN
 Positive for fanning or MONTHS GROWTH AND REMARKS
extension of toes when the DEVELOPMENT
0–2 Growth and Infant cannot lift
sole of the foot is stroked development on the head. There
 Disappears at about one (1) UPPER NECK is HEAD LAG.
year of age Back muscles
 Presence is indicative of are not yet
immature nervous system developed.
DO NOT
 In adults, the presence of PLACE INFANT
Babinski reflex indicates a IN PRONE
NEUROLOGIC PROBLEM POSITION. This
results to
GROWTH AND DEVELOPMENT RESPIRATORY
PROBLEMS.
 Should be a continuous Best position is
process SIDE LYING
 Certain directions should be POSITION
followed: 4 Growth and LIFTS HEAD
o Cephalocaudal development on Infant can now
LOWER NECK be placed in
 Growth and and UPPER PRONE
development BACK POSITION
starts from the 6 Growth and Infant SITS
head going to development on WITH
the lower THORACIC SUPPORT.
AREA Infant SITS
extremities WITHOUT
o Proximodistal SUPPORT
 Growth and MOMENTARILY
development 8 Growth and Infant SITS
starts from the development on WITHOUT
LUMBAR AREA SUPPORT
center of the 10 Growth and Infant
body going development on CRAWLS,
outward BIG MUSCLE STANDS WITH
OF THE THIGH SUPPORT
Cephalocaudal Pattern of Growth 12 Growth and Infant STANDS
development on WITHOUT
and Development
the LOWER SUPPORT,
 Starts from the head LEG WALKS WITH
 Has something to do with the SUPPORT
growth of BIG MUSCLES
 Has something to do with the
development of GROSS
MOTOR ACTIVITIES (i.e.
walking) Important Concept!

12
  Correct Sequence of Growth  Infant recognizes rough /
and Development in terms of smooth objects (simple tasks)
Cephalocaudal Development before recognizing love and
o Sit hate (emotions)
o Crawl
o Stand MODES OF HEAT TRANSFER
o Walk Newborn loses heat through the
following ways:
Proximodistal Pattern of Growth
and Development CONDUCTION
 Starts from the center of the  Transfer of heat from one
body going outward body surface to another WITH
 Growth involves SMALL CONTACT
MUSCLES  Nursing Management
 Development involves FINE o Place newborn at chest
MOTOR development or FINE part of mother because
MOTOR SKILLS (i.e. hand heat is obtained by the
writing) baby through
conduction
GROWTH AND DEVELOPMENT
DURING THE FIRST YEAR OF RADIATION
INFANCY BASED ON  Transfer of heat from one
PROXIMODISTAL PATTERN body surface to another
MONTH GROWTH AND REMARKS WITHOUT CONTACT
DEVELOPMENT
0 Hands are CONVECTION
CLOSED  Heat transfer THROUGH AIR
3 Hands are
OPEN
CURRENTS
6 PALMAR Best time to  Nursing Management
GRASP give feeding o Close windows
REFLEX bottle to o Increase temperature
PRESENT baby
(palm)
of thermostat
9 PINCER GRASP Objects are
REFLEX picked up EVAPORATION
PRESENT using the  Transfer of heat through
(fingers) fingers VAPORIZATION
12 HAND FULLY Stacks  Nursing Management
DEVELOPED objects
o Do not place baby in a
DIFFERENTIATION THERMOSTAT
 Baby learns SIMPLE TASKS because this does not
FIRST before learning contain normal
COMPLEX TASKS temperature
 Infant walks first (gross motor
activity) before learning to Important Concepts!
write with the hand (fine motor  Newborns NEVER SHIVER
activity)

13
  They CANNOT GENERATE  Vomiting results into what
HEAT type of acid-base imbalance?
o Metabolic Acidosis?
 This is a cause of o Metabolic Alkalosis?
HYPOTHERMIA Answer:
 It depends on what is being
 Infant generates heat through vomited
FLEXION
VOMITING
 FLEXION decreases body ▼▼▼▼▼▼▼▼▼▼▼
surface area, therefore, Gastric Secretion Blood
decreases the chances of ▼▼▼ ▼▼▼
suffering from hypothermia Decreased Decreased
levels levels
 Vasoconstriction is less of Hydrochloric Acid of Oxygen
developed ▼▼▼ ▼▼▼
Metabolic Anaerobic
COLD STRESS Alkalosis Respiration
 This is a common ▼▼▼
complication of Increased
HYPOTHERMIA levels of
 Cold constricts blood vessels Lactic Acid
▼▼▼
Metabolic
Acidosis
COLD STRESS
▼▼▼ MORPHINE SULFATE TOXICITY
Vasoconstriction  Results to RESPIRATORY
▼▼▼ ACIDOSIS
Decreased Tissue Perfusion
▼▼▼ MORPHINE SULFATE TOXICITY
Decreased Tissue Oxygenation ▼▼▼
▼▼▼ Respiratory depression
Anaerobic Respiration ▼▼▼
▼▼▼ Hypoventilation
Accumulation of Lactic Acid ▼▼▼
▼▼▼ Decreased Respiratory Rate
METABOLIC ACIDOSIS (a basic ▼▼▼
complication of Cold Stress) Increased Levels of Carbon Dioxide
▼▼▼
Respiratory Acidosis

HYPOVENTILATION
VOMITING  Results to RESPIRATORY
Question: ACIDOSIS

14
Important Concepts on Newborn APGAR SCORING
Respiration  First Minute
 Newborns are NASAL o Purpose is to check if
BREATHERS newborn can adjust to
o First order of extrauterine
respiration environment
 Newborns only breathe  After Five Minutes
through the mouth if there is o To check the overall
CHOANAL ATRESIA status of the newborn

Important Concepts! Components of the APGAR SCORE

 Normal color of the eye at SCORE 0 1 2
Heart Rate Absent Less than Greater
birth is GRAY 100 beats than 100
 Natural eye color appears at per minute beats per
minute
age three (3) Respiratory Absent Weak Cry / Good Cry
 If the eyes are color blue at Effort Irregular
Respiration
birth, then the infant is Reflex No Weak Cry / Vigorous
suffering from Irritability response Grimace Cry / Lusty
Cry
PHENYLKETONURIA Muscle Flaccid; Some flexion Full
Tone Full Flexion or
extension Active
ASSESSMENT IN THE NEWBORN of Flexion
Consists of: extremity
Skin Color Completely Acrocyanosis Completely
 Initial Assessment pale / / Body is pink Pink
 On-going Assessment Completely and
cyanotic extremities
 Physical Assessment are blue
 Behavioral Assessment
Important Concepts!
1. INITIAL ASSESSMENT  If Apgar Score is nine (9),
 Mnemonic is ABCMP patient exhibits
ACROCYANOSIS
A is for:  Most patients are
 AIRWAY experiencing this!
 APGAR SCORING
Interpretation of APGAR Score
AIRWAY SCORE RATING REMARKS
 Basic priority in newborn 0-3 POOR Give
resuscitation to
 Perform suctioning in the newborn
newborn 4-6 FAIR Newborn can
survive with or
 Mouth is suctioned first before without support
the nose 7-10 GOOD Newborn can
survive
 Use bulb syringe when extrauterine
suctioning the infant environment
 Press bulb syringe before
putting it in nose or mouth of B is for
the newborn  BODY TEMPERATURE
 BONDING
 BANDS

15
 BANDS
BODY TEMPERATURE  Purpose is for identification of
ASSESSMENT infants
 Expose only the body part you  Important Concepts!
will assess o The newborn’s
 Infant is prone to hypothermia FOOTBAND is the
 Wrap head to prevent Cold most accurate way of
Stress identifying the newborn
 Important Concepts in  In the United States, use of
Temperature taking pictures to identify the
o Rectal temperature is newborn is being done. This
most accurate is done every eight (8) hours
o Measurement of rectal
temperature is C is for:
indicated in  CORD CARE
 Stable Patients
 Ambulatory CORD CARE
Patients  Profuse bleeding is NOT
o Rectal temperature is NORMAL
contraindicated in  Triple Dye Solution
patients with o Can cause
hemorrhoids vasoconstriction of
o If patient has sinus umbilical cord to
tachycardia, use rectal prevent profuse
measurement of bleeding
temperature to produce  If profuse bleeding occurs,
vagal stimulation and this indicates THE EARLIEST
reduce heart rate SIGN OF HEMOPHILIA
o For oral measurement o Check the gender first
of temperature, if hot o If male, infant is
drinks were taken by possibly positive for
patient, obtain oral Hemophilia
temperature after thirty o Only males are
(30) minutes symptomatic for
Hemophilia
BONDING
 Promote mother-infant M is for:
bonding through BREAST  Meconium and Voiding
FEEDING
 If mother develops EYE- MECONIUM AND VOIDING
CONTACT with infant, she is  Should occur within twenty-
ready for mother-infant four (24) to forty-eight (48)
bonding! hours
P is for:
 POSITIONING
 PRINTS

16
  VITAL SIGNS
POSITIONING  VITAL STATISTICS
 Head of the infant should
always be lower than the VITAL SIGNS
chest Normal Vital Signs in Infants
o This is to allow PARAMETER NORMAL REMARKS
secretions to go to the VALUE
Respiratory 30 – 60
mouth and nose Rate breaths
 Suction first the mouth before per
the nose minute
 Never do Trendelenburg Cardiac Rate AWAKE:
position in infants 120 –
160 beats
o This may result to per
INCREASED minute;
INTRACRANIAL ASLEEP:
PRESSURE 100 beats
 Modified Trendelenburg per
minute
position is best for patients CRYING:
suffering from SHOCK 180 beats
per
PRINTS minute
 Get footprint Temperature 36.8°C Initial
temperature
 How is this done? taking is done
o Work on the heel first rectally; This is
before working on the the most
toes accurate and
serves as a
 Rationale:
check for the
o It is easier to put the presence of
heels on the stamp pad IMPERFORATE
relative to the toes ANUS
Blood 80 / 46
Pressure
IMPORTANT CONCEPT IN
ANSWERING LOCAL BOARD Important Concepts!!!
EXAMINATION QUESTIONS  In obtaining the blood
 If the question or situation pressure of infants, check the
asks for THE INITIAL THING blood pressure on both the
THE NURSE MUST DO or for upper and the lower
the PRIORITY THING TO DO, extremities
the correct answer is always
involves ASSESSMENT  Blood pressure on LOWER
EXTREMITY is NORMALLY
HIGHER than blood pressure
2. ON-GOING ASSESSMENT on UPPER EXTREMITY (BPLE
 Mnemonic is VGAP > BPUE)
 A HIGHER blood pressure
V is for: reading on the UPPER
EXTREMITY relative to the

17
 LOWER EXTREMITY is o Head Circumference is
ABNORMAL (BPUE > BPLE) greater than Chest
Circumference
 This abnormality is a
CARDINAL SIGN of  Initial sign of Increased
COARCTATION of the AORTA Intracranial Pressure
o Irritability
Important Concepts in Vital Signs
Taking in Pediatric Patient  Increased Respiratory Rate is:
 Do first the least invasive and o NOT INDICATIVE of
the least painful Increased Intracranial
 Do Respiratory Rate and Pressure
Heart Rate first o It indicates
 Do Blood Pressure and DECREASED LEVELS
Temperature last of Intracranial Pressure
 If you get the Temperature
first, the newborn becomes
agitated Important Concepts on Increase in
o It would then be difficult Weight in Newborn
to obtain the other vital
signs  Birth weight DOUBLES in SIX
(6) MONTHS
VITAL STATISTICS OF NEWBORN
PARAMETER NORMAL VALUE  Birth weight TRIPLES in ONE
Birth Weight 2,500 – 4,000 grams
Birth Length 19 – 21 inches
(1) YEAR
Head Circumference 13 – 14 inches
Chest 12 – 13 inches  Birth weight QUADRUPLES in
Circumference (One inch less than TWO and a HALF (2.5)
Head YEARS
Circumference)
Important Concepts! G is for:
 It is normal in newborns to  GESTATIONAL AGE
find the HEAD ASSESSMENT
CIRCUMFERENCE greater
than the CHEST GESTATIONAL AGE OF UNBORN
CIRCUMFERENCE INFANT
 Full Term Baby
 Head Circumference is about o Thirty-eight (38) to
one (1) inch or about two (2) Forty-two (42) weeks
centimeters larger than the  Pre-term Baby
Chest Circumference o Less than thirty-eight
(38) weeks
 In infants with
 Post-term Baby
HYDROCEPHALUS:
o More than forty-two
o Anterior fontanelle is
(42) weeks
open

18
A is for: o Beutler Test
 Administration of Certain  Also done within
Medications twenty-four (24)
hours, together with
Administer the following Guthrie Test
medications:  Done to check if
 Vitamin K client has
 Erythromycin GALACTOSEMIA

Vitamin K Important Concepts in Rh

 For prevention of bleeding Incompatibility
 Given at vastus lateralis  The blood type of the Fetus
 Route is intramuscular would ALWAYS BE THE
 Given only to the gluteal SAME as the blood type of
muscle if the baby has the Father
already walked o If the Father is Rh+, the
fetus would also be
Erythromycin Rh+
 Prophylaxis to ophthalmic o If the Father is Rh-, the
neonatorum fetus would also be Rh-
 Administered from INNER to  In a situation where the
OUTER CANTHUS Father is Rh+ and the Mother
 If liquid eye drops are used, is Rh-, the Fetus would also
place drop at LOWER be Rh+
CONJUNCTIVAL SAC  However, the Fetus WILL
 Press the lacrimal sac to SURVIVE because BLOOD
prevent systemic effects. CANNOT CROSS THE
PLACENTA
 Right after the mother delivers
and the placenta is removed,
P is for: FETAL BLOOD ENTERS THE
 PERFORM LABORATORY MATERNAL CIRCULATION
TESTS through wounds developed
upon the removal of the
 Important Laboratory Tests placenta
to be Perfomed  Thus, the MOTHER WILL
o Coomb’s Test DEVELOP ANTIBODIES.
o Bilirubin Test  If the SECOND CHILD is Rh+,
o Erythrocyte Test it will not survive as the
o Guthrie Test mother has developed
 Done within antibodies
twenty-four (24) hours  To prevent the development of
of delivery antibodies, administer
 Done to check if RHOGAM to the mother NOT
client has LATER THAN FORTY-EIGHT
PHENYLKETONURIA

19
 (48) TO SEVENTY-TWO (72)
HOURS AFTER BIRTH NORMAL CHARACTERISTICS OF
 Similarly, RHOGAM is THE EYES AT BIRTH
administered to the mother  Normal Color at Birth
who has undergone o GRAY
ABORTION, likewise forty-
eight (48) to seventy-two (72)  Normal for SEARCHING
hours after the procedure to NYSTAGMUS
prevent formation of o Due to immaturity of
antibodies ocular muscles

3. PHYSICAL ASSESSMENT  Normal for EDEMATOUS

EYELIDS
HEAD o This is part of the
Fontanelles birthing process
Normal
 Must be soft and firm  Normally DOES NOT
 If they are depressed PRODUCE TEARS
o Indicative of
DEHYDRATION  Due to immaturity of the
 If they are bulging LACRIMAL GLANDS
o Indicative of
INCREASED EARS
INTRACRANIAL
PRESSURE To straighten the Eustachean
 Anterior Fontanelle tube, pulling of the ear should be:
o Diamond-shaped  In infants to three (3) year
o Closes in Eighteen (18) olds
months o Downward and
 Posterior Fontanelle Backward
o Triangular-shaped  In adults
o Closes in two (2) to o Upward and Backward
three (3) months
 Important Concepts!!! Important Concept!
o If the ANTERIOR  Expect that all sense organs
FONTANELLE is STILL of newborn should be present
OPEN at TWO YEARS at birth
of AGE, then this is
INDICATIVE OF DIFFERENCES BETWEEN
HYDROCEPHALUS CEPHALHEMATOMA AND
o Nurse assesses head CAPUT SUCCEDAENEUM
circumference until the CEHPHAL CAPUT
HEMATOMA SUCCEDANEUM
thirty-sixth (36th) month What Accumulation Edema
of age is it? of blood
between the
EYES periosteum

20
 and skull of o Preserve the evidence
bones  Do not do
When Disappears Disappears in
does it in WEEKS DAYS douching
Dis-  Do not take a
appear bath

MONGOLIAN SPOTS Characteristics of Parents who are

 These are NORMALLY Child Abusers
present in infants  Mnemonic is VISEN
LETTER CHARACTERISTIC
 They are deep-blue V Came from a VIOLENT family
I Inconsistent
pigmentations at the buttocks
S Socially isolated; violates laws
Sexually abused as a child
 They disappear at about five E Emotionally immature
(5) years of age These are the young couples
o If they disappear at a (aged 16 –17)
These are the newly-wed
time less than five (5)
couples
years of age, this is Nursing Management involves
NORMAL placing them on therapy
o If they disappear at a regarding Growth and
time greater than five Development
N Negligence in terms of Growth
(5) years of age, this is and Development
indicative of CHILD
ABUSE CHEST CIRCUMFERENCE
 Transverse Diameter (TD)
CHILD ABUSE o Left to Right Diameter
The following could be observed:
 Anteroposterior Diameter
 Wounds or bruises on the
(APD)
body of the child in
o Front to Back Diameter
DIFFERENT STAGES OF
 Important Concepts!!!
HEALING
o In Adults
 Inconsistencies of the stories  Normally, TD >
of the parent APD
 If APD = TD,
 Differences in the length of then there is the
the child’s hair strands presence of a
BARREL
Important Concepts in Child CHEST
Abuse  In Infants
 Check or validate the o APD = TD
occurrence of Child Abuse by
providing privacy to the child LABIA and CLITORIS
 It is normal for theses
 Priority in Sexually Abused structures to be EDEMATOUS
Child at birth

21
 FSH-RH LH-RH
Important Concept!!! (Follicle (Leutinizing
 There is Stimulating Hormone
PSEUDOMENSTRUATION at Hormone Releasing
birth of a female infant Releasing Hormone)
 This is a normal occurrence Hormone) ▼▼▼
▼▼▼ ▼▼▼
Important Concept!!! Stimulates the ANTERIOR
In menstruation: PITUITARY GLAND (APG)
 Shedding of endometrium ▼▼▼ ▼▼▼
occurs due to: Release of FSH Release of LH
o Decrease in levels of (Follicle (Leutinizing
Estrogen Stimulating Hormone)
o Decrease in levels of Hormone) ▼▼▼
Progesterone ▼▼▼ ▼▼▼
 This results into bleeding Maturation of Maturation of
within three (3) to five (5) days GRAAFIAN CORPUS
FOLLICLE LUTEUM
Decreased levels of ESTROGEN ▼▼▼ ▼▼▼
and PROGESTERONE Increased levels Increased levels
▼▼▼ of Estrogen; of Progesterone;
Shedding of the Endometrium PROLIFERATIVE SECRETORY
▼▼▼ PHASE PHASE
Bleeding or Menstruation occurs ▼▼▼ ▼▼▼
No bleeding No bleeding
Important Concept!!!
When the levels of Estrogen and Important Concept!!!
Progesterone drop, the  Increased levels of Estrogen
HYPOTHALAMUS secretes the and Progesterone trigger a
following substances: Negative Feedback
 FSH-RH o Hypothalamus no
o Follicle Stimulating longer secretes FSH-
Hormone – Releasing RH and LH-RH
Hormone o The net effect would be
 LH-RH decreased levels of
o Leutenizing Hormone – Estrogen and
Releasing Hormone Progesterone
 Therefore, MENSTRUATION
OCCURS
Decreased levels of ESTROGEN  Note that the MENSTRUAL
AND PROGESTERONE PHASE is characterized by:
▼▼▼ o Decreased levels of
Stimulates the HYPOTHALAMUS to Estrogen
release substances o Decreased levels of
▼▼▼▼▼▼▼▼▼▼▼▼ Progesterone

22
Important Concepts in Pregnancy  Chemotherapeutic drugs
 Estrogen and Progesterone attack rapidly dividing cells:
are both produced by the o Cancer cells
PLACENTA o Other body cells that
o Therefore, there is no are rapidly dividing:
bleeding due to  Hair cells
shedding of the  Skin cells
endometrium during  Mucous
pregnancy membrane cells
o Therefore, there is no  Side Effects of
menstruation during Chemotherapeutic Drugs
pregnancy o Alopecia
 There is AMENORRHEA  Hair cells
multiply quickly
Important Concepts in Clamping o Hyperpigmentation
of the Umbilical Cord  Skin cells
 In clamping of the umbilical multiply quickly
cord, there is decreased o Stomatitis
levels of Estrogen and  Mucous
Progesterone membrane cells
 This leads to multiply quickly
PSEUDOMENSTRUATION o Nausea and Vomiting
 Stomach lining
Important Concept on the TESTES cells multiply
of the Newborn quickly
 The testes of the newborn is o Decreased peristalsis
NORMALLY UNDESCENDED and constipation
 Descent normally occurs  Small and large
AFTER SIX (6) WEEKS intestine lining
 If descent does not occur after cells multiply
this period, there is quickly
CRYPTORCHIDISM o Anemia
 Nursing Responsibility
 Bone marrow
o Check for
suppression
undescended testes results into
 Warm hands decreased
 Palpate testes levels of RBC
o Avoid stimulating the o Infection
cremasteric reflex  Bone marrow
 Presence of cold temperature suppression
will prevent the descent of the results into
testes and will make it ascend decreased
to the pelvic area levels of WBC
o Bleeding
Important Concepts in Use of
 Bone marrow
Chemotherapeutic Drugs
suppression

23
 results into DPT
Diphtheria
I.M. or
Intramuscular
Three
Doses:
decreased Pertussis 1st Dose 0.5 ml Vastus
levels of Tetanus (at
weeks)
6 lateralis

platelets or
thrombocytes 2nd Dose
(at 10
0.5 ml Vastus
lateralis
weeks)
Important Concepts on 3rd Dose 0.5 ml Vastus
Administration of Immunization in (at 14 lateralis
Infants undergoing Chemotherapy weeks)
OPV P.O. or per Three
 Administer DPT Oral Polio orem Doses:
o This is an Artificially Vaccine 1st Dose 2 – 3 Mouth
(at 6 drops
Acquired Passive form weeks)
of Immunity 2nd Dose 2 – 3 Mouth
o Antibodies are received (at 10 drops
weeks)
by the patient
 Do NOT ADMINISTER OPV 3rd Dose 2 – 3 Mouth
(at 14 drops
o This is an Artificially weeks)
Acquired Active form of
Hepatitis i.M. or Three
Immunity B vaccine Intramuscular Doses:
o This can cause 1st Dose 0.5 ml Vastus
(at 6 lateralis
possible infection of the weeks)
siblings as the virus is
2nd Dose 0.5 ml Vastus
eliminated through the (at 10 lateralis
stool. weeks)

3rd Dose 0.5 ml Vastus

STAGES OF GROWTH AND (at 14 lateralis
weeks)
DEVELOPMENT Measles S.Q. or One 0.5 ml Deltoid
Vaccine Subcutaneous Dose; muscle
Given at
INFANCY 9 months
 From birth to one (1) year of of age
age
 Mnemonic is INFANTS Important Concept!
 During immunization, do not
I is for: use the following solutions in
 IMMUNIZATION dipping the cotton balls:
o Alcohol
o Betadine
IMMUNIZATION o Hydrogen Peroxide
VACCINE ROUTE NUMBER DOSAGE SITE
OF
 Use only Cotton balls dipped
DOSES in sterile water or in boiled
BCG I.D. or Two
Bacillus Intradermal Doses:
water
Calmette 1st Dose 0.05 ml Right  Rationale:
Guerin (at brth); Deltoid
o Alcohol, betadine and
2nd Dose 0.10 ml Left hydrogen peroxide will
(upon Deltoid
School kill the attenuated
Entrance) organisms in the

24
 vaccine and will render thing to check for is THE
them ineffective ABILITY TO CHEW

Important Concepts in the  The following reflexes should

Administration of Vitamin A also be present:
 Use scissors needed in o Gag Reflex
opening Vitamin A sac used in o Swallowing Reflex
administration o Cough Reflex
 Deficiency in Vitamin K leads
to night blindness  Ideally, the gag reflex is
o In night vision, details checked by the use of the
are seen due to the tongue depressor to touch the
presence of rhodopsin posterior portion of the tongue
 During the day, details are o However, the BEST
seen even in the absence of WAY TO CHECK FOR
rhodopsin THE GAG REFLEX IN
o Rhodopsin is broken INFANTS is to check
down into for the ability to SIP
 Scotopsin SMALL AMOUNTS OF
 Retivene FLUID
 Transformed
into Vitamin A  Give Vitamin C or orange
juice to enhance the
Important Concepts in Iron absorption of Iron
Administration
 Best time to give Iron to infant  If Iron is given to toddlers, use
o After four (4) to six (6) a straw to prevent
months DISCOLORATION OF THE
o This coincides with the TEETH
best time for weaning
and giving of semi-solid N is for:
foods  Note changes in infant’s
o This is the same period weight
when the extrusion
reflex disappears

 First type of semi-solid food to F is for:

give to infant  Most common FEAR of
o Cereal or Rice Cereal Infants
o Give one flavor at a
time to check for the Important Concepts!
occurrence of allergies  FEAR OF STRANGERS
o Peaks at about eight
 If baby is on a liquid diet and (8) months
the physician orders for semi-
solid food, the most important A is for:

25
  ALLOW STAGE
Important Concepts:
 Use pacifier when the patient
is on NPO
 According to Freud, the mouth
is the most important part of
the body during the Oral
Stage
N is for:
 NO CHOKING HAZARD
Important Concepts!
 Take precautions so that
infant does not choke from
small objects placed in the
mouth
 Palmar and pincer grasp
reflexes are present
 Pleasure principle at the
ORAL STAGE is to put
objects in the MOUTH.
T is for:
 Trust versus Mistrust
Important Concepts!
 Hunger is an unpleasurable
principle
 When the baby is hungry, (he
experiences an unpleasurable
principle) he cries
 When the baby cries, the
mother feeds the baby
 Feeding is done through the
mouth (the most important
part of the body in the Oral
Stage)
 When feeding through the
mouth is facilitated by the
mother, the baby’s hunger is
diminished (a pleasure
principle)
 Therefore, when food is given
to the baby to satisfy his
26
hunger when he cries, the
pleasure principle is achieved
and he DEVELOPS TRUST
 On the other hand, when food
is not given to the baby to
satisfy his hunger when he
cries, the unpleasurable
principle persists and he
CEASES TO CRY because he
has DEVELOPED MISTRUST
 Key Concept!!!
o The most important
person in the INFANCY
STAGE is the
MOTHER
S is for:
 SOLITARY PLAY
Important Concept
 Solitary play is the type of
play that mostly occurs during
the infancy period
TODDLERS
 Mnemonic is TODDLER
T is for:
 Talk in SIMPLE TERMS
Sample Board Question!
 How does a nurse explain a
procedure to a toddler?
Answer
 Use simple terms!
Important Concept!
 In explaining a procedure, the
nurse will explain to the
toddler, in simple terms, what
the toddler will
o Expect and;
o Experience during the
procedure
 Example:
In a procedure like cardiac  Client is placed on a HIGH
catheterization, the nurse talks to the ALLERGIC REACTION
toddler in simple terms: PRECAUTION
WHAT TO EXPLANATION EXPLANATION
EXPLAIN TO AN TO A
ADULT TODDLER
 Keep the following nearby:
Skin Betadine will be A special brown o Epinephrine
preparation used to clean solution will be o Corticosteroid
your skin used to clean
your skin
Anesthetic Anesthesia will A special O is for:
administration be administered solution will put  OFFER CHOICES
to your skin your skin to
sleep
Catheter A catheter will A special tube Situation:
insertion be inserted will be inserted  In giving medications to a
and you will
experience a toddler, expect a “NO” answer
pulsating from the toddler.
sensation
Contrast A contrast A special
Medium medium would colored solution Sample Board Question:
be used would be used When the toddler says “No” when
and you will you are about to give him his
experience a
flushing medication, what will you do?
sensation a) Leave the room
X-ray A series of x- Lights will be b) Insist that the medication be
rays would be turned off and a
conducted series of picture
given
taking will occur c) Inform the physician
Model of the Needed in Not needed as d) Give the medication to the
Heart explaining this is not
necessity of the comprehended
mother for her to administer
procedure to by the toddler
the patient Answer:
 Letter A!
Important Concepts!
 In explaining any procedure
that would be done on a
toddler, IT IS ALWAYS BEST Sample Board Question:
TO INCLUDE THE PARENTS If after an hour, the toddler still
 Parents are important people says “No” to the medication, what
to toddlers!!! will you do?
a) Leave the room
Key Concepts in Cardiac b) Insist that the medication be
Catheterization given
 Check the patient for allergies c) Inform the physician
to seafoods d) Give the medication to the
mother
 If patient is allergic to
seafoods, continue with the Answer:
procedure  Still Letter A!!!

27
 Important Concepts!
Important Concept!!!  The anal part is most
 Therefore, GIVE THE important at this stage of
TODDLER A CHOICE for him development
not to answer “No”  The best time for toilet
 Example: training:
o “Do you want to drink o When child is around
your medication with eighteen months old
water or with juice?” o When child is
physically ready – can
D is for: sit without support
 DOUBT and SHAME versus o When child is
AUTONOMY psychologically ready –
with urge to defecate
Important Concept!  When done improperly and at
 Toddlers want to establish the wrong time, toilet training
SELF CONTROL may lead to an OBSESSIVE-
COMPULSIVE BEHAVIOR
D is for:  Best management for
 DO NOT LEAVE THE Obsessive-Compulsive
TODDLER UNATTENDED IN behavior
THE SWIMMING POOL OR o Allow client to do the
IN THE BATH TUB rituals in order to
decrease levels of
Important Concept! anxiety
 Drowning is the most common o If hand is swollen
cause of death in toddlers  Do not stop the
performance of
L is for: the rituals
 LEARNING ABOUT THE  This is still
CONCEPT OF DEATH needed to
reduce the
Important Concepts! client’s anxiety
 Learning about the concept of levels
death o Provide gloves to the
 Usually starts at the age of client to keep skin
three (3) integrity and allow him
 The toddler’s concept of death to continue on with the
o It is reversible rituals
E is for: R is for:
 ELIMINATION  RITUALS and ROUTINES

Important Concept!
 Read bedtime stories to
toddlers to put them to sleep

28
  Toddler tries to establish
autonomy through rituals and Mother brings the toddler to the mall
routines ▼▼▼
 Always PRAISE a toddler If the object (i.e. a G.I. Joe toy) the
whatever he does to establish toddler wants is not bought
autonomy ▼▼▼
o Except when he is Temper Tantrums now extended for
having TEMPER ten minutes; Autonomy established
TANTRUMS in ten minutes
o The best way to handle ▼▼▼
temper tantrums is to Mother buys the G.I. Joe toy
IGNORE IT but
PROVIDE SAFETY IMPORTANT CONCEPT!
 Autistic children  Another mnemonic for
o Do not talk toddlers is PRAISE
o Like inanimate objects
o Do head banging! P is for:
 Therefore, put a  PARALLEL PLAY
helmet on their
head Important Concepts!
 Ways of Ignoring Toddler’s  In parallel play:
Temper Tantrums to Decrease o Two toddlers are
Anxiety playing
o Allow the toddler to o They are playing WITH
FACE THE WALL or THE SAME TYPE OF
SIT ON A CHAIR TOY but WITH TWO
o TIME OUT DIFFERENT TOYS.
 The best way o Each toddler has his
 Temper own toy, which is
Tantrums occur exactly the same as
because of the the one the other
parents toddler is playing with
 Toddlers forget the concept of
Sharing
Example:  Key Concept!
Mother brings the toddler to the mall o Most IMPORTANT TOY
▼▼▼ FOR TODDLERS
If the object (i.e. a TOY GUN) the  Push-Pull Toys
toddler wants is not bought o Rationale:
▼▼▼  Pincer grasp
Temper Tantrums occur for five has already
minutes; Builds autonomy been developed
▼▼▼ and they are
Mother buys the toy gun able to walk

Second time around. . . R is for:

29
  ROUTINES E is for:
 EXPLAIN THE PROCEDURE
A is for: TO THE CLIENT
 AUTONOMY versus SHAME
and DOUBT S is for
 SCHOOLMATES
I is for:
 INVOLVE PARENTS ALWAYS Important Concept:
 Most important person to a
S is for: Pre-schooler:
 SEPARATION ANXIETY o Same age group
 Therefore, give
Important Concept! room
 This is the most common assignments to
cause of FEAR in a toddler pre-schoolers
using the same
E is for: age group
 ELIMINATION  Key Concept!
o In choosing a patient or
Important Key POINTS TO patients a pre-schooler
REMEMBER! would share a room or
 Toddlers always say “NO” ward with in the
 Preschoolers always ask hospital, choose the
“WHY” least infective
companion (i.e. a post-
PRE-SCHOOLERS operative pre-schooler
 Mnemonic is PRESCHOOL or a pre-schooler with
impetigo)
P is for:
 PLAY
Important Concepts!!! C is for:
 Play is associative or  CURIOSITY
cooperative
 Involve pre-schoolers in any Important Concept!
group play  Pre-schoolers always ask
 To elicit cooperation, utilize “WHY”
“Simon says…” game
H is for:
R is for:  HIGHLY IMAGINATIVE
 REGRESSION
Important Concept!
Important Concept!  Pre-schoolers have
 Regression is common during IMAGINARY PLAYMATES
hospitalization  This is NORMAL in pre-
 This is a NORMAL behavior schoolers

30
O is for: A is for:
 OBSERVE FOR INITIATIVE  Same AGE GROUP
versus GUILT
G is for:
O is for:  GUILT
 OFF LIMITS TO THE
KITCHEN I is for:
 INITIATIVE
Important Concept!
 The most common causes of C is for:
accidents in pre-schoolers  CURIOSITY
are:
o Poisoning POISONING
o Burns  Occurs mostly in the house

L is for: Sequence of Steps in the

 LOSS OF BODY PART or Management of Poisoning
BODY CASTRATION
1. Call the POISON CONTROL
Important Concepts!!! CENTER (PCC)
 This is their most common  PCC provides step-by-step
cause of fear procedure in the management
 This is also the most fearful, of poisoning
in terms of injury, among all
age groups 2. Identify the Poison
 If possible, ask the victim
IMPORTANT CONCEPT! what he took
 Because Pre-schoolers are  If the victim is an infant or is
imaginative, another comatose
applicable mnemonic is o Ask witnesses
MAGIC  If there are no witnesses
o Check for the presence
of the container of the
M is for: poison
 MUTILATION
3. Remove the poison
Important Concept!  Induce vomiting
 Mutilation is the most o Give syrup of Ipecac
common cause of fear  If victim is less than six (6)
 Displacement is another months of age
common cause of fear o Do not give Ipecac
o Therefore, allow the o Do not induce vomiting
pre-schooler to use or o They have weak gag
wear his uniform in the and swallowing reflex
hospital  If victim is six (6) to twelve
(12) months

31
 o Give ten milliliters (10
ml) of Ipecac
o Ideally, victim will vomit
within twenty (20) to
thirty (30) minutes
o If victim does not vomit,
DO NOT REPEAT THE
DOSAGE
 If victim is one (1) to twelve
(12) years old
o Give fifteen milliliters
(15 ml) of Ipecac
o Ideally, victim will vomit
within twenty (20) to
thirty (30) minutes
o If victim does not vomit,
repeat the same dose
 If victim is twelve (12) years
old and above
o Give thirty milliliters (30
ml) of Ipecac
o Ideally, victim will vomit
within twenty (20) to
thirty (30) minutes
o If victim does not vomit,
repeat the same dose
Key Concepts!!!
 Never induce vomiting in the
following situations:
o Unconscious patient
o Comatose patient
o Patient prone to
seizures
o When poison is
corrosive
 Strong acids
 Strong alkali
 Causes
double
injury
o When poison is a
hydrocarbon
 Kerosene
 Gasoline
32
4. Decrease the absorption of the
poison
 Give activated charcoal
 Give one gram (1 g) per
kilogram body weight
5. Bring victim to pediatric
hospital together with:
 Vomitus
 Container of poison
 Urine of victim (if available)
Important Concepts!!!
 Usual cause of poisoning is
ASPIRIN TOXICITY
o This damages the
eighth (8th) cranial
nerve leading to
TINNITUS or problems
in terms of BALANCE
- a major function of
the vestibulocochlear
nerve
 Antidote for Aspirin
o N-acetylcysteine
 Other antidotes:
o For Acetaminophen
 N-acetylcysteine
o For Bleeding
 Vitamin K
o For Acidity effect
 Sodium
Bicarbonate
(NaHCO3)
Key Concept!!!
Most common type of poisoning in
school age children is LEAD
POISONING or PLUMBISM
Important Concepts in PLUMBISM
or LEAD POISONING
 In the assessment for lead
poisoning, ask the following
questions:
 o Is your house build o Do CHELATION
during the 1960s or THERAPY
during the 1970s? o Remove lead inside the
o Are you living in old body
Hispanic houses? o Drug of Choice
 Rationale:  EDTA
o These houses utilized  Calcium
paint containing lead Disodium
Edetate
Three (3) Effects of LEAD
POISONING or PLUMBISM SCHOOL AGE CHILDREN
 Hematologic Effect Mnemonics are:
 Renal Effect  SCHOOLER
 Nervous System Effect  DIMPLE

Hematologic Effect For SCHOOLER:

 Interferes with the synthesis
of iron S is for:
 Leads to ANEMIA  SCHOOLMATE
o This is the EARLIEST
SIGN of lead poisoning Important Concept!
o This is a REVERSIBLE  The most important person in
PROBLEM the school-age child is the
SCHOOLMATE OF THE
Renal Effect SAME SEX GROUP
 Damages kidney by
INCREASING ITS C is for:
PERMEABILITY  COMPETITIVE PLAY
 The kidney is no longer
capable of properly filtering Important Concepts!
blood and this leads to:  Commonly played games are
o Glucosuria competitive in nature.
o Proteinuria  These are:
o Ketonuria o Chess
 All of these problems are o Checkers
REVERSIBLE o Tug-of-war

Nervous System Effect H is for:

 This is the PRIMARY  HERO WORSHIP
CONCERN in lead poisoning
 This results to MENTAL Important Concept!
RETARDATION  Hero worship PEAKS at NINE
 This is an IRREVERSIBLE (9) YEARS OF AGE
PROBLEM
 Management O is for:

33
  OBSERVE for INDUSTRY I is for:
versus INFERIORITY  INDUSTRY versus
INFERIORITY
O is for:
 OFF LIMITS TO VEHICLES Important Concept!
 Part of the psychological
Important Concepts! tasks of the school age child
 Most common cause of is a SENSE OF
accident in school age COLLECTION OF OBJECTS
children is VEHICULAR
ACCIDENTS M is for:
 Best topic for safety and  MODESTY
accident prevention for school
age children is USE OF Important Concept!
SEATBELTS  Provide privacy in the
following situations:
L is for: o Grieving
 LOSS OF CONTROL o Crying
o Times of emotional
Important Concept! upset
 Loss of control is the most
common cause of fear in P is for:
school age children  PEERS

E is for: Important Concept!

 EXPLAIN THE PROCEDURE  Peers of school age children
are THE SAME AGE GROUP
R is for:
 REGRESSION COMMON
DURING HOSPITALIZATION L is for:
 LOSS OF CONTROL

For DIMPLE Important Concept!

 Loss of control is integrated to
D is for: DECISION MAKING
 DEATH
E is for:
Important Concepts!  EXPLAIN THE PROCEDURE
 Universal concept of death is
now known to the school age ADOLESCENT
child  Mnemonic is PAIRS
 Death is considered
IRREVERSIBLE P is for:
 Death caused by the  PEERS
BOOGEYMAN is feared

34
 Important Concepts!!!
 The most important people to Important Concepts!!!
adolescents are their PEERS  What is the role of the
 Peer pressure starts here adolescent in the society?
 Adolescent does not want to  To pursue education
be different from other  To pursue career
adolescents
 Cases of adolescent abuse R is for:
(i.e. of alcohol) can be treated  ROLE CONFUSION
by group therapy – Stop
drinking alcohol. Important Concepts!!!
 If there are problems in
A is for: identity, ROLE CONFUSION
 ALTERATION OF BODY arises
IMAGE  If role identity is not
established, the adolescent
Important Concepts!!! develops ISOLATION
 Alteration of body image is the
most common NURSING S is for:
DIAGNOSIS in adolescents  SEPARATION FROM FEARS
 In scoliotic patients, nursing
management is to provide a Important Concept!
MILWAUKEE BRACE  This is the most common
 In a colostomy patient, there cause of adolescent fear
is no bowel control.
o Nursing Management:
 Provide a
colostomy bag
 Control odor in
colostomy bag
 Decrease odor RESPIRATORY SYSTEM
by ABC DISORDERS IN PEDIATRIC
 A – A NURSING
greeny
dark CHOANAL ATRESIA
vegetable
 B – Key Concept!
Bismuth  Atresia
powder o Always pertains to the
 C – presence of an
Charcoal obstruction
(put in
stoma) Choanal Atresia
 Is a congenital disorder
I is for: involving an obstruction at the
 IDENTITY

35
 POSTERIOR the obstruction at the level of
NASOPHARYNX the nasopharynx
 This obstruction is in the form  Therefore, there is
of: DECREASED
o A membrane OXYGENATION – an
o A bony growth unpleasurable principle

Passage of Air and Oxygen FIRST Important Concept!

through the respiratory system:  To compensate for the
decreased oxygenation, the
Air and oxygen enters patient will OPEN his MOUTH
▼▼▼ AND CRY
Nose  Oxygen will enter the MOUTH
▼▼▼ or at the LEVEL OF THE
Nasopharynx OROPHARYNX
(in Choanal Atresia, obstruction is  This will result in an increase
present in this area) in oxygenation of the lungs –
▼▼▼ a pleasurable principle
Oropharynx  An infant suffering from
▼▼▼ choanal atresia develops
Laryngopharynx TRUST IN OPENING THE
▼▼▼ MOUTH
Larynx  These patients are MOUTH-
▼▼▼ BREATHERS!!!
Trachea
▼▼▼ SECOND Important Concept!
Primary Bronchi  If the patient is hungry and
▼▼▼ feeds, the patient opens the
Secondary Bronchi mouth
▼▼▼  With the passage of food,
Bronchi there is decreased
▼▼▼ oxygenation – an
Lungs unpleasurable principle
▼▼▼  Therefore, these patients DO
Increased oxygenation NOT SUCK

Important Concept!!! THIRD Important Concept!

 Increased oxygenation of the
lungs is a pleasurable
principle
Important Concepts in Choanal
Atresia
 Oxygen can enter through the
nose but cannot pass through
 When in the REM stage of
sleep, the mouth closes
 This results in decreased
oxygenation – an
unpleasurable principle
 This stimulates the medulla
oblongata and gives rise to
SLEEP APNEA or the
INABILITY TO SLEEP

36

Three (3) Cardinal Signs of
Choanal Atresia
 Mouth-breathers
 Patient does not suck
 Sleep apnea or inability to
sleep
How to Check for Presence of
Choanal Atresia
 Use of NGT
o Positive (+)
resistance when NGT
is inserted
 Try to close mouth of newborn
and close one nostril at a time
o If patient suffers from
air hunger, patient
possibly has choanal
atresia
o If you press the left
nostril and there is air
hunger, the choanal
atresia or
obstruction is at the
RIGHT SIDE.
Management for Choanal Atresia
 Perform local piercing
TONSILLITIS
Different Types of Tonsils
 Palatine tonsils
 Adenoids
 Lingual tonsils
 Tubal tonsils
o Located in the ears
Cardinal Signs of Inflammation
 Rubor
o Redness
 Calor
o Heat
 Tumor
o Edema
 Dolor
o Presence of pain
 Functiolaesa
o Loss of function
Signs and Symptoms of Tonsillitis
 If Palatine tonsillitis
o Difficulty of swallowing
or Dysphagia
 If Adenoid tonsillitis
for o Problems of breathing
 If Lingual tonsillitis
o Problems with speech
 If Tubal tonsillitis
o Problems with hearing
Common Causative Organism in
Tonsillitis
 GABHS
 Group A Beta-hemolytic
Streptococcus
o A streptococcal
the infection!!!
Pharmacological Management of
Tonsillitis
 Drug of Choice
o Penicillin
 If client is allergic to Penicillin
o Never give Amoxicillin
o Patient will also be
allergic to Amoxicillin
 Drug of Choice in the
presence of allergies to
Penicillin is ERYTHROMYCIN
 Administer antibiotics for
seven (7) to ten (10) days
Surgical Management
 If antibiotics cannot cure
tonsillitis, a
TONSILLECTOMY is
performed
 When is the best time for a
tonsillectomy?
37
 o If there is recurrent Post-operative Phase
tonsillitis for five (5) to 1. Positioning immediately after
six (6) times a year Tonsillectomy
with cardiac and  Priority is to prevent aspiration
respiratory involvement of secretions
o Prone position or on
Nursing Responsibilities in his abdomen
Tonsillectomy o Side-lying position
 If pediatric is fully awake
Pre-operative Phase o Position him or her on
1. Test for the bleeding time any comfortable
 The most common position
complication of tonsillectomy 2. Diet of a post-tonsillectomy patient
is bleeding must satisfy all three (3) criteria:
2. Ask the patient to visit a dentist  Clear
 The most important person for  Cold
the patient at this time is the  Non-irritating
dentist o Only APPLE JUICE
 The dentist needs to check if and CLEAR WATER
the patient has any loose satisfies the
teeth abovementioned three
 If loose teeth are present, (3) criteria
tonsillectomy may be delayed 3. Assess for signs and symptoms of
or rescheduled bleeding
 Loose teeth may dislodge and  Bleeding is present if
cause airway obstruction o There is frequent
3. Provide the patient and the swallowing
parents a pediatric operating room o There is frequent
tour clearing of the throat
o There is frequent
Intra-operative Phase
tossing of the pediatric
 Anesthesia of Choice
o Drooling of bright red
o Ketalar
secretions
o Ketamine
 When an
 Basic Nursing Responsibility incision is
o No premature present
awakening of the  There is pain
patient  Blood
o If this happens, this accumulates
could cause the in the airway
following:  Drooling
 Auditory occurs
hallucinations  When does bleeding occur in
 Visual post-tonsillectomy patients?
hallucinations o Bleeding normally
occurs:

38
 Within twenty-  Brassy spasmodic
four (24) hours hoarseness of the voice
after the  Stridor is the abnormal breath
procedure and; sound hears
 Five (5) to seven  Important Concepts on
(7) days post-op Abnormal Breath Sounds
o Therefore, patient o Crackles
could only engage in  Indicates the
non-contact sports presence of fluids in
the airway
Important Post-tonsillectomy  Heard in
Concepts!!! Congestive Heart
 Speaking and talking are NOT Failure patients
CONTRAINDICATED post- o Wheezes
tonsillectomy  Indicates narrowing
 Patient is not advised to of the airway
watch a championship ball  Heard in Asthma
game post-tonsillectomy o Stridor
o Rationale:  Indicates
 Patient has laryngeal
breathing obstruction
problems and  Heard in
should avoid Laryngotracheo
crowded areas, bronchitis
wherein he  Laryngospasm
would be prone o May cause total
to infections obstruction
 Aspirin is
CONTRAINDICATED as it Sample Board Question
would cause bleeding If a client with
 Valsalva maneuver is also laryngotracheobronchitis
CONTRAINDICATED as develops laryngospams, what
severe tension at the suture should the nurse do?
line causes bleeding a) give steroids
b) bring the patient to the
CROUP hospital
 Also called c) bring the patient to the
Laryngotracheobronchitis or bathroom
LTB d) insert a tracheostomy tube
 Caused by viral infection  Answer
 If caused by a bacteria (H. o Letter C
influenzae) it is known as o Bring the patient to the
EPIGLOTITIS bathroom, close the
door, and open the hot
Signs and Symptoms of shower.
Laryngotracheobronchitis  Rationale

39
 o Hot shower relieves Important Concepts!
laryngospasm  Decreased RBC
 Other choices: o Predisposes patient to
o Steroids need a long anemia
time to take effect  Decreased WBC
o Patient may die before o Predisposes patient to
reaching the hospital infections
o Inserting a  Decreased platelets or
tracheostomy tube is thrombocytes
normally not done o Predisposes patient to
bleeding
Management of
Laryngotracheobronchitis I is for:
1. Administer steroids  INCREASED
 Purpose of Steroids GASTROINTESTINAL
 For anti-inflammatory effect TRACT UPSET
 Important Concepts!!!
 Steroids provide Important Concepts!
 Death to inflammation  Take steroids with meals
 Birth to side effects  Take steroids after meals to
Sample Board Question prevent gastric irritation and
In a client receiving steroids, which GI bleeding
food should be omitted from the
diet? R is for:
a) toast  RENAL PROBLEMS
b) jam
c) egg T is for:
d) coffee  TINNITUS
Answer:
 Letter C H is for:
 Rationale:  HEPATOTOXIC MEDICATION
o Steroids cause Bone
Marrow Depression (BMD) 2.Administer RACEMIC
o This predisposes the EPINEPHRINE
patient to infection  To relax smooth muscles
o Egg may cause infection if
it contains Salmonella 3. Place on MIST TENT or
CROUPETTE
Side Effects of Steroids  Nursing Responsibilities
 Mnemonic is BIRTH o Frequently change the
linen, beddings, and
B is for: clothing of the pediatric
 BONE MARROW because they are
DEPRESSION always wet
o Ideally feeding is done
outside the croupette

40
 o If respiratory distress  Check for
occurs viral
 Stop feeding infection
 Bring pediatric  Check for
back inside the ingestion of
croupette aspirin
 Acute
Important Concepts on the Use of Encephalitis
a Croupette!  Can cause
 Mobile Toys mental
o Could not be placed retardation
inside the croupette  There is no cure for this
o This would cause disease
combustion of oxygen
inside the croupette, EPIGLOTTITIS
leading to an explosion  Bacterial Croup
o Therefore, DO NOT
USE MOBILE TOYS or Important Concepts
OTHER TOYS THAT  Esophagus is posterior to the
CAUSE FRICTION trachea
 If there is a fire  Epiglottis is a leaf-like
o The first thing to do is structure above the airway
to TURN OFF THE o It closes when
VALVE OF THE swallowing
OXYGEN TANK TO o It closes when food
SHUT IT OFF enters the GI tract
 Second step is to BRING OUT
THE PEDIATRIC Epiglottitis
 Third step is to ACTIVATE  Inflammation of the epiglottis
THE FIRE ALARM  Cherry red epiglottis
 Key Concept during a Fire!
o Never attempt to Signs and Symptoms of
control the fire Epiglottitis
o You are a nurse! Not a  Difficulty of Breathing
fireman!  Tripod Position or Sniffing
Position
Other Important Concepts on o Sitting in a leaning
Laryngotracheobronchitis forward position
Fever is common in o Sign of epiglottitis
laryngotracheobronchitis patients  Exhibiting universal sign of
 If aspirin is ordered for an LTB choking
patient, VERIFY THE ORDER
 Never give aspirin to clients Three (3) Ds: The three (3)
with VIRAL INFECTION Classical Signs of Epiglottitis
o This may cause  Drooling
 Reye’s Disease  Dysphonia (ngongo)

41
  Dysphagia  Place pediatric in a croupette
 No ET tube is utilized in an
Nursing Alert epiglottitis patient
 Always place patient with  Prepare tracheostomy set at
epiglottitis on NPO bedside for an epiglottitis
 Closure of epiglottis causes patient
total airway obstruction  Endotracheal tube can be
utilized in a
Pharmacological Management of laryngotracheobronchitis
Epiglottitis patient
 Drug of Choice
o Chloramphenicol Important Concept!
 Never given per  If a client who is at home
orem develops total airway
 Given per I.V. obstruction
 Antibiotics o Do not do CPR
 Do culture and sensitivity o Do not bring to the
before administering hospital
antibiotics o Cut throat and do a
tracheostomy
Sample Board Question:  Put a straw
If the doctor orders a throat swab in  This acts as a
a patient with epiglottitis, what will temporary
the nurse initially do? tracheostomy
a) Explain the procedure to the BRONCHIOLITIS
patient  Most common etiologic agent
b) Gather the materials needed is RSV
c) Wear mask Signs and Symptoms of
d) None of the above Bronchiolitis
Answer:  Starts as a simple Upper
 Letter D Respiratory Tract Infection
o None of the above  Progresses to:
Rationale: o Hypoxia
 Nurse has to verify the  Decreased
doctor’s order because this levels of
procedure causes total oral oxygenation
obstruction o Hypercapnia
o Therefore, do culture and  Increased levels
sensitivity test using of carbon
BLOOD as specimen dioxide
o Never use a tongue  Acidosis
depressor on an  Wheezing
Epiglottitis patient
Pharmacologic Management of
Management of Epiglottitis Bronchiolitis
 Same as with LTB  Drug of Choice

42
 o Rivabirin  Medications
 Only  Pollen
administered in  Food Dust
an OXYGEN
HOOD or a Extrinsic Factors
MIST TENT ▼▼▼
 In the United Stimulates Beta lymphocytes
States, an ▼▼▼
oxygen hood nor Release of IgE
a mist tent is no ▼▼▼
longer used. Attach to Mast Cell and together with
What is utilized Basophils
is a SMALL ▼▼▼
PARTICLE Release of Chemical Mediators
AEROSOL (Histamine, Prostaglandin,
GENERATOR or Bradykinin)
SPAG ▼▼▼
 Rivabirin is TERATOGENIC Causes bronchospasm
o Can affect the pregnant ▼▼▼
nurse Narrowing of Airway (wheezes can
o It can be absorbed be heard with a stethoscope
through the mucous ▼▼▼
membrane Increased airway resistance
 Conjunctiva
 Nose
 Mouth INTRINSIC ASTHMA
o Therefore, a pregnant  Non-allergic asthma
nurse cannot  Common in adults
administer Rivabirin
 When administering Rivabirin, Intrinsic Factors
always wear ▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼P
o Mask arasympathetic Sympathetic
o Goggles Nervous Nervous
Response Response
 Hold your breath when you
▼▼▼▼▼ ▼▼▼▼▼
are administering Rivabirin
Release of Release of
Acetylcholine Basophils and
ASTHMA
▼▼▼▼▼ Mast Cells
 Two (2) types:
▼▼▼▼▼ ▼▼▼▼▼
o Extrinsic Asthma
Bronchoconstriction Release of
o Intrinsic Asthma
▼▼▼▼▼ Chemical
▼▼▼▼▼ Mediators
EXTRINSIC ASTHMA ▼▼▼▼▼ ▼▼▼▼▼
 Allergic asthma ▼▼▼▼▼ Bronchospasm
 Common in pediatrics ▼▼▼▼▼ ▼▼▼▼▼
EXTRINSIC FACTORS

43
Narrowing of Airway (Wheezes can  Most common cause of death
be heard through the stethoscope) in clients with cystic fibrosis is
▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼ RESPIRATORY FAILURE
Increased airway resistance
Important Concepts!
Important Concepts in Asthma!  The exocrine function of the
 Absence of wheezes pancreas is to secrete the
o A bad sign following enzymes:
o Indicates absence of o Pancreatic amylase
breathing  To break down
 Best pet for an asthmatic carbohydrates
patient o Pancreatic lipase
o A fish!  To break down
fats
Management of Asthma o Trypsin
 Give steroids  To break down
o Purpose is anti- proteins
inflammatory  These enzymes normally
 Generally, if the patient has enter the duodenum for
respiratory problems digestive purposes
o Decrease oxygen
demand by: Important Concepts in Cystic
 Providing Fibrosis
periods of rest  There is over secretion of
 Small frequent feedings digestive enzymes by the
pancreas
CYSTIC FIBROSIS  There is an increase in the
 An autosomal recessive levels of the various
disorder pancreatic enzymes
 Other autosomal recessive
disorders are: Signs and Symptoms of Cystic
o Phenylketonuria Fibrosis
o Sickle Cell anemia 1. Malnutrition
 Only a 25% chance of a Increased levels of pancreatic
patient developing this enzymes
disease or 1:4 ratio in each ▼▼▼
pregnancy May cause obstruction in the
 Both bad traits coming from pancreatic duct
parents ▼▼▼
 It is an EXOCRINE Digestive enzymes could not reach
DISORDER of the pancreas the duodenum
o There is oversecretion ▼▼▼
of exocrine products of Food cannot be digested
the pancreas ▼▼▼
Leads to MALNUTRITION

44
2. Steatorrhea
 Presence of bulky, greasy and Management of Cystic Fibrosis
foul smelling stool  Drug of Choice:
o Cotazym
Increased levels of pancreatic  An artificial
enzymes pancreatic
▼▼▼ enzyme
May cause obstruction in the  Give medication BEFORE
pancreatic duct MEALS so that pancreatic
▼▼▼ enzymes would be present
Lipase could not reach the o Could also be given
duodenum WITH MEALS
▼▼▼ o NEVER GIVEN AFTER
Fat cannot be digested MEALS
▼▼▼  Do not administer Vitamin
Gives rise to steatorrhea ADEK supplementation
o Rather give water
3. Deficiency in Fat-soluble miscible form of
vitamins – ADEK Vitamins A,D,E and K
 Give calcium supplementation
Increased levels of pancreatic  All these measures do not
enzymes have any effect on the blood
▼▼▼ sugar level of the patient
May cause obstruction in the
pancreatic duct
▼▼▼ Signs and Symptoms of Exocrine
Lipase could not reach the Involvement
duodenum 1. Salty Sweat
▼▼▼  Overproduction of sweat by
Fat cannot be digested sweat glands
▼▼▼ o Leads to imbalance in
No fat-soluble vitamins could be sodium and chloride
absorbed levels
▼▼▼  Due to the excretion of salty
Deficiency in Fat-soluble vitamins – sweat (normally as verbalized
ADEK by the mother of the pediatric
4. Hypocalcemia Sweat Chloride Test
 Calcium always binds with  Test for Cystic Fibrosis
undigested fat  How is it done?
 Since undigested fat is o Place sterile gauze on
eliminated in the stool,
skin
calcium is also eliminated via
o Give Pilocarpine
the stool
 A cholinergic
 Net effect is decreased serum
drug
levels of calcium

45
  A o The most common
Parasympathetic cause of death is
drug Cystic Fibrosis
 Will stimulate  This is due to accumulation of
the sweat fluid in the lungs or
glands emphysema secondary to
 Sweat will Cystic Fibrosis
accumulate at o Patient develops a
the gauze barrel chest
o Use forceps in picking
up the gauze to Surgical Management for Cystic
prevent mixture of Fibrosis
sweat  Do multiple lung transplant if
o The range to be there is fluid accumulation
observed is between  Drain secretions
Forty (40) and Sixty  Do Chest Physiotherapy
(60) milliequivalents (CPT)
per liter o Do this before meals
 If value obtained o Never do CPT after
is less than meals
Forty (<40  Postural Drainage
meqs/liter) o Done using the
milliequivalents principle of gravity
per liter, then o Oral care is done after
this is NORMAL postural drainage
 If value obtained
is more than Key Concept!
Sixty (>60  If pediatric patient with Cystic
meqs/liter) Fibrosis cannot void
milliequivalents o Ask him to milk or strip
per liter, then the penis
there is Sodium o There is obstruction
and Chloride
o Masturbation is also
imbalance
advised
 Nursing Management
 Removal of sperm to remove
o During hot weather
obstruction
 Increase fluid
intake
Effects of Sympathetic and
 Increase sodium
Parasympathetic Nervous Systems
intake
on Various Organs and Body
o Client can go to the
Systems
beach Sympathetic Parasympathetic
Nervous Nervous
System System
Important Concept!
 Respiratory Failure

46
Pupils Dilate Constrict  2. Right Side of the heart
Bronchioles Bronchodilation Bronchoconstriction
Cardiac Rate Increase Decrease receives blood from the
Blood Increase Decrease organs
Pressure
Blood Vessels Constrict Dilate
Smooth Relax Contract  3. Right Side of the heart
Muscles
Uterus Relax Contract
gives blood going to the
Bladder Relax Contract; Lungs
Decreased urine Increased urine
output output
Small Intestine Decreased Increased  4. Left Side of the heart
and Large peristalsis peristalsis receives blood from the Lungs
Intestine Constipation Diarrhea
Salivary Decreased Increased activity and gives blood to the organs
Glands activity Increased salivation
Dry mouth
Sweat Glands Decreased Increased  5. The LEFT VENTRICLE has
Skeletal Increased Decreased the HIGHEST PRESSURE
Muscle
Strength among the four (4) chambers
of the heart
Important Concepts!
Atropine sulfate  6. The LEFT SIDE of the heart
 Anti-cholinergic Drug has A HIGHER PRESSURE
 Characteristic Effects relative to the RIGHT SIDE of
o Cannot see the heart.
o Cannot pee
o Cannot speak  7. AORTA has a HIGHER
o Cannot shit PRESSURE relative to the
PULMONARY ARTERY
Cholinergic Drugs
 Pilocarpine
 8. Left Side of the heart has
 Tensilon
GREATER OXYGENATED
 Mestinon
BLOOD LEVELS relative to
Right Side of the heart.
CIRCULATORY SYSTEM
Acyanotic Congenital Heart
DISORDERS IN PEDIATRIC
Diseases
NURSING
 Characterized by the
ABSENCE of CYANOSIS AT
CONGENITAL HEART DISEASES
BIRTH
Two (2) Classifications
 Cyanotic
Cyanotic Congenital Heart
 Acyanotic
Diseases
 Characterized by the
Important BASIC CONCEPTS!!!
PRESENCE of CYANOSIS AT
 1. Reason for Cyanosis
BIRTH
o Due to INCREASED
LEVELS of
ACYANOTIC CONGENITAL HEART
UNOXYGENATED
DISEASES
BLOOD
 Atrial Septal Defect
 Ventricular Septal Defect

47
  Patent Ductus Arteriosus BLOOD at the Left Atrium,
 Coarctation of the Aorta less oxygenated and
unoxygenated blood goes to
1. ATRIAL SEPTAL DEFECT (ASD) the Left Ventricle and the
Characterized by: Aorta
 Presence of a HOLE between o THERE IS LESS
the Right Atrium and the Left TISSUE PERFUSION
Atrium (by both oxygenated
 There is a COMMUNICATION and unoxygenated
between the Right Atrium and blood)
the Left Atrium
 Failure of the FORAMEN  THEREFORE, ATRIAL
OVALE to CLOSE AFTER SEPTAL DEFECT IS
BIRTH CONSIDERED AS
ACYANOTIC AT BIRTH due
Important Concepts!!! to DECREASED LEVELS OF
If there is a HOLE in the LEFT UNOXYGENATED BLOOD
ATRIUM: GOING TO THE TISSUES

 Shunting of blood is from the  Right Atrium receives blood

LEFT ATRIUM going to the BOTH FROM THE ORGANS
RIGHT ATRIUM AND FROM THE LEFT
o Due to the greater ATRIUM
pressure on the Left
Atrium relative to the  Therefore, there is MORE
Right Atrium blood in the RIGHT ATRIUM
(normally, it only receives
 There is MIXING OF BLOOD blood from the organs, but in
at the Right Atrium Atrial Septal Defect, it ALSO
o Blood from the Left RECEIVES BLOOD FROM
Atrium goes to the THE LEFT ATRIUM
Right Atrium
o Net effect is  In effect, the RIGHT
DECREASED LEVEL VENTRICLE and the
OF OXYGENATED PULMONARY ARTERY
BLOOD at the LEFT RECEIVES MORE BLOOD
ATRIUM THAN THEY USUALLY DO
o Another net effect is
DECREASED LEVEL  This leads to INCREASED
OF UNOXYGENATED PULMONARY ARTERY
BLOOD AT THE LEFT PRESSURE
ATRIUM
 This means that the LUNGS
 Since there is a decreased RECEIVE MORE BLOOD
level of BOTH OXYGENATED THAN IT USUALLY DOES
and UNOXYGENATED

48
  Therefore, this gives rise to LEVELS OF
PULMONARY CONGESTION UNOXYGENATED BLOOD
GOING TO THE TISSUES
2. VENTRICULAR SEPTAL
DEFECT (VSD)  Right Ventricle receives blood
Characterized by: BOTH FROM THE RIGHT
 The presence of a HOLE ATRIUM and THE LEFT
between the Right Ventricle VENTRICLE
and the Left Ventricle
 There is a COMMUNICATION  Therefore, there is MORE
between the Right Ventricle blood in the RIGHT
and the Left Ventricle VENTRICLE (normally, it only
receives blood from the Right
Important Concepts in VSD: Atrium, but in Ventricular
If there is a hole in the LEFT Septal Defect, it ALSO
VENTRICLE: RECEIVES BLOOD FROM
THE LEFT VENTRICLE
 Shunting of blood is from the
LEFT VENTRICLE to the  In effect, PULMONARY
RIGHT VENTRICLE ARTERY RECEIVES MORE
BLOOD THAN IT USUALLY
 Due to the PRESENCE OF DOES
GREATER PRESSURE on
the LEFT SIDE of the heart  This leads to INCREASED
RELATIVE TO THE RIGHT PULMONARY ARTERY
SIDE PRESSURE

 There is MIXING of blood at  This means that the LUNGS

the RIGHT VENTRICLE RECEIVE MORE BLOOD
 As blood is shunted from the THAN IT USUALLY DOES
Left Ventricle to the Right
Ventricle, THERE IS LESS  Therefore, this gives rise to
OXYGENATED and PULMONARY CONGESTION
UNOXYGENATED BLOOD IN
THE LEFT VENTRICLE 3. PATENT DUCTUS ARTERIOSUS
(PDA)
 This translates into decreased Characterized by:
tissue perfusion of BOTH  Persistence of the ARTERY
OXYGENATED AND THAT CONNECTS THE
UNOXYGENATED BLOOD AORTA TO THE
PULMONARY ARTERY
 THEREFORE,  Shunting is from the Aorta to
VENTRICULAR SEPTAL the Pulmonary Artery
DEFECT IS CONSIDERED  This is also a LEFT TO
AS ACYANOTIC AT BIRTH RIGHT SHUNT
due to DECREASED

49
  Due to HIGHER PRESSURE  This leads to INCREASED
on the AORTA RELATIVE TO PULMONARY ARTERY
THE PULMONARY ARTERY PRESSURE

Important Concepts in PDA:  This means that the LUNGS

If there is a PATENT DUCTUS RECEIVE MORE BLOOD
ARTERIOSUS: THAN IT USUALLY DOES

 Amount of OXYGENATED  Therefore, this gives rise to

BLOOD in the AORTA PULMONARY CONGESTION
DECREASES
4. COARCTATION OF THE AORTA
 Amount of UNOXYGENATED Characterized by:
BLOOD in the AORTA ALSO  A NARROWED PORTION of
DECREASES the aorta

 This translates to Important Concepts in

DECREASED TISSUE COARCTATION OF THE AORTA!!!
PERFUSION Because of the narrowed portion,
NOT ALL OF THE BLOOD PASSES
 THEREFORE, PATENT THROUGH THE AORTA:
DUCTUS ARTERIOSUS IS
CONSIDERED AS  Organs receive LESS
ACYANOTIC AT BIRTH due OXYGENATED and LESS
to DECREASED LEVELS OF UNOXYGENATED BLOOD
UNOXYGENATED BLOOD
GOING TO THE TISSUES  There is decreased tissue
perfusion of BOTH
 There is MIXING OF BLOOD OXYGENATED and
in the PULMONARY ARTERY DEOXYGENATED BLOOD

 Therefore, there is MORE  THEREFORE,

blood in the PULMONARY COARCTATION OF THE
ARTERY (normally, it only AORTA IS CONSIDERED AS
receives blood from the Right ACYANOTIC AT BIRTH due
Ventricle, but in Patent Ductus to DECREASED LEVELS OF
Arteriosus, it ALSO UNOXYGENATED BLOOD
RECEIVES BLOOD FROM GOING TO THE TISSUES
THE AORTA
 There is NO MIXING OF
 In effect, PULMONARY BLOOD
ARTERY RECEIVES MORE
BLOOD THAN IT USUALLY  There is NO SHUNTING OF
DOES BLOOD

50
  There is ACCUMULATION OF
BLOOD at the AORTA In PATENT DUCTUS
ARTERIOSUS,
 There is CONGESTION OF  The MURMUR is
BLOOD at the LEFT MACHINERY-LIKE
VENTRICLE
In COARCTATION OF THE AORTA,
 The NET EFFECT is  The Blood Pressure on the
CONGESTION OF BLOOD UPPER EXTREMITY is
toward the LUNGS GREATER RELATIVE TO the
Blood Pressure on the
 Therefore, this gives rise to LOWER EXTREMITY
PULMONARY CONGESTION Signs and Symptoms include:
 Epistaxis
KEY CONCEPTS!!!  Gum bleeding
 In the four (4) most common  Most common cause of death
types of ACYANOTIC in Coarctation of the Aorta is
Congenital Heart Diseases, INTRACRANIAL
the SINGLE PROBLEM is HEMORRHAGE due to
PULMONARY CONGESTION increased blood pressure in
the aorta
Signs and Symptoms of Acyanotic
Congenital Heart Disease
 Dyspnea
o Difficulty of Breathing
 Wheezes
 Crackles
Management of Acyanotic
Nursing Responsibilities in Congenital Heart Diseases
Acyanotic Congenital Heart
Disease In ATRIAL SEPTAL DEFECT and
 Decrease Oxygen demand VENTRICULAR SEPTAL DEFECT:
o Provide adequate rest  If the HOLE is compatible with
periods life or it DOES NOT
o Provide small frequent INTERFERE with activities of
feedings daily living, then SURGERY
IS NOT NEEDED
IMPORTANT KEY CONCEPTS!!!  If the HOLE is NOT
compatible with life or it
In ATRIAL SEPTAL DEFECT and DOES INTERFERE with
VENTRICULAR SEPTAL DEFECT activities of daily living, then
Signs and Symptoms include: SURGERY IS NEEDED
 PRESENCE OF MURMURS o Put a DACRON PATCH
 The LARGER THE HOLE in o OPEN HEART
the patient with ASD or VSD, SURGERY is
the LOUDER THE MURMUR performed for ATRIAL

51
 SEPTAL DEFECT and CATHETER to INCREASE the
VENTRICULAR DIAMETER of the LUMEN of
SEPTAL DEFECT the AORTA
o This is usually done
In PATENT DUCTUS with CARDIAC
ARTERIOSUS: CATHETERIZATION
 Physician waits for fifteen (15)  If this measure is not effective,
minutes to twelve (12) hours surgery is done to LIGATE the
(this is the normal time it portion of the aorta with the
takes for the Ductus coarctation and then END-TO-
Arteriosus to CLOSE) END ANASTOMOSIS is
 If the Ductus Arteriosus FAILS performed
TO CLOSE after twelve (12)
hours, there is NO SURGERY POST-OPERATIVE NURSING
YET. RESPONSIBILITIES FOR
 Physician gives ACYANOTIC CONGENITAL HEART
INDOMETHACIN DISEASES
o A prostaglandin  Same as other cardiac post-
inhibitor operative nursing
 Indomethacin responsibilities
can cause
VASOSPASM of
the Ductus
Arteriosus
 This will bring CYANOTIC CONGENITAL HEART
about the DISEASES
CLOSURE of  Tetralogy of Fallot
the Ductus  Transposition of the Great
Arteriosus Vessels
o A gastric irritant
 Causes gastric TETRALOGY OF FALLOT
bleeding Consists of four problems:
 Surgery is done if Ductus  TWO (2) MAJOR
Arteriosus remains patent PROBLEMS:
after administration of o Pulmonary Stenosis
Indomethacin o Ventricular Septal
o Purpose of surgery is Defect
to dilate the Ductus  TWO (2) MINOR
Arteriosus PROBLEMS:
o This is procedure o Right Ventricular
involves a CLOSED Hypertrophy
HEART SURGERY  Secondary to
Pulmonary
In COARCTATION OF THE AORTA, Stenosis
 Physician inserts a o Overriding of the Aorta
BALLOON-TIPPED

52
  Secondary to  This is secondary to
Ventricular Ventricular Septal Defect
Septal Defect
Signs and Symptoms of Tetralogy
of Fallot
PULMONARY STENOSIS Hypoxia and Increase in
Characterized by: Unoxygenated Blood to the tissues
 The presence of resistance results into:
 Blood cannot enter the  Clubbing of the fingers
Pulmonary Artery  Polycythemia
 Right Ventricle compensates
by pumping more pressure Hypoxia and Increase in
 Right Ventricle INCREASES Unoxygenated Blood to the Tissues
IN SIZE ▼▼▼ ▼▼▼
 This results into RIGHT Clubbing of the Decreased tissue
VENTRICULAR Fingers Perfusion to the
HYPERTROPHY Kidneys
o (this is secondary to ▼▼▼
Pulmonary Stenosis) Release of
 There is greater pressure at Erythropoietin
the Right Ventricle ▼▼▼
 Thus, shunting of blood is Bone Marrow
from the right side of the heart ▼▼▼
to the left side of the heart Increased levels
 Therefore, there is increase in of RBC
both oxygenated and ▼▼▼
unoxygenated blood going to Polycythemia
the left side of the heart and
eventually to the tissues. Important Concepts!
 Organs receive an increased In Tetralogy of Fallot:
amount of UNOXYGENATED  Clubbing of fingers is
BLOOD o Due to prolonged
 THEREFORE, PULMONARY hypoxia
STENOSIS IS CONSIDERED o A permanent deformity
AS CYANOTIC AT BIRTH o Secondary to hypoxia
due to INCREASED LEVELS o Hypoxia is left-sided
OF UNOXYGENATED  Polycythemia
BLOOD GOING TO THE o Is left sided because it
TISSUES is also secondary to
hypoxia
VENTRICULAR SEPTAL DEFECT
 Aorta slips to VSD Important Concepts!
 Therefore, there is  Tetralogy of Fallot Spells
OVERRIDING OF THE o Due to decreased
AORTA cerebral tissue
perfusion

53
  Patient goes to SQUATTING  Low sodium diet is also given
POSITION with Tetralogy of to prevent Congestive Heart
Fallot Spells Failure
o Rationale:
 Squatting Key Concepts on Digoxin
compresses Digoxin has:
veins in the  A positive (+) INOTROPIC
lower extremity. EFFECT
o Purpose is to: o It INCREASES the
 Decrease STRENGTH of
venous return MYOCARDIAL
 Decrease levels CONTRACTIONS
of unoxygenated  A negative (-)
blood to the CHRONOTROPIC EFFECT
tissues o It DECREASES the
 Thus, Tetralogy of Fallot spells CARDIAC RATE
are RELIEVED by the  Antidote of Digoxin
SQUATTING POSITION. o DIGIBIND
 Knee-Chest position may also  Earliest signs of Digoxin or
be considered for relieving Digitalis Toxicity
Tetralogy of Fallot Spells (if o Gastrointestinal
squatting position is not Problems
included in the list of choices)  Nausea
 Vomiting
Important Concepts!!!  Diarrhea
 In Tetralogy of Fallot, the
following medications are Nursing Responsibilities with the
given in order to prevent Use of Diuretics
CONGESTIVE HEART  Mnemonic is DIURETIC
FAILURE:
o Digoxin D is for:
 A cardiac  DIET
glycoside
 Be sure to check Important Concepts!!!
Cardiac Rate  Diet must be high in
prior to its potassium
administration  Except for Aldactone
 If Cardiac Rate o A potassium-sparing
is below sixty diuretic
(60) beats per
minute, do not I is for:
administer  Monitor INPUT and OUTPUT
Digoxin

 Administer Diuretics

54
 Important Concept!  TAKE DIURETICS WITH
 Expected outcome with FOOD
diuretic use is increased urine
output Important Concept!
 The best time to take a
U is for: diuretic is in the morning
 UNDESIRABLE SIDE
EFFECTS I is for:
 INCREASED TENDENCY TO
Important Concepts!!! DEVELOP OTHROSTATIC
 Electrolyte imbalances HYPOTENSION
leading to weakness may
occur. C is for:
 These electrolyte imbalances  CANCEL ALCOHOL
are:
o Hypokalemia Important Concept!
o Hyperkalemia  Alcohol also has a diuretic
effect
R is for:
 RECORD Important Concepts on Diet for
Tetralogy of Fallot Patients
Important Concepts!!! For low sodium diet
 Record the following  Avoid processed foods
information: o Hotdogs
o Blood Pressure o Pickles
 Patient is prone
to Medical Management of Tetralogy
ORTHOSTATIC of Fallot
HYPOTENSION  Phlebotomy for Polycythemia
o Weight of Client
 Decrease in Surgical Management for
weight reflects Tetralogy of Fallot
the therapeutic  Blalock Taussig Surgery
effect of o Creates a connection
diuretics between the
Pulmonary Artery and
E is for: the Aorta
 ELDERLY o Creates a DUCTUS
ARTERIOSUS
Important Concepts!!!
 Take special precaution when TRANSPOSITION OF THE GREAT
using diuretics in the elderly VESSELS
 Elderly tends to lose more  Also known as TOGV
water than ordinary adults

T is for:

55
Important Concepts!!! FORAMEN OVALE MUST
 In the NORMAL ANATOMY of REMAIN OPEN
the HEART,  Thus, Physician orders
o The Aorta is connected PROSTAGLANDIN to
to the Left Ventricle MAINTAIN the PATENCY of
o The Pulmonary Artery the DUCTUS ARTERIOSUS
is connected to the (Remember! – Indomethacin
Right Ventricle is anti-prostaglandin)
 Physician inserts a
In Transposition of Great Vessels BALLOON-TIPPED
 The Aorta is connected to the CATHETER to maintain the
Right Ventricle patency of the FORAMEN
 The Pulmonary Artery is OVALE
connected to the Left Ventricle
Signs and Symptoms of
Important Concepts on Transposition of Great Vessels
Transposition of Great Vessels  Same as that of Tetralogy of
 TOGV is NOT compatible with Fallot
life  Cyanosis
 Client with TOGV experiences  Clubbing of the Fingers
CYANOSIS  Polycythemia
 Since the Aorta is connected
to the Right Ventricle, Nursing Management for Patients
UNOXYGENATED BLOOD with Transposition of Great
from the Right Ventricle goes Vessels
to the Aorta – THIS IS THE  Same as that of Tetralogy of
MAIN PROBLEM Fallot
 Physician does NOT do Surgical Management for
surgery RIGHT AWAY!!! Transposition of the Great Vessels
 Maintain Tissue Perfusion first  ARTERIAL SWITCHING
 Physician will NOT give
INDOMETHACIN
 Since Pulmonary Artery is
connected to the Left RHEUMATIC FEVER
Ventricle, there is  Always secondary to GABHS
INCREASED PRESSURE in or Group A Beta-hemolytic
the PULMONARY ARTERY Streptococcus
 Blood must flow from the
PULMONARY ARTERY Important Concept!!!
through the DUCTUS  In the assessment phase, the
ARTERIOSUS to the AORTA nurse should ask the patient if
so that the tissues would he has any of these:
receive OXYGENATED o Tonsillitis
BLOOD o Sore Throat
 Therefore, the DUCTUS o Impetigo
ARTERIOSUS and

56
Key Concept!  Ask the client to
 A client with previous tonsillitis count from one
is prone to Rheumatic Fever (1) to twenty
(20) in a very
Sample Board Question: rapid manner
Which of the following would  If, (in the
predispose a person to Rheumatic vernacular)
Fever? bulol, then he
a) Swimming has this sign.
b) Profuse Bleeding o This is temporary in
c) Bull’s eye lesion nature
d) Forgot a baseball cap  Erythema Marginatum
Answer:
 Letter D MINOR JONES CRITERIA
Rationale:  Elevated White Blood Cell
 If you borrow a baseball cap Count
(to play a game) from a  Elevated C Reactive Protein
person with impetigo, that  Elevated ASO Titer
would predispose you to  Elevated Platelets
Rheumatic Fever.  Prolonged PR interval
 Other options are not related o Reflected at the ECG
to Rheumatic Fever. Bull’s  History of Streptococcal
eye lesion is characteristic of infection
Lyme’s Disease
Diagnosis of Rheumatic Heart
Rheumatic Fever Secondary to Disease
Group A Beta-Hemolytic  If you have:
Streptococcus o At least two (2) MAJOR
▼▼▼ JONES CRITERIA
Damages valves of the heart  then you are
▼▼▼ POSITIVE (+)
Rheumatic Heart Disease for Rheumatic
▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼ Heart Disease
▼▼▼ ▼▼▼  If you have:
Major Jones Minor Jones o One (1) MAJOR
Criteria Criteria JONES CRITERIA
o Two (2) MINOR
MAJOR JONES CRITERIA JONES CRITERIA
 Carditis o History of
 Polyarthritis
Streptococcal Infection
 Subcutaneous nodules
 Then you are
o How are they
POSITIVE (+)
assessed? for Rheumatic
 Palpate the skin Heart Disease
 Chorea of St. Vitus Dance
o How is this assessed? Management of Rheumatic Fever

57
Antibiotics o A platelet receptor
 Drug of Choice inhibitor
o Penicillin (never o Inhibits the occurrence
Amoxicillin) of Myocardial Infarction
 Give Phenobarbital to treat  Steroids
Chorea o Also for anti-
inflammatory effect
KAWASAKI’S DISEASE  N-gamma globulin
o To decease immune
Kawasaki’s Disease response
▼▼▼
Presence of Fever (which is BLOOD DISORDERS IN
unresponsive to ANTIPYRETIC PEDIATRIC NURSING
medication)
▼▼▼ SICKLE CELL ANEMIA
Vasculitis (A life-threatening  An AUTOSOMAL
condition) RECESSIVE DISORDER
▼▼▼  Major Problem
Aneurysm o Body produces
(Asymptomatic bursting of a blood ABNORMAL
vessel) HEMOGLOBIN
or
Myocardial Infarction

Signs and Symptoms of Abnormal Hemoglobin (initial shape

Kawasaki’s Disease is ROUND)
 Conjunctivitis ▼▼▼
 Enlargement of Cervical ▼▼▼ Infection,
Lymph Nodes ▼▼▼ Acidosis,
 Strawberry Tongue (Red ▼▼▼ High Altitude,
Beefy Tongue is present in ▼▼▼ Hypoxia
Pernicious Anemia) ▼▼▼ Dehydration
 Abdominal Pain ▼▼▼ Diarrhea
 Desquamation of Palms and ▼▼▼
Soles of the feet Sickle Cell Crisis (Sickle Cell Shaped
 Elevated Platelets Hemoglobin)
o This is the reason for ▼▼▼
developing Myocardial Vasoocclusion (due to clumping)
Infarction
Nursing Management:
Treatment of Kawasaki’s Disease  Priority is to prevent the
 Aspirin patient from experiencing
o For anti-inflammatory VASOOCCLUSION
effect  Also prevent the signs and
 Abciximab symptoms from occurring

58
Signs and Symptoms of Sickle  Administer oxygen via nasal
Cell Anemia cannula
 Mnemonic is SHIP
Next thing to do:
S is for:  Increase the FLOW RATE of
 SEVERE PAIN the I.V.

Vasoocclusion  This will remove the

▼▼▼ vasoocclusion
Decreased Tissue Perfusion
▼▼▼  Administer oxygen
Decreased Oxygenation o (oxygen will not travel
▼▼▼ to the body due to
Anaerobic Respiration vasoocclusion)
▼▼▼
Lactic Acid Accumulation
▼▼▼
Pain

H is for:
 HEMATURIA Diagnostic Tests for Sickle Cell
Anemia
Important Concept!
 This is due to decreased SICKLE DEX TEST
tissue perfusion  Used to determine and
identify the trait of the sickle
I is for: cell anemia
 IRRITABILITY
Hemoglobin Electrophoresis Test
P is for:  To determine the disease
 PALE IN COLOR
THALASSEMIA
Management of Sickle Cell Anemia  Also called:
 Mnemonic is HOP o Cooley’s Anemia
 Provide the following in a o Mediterranean Anemia
sequential manner:  Major Problem
o Hydration o Produces an
o Oxygen Therapy ABNORMALLY
o Pain Medication FRAGILE hemoglobin
with a SHORT LIFE
Important Concepts!!! SPAN
First thing to do:
Abnormal Hemoglobin (very fragile
 Assess or check the patency and with short life span)
of the I.V. tubing ▼▼▼
Increased rate of hemolysis

59
 ▼▼▼  Remove iron by CHELATION
Gives rise to the various signs and THERAPY
symptoms of the disease o Drug of Choice
 Desferol
Signs and Symptoms of  Remove Spleen by
Thalassemia SPLENECTOMY
 Hemosiderosis o Patient
o Increased rate of Teaching
hemolysis of RBC  Client should
leads to increased always receive
amounts of iron in the prophylaxis for
body life
o This tends to deposits  Steroids
in the tissues causing o To decrease activity of
Hemosiderosis the bone marrow
 Jaundice o For
o Increased rate of immunosuppression
hemolysis of RBC
leads to increased
levels of indirect  Blood Transfusion
bilirubin o Patient’s packed RBC
o This leads to Jaundice is changed
 Splenomegaly o If there is any reaction
o Increased rate of to Blood Transfusion:
hemolysis of RBC  Stop
overworks the spleen  Open the main
and gives rise to I.V. line (normal
increased levels of saline solution)
dead RBC o Call the doctor
o This leads to
Splenomegaly HEMOPHILIA
 Aesthetic Problems  A sex-linked disorder
o RBC leads to  Only MALES are
decreased levels of SYMPTOMATIC
RBC  Major Problem
o The body compensates o Deficiency in clotting
by increasing the factors
activity of the bone  Makes the patient prone to
marrow bleeding
o This produces
hypertrophy of the
bone marrow leading to Signs and Symptoms of
Aesthetic Problems Hemophilia

Nursing Management for  Hemarthrosis

Thalassemia o Bleeding in the joints

60
 o Clients are usually
hospitalized due to Injured Tissue
hemarthrosis ▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼
o This is also the usual Releases Bleeding
cause of pain in Thromboplastin ▼▼▼
hemophiliacs ▼▼▼ Vasoconstriction
Thromboplastin of blood vessels
 Epistaxis and Gum bleeding converts to stop bleeding
Prothrombin (apply cold)
 Intracranial Hemorrhage to Thrombin ▼▼▼
o This is the most ▼▼▼ Vasodilation
common cause of Thrombin converts for wound
death Fibrinogen to healing
Fibrin (blood clot) (apply hot)
Important Concepts!!!
Earliest sign of hemophilia Important Concept!!
 In Hemophilia, there are NO
 First choice: CLOTTING FACTORS
o Profuse bleeding in the
umbilical cord Types of Hemophilia

 Second choice: Hemophilia A

o Profuse bleeding at the  Absence of Clotting Factor
circumcision site No.8
 Absence of Anti-hemophilic
Key Concepts!!! Factor
Prothrombin Time (PT)
Hemophilia B
 Time for blood to clot after  Absence of Clotting Factor
putting thromboplastin No. 9
reagent  Absence of Christmas Factor

 PT is normal in client with Hemophilia C

hemophilia  Absence of Clotting Factor
No. 10
 In hemophilia, there are NO  Absence of Stuart Factor
CLOTTING FACTORS

 Normal Value
o Eleven (11) to Sixteen
Nursing Responsibilities in
(16) seconds
Hemophiliac Patients
 If this is elevated
1. If client is bleeding due to
o This signifies bleeding
hemophilia, the first thing to do is to
apply the RICE technique
 If this is decreased
o This signifies clotting

61
R is for:  This results to its major
 REST problem, which is ORGAN
INFILTRATION
Important Concept!
 Immobilize the affected area Signs and Symptoms of Leukemia
1. Pain
I is for:  Increase in number of
 ICE immature WBCs makes the
body compensate by
Important Concept! increasing the activity of the
 Vasoconstriction of blood Bone Marrow
vessels to stop bleeding  This leads to Bone Marrow
Hypertrophy
C is for:  Bone Marrow Hypertrophy is
 COMPRESS the common cause of Pain in
Leukemia patients
Important Concept!
 Put pressure to stop bleeding 2. Infection
 Increase in the number of
E is for: immature WBCs makes the
 ELEVATION body compensate by
increasing the activity of the
Important Concept! Bone Marrow
 Elevate affected part  This leads to further
production of immature
2. Blood transfusion is needed WBCs, which makes the
 Provide CRYOPRECIPITATE Leukemic patient predisposed
to infection
3. Drug of Choice to prevent further
bleeding is VASOPRESSIN 3. Anemia
 This is given NASALLY  Increase in the number of
 Patent is placed in a SUPINE immature WBCs makes the
POSITION body compensate by
o Head is hanging on the increasing the activity of the
edge of the bed Bone Marrow to produce
o Tilted down more WBCs (which are also
 Vasopressin is then immature)
administered  This leads to decreased levels
of Red Blood Cells, which
makes the Leukemic patient
LEUKEMIA prone to Anemia
 Characterized by increase in
the number of immature White 4. Bleeding
Blood Cells  Increase in the number of
immature WBCs makes the
body compensate by

62
 increasing the activity of the  Nursing Responsibility in the
Bone Marrow to produce Maintenance Therapy Phase
more WBCs (which are also o Advice client to
immature) undergo COMPLETE
 This leads to decreased levels BLOOD COUNT
of platelets, which o This is to check if the
predisposes the Leukemic client is responding to
patient to bleeding the therapy

Four (4) Phases of Medical GASTROINTESTINAL SYSTEM

Management in Leukemia DISORDERS IN PEDIATRIC
NURSING
Phase 1 - Remission Induction
 Remove the symptoms of the Two (2) MAJOR PROBLEMS:
patient  Structural problem
o Increase the Bone  Metabolic problem
Marrow activity
 Give steroids STRUCTURAL
 Give Vincristine GASTROINTESTINAL SYSTEM
 Nursing Responsibility in the PROBLEMS in PEDIATRIC
Use of Vincristine PATIENTS
o Always increase fiber  Cleft Lip
in the patient’s diet  Cleft Palate
o This drug causes  Esophageal Atresia
SEVERE  Tracheoesophagel Fistula
CONSTIPATION  Pyloric Stenosis
 Intussusception
Phase 2 - Central Nervous System  Hirschprung’s Disease or
Prophylaxis Aganglionic Megacolon
 Give Methotrexate  Imperforate Anus
o Never given per I.V. as
it does not cross the CLEFT LIP
BLOOD BRAIN  This is a very obvious
BARRIER congenital deformity at birth
o It is given SPINALLY or  Surgery
INTRATHECALLY o Cheiloplasty
o Done at six (6) to
Phase 3 - Consolidation / twelve (12) months of
Intensification age
 Combination of Phase 1 and  Best Post-operative position
Phase 2 o Side lying position
 Best feeding material
Phase 4 - Maintenance Therapy o Rubber-tipped
 Give Steroids medicine dropper
 Give Vincristine  Use of Restraints Post-
operatively

63
 o The best restraint to  The most important people for
use for a post- a cleft lip or a cleft palate
cheiloplasty patient is patient are the following:
an ELBOW o Audiologist
RESTRAINT o Speech Therapist
o If patient has already o Dentist
rolled-over, the best  In pre-cheiloplasty cleft lip
restraint to use for a patient or in a pre-uranoplasty
post-cheiloplasty cleft palate patient, the person
patient is a JACKET who is MORE ANXIOUS is
RESTRAINT the MOTHER OF THE
PATIENT (rather than the
CLEFT PALATE patient)
 This is a NOT AN OBVIOUS  Sample Board Question:
congenital deformity at birth The best way to relieve the
o This requires thorough anxiety of the mother is to:
mouth inspection a) let the father see the
o Usually remains operation
undiagnosed despite b) show pictures of cleft
thorough mouth palate and cleft lip before
inspection and after surgery
 Surgery c) breast feeding
o Uranoplasty d) family support
o Delayed until one (1) to  Answer
two (2) years of age o Letter B
o Rationale for the delay:  Nursing priority before
 To allow the corrective surgery (either
growth of the cheiloplasty or uranoplasty) is
hard palate PROPER NUTRITION
 Before speech o Therefore, use
would develop ALTERNATIVE
 Best Post-operative Position FEEDING
o Prone position or lying TECHNIQUES
on abdomen
 Best feeding material How does the Nurse Retain
o Feeding Cup Feeding in a Pre-operative Cleft
Lip of Cleft Palate Patient?
IMPORTANT CONCEPTS FOR  Burping or Bubbling (Frequent
BOTH CLEFT LIP AND CLEFT Burping)
PALATE!!!  Small Frequent Feedings
 The best teaching for a pre- o Increase the size of the
cheiloplasty patient or a pre- nipple of the bottle by
uranoplasty patient is what cutting the nipple of the
the patient will have to do bottle
after the procedure

64
Important Post-Cheiloplasty or through the esophagus may
Post-Uranoplasty enter the trachea and the air
Nursing Responsibilities passing through the trachea
 Post-operative priority is to may enter the esophagus
prevent infection
 For both procedures Nursing Priority in
o Clean suture line Transesophageal Fistula:
before and after  Airway
feeding  TEF patient is more prone to
 Never give a straw to post- infection
operative patient o Pneumonitis
 Due to the
ESOPHAGEAL ATRESIA possible
 There is an obstruction in the presence of food
esophagus in the lungs
 The esophagus is not
continuous

Diagnostic Tests for Esophageal Signs and Symptoms of

Atresia Transesophageal Fistula
 X-ray  Same as with Esophageal
 Use of Nasogastric Tube Atresia
(NGT) o Drooling
 If there is resistance upon
insertion of the NGT, there is Three (3) Major Symptoms in
esophageal atresia Tracheoesophageal Fistula
 Coughing
Nursing Priority in Esophageal  Choking
Atresia:  Cyanosis
 Nutrition Important Concept!
 If patient has both
Signs and Symptoms of Esophageal Atresia and
Esophageal Atresia Transesophageal Fistula,
 Drooling surgical management involves
 Patient experiences this placing a patch in the
immediately after feeding connection between the
esophagus and the trachea
TRANSESOPHAGEAL FISTULA
(TEF) Important Fundamentals of
 Normally, the esophagus and Nursing Concept!!! (interjected)
the trachea are two separate  If the patient is a stroke
passageways patient,
 In Transesophageal Fistula, o Perianal area is the
there is a connection between dirtiest area
the esophagus and the  Therefore, clean
trachea so that food passing this last when

65
 you do the bed o Liver produces bile and
bath stores it in the gall
 If the patient is normal. bladder
o Feet are the dirtiest o If fat is present in the
area of the body duodenum, the
 Therefore, clean duodenum releases
this last when Cholecystokinin
you do the bed Pancreozymin (CCK) –
bath a substance that
causes the gall bladder
PYLORIC STENOSIS to contract and release
 This disease is characterized bile
by the affectation of the o Gall bladder releases
pyloric sphincter bile through the cystic
 The pyloric sphincter is the duct to the common
structure at the distal end of bile duct and through
the stomach, which prevents the ampulla of vater
the backflow of food from the going to the duodenum
duodenum to the stomach o Since bile is reaches
 In Pyloric Stenosis, there is the food in the
hypertrophy of the pyloric duodenum, the vomitus
sphincter in pyloric stenosis does
 This may cause obstruction not have bile

Signs and Symptoms of Pyloric 3. Palpable Olive-shaped Mass

Stenosis  This is due to the
hypertrophied pyloric
1.Abdominal Distention or Gastric sphincter
Distention  This is the CARDINAL SIGN
 Hypertrophy of the pyloric of pyloric stenosis
sphincter causes obstruction o However, this is NOT
 Therefore, not all of the food PALPABLE in OBESE
ingested goes to the intestine PYLORIC STENOSIS
 There is accumulation of food PATIENTS
in the stomach causing gastric
or abdominal distention 4. Visible Peristalsis
 This can be seen and is
2. Projectile Vomiting observable or noticeable in all
 Due to increased pressure in pyloric stenosis patients
the stomach
 Important Concepts!!!
o There is NO BILE in Diagnostic Test for Pyloric
the vomitus Stenosis
 Barrium Swallow
 Key Concepts!!! o This will reveal the
STRING-LIKE

66
 APPEARANCE o Secondary function of
characteristic of pyloric this test is therapeutic
stenosis in purpose
 Due to the
Treatment for Pyloric Stenosis pressure
 Fredet Ramstedt Procedure exerted in
o This is the surgery for barium enema,
pyloric stenosis the small
o Also called intestine is
PYLOROMYOTOMY stretched
 The stretching of
INTUSSUSCEPTION the small
Major Problem intestine causes
 There is a telescoping of the a reduction in
small intestine the
 Part of the small intestine intussusception
enters into itself
 Food accumulates into the Medical Management for
part where the intestine enters Intussusception
into itself  Surgery involves cutting the
part with the invagination
Signs and Symptoms of followed by end-to-end
Intussusception: anastomosis

1. Gastric or Abdominal Distention HIRSCHSPRUNG’S DISEASE

 Due to the accumulation of  Also called Aganglionic
food in the portion where Megacolon
there is invagination of the o Problem occurs in the
small intestine into itself Large Intestine
o There is absence of
2. Palpable Sausage-shaped Mass nerves or ganglia in a
portion of the Large
3. Vomitus with Bile Intestine
o Specifically, the
4. Currant Jelly Stool DISTAL PART of the
DESCENDING
Diagnostic Test for COLON does NOT
Intussusception CONTAIN nerves and
 Barium Enema ganglia
o Primary function of this o Therefore, there is NO
test is diagnostic in PERISTALSIS
purpose  Stool accumulation from lack
 This is done to of peristalsis occurs in the
check on the large intestine
EXTENT of the o The accumulation of
intussusception stool causes

67
 enlargement of the Treatment of Imperforate Anus
colon – a phenomenon  Local Piercing
known as a
MEGACOLON METABOLIC GASTROINTESTINAL
SYSTEM PROBLEMS in
Signs and Symptoms of PEDIATRIC PATIENTS
Hirschsprung’s Disease  Phenylketonuria
 Galactosemia
In the newborn  Coeliac Disease
 Absence of meconium for the
first twenty-four (24) to forty- PHENYLKETONURIA
eight (48) hours  An autosomal recessive
disorder
In the infant  Major Problem
 Presence of explosive o Inability to metabolize
diarrhea Phenylalanine
o Characterized by the
In the child absence of the enzyme
 Presence of ribbon-like stool PHENYLALANINE
HYDROXYLASE
Management of Hirschsprung’s  Phenylalanine hydroxylase
Disease converts phenylalanine to
 Surgeon ligates the portion tyrosine
with Hirschsprung’s Disease
and then does end-to-end NORMAL METABOLISM OF
anastomosis PHENYLALANINE

 Temporary colostomy is done Phenylalanine

o To promote healing of ▼▼▼
surgical wound ▼▼▼
o To prevent infection ▼▼▼ Converted by Phenylalanine
▼▼▼ hydroxylase into
Important Concept! ▼▼▼
 If digital rectal examination is ▼▼▼
done, stool cannot be Tyrosine
palpated ▼▼▼
Melanin (Brown Pigment)
IMPERFORATE ANUS
 Problem Important Concept!
o Lack of an anal  The more melanin you have,
opening the darker you are

Sign and Symptom of Imperforate In Phenyketonuria:

Anus
 Absence of Meconium Phenylalanine
▼▼▼

68
▼▼▼ Absence of Phenylalanine
▼▼▼ hydroxylase does not convert Also, in Phenylketonuria
▼▼▼ Phenylalanine to tyrosine
▼▼▼ Phenylalanine
No tyrosine produced ▼▼▼
▼▼▼ ▼▼▼ Absence of Phenylalanine
No new melanin produced ▼▼▼ hydroxylase does not convert
Decreased levels of melanin ▼▼▼ Phenylalanine to tyrosine
▼▼▼ ▼▼▼
Leads to Fair Skin There is accumulation of
(Normal at Birth); Phenylalanine leading to
Leads to Blonde Hair increased levels of phenylalanine
(Normal at Birth); ▼▼▼
Leads to Blue Eyes CENTRAL NERVOUS SYSTEM
(Abnormal at Birth) DAMAGE
▼▼▼ (continued on next page)
Important Concept! Mental Retardation
 At birth a pediatric normally There is no treatment for this!!!
has GRAY EYES
 In phenylketonuria, the Important Concepts!
pediatric abnormally has  In phenylketonuria, increased
BLUE EYES at birth levels of phenylalanine cause
CNS damage that leads to
Important Concept! Mental Retardation
 At birth a pediatric normally  Prevention of Mental
has odorless urine Retardation is done by
 In phenylketonuria, the providing a MODIFIED DIET
pediatric has a MUSTY composed of PKU1 infant
ODOR urine at birth formula or LOPENALAC

Phenylalanine Signs and Symptoms of

▼▼▼ Phenylketonuria:
▼▼▼ Absence of Phenylalanine  Presence of BLUE EYES at
▼▼▼ hydroxylase does not convert birth
▼▼▼ Phenylalanine to tyrosine  Presence of MUSTY ODOR
▼▼▼ URINE at birth
There is accumulation of  MENTAL RETARDATION
Phenylalanine leading to
increased levels of phenylalanine Important Concepts on MODIFIED
▼▼▼ DIET for PHENYLKETONURIA
Phenyl Pyruvic Acid PATIENT
is excreted in the urine  Give PKU1 infant formula or
Gives urine its MUSTY ODOR LOPENALAC
This is the EARLIEST SIGN OF  Breast feeding is not
PHENYLKETONURIA contraindicated but should be
This is ABNORMAL at birth provided only partially

69
  Modified diet is always given Diagnostic Tests for
for metabolic disorders Phenylalanine
 Done until six (6) to eight (8) Guthrie Test or Capillary Prick
years old Test
o Rationale:  This is a test for the presence
 It is at this age of Phenylketonuria
that MAXIMUM  Basic Nursing Responsibilities
BRAIN in performing the Guthrie Test
DEVELOPMENT o Warm the heel of the
occurs foot to improve
 This is the also the period circulation
wherein mental retardation  If result is less
has the last chance of than 2 mg/dl,
developing this is a
NORMAL
Important Concepts on Mental RESULT
Retardation  If result is
 Normal blood level or greater than 4
Therapeutic level of mg/dl, this
Phenylalanine is six (6) to indicates a
eight (8) mg / dl. POSITIVE
 If blood level of Phenylalanine RESULT FOR
is greater than 10 – 15 mg / GUTHRIE TEST
dl, this would cause mental or the presence
retardation of
 If pediatric has a blood phenylketonuria
phenylalanine level of 12 o Before client
mg/dl, the nurse should: undergoes Guthrie
o Continue modified diet Test, patient should
o Never stop giving foods ingest foods rich in
rich in phenylalanine phenylalanine
 Rationale: o For the newborn, give
 Decrease in formula milk or breast
phenylalanine milk before undergoing
triggers test
increased  False-positive
protein results may be
breakdown obtained if nurse
resulting into a fails to give
sudden increase feeding to the
in phenylalanine pediatric who
levels leading to underwent the
mental Guthrie Test
retardation Important Concept!
 Allow child with
Phenylketonuria to go to

70
 birthday party but he has to
bring his own type of feeding Never administer PENICILLIN nor
AMOXICILLIN
GALACTOSEMIA  Both these drugs contain
Major Problem GALACTOSE
 Galactose cannot be  Give ERYTHROMYCIN
absorbed instead!!!
 This is due to the absence of
the enzyme GALACTOSE COELIAC DISEASE
TRANSFERASE Major Problem
 This would give rise to  Gluten cannot be digested
increased levels of Galactose

RENAL SYSTEM DISORDERS IN

Signs and Symptoms of PEDIATRIC NURSING
Galactosemia  Nephritis and Wilm’s Tumor
 Acute Glomerulonephritis
1. Gastrointestinal System  Nephrosis
disturbances
 Nausea NEPHRITIS AND WILM’S TUMOR
 Vomiting  Do not palpate the abdomen
 Diarrhea  This will cause metastasis of
 These three (3) signs are cancer cells
considered the EARLIEST ACUTE GLOMERULONEPHRITIS
SIGNS of GALACTOSEMIA (AGN)
2. Also causes MENTAL  Secondary to Group A Beta-
RETARDATION hemolytic Streptococcal
infection
Important Nursing  Causes increase in ASO titer
Responsibilities in Patients with
Galactosemia: Acute Glomerulonephritis (secondary
to GABHS infection seen in tonsillitis,
Provide MODIFIED DIET impetigo, sore throat)
 This is given up to six (6) to ▼▼▼
eight (8) years of age Damage to the Kidneys
 Diet is SOY BASED ▼▼▼
FORMULA Increased Kidney Permeability
▼▼▼
Do not allow breastfeeding Hematuria (as evidenced by tea-
 Breast milk contains colored, smoky brown-colored or
LACTOSE cola-colored urine)
 Lactose is a disaccharide ▼▼▼
 When broken down to simple Decreased levels of RBC
sugars, lactose provides ▼▼▼
glucose and GALACTOSE Decreased Blood Tissue Perfusion

71
 ▼▼▼
Increased secretion of Renin NEPHROSIS
▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼  Cause is UNKNOWN
Conversion of Aldosterone  Considered as an
Angiotensin I to ▼▼▼ AUTOIMMUNE disease
Angiotensin II Sodium Retention
▼▼▼ ▼▼▼ ▼▼▼ Nephrosis
Increased BP Periorbital Decreased ▼▼▼
(HPN) Edema; Urine Autoimmune Disease
▼▼▼ Puffiness Output ▼▼▼
Fussy, of the eye ▼▼▼ Anti-bodies produced to destroy the
Irritable Oliguria kidney
▼▼▼ ▼▼▼

Concentrated Urine Increased Kidney permeability

▼▼▼ ▼▼▼
Increased Urine Specific Gravity Proteinuria (evidenced by frothy
urine)
Signs and Symptoms of Acute ▼▼▼
Glomerulonephritis Decreased levels of albumin
 Hematuria ▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼
 Hypertension Hyperlipidemia Decreased
 Periorbital edema (liver produces Oncotic
 Sodium Retention lipoproteins) Pressure
 Oliguria ▼▼▼
 Increased Urine Specific (continued)
Gravity (continued from previous page)
 Increased ASO titer Decreased Oncotic Pressure
▼▼▼
Management of Acute Fluid Shifting
Glomerulonephritis ▼▼▼
 Drug of Choice Edema
o Penicillin ▼▼▼▼▼▼▼▼▼▼▼▼▼▼▼
 If pediatric has allergy to Decreased Ascites Anasarca
penicillin Urine
o Give Erythromycin Output
instead ▼▼▼
 Diet Increased Concentrated Urine
o Low sodium ▼▼▼
o Low protein Increased Urine Specific Gravity
 Taxes the
kidneys Important Concepts in Nephrosis
 Provide Complete Bed Rest  There is NO ASO TITER
 Administer ACE inhibitors for ELEVATION
hypertension  There is NO
o Capoten HYPERTENSION

72
 o Blood Pressure is
NORMAL S is for:
 SIGNS
Management of Nephrosis o Increased Blood
 Give steroids Pressure
o For o Increased Temperature
immunosuppression o Decreased Respiratory
 No Antibiotics Rate
 Diet o Decreased Pulse Rate
o Increased protein  Widened Pulse Pressure
o Decreased sodium
 Decreased fat

Important Concepts in Seizures in

CENTRAL NERVOUS SYSTEM Pediatric Patients
DISORDERS IN PEDIATRIC  Seizures in infants are always
NURSING FEBRILE SEIZURES
NEUROLOGICAL DISORDERS  These can be outgrown by the
 The most common symptom pediatric
in neurologic problems is  At age of five (5) to seven (7)
INCREASED INTRACRANIAL these seizures are outgrown
PRESSURE by the pediatric
 Mnemonic is BRAINS  Never use a tongue
depressor, before or during
B is for: seizures.
 BULGING FONTANELLES  If broken, this could bring
R is for: about aspiration
 REFUSAL TO SUCK;  If pediatric experiences
DIFFICULTY IN FEEDING seizures while on a chair,
TRANSFER HIM TO THE
A is for: FLOOR
 ALTERATIONS IN THE  If pediatric experiences
LEVEL OF seizures while he is on a bed,
CONSCIOUSNESS: PLACE HIM ON THE FLOOR
o Confusion  The best thing to do BEFORE
o Lethargic A SEIZURE is to NOTE THE
o Stuporous AURA
o Coma  The best thing to do DURING
 A HIGH PITCHED CRY A SEIZURE is to NOTE THE
ACTIVITY
I is for:  The best thing to do AFTER A
 IRRITABILITY SEIZURE is to NOTE THE
DURATION
N is for:
 NOTE FOR PROJECTILE
VOMITING MENINGITIS

73
  Mnemonic for signs and
symptoms is CHIPS H is for:
 Mnemonic for management is  HYPOTHERMIC BLANKET
AHOY DUE TO FEVER

Signs and Symptoms of O is for:

Meningitis  OXYGEN THERAPY

C is for: Y is for:
 COMA  YES TO ISOLATION
PRECAUTION

Important Concepts!
 Alteration in level of CEREBRAL PALSY
consciousness  Mnemonic for the different
 Coma is the last stage classifications is ARMS

H is for: DIFFERENT CLASSIFICATIONS

 HIGH PITCHED CRY OF CEREBRAL PALSY

I is for: A is for:
 IRRITABILITY  ATAXIC CEREBRAL PALSY
o Walking or movement
P is for: problem
 PROJECTILE VOMITING and o With unsteady or wide-
PETECHIAL RASHES based gait
S is for:  ATHETOID CEREBRAL
 SIGNS PALSY
o Ophistotonous arching o Articulation
of the back o Facial Grimacing
o Kernig’s Sign
 There is R is for:
resistance at the  RIGID CEREBRAL PALSY
knee when it is
pulled Important Concepts!
o Brudzinski’s Sign  Loss of active motion
 Flexion of the  Rigid posture
neck results to
flexion of the hip M is for:
and leg  MIXED CEREBRAL PALSY

Management of Meningitis Important Concept!

 Any combination of all the
A is for: types
 ANTIBIOTIC THERAPY

74
S is for:  Head of the femur is
 SPASTIC CEREBRAL PALSY displaced
 Head of the femur floats in the
Important Concepts! acetabulum
 Hyperactive deep-tendon
reflexes Signs and Symptoms of
 Hyperactive Stretch muscles Congenital Hip Dislocation
 With scissory gait  Mnemonic is FLOAT
 Walks in a tip-toe manner
F is for:
Management of Cerebral Palsy  FOLDS / GLUTEAL FOLDS
 Place the patient on BED ARE INCREASED

B is for:
 BRACES / SPLINT L is for:
 LIMB / AFFECTED LIMB IS
E is for: SHORTER THAN
 Promote EXERCISE / UNAFFECTED LIMB
ACTIVE RANGE OF MOTION
EXERCISES O is for:
 ORTOLANI’S SIGN
D is for:
 DRUGS Important Concepts!
 This is used to check for the
Important Concept! presence of Congenital Hip
 Administer MUSCLE Dislocation
RELAXANT  This is a CLICKING SOUND
on ABDUCTION OF THE HIP
Key Concept!
 Never place a cerebral palsy A is for:
patient in a walker  ALLIS’ SIGN
 This will result into accidents
Important Concept!
MUSCULOSKELETAL SYSTEM  One knee is lower than the
DISORDERS IN PEDIATRIC other
NURSING
 Congenital Hip Dislocation T is for:
 Scoliosis  TRENDELENBURG SIGN
 Club Foot
o Talipes Equinovarus Management of Congenital Hip
 Duchenne Muscular Dislocation
Dystrophy  Pavlik’s Harness
 Double / Triple Diaper
CONGENITAL HIP DISLOCATION Technique

75
SCOLIOSIS
 Lateral curvature of the body
 Priority is respiration
 Ages ten (10) to fifteen (15) or
adolescents are screened
 More common in females
Screening Test for Scoliosis
 Let the pediatric lie down
 Let the pediatric bend
 If the skirt is oblique, then this
is indicative of scoliosis
 Then, confirm diagnosis with
X-ray
Confirmatory Diagnostic Test for
Scoliosis
 X-ray
o Pushing self from the
floor using the hands
o If client is on the floor,
he uses his hands to
stand up
 This is indicative of Duchenne
Muscular Dystrophy
CARDIOPULMONARY
RESUSCITATION (CPR)
Important Concepts on CPR!
 Do scene survey first
 Ensure safety of the rescuer
 Good Samaritan Principle

Management of Scoliosis
 Use MILWAUKEE BRACE
 An orthopedic device
 Use for twenty-three (23)
hours in a day
 Pediatric can swim for one (1)
hour without the Milwaukee
Brace

CLUB FOOT
 Talipes Equinovarus (TEV)

Management of TEV
 Use Denis-Browne Splint
 If client is still growing,
frequently adjust the
therapeutic device

DUCHENNE MUSCULAR
DYSTROPHY
Major Problem
 Increased muscle fiber
breakdown due to decreased
DYSTROPHIN
 Priority is respiration due to
breakdown of the diaphragm
 Gower’s Sign

76
77
78