Pedia Review Final Growth and Developement

GROWTH & DEVELOPMENT
Maricel S. Jose MD;RN
DEFINITION
Growth progressive increase in physical size ( cm, kg) Development progressive increase in skill & the ability to function Maturation readiness ( learning takes place quickly & effortlessly when the child is ready.
DEVELOPMENT
Developmental milestone standard of reference by which to compare the childs behavior at specific ages Developmental delay(s) variable of development which lags behind the range of a given age
DEVELOPMENT
Developmental task skills and competencies associated with each developmental stage
Stages
A. First Stage pre-natal begins from conception to birth. B. Second stage from birth to 12 months 1. neonatal first 28 days, first 4 weeks. 2. Infancy 1 to 12 months
C. Third Stage Early Childhood( 1-6 y/o)

1. Toddler 1-3 y/o 2. Pre- school 4-6 y/o D. Fourth Stage Middle Childhood 1. School age 6-11 y/o 2. Adolescence 13 18 y/o
Principles of Growth & Development ** G & D follows a trend or pattern: A. Directional Trends directional, sequential ( reflects neuromuscular development)
a. Cephalocaudal pattern of development that proceeds from the head, down the spinal column, then to the toes.
b. Proximodistal pattern of development that proceeds from the midline of the body to the extremities ( arm movement development before fine motor finger ability ) c. Mass to specific differentiation ** child masters simple operation before complex operation. ** moves from a broad general pattern of behavior to a refined pattern.
B. Sequential trend predictable sequence: ( crawls > creeps> stands> walk> run ) Principles of Asynchronous growth: ** Not all parts of the body grow at once, at the same time , & at the same rate.
G & D is a continuous process ( conception to death, womb to tomb) - rapid fetal, infancy, adolescence - alternating rapid & slow toddler, pre-school - slow school age.
PRINCIPLES
1. Continuous 2. Orderly and sequential 3. Highly individualized
4. Different rates
PRINCIPLES
5.Cephalocaudal 6. Proximodistal 7. Simple to complex 8. Sensitive periods 9. Practice
FACTORS THAT AFFECT GROWTH AND DEVELOPMENT

I. Genetics a. Gender b. Health c. Intelligence d. Temperament
FACTORS THAT AFFECT GROWTH AND DEVELOPMENT

II. Environment a. Socioeconomic level b. Parent-Child Relationship c. Ordinal position in the family d. Health
THEORIES OF GROWTH & DEVELOPMENT

1. 2. 3. 4. 5. 6. FREUD PSYCHOSEXUAL ERICKSON - PSYCHOSOCIAL SULLIVAN INTERPERSONAL KOHLBERG-MORAL PIAGET COGNITIVE HAVIGHURST DEVELOPMENTAL TASK
PSYCHOSEXUAL DIMENSION (FREUD)

A. B. C. D. E. Oral ( 0-1 years old ) Anal ( 1-3 years) Phallic / Oedipal (3-7 years) Latency ( 7-11 years) Genital ( 11-21 years )
Freuds Psychosexual Theory

- Experience at different stages influences personality traits
Oral (0 1 y/o)
- oral stimulation for nutrition, enjoyment and release of tension NI: provide oral stimulation pacifiers, breastfeeding
Anal (1 3 y/o)
- elimination is a way of discovery and exerting independence NI: achieve bowel and bladder control even if hospitalized
Phallic (3 6y/o)
- increased knowledge of 2 sexes NI: accept sexual interest and answer questions about birth or sexual difference
Latency (6 12y/o)
- libido diverted to school NI: achieve positive experiences to promote self esteem
Genital (>12y/o)
- establish sexual aims and finding new love objects NI: opportunities to relate w/ opposite sex; verbalization about new feelings
Psychological Dimension ( Erickson)

A. B. C. D. E. Trust vs Mistrust ( 0-1 years old ) Autonomy vs shame & doubt (1-3 y) Initiative vs Guilt (3-7 yrs old ) Industry vs Inferiority (7-11y) Identity vs role confusion (11-21 y)
OVERVIEW OF ERIKSONS DEVELOPMENTAL TASKS THROUGHOUT THE LIFESPAN Age Stage Eriksons Positive Outcome Negative Outcome Task Birth to Infancy Trust vs. Trusts self and others Demonstrates an 18 mos Mistrust inability to trust; withdrawal, isolation 18 mos Toddler Autonomy Exercises self-control and Demonstrates defiance to 1 y vs. Shame influences the and negativism and Doubt environment directly 3 to 6 y Preschool Initiative vs. Begins to evaluate own Demonstrates fearful, Guilt behavior; learns limits on pessimistic behaviors; influence in the lacks self-confidence environment 6 to 12 y School age Industry vs. Develops a sense of Demonstrates feelings Inferiority confidence; uses of inadequacy, creative energies to mediocrity, and selfinfluence the doubt environment 12 to 20 Adolescenc Identity vs. Develops a coherent Demonstrates inability y e Role sense of self; plans for a to develop personal confusion future of work/education and vocational identity
ERIKSONS PSYCHOSOCIAL THEORIES

1. Social development 2. Role of play in development
Developmental task
- skill or growth responsibility arising at a particular time in an individuals life - foundation of accomplishment of future tasks
Trust vs Mistrust (Infancy)

T: safe environment; dependable people M: suspicious, fearful, shun emotional involvement
NI: provide primary caregiver and visual stimulation
Autonomy vs Shame and Doubt (Toddler)

A: build on new motor and mental abilities, take pride in accomplishments
S: doubt and stop trying NI: provide opportunities for decision making and give praises
Initiative vs Guilt (Preschooler)

I: how to do basic things well, encourage if the parents answer the childs question G: limited brainstorming and problemsolving skills, wait for clues NI: provide opportunities for exploration, imagination and creativity answer questions and do not inhibit fantasy
Industry vs Inferiority (School-Age)

Ind: how to do things well Inf: always worried about poor or incorrect performance NI: provide opportunities for completing short projects, give praise and rewards
Identity vs Role Confusion (Adolescence)

I: learns who is he or what kind of person he will become R: unsure of who they are or who they can become, may rebel
NI: provide opportunities to discuss feelings and support and praise for decisionmaking
Cognitive (Piaget )
A. B. C. D. Sensorimotor 0-2 years old Pre-operational 2-7 years old Operational concrete 7-12 yrs old Operational formal 12 years old- adult
Sensorimotor ( 0-2yr old)

- relate through senses, separate from environment, practical intelligence - Practical intelligence - Words and symbols is not yet available - Primary Circular Reaction - Secondary Circular Reaction - Tertiary Circular Reaction
Primary Circular Reaction (1- 4 months)

Hand-mouth and ear-eye coordination develop Infants spends time looking at objects and try to separate self from the object Enjoyable activity: rattle or taped voice of the parent
Secondary Circular Reaction ( 4-8 months)

Infants learns to initiate, recognize and repeat pleasurable experiences from the environment Memory traces are present, infant anticipates familiar events Good toy: mobile Good game: peek-a-boo
Coordination of Secondary Reactions ( 8-12 months)

Infants begin to demonstrate goal-directed behavior ( infant dont just want to hit the mobile but he also wants to reach it) Recognizes shapes and sizes of familiar objects Good toy: colored boxes
Tertiary Circular Reaction (12-18 months)

Children use trial and error to explore both permanence and the different actions of things/toy Child is able to experiment to discover new properties of objects and events Capable of space and time perception Objects outside self are understood as causes of their actions Good game: throw and retrieve
Preoperational ( 2-7yr old)

toddler: symbolism, animism, simple abstractions, prelogical thinking, poor concept of time and distance pre-schooler: centering, egocentric, literal thinking, static thinking, no conservation or reversibility, no cause and effect, assimilation, role fantasy, magical thinking, accomodation Good toy: items that require imagination- modeling clay
Concrete Operational ( 7-12yr old)

- Systematic reasoning - Concept of reversibility cause and effect) - inductive reasoning (specific to general) - Concept of conservation (7 yo numbers; 7-8 yo quantity; 9 yo weight; 11 yo volume) - Good activity: collecting and classifying natural objects( plants, seashells)
Formal Operational Thought (>12yr old)

- solve hypothetical problems, abstract thought, deductive reasoning (general to specific), causality, time - talk time to sort attitudes and opinions
Moral / Ethical (Kohlberg)

PRECONVENTIONAL LEVEL I Stage I PREMORAL ( 0-6 mos) stage of gratification Stage II PREMORAL ( 6-12 months) stage of end justify the mean Stage III- PREMORAL (1-3 years old) morality/ avoidance of punishment Stage IV Nave instrumental hedonism (3-7 years old ) scratch my back and Ill scratch yours CONVENTIONAL LEVEL II Stage V Conformity (7-9 years old) Stage VI Law & order (9-12 yrs old ) POST CONVENTIONAL LEVEL III Stage VII- first stage of true morality (12-18 yrs old) Stage VIII True morality (18-21 years old ) universal moral- ethical orientation
INFANCY (28 DAYS TO ONE YEAR)
I- PSYCHOSEXUAL STAGE ( FREUD): ORAL II PSYCHOSOCIAL STAGE ( ERICKSON):
TRUST VS. MISTRUST

A. CENTRAL PERSON: PRIMARY CAREGIVER/MOTHER B. BEHAVIORAL INDICATORS: a. CRYING IS THE ONLY MEANS OF COMMUNICATING NEEDS. b. QUIETING USUALLY MEANS NEEDS ARE MET
III COGNITIVE STAGE( PIAGET) :

SENSORIMOTOR ( 0-2 YRS) PLAY : SOLITARY (THEY PLAY WITH THEIR OWN BODY) 1. TO PRACTICE MOTOR SKILLS 2. TO GAIN COORDINATION
3. TO RELATE TO OBJECTS & PEOPLE

*infants usually do not seek out the company of other infants to play. This does not mean that the infant should be left alone with toys; however, social stimulation from parents, older siblings & children is still critical to the infants development.
Age appropriate toys: 0-2 YRS * should stimulate all senses & be bright & multicolored. 1. mobiles 2. rattles 3. musical box 4. squeeze toys 5. teething rings 6. textured balls 7. large, soft cuddly toys 8. brightly colored pictures
Best color: red

Auditory stimulation: sing & talk to the infant * musical mobiles, bells, rattles
Tactile stimulation: 1. Hold, pat, touch, cuddle, swaddle/keep warm; rub body with lotion, powder. Toys: various textures; nesting & stacking, plastic milk bottle with blocks to dump in & out. Kinetic stimulation: 1. Cradle, stroller, carriage, infant seat, car rides, wind-up infant seat, walker Toys : cradle gym, push-pull
1V Greatest Fear Stranger anxiety ( starts at 6 months and peaks at 8 months)- normal indicates attachment of infant to caregiver. Nurse Alert Most common accident during the first twelve months is the aspiration of foreign bodies. PHYSICAL GROWTH: 1. Height ( length) 50% increase by first birthday 2. Weight
Doubles by 6 months ( gains 5-7 oz./wk in 1st 6 mos.; gains 3-5 oz/wk in 2nd month)
Triples by 1 year
*Bruxism

2 months
G: 45 degree head control F: EYES midline S: SOCIAL SMILE L: CRYING Rooting/Extrusion reflexes diminish Posterior fontanelle closes
GROWTH AND DEVELOPMENT

3 MONTHS G: 3 mos - 90 deg head control (no head lag)
F: 3 mos eyes past midline

L: 3 mos squeals, laughs, bables
S: 3 mos recognize, familiar faces

4 months
G : lifts head and chest when prone F: brings hands together (3rd month: HAND RECOGNITION) L: COOS/GURGLES/ SQUEALS , moves head to sound S: plays with rattles, enjoys social interaction (-)PALMAR/STEPPING (-) Extrusion/ MORO

5 MONTHS G: 5 mos rolls from front to back F: 5 mos grasps
voluntarily L: 5 mos - simple

vowel sounds S: 5 mos smiles
at mirror image
GROWTH & DEVLOPMENT

6 months
G: good head control *HEADBANGING F: holds object in 1 hand and reaches out for another object L: simple vowel sounds S: recognizes familiar faces *STRANGER ANXIETY P: TEETHING 2X Birthweight, (-) SUCKING

7 MONTHS G: sits w/ support F: hand to hand transfer L: ma when crying PS: feeds self w/ crackers, recognizes
familiar faces

8 months
G: sits without support, CRAWLS F: hand to hand transfer of objects, waves BYEBYE S: STRANGER ANXIETY peaks L: 8 mos pronounces combined syllabus (mama) (-) PLANTAR

9 MONTHS
G: pulls self to stand, creeps
F: neat pincer grasp L: mama, dada, understands no-no S: waves bye bye

10 months
G: CREEPS, CRUISES, STAND ALONE F: PINCER GRASP S: responds to NAME when called, enjoys nursery games (peeka-boo) L: understand gesture P: Nursery games

11 MONTHS G: Stands alone, attempt to walk F: bangs objects together
PS: holds arm or foot out in dressing

12 months
G: stands alone, walks with assistance F: throws toys, attempts at 2 tower blocks, attempts to use SPOON L: one word other than mama, dada S: shows jealousy and affection P: weaning off from bottle to CUP *BABY BOTTLE SYNDROME 3X Birthweight 2X Birthlength
PLAY solitary play

1-3 mos Balloon mobiles Mirror play Stuffed animals rattles Being held 4-6 mos Squeeze toys Busy boxes Play gyms 7-9 mos Block play Splashing bath toys Cloth textured toys Large balls
10-12 mos Picture books Large blocks Nesting cups
PLAY
Peek-a-boo Rocking Singing games Squeaky toys Pat-a-cake Peek-a-boo Feet & toes games Fingers & hand games Listening to stories Making faces
Calories: 100-115 kcal/kg/day 0-3 mos - breastmilk 4-6 mos - semi-solid food Introduce one at a time Start with small quantities Cereals, strained vegetables, meat 7-9 mos - Finger food, fluids 10-12 mos 3 meals w/ snacks Water 125-150 ml/k/day from 0-6 mos - 135 ml/kg/day from 6-12 mos
DAILY CARE
- bathing
- diaper care - care of teeth - dressing - sleep 16-20hrs/day; - 6 mos- 1-2 naps, with 12h at night - 12 mos old; 1 nap with 12h at night - exercise
Concerns
- Constipation /Loose
Stools
- Teething cleanliness - sleep problems breastfed infants wake up sooner - COLIC paroxysmal abdominal pain - DIAPER DERMATITIS - MILIARIA - OBESITY
- Thumb sucking until school age

- pacifiers wean after 3 months - spitting up
REACTION TO ILLNESS
NURSING CARE
Discomfort and pain Lack of stimulation Separation anxiety Disruption of routine
Soothing stimulation Toys from home Human contact Provide/Anticipate needs
** Best color for neonates: black & white
** Best color for infants: red **Use CAR SEATS for children according to Rule of 4s when traveling = 4 years or younger
= 40 lbs or less
= 40 in. tall or shorter
TODDLER 1 3 yo
TODDLER
( 1-3 YEARS OLD) I PSYCHOSEXUAL STAGE ( FREUD): ANAL - LEARNING MUSCLE CONTROL FOR TOILET TRAINING. - SOURCE OF ENJOYMENT /GRATIFICATION IS THE ACT OF RELEASING CONTENTS OF BOWEL & BLADDER. - NEGATIVISM ASSERTION OF INDEPENDENCE
- INTRODUCTION OF REALITY PRINCIPLE; EGO DEVELOPMENT
II CENTRAL FIGURE: PARENTS III PSYCHOSOCIAL STAGE:( ERICKSON): CENTRAL TASK: AUTONOMY VS. SHAME & DOUBT 1. AUTONOMY- SENSE OF INDEPENDENCE IS DEVELOPED BY ALLOWING THE CHILD TO EXPLORE UNDER SUPERVISION IN A CONTROLLED ENVIRONMENT. - SIGNS OF INDEPENDENCE:
** TEMPER TANTRUMS
** SAYS NO( THEY LEARN TO SAY NO BEFORE THEY LEARN TO SAY YES.
** INSISTS ON PUTTING ON THEIR OWN CLOTHES & GET THEIR FEET ON THE WRONG SHOES.
** INSISTS ON WINDING A TOY & BREAKING IT.

2. GAIN CONTROL OF BODY FUNCTION: ** SELF-FEEDING, DRESSING, UNDRESSING, & HYGIENE
3. TOILET TRAINING BEGIN TRAINING WHEN READY:

** CAN STAND ALONE & WALK STEADILY
** IF CHILD IS ABLE TO KEEP HIM/HERSELF DRY FOR 2-3 HOURS ( INVOLUNTARY CONTROL)
** IS ABLE TO SAY WEEWEE OR POOPOO ** DESIRES TO PLEASE PRIMARY CARETAKER GUIDELINES: 1. REWARD POSITIVE BEHAVIOR WITH PRAISE & AFFECTION. 2. MAINTAIN RELAXED & NON-PUNITIVE ATTITUDE 3. DISCIPLINE CONSISTENTLY, IMMEDIATELY, & APPROPRIATELY 4. USE CORPORAL PUNISHMENT, SPARINGLY LIKE
SPANKING, NEVER IN ANGER FOR THE CHILDS SAFETY.

5. DO NOT BRING FAVORITE TOY DURING TRAINING 6. PUT ON TRAINER FOR 10 MOS; DO NOT LEAVE ALONE. ** BOWEL CONTROL AT 18 MOS; DAYTIME BLADDER CONTROL AT 2 TO 2 YEARS & NIGHTIME BLADDER CONTROL AT 3 YEARS
IV COGNITIVE STAGE: ( PIAGET): STAGE 1
( PRECONCEPTUAL STAGE) OF THE PREOPERATIONAL THOUGHT PERIOD (2-4 YRS) = CHARACTERIZED BY EGOCENTRICITY EXPRESSED IN RELATING EVERYTHING TO SELF, CONCEPTS OF IDEAS WITHOUT LOGIC
V - MORAL (KOHLBERG) PRECONVENTIONAL LEVEL 1 STAGE 1- PUNISHMENT AND OBEDIENCE
VI PLAY = PARALLEL
VII GREATEST FEAR: SEPARATION ANXIETY ( most acute at 2- 2 years of age)
TODDLER
Slowed growth Wt gain 5-6 lbs (2.5 kg) 5 in (12 cm) Baby fat disappears brain 90 % adult size Birth weight quadruples at 2 yo Full binocular vision well developed Visual acuity 20/40
GROWTH AND DEVELOPMENTAL MILESTONES

GROSS: 15 mos walks alone well, uses spoon but spills 18 mos run and jump in place - walk up & down stairs holding on to railing - seat self in chair 24 mos walks up & down stairs w/ both feet same step, same time, uses the fork, imitates a horizontal line 2 yo tiptoes 3 yo - throws balls, rides tricycles - stands on 1 foot momentarily ,
LANGUAGE
15 mos - vocalizes wants - 3 words other than dada, mama 18 mos - uses phrases 2 yo - short sentences; 2-3 words - points to one body part 3 yo - speaks fluently using longer sentences, says 900 words - tells stories - plurals
PERSONAL/SOCIAL
15 mos - pats pictures - imitates housework 18 mos - turns page 2-3 at a time - uses spoon 2 yo terrible stage - removes garments - toilet trained by day (2-3 yo) 3 yo trusting three - dry by night (3-4 yrs old) - washes and dries hands
NUTRITION
Decrease in appetite because of the slow growth rate Picky eaters, dawdling with meals 1, 300 kcal/day Allow self feeding Allow choice between 2 types of food Offer finger food, appetite of 3 year olds is more capricious than that of 1 year olds Risk of aspiration
PLAY Parallel Play TODDLERS

Babbling and talking Ball games Clay Listening to music Listening to stories Making music and noise Push and Pull toys Puppet play Scribbling Stack-and-dump toys
- Building blocks - Toys to ride on
Parallel Play two toddlers play next to but not necessarily with each other. They are engaged in separate activities , do not have shared rules & have no apparent organization.
DAILY CARE
- dressing can put on socks, underpants, undershirt
- sleep 12-14H/night w/ 1 nap - dependency on security object (transitional toy) - may ask to sleep with bottle - may rebel against going to sleep - bathing - care of teeth-since all 20 deciduous teeth are out by 2 yrs, start teaching brushing of teeth; first dental check up shld be bet. 12-18 mos.
Negativism they are slowly moving out of infancy & are more closely defining their own independent activity. Temper Tantrums-in order to control self & others. Mx: IGNORE THE BEHAVIOR or direct them to activities they can master.( When things are rearranged or are strange; or when persons or places are unfamiliar) Accidents from falls, poisoning,electrical burns because they are , naturally active, mobile & curious (set limits & exert external control . LOVE & CONSISTENCY are the 2 most important concepts in child rearing. Rituals- rigid, repetitive & steroetyped.
EGOCENTRIC uses MINE for everything.
Sibling rivalry Discipline Separation anxiety
REACTION TO ILLNESS and NURSING INTERVENTIONS
Regressive behaviors - reassurance Nutrition allow finger food Dressing changes allow to pull off tape Medication allow choices of chaser after oral medication
Hygiene allow choice of bath time toy, allow to put toothpaste

Pain allow to express pain Stimulation
Elimination continue potty training

Rest allow choice of toy at bedtime
TODDLERS
NOTES:
1. Accidents are the chief cause of death in toddlers. Most accidental deaths in children under age 3 years are related to MOTOR VEHICLE ACCIDENTS.
2. When caring for a toddler in the hospital, the nurse should prevent SEPARATION ANXIETY by encouraging rooming-in. To help the toddler deal with frustration & loss of autonomy, the nurse should provide the toddler with a POUNDING BOARD or PUNCHING BAG.
3. SECURITY OBJECT something a toddler becomes strongly attached to like doll, stuffed animal, pillow or blanket; if separated from the security object, the toddler usually reacts with extreme frustration & anxiety. 4. The DENVER DEVELOPMENT SCREENING TEST is used to screen the development of toddlers. ( ex. Most toddlers can remove their own clothes between 12 & 18 mos. And put their own clothes between 19-24 mos. 5. Turn pot handles in when on stove top. 6. Poisoning: most common in 2 year olds
** Consider every non food substance a hazard and place out of childs sight/ reach. ** Keep all medications, cleaning materials etc. in clearly marked containers in locked cabinets. ** provide barrier on open windows to prevent falls.
PRE SCHOOL 4-6 yo
PRESCHOOL AGE 4-6 YEARS OLD

I PSYCHOSEXUAL STAGE ( FREUD): PHALLIC 1. gender identification and genital awareness; pleasure through genitals. 2. child discovers anatomical difference between sexes
3. sexual fantasies about parent of the opposite sex and guilt about the fantasies
4. oedipal and electra issues ;
5. castration in males & penis envy in females.
II PSYCHOSOCIAL STAGE ( ERICKSON)

INITIATIVE VS. GUILT 1. Provide play materials to develop initiative: - playhouse - housekeeping toys
- toy trucks, planes, cars

- construction set ( lego)
- coloring materials
- playground equipment
ASSOCIATIVE PLAY preschoolers play in a group, in activities that may be the same or similar, but there are few, if any, rules and little organization to the group. COOPERATIVE PLAY slightly more advanced than associative play; preschooolers will play in a group with other preschoolers in one organized activity that has rules and goals. III Greatest Fears: 1. Castration fear/ Body mutilation 2. Fear of the dark IV SIGNIFICANT FIGURE: Basic Family V- COMMON PROBLEM: Vehicular accident, poisoning
PRE SCHOOL
Future body build apparent
Increased skeletal growth
Handedness
5 yo - may have permanent teeth
Tonsils increase in size

IgG and IgA increases
PRE SCHOOL
HR 85 bpm BP 100/60 4.5 - 5 kg/yr
2 - 3.5 in/yr
Frequent voiding
Gross 3 1/2 yo - stands on 1 foot 5 sec - upstairs on 1 foot/step; down 2 feet /step - can pedal a tricycle - walks backwards - uses scissors - helps dress himself
4 4 - climbs stairs with alternate steps - hops on 1 foot - can tie own shoes - can verbalize number sequence ex. telephone numbers. 5 yo heel to toe walk, skips & runs, dress and undress w/o help 6 yo- ventures in the neighborhood, graceful w/ good posture
FINE MOTOR
4 - draws man w/ 3 parts - copies square - print name 5 yo - copies triangle - writes alphabet - draws man with 9 parts 6 yo- draws bahay kubo and basic figures
LANGUAGE
3 yo - gives full name, sex - counts to 3 or more 4 yo - exaggerates and boasts, says 500 words 5 yo- talks constantly - gender specific behavior 6 yo- says 2500 words
PERSONAL/SOCIAL
3 yo - dresses w/ supervision,separate s more easily from mother 4 yo furious four, buttons up,magical thinking 5 yo frustrative five, uses a knife 6 yo- transition stage, eruption of 1st molar
NUTRITION
Slow/Steady growth Decreased appetite Offer small servings
Healthy snack food
PLAY associative play

Dress up clothes Housekeeping toys Dolls and other toys for pretending Bikes, tricycles Paper and crayons Playground toys (seesaw, swing, slide) Watercolors, fingerpaints, clay Materials for cutting, pasting
PRESCHOOL
DAILY CARE
accidents bicycle safety, seat belts dressing choose own clothes sleep resist taking naps exercise very active bathing can wash and dry hands; need supervision care of teeth independent brushing - 1st dental visit
CONCERNS - They love to watch adults & imitate their behavior

- Oedipus and electra complex - gender roles need exposure to parents of opposite sex - Socialization capable of sharing - Discipline time out - Common fears dark, mutilation, separation - Telling lies & brag & boast in order to impress others - Imaginary friends & playmates are common
-They are very creative and curious, that is why their favorite word is why? -- they enjoy offensive language -- age of sibling rivalry -- questions about sex should be answered honestly at the level of their understanding.
-- MASTURBATION is common in some do not make a fuss about iT or punish the child; just give toys to play as substitute
- sharing define limits and teach property rights - Regression reaction to stress - Sibling rivalry - sex education - pre-school center - broken fluency - swearing - High energy level - Curiosity
REACTIONS/CONCERNS IN ILLNESS AND NURSING INTERVENTIONS

- fear of the dark allow dim light and parent to sit beside child - Fear of body mutilation - Prepare for and explain procedure; reassure - Fear of injury, pain and the unknown - Encourage expressive play/medical play
- Fear of separation/abandonment relate time and space to familiar situations
nutrition food in animal/alphabet shapes dressing change allow to measure, cut tape, see incision site medication allow to choose chaser hygiene allow choice of toys, wash hands and face pain allow pain expression, handle syringe, analgesic stimulation
School Age 7 12 yo
SCHOOL AGE 7-12 YEARS OLD

I- PSYCHOSEXUAL STAGE ( FREUD) LATENCY - repression of sexuality; sexual drive is inactive
until pubescence. Sexual urges are submerged; they put their energies into acquiring cultural skills. - Institution of the superego at the close of oedipal period & further maturation of ego functions allow for considerably greater degree of control over instinctual impulses.
- development of sense of industry and capacity for mastery of concepts and objects.
-
II PSYCHOSOCIAL STAGE ( ERICKSON)

INDUSTRY VS. INFERIORITY 1. Learn how to do things well and strives to achieve success 2. Introduction to formal school 3. Offer opportunities to pursue individual interest: collecting objects, projects and visiting museums
4. Respect need for privacy

5. Encourage interaction with peers
III PLAY Competitive

Age Appropriate Toys: 1. Dolls 2. Trains and model kits 3. Games, jigsaw puzzles; magic tricks
4. Books; table games; board games

5. TV, video, records
6. Bicycles, skateboards
7. Collecting objects
IV Greatest Fears
1. Fear of replacement in school 2. Loss of privacy 3. Fear of death V CENTRAL PERSONS: SCHOOL, NEIGHBORHOOD FRIENDS.
SCHOOL AGE
3-5 lb/yr 1-2 in /yr 10 yo brain growth complete Adult vision Abundant tonsillar and adenoid tissue HR 70 bpm BP 112/60 32 permanent teeth Pubertal onset
SECONDARY SEX CHARACTERISTICS

AGE 9-11 11-12 BOYS Wt gain Sparse pubic hair growth of penis & testis Sebaceous gland sec Pubic hair increases Penis lengthens Linear growth spurt Breast enlargement GIRLS Breast bud Pubic hair along labia Sebaceous gland sec Growth spurt Pubic hair darker Breasts enlarge Axillary hair menarche
12-13
GROWTH AND DEVELOPMENTAL MILESTONES 6 yo skip, jump, tumble, hop, ride bicycle, walk a straight line; 7 yo first molars & lateral incisors; sexual differences seen in play; quiet play - visual acuity is 20/20 - withdrawn & moody; prefer to be alone watching TV or listening to radio 8 yo improved coordination; playing w/ gang important; with 10-11 permanent teeth; prefer playmates of own sex; collects objects ex, stamps
GROWTH AND DEVELOPMENTAL MILESTONES 9 yo all activities done w/ gang, friends - hero worship, lying and stealing may become problems 10 yo more improved coordination - well mannered w/ adults 11 yo active but awkward - mixed sex activities; interest in the opposite sex 12 yo coordination improves - joins organizations
PERSONAL/SOCIAL/PLAY
Competitive play and recreational activities
Hobbies and personal interests Arts and crafts Biking Board games Clubs Collecting items Chess
NUTRITION
Good appetite Food w/ high nutritional value - more calories and nutrients - hungry after school give snacks and make mealtimes enjoyable
DAILY CARE
dressing influenced by peers sleep 8-12 hrs; no naps exercise games, bike riding, walking hygiene 8 yo capable of bathing alone care of teeth 2x yearly visit to the dentist; brush daily safety bicycle, school bus safety, prevention of falls and sports injuries -
CONCERNS
problems w/ articulation disappears 9 yo

School anxiety and phobia Sex education Stealing 7 yo importance of money Violence/terrorism education;reassurance Bullying Recreational drug and alcohol use Likes to stay up late; slumber parties Nightmares common Awakens early in the morning
REACTION TO ILLNESS AND NURSING INTERVENTIONS

Death and disability - Still need comfort Unknown events & procedures - Allow to help w/ care & treatment Loss of ctrl & independence - Give choices Loss of contact w/ peers - Allow visits Disruption of school - Talk about interests
nutrition allow choices dressing ask opinions on bulk of dressing and where to apply tape medicine teach name and action, allow to choose form if possible pain allow expression of pain, explain source and cause stimulation
ADOLESCENT 13-18 yo
ADOLESCENCE 12-18YO
1. PSYCHOSEXUAL STAGE ( FREUD) GENITAL - CHANNELING SEXUALITY INTO RELATIONSHIPS WITH OPPOSITE SEX - PHYSIOLOGICAL MATURATION OF GENITAL/ SEXUAL FUNCTIONS & HORMONAL SYSTEMS LEAD TO INTENSIFICATION OF DRIVES, ESPECIALLY LIBIDINAL ONES -. DEVELOPMENT OF SEXUAL IDENTITY, ABILITY TO LOVE AND WORK
11 PSYCHOSOCIAL STAGE ( ERICKSON) ROLE IDENTITY VS. ROLE CONFUSION

A. To establish sense of identity
- accept changed body image, preoccupied with physical appearance

- establish the kind of person he/she is
- make a career decision

- gain emancipation from parents - hero worship ideology
ADOLESCENT
Girls taller than boys 2-8 in, 15-55 lbs Growth stops 16-17 yo Boys grow 4-12 in and gain 15-65 lbs Growth stops 18-20 yo Heart and lung size increase more slowly HR 70 bpm RR 20 breaths/min BP 120/70
ADOLESCENT
Androgen inc sebaceous gland activity resulting in acne Apocrine glands inc activity 13 yo 2nd molars PUBERTY capable of sexual reproduction Secondary sexual characteristics 32 permanent teeth should be present by age 18-21 yrs

13 yo sports 15 yo - enjoys privacy - stays in room 16 yo - part time job - charitable causes
NUTRITION faddish diet give responsibility for food planning increased calories
DAILY CARE dressing and hygiene care of teeth sleep need more sleep exercise daily
CONCERNS
- Socialization falling in love - Obesity; Diseases HPN - Acne - Body piercing - Fatigue - emotional fatigue - Menstrual irregularities - Sexuality and sexual activity - Poor posture - Stalking educate girls - Substance abuse - Suicide - runaways
ADOLESCENCE
1. Certain areas require special focus: a. Skin: The degree of acne and patients level of concern about acne should be evaluated. Facial and axillary hair development are markers used for assessment of pubertal development. b. Eyes: Myopia may occur during pubertal development. The adolescent may ignore eye problems because of reluctance to wear glasses.
a. Neck: The size of the thyroid gland should be noted. b. Breast: Examination should include determination of the stage of development. Tenderness, erythema, dimpling, asymmetric masses or size, discharge and axillary adenopathy should be noted. Routine breast self-examination should be encouraged. c. Dentition: Evaluating the level of hygiene, discussion of the frequency of dental care, and a review of the development of the third set of molar teeth should be undertaken.
1. d. Heart sounds may be accentuated because of a

thin chest wall, and functional murmurs may become more apparent.
2. e. Male genitourinary tract examination includes determination of the stage of development and evaluation for urethral discharge, scrotal masses, testicular size, inguinal adenopathy, and evidence of inguinal hernia. In a boy with uncircumcised penis, hygiene practices should be reviewed and particular attention should be given to possible lesions below the foreskin. Routine testicular examination should be encouraged.
f. Female genitourinary tract: Examination includes determination of the stage of development as well as an assessment of delayed puberty and abnormal pubertal development. A pelvic examination is indicated in vulvar lesions; vaginal symptoms such as itching unusual discharge or burning; lower abdominal pain; dysmenorrhea of greater than 3 day duration; menstrual dysfunction, & exposure to sexually transmitted infection. Examination is also warranted in cases of maternal exposure to diethylstilbestrol (DES), desire for contraception, and premarital assessment.
2. Pubertal development: a. Female: pubertal changes start between ages 8 and 13 years and changes take place for 3 to 4 years. Breast development commonly precedes pubic hair development. Most girls reached adult height midway through puberty. b. Male: pubertal changes start between age 9 and 13 years and changes take place for about 3 years. Testicular enlargement is usually the first sign of male pubertal development. Most boys reached adult height during the latter half of puberty.
3. The pubertal growth spurt is the third and last rapid growth stage during childhood. The first and second rapid growth stages occur in utero and shortly after birth. a. Adolescents gain up to 25% of adult height and 50% of adult weight gain during this period. b. Individuals vary widely in the onset and rate of pubertal development. It is important to talk about this variability with adolescents, and, where appropriate, reassure them about the normal nature of their pubertal development. c. This growth spurt is associated with muscle development in males and fat deposition in females.
ADOLESCENCE
1. Height, weight, and blood pressure should be taken and the data plotted in the appropriate charts. Blood pressure should be taken in an adult cuff. 2. Vision, hearing, and immunizations should be checked. A tetanus booster should be given within the past 10 years
ADOLESCENCE
1. Laboratory studies: a. A complete blood count is helpful, especially in monitoring changes in hematocrit levels due to increased erythropoietin activity subsequent to changes in the level of circulating androgens. Other screening studies include urinalysis, tuberculin skin test, rubella titers (in females), and mump titers (in males). b. Syphilis testing should be done in adolescents who are sexually active. A culture or test for chlamydial infection and gonorrhea should be done during every pelvic examination.
d. Papanicolaou (Pap) test should be done once a year on all sexually active adolescent females. E. Pregnancy test with a rapid urine immunoenzymatic assay for human chorionic gonadotropin should be performed in sexually active females who are not using any form of contraception or who experience a delayed or abnormal menstrual period.
REACTION TO ILLNESS
AND NURSING INTERVENTION
Main issue body image educate and Allow participation in tx decisions; compassionate understanding Fears loss of control and independence Respect privacy and confidentiality Fears injury and pain - Provide opportunities for self expression Separation from peers and lack of emotional support - Approach w/ caring and understanding, age compatible roommate, Phone at bedside
Nutrition food preferences Dressing final appearance of dressing, and time for changing Medicine choice for injection site, teach name and action Rest time and length of rest periods Hygiene respect modesty, extent of self care Pain allow pain expression, ask for analgesics stimulation
MARAMING SALAMAT PO!
COMMON DISORDERS IN CHILDREN
RESPIRATORY DISORDERS
Upper Respiratory Tract

a. nose b. Para nasal sinuses c. pharynx d. larynx e. Epiglottis f. trachea
Lower Respiratory Tract

a. bronchi b. bronchioles c. lungs
FUNCTION
The major function of the respiratory system is to deliver O2 to arterial blood and remove CO2 from the venous blood known as gas exchange.
Normal Gas Exchange

1. Ventilation- movement of gases from the atmosphere into and out of the lungs. This is accomplished through the mechanical acts of INSPIRATION & EXPIRATION. 2. Diffusion movement of inhaled gases in the alveoli & across the alveolar CAPILLARY MEMBRANE. 3. Perfusion movement of oxygenated blood from the lungs to the tissues
VENTILATION
inspiration- deliver warm and moistened air to the alveoli transport O2 across the alveolar membrane to hgb laden RBC allow CO2 to diffuse from RBC back to alveoli thru expiration, CO2 filled air is discharged to outside
PHYSICAL ASSESSMENT OF RESPIRATORY ILLNESS

A. Cough- a reflex initiated by stimulation of nerve of respiratory tract mucosa by the presence of dust ,chemicals, mucus or inflammation - useful procedure to clear excess mucus paroxysmal cough - refers to series of expiratory cough after deep expiration (seen in whooping cough, aspiration )

B. rate and depth of respiration: tachypnea - 1st indicator of airway obstruction in young children C. Retraction - inward drawing of the chest - causes: airway obstruction, stiff lungs non compliant lung - commonly seen in infants and newborns because intercostal tissue is weaker and less developed
Retraction
Supraclavicular/ Suprasternal retraction suggest upper airway obstruction
intercostal retraction- suggest lower airway obstruction

D. Restlessness - when infant or children have decreased O2 they become anxious and restless E. Cyanosis blue tinged to the skin - become apparent when PO2 is < 40mmhg result in inc. RR

F. Clubbing of fingers: - change in the angle between the fingernail and nail bed because of increase capillary growth in the fingertips G. Adventitious sounds: - extra or abnormal breathing sounds - I/E ratio is reversed (bronchial or tubular breathing)
TYPES OF ADVENTITIOUS SOUNDS

1. Rhonchi - obstruction at the level of nose or pharynx 2. Stridor - obstruction at the level of larynx (best heard when placed in supine position) 3. Wheezing obstruction is in the lower trachea or bronchioles (expiration) 4. Rales when alveoli are filled with fluids, fine crackling sounds

H. Chest diameter: - in children with COPD unable to exhale completely air trapped in lung alveoli (hyperinflation), produce elongated A-P diameter of the chest (pigeon chest)
LABORATORY TEST
A. blood gas analysis - an invasive method for determining the effectiveness of ventilation acid-base status Provide information about oxygenation of the blood as well as O2 saturation of Hgb
CAUSES OF DECREASED O2 SATURATION

1. Patient
with respiratory distress (O2 cannot reach the bloodstream) 2. Hgb is defective cannot carry a full complement of O2 PCO2 measure efficiency of ventilation increase PCO2 - seen in children who are hyperventilating (breathing deeply) - blowing off too much PCO2 decrease PCO2- seen in children who are hypoventilating (breathing very shallow) - cant blow the CO2
LABORATORY TEST
B. Pulse oximeter C. Nasopharyngeal culture D. Respiratory syncytial virus nasal washing - pt is placed in supine position and 1-2 ml of sterile saline is dropped with sterile needle less syringe into one nose, then nose is aspirated using small, sterile bulb syringe E. Sputum analysis: - rare in children younger than school age
DIAGNOSTIC TEST
1. chest X-ray 2. bronchography 3. pulmonary function test - measure the forces of inertia, elasticity, and flow resistance measure by the use of spirometry (device that record the force of air exchange )
THERAPEUTIC TECHNIQUE
Expectorant therapy
1. Coughing 2. Chest physiotherapy - 3 technique are involved 1. postural drainage 2. percussion 3. vibration 3. Mucus clearing devices - by use of flutter device stainless steel ball inside the device move when the child breath out - causing vibration in the lung help loosen the mucus
THERAPY TO IMPROVE OXYGENATION

A. O2 administration: via hood, nasal cannula, and O2 mask B. Pharmacologic therapy C. Incentive spirometry - device that encourage children to inhale deeply to aerate the lung
PHARMACOLOGIC THERAPY
1. antihistamine 2. decongestant causes vasoconstriction leading to shrinkage of mucous membrane 3. Expectorant - help raise mucus 4. Antitussive cough suppressant 4. Bronchodilator - use to open lower airway 5. Metered dose inhaler
THERAPY TO IMPROVE OXYGENATION

D. Breathing technique - blowing ball, blowing out with purse lips E. Tracheostomy - opening in the trachea to create an artificial airway to relieve respiratory obstruction F. Endotracheal intubation
DISORDERS OF THE UPPER RESPIRATORY TRACT

Common Colds Pharyngitis Tonsillitis Epistaxis Sinusitis
DISORDER OF UPPER RESPIRATORY TRACT

Laryngitis Congenital laryngomalacia/ tracheomalacia Croup Epiglottitis Aspiration Bronchial obstruction
ACUTE NASOPHARYNGITIS (CORYZA)

Most frequent infectious disease in children Average of 10-12 colds/ year Incubation period- 2-3 days The COMMON COLDS
ETIOLOGIC AGENT
1. Rhinovirus-most common cause 2. Parainfluenza virus 3. Respiratory syncitial virus 4. Adenovirus 5. Influenza virus 6. Coxsackie virus
SIGNS AND SYMPTOMS

1. nasal congestion 2. watery rhinitis 3. low grade fever 4. mucus membrane is edematous 5. cervical lymph node may be swollen and palpable 6. body malaise
PATHOPHYSIOLOGY
initial pathology is submucosal edema of nasal mucosa followed by shedding of ciliated epithelial cells( 5th day) nasal mucopurulent discharge, then release of interferon (play major role in recovery)
TREATMENT
Common colds is self-limiting supportive care relief of nasal obstruction - use of isotonic saline drops and aspiration antipyretic or analgesic agents antitussive is sometimes used for persistent cough
PHARYNGITIS
it is an inflammation of mucous membrane of the throat and involves the nasopharynx, uvula and soft palate peak incidence - 4 to 7 y either bacteria or viral result of a chronic allergy
VIRAL PHARYNGITIS
- Manifestations are generally mild - Sx include sore throat, fever & general malaise, enlarged lymph nodes, erythema of the pharynx
TREATMENT
1. antipyretic 2. gargle with warm water- (school age) 3. provide liquid foods - (+) difficulty of swallowing Nursing diagnosis: Risk for fluid volume deficit
STREPTOCOCCAL PHARYNGITIS
cause by group A beta-hemolytic streptococcus can lead to cardiac and kidney damage (autoimmune diseases) more severe than viral infection
SIGN AND SYMPTOMS

1. marked erythema of the back of throat and palatine tonsils 2. tonsils are enlarged and white exudates in the tonsillar crypts 3. high grade fever 4. difficulty swallowing
Dx: throat swab and culture
TREATMENT
1. antibiotics- 10 day-course of oral antibiotics (Pen G or Clindamycin) 2. high fluid intake 3. relief of pain
COMPLICATION
1. Rheumatic fever Rheumatic Heart Disease 2. Glomerulonephritis
TONSILLITIS
- term commonly used to refer to infection and inflammation of palatine tonsils palatine tonsils - located on both side of pharynx Adenitis - refers to infection and inflammation of the adenoids ( pharyngeal) tonsils adenoids - located in the nasopharynx Tubal tonsils - located at entrance to the Eustachian tube lingual tonsils - located at base of tongue
SIGNS AND SYMPTOMS

1. 2. 3. 4. 5. 6. 7. 8. difficulty of swallowing (dysphagia) painful swallowing (odynophagia) fever lethargy mouth breathing difficulty hearing (Eustachian tube) halitosis sleep apnea
ETIOLOGY
<3 years old - often viral school age children
TREATMENT
1. antipyretic 2. analgesics 3. Antibiotics ( 10 day course usually Penicillin but may be Erythromycin if allergic to penicillin) is prescribed for bacterial infections to prevent the complication of rheumatic fever. 4. Surgical tonsillectomy with adenoidectomy
Post op Care:
1. Observe for, & report unusual bleeding ( frequent swallowing) 2. Help prevent bleeding by discouraging the child from coughing & clearing the throat.
3. Position the child on the side or the abdomen (prone) to facilitate drainage from the throat
4.Provide appropriate teaching . Instruct the child & parents to:
4. Provide appropriate teaching . Instruct the child & parents to: a. Observe activity restrictions, especially upon the childs return to school.
b. Avoid persons with known infections. c. Avoid acidic & other irritating foods. d. Monitor the child for bleeding, especially immediately postoperatively & 5 to 10 days post op when tissue sloughing occurs.
INDICATIONS for TONSILLECETOMY

1. chronic tonsillitis (not done if inflamed because may spread infection) 2. Recurrent tonsillitis (4-6x/year) 3. Sleep apnea
Nursing diagnosis: Pain related to Surgical Procedure
EPISTAXIS
- NOSEBLEEDING
MANAGEMENT
1. keep pt in upright position with head tilted slightly forward to minimize the amount of blood pressure in nasal vessels, keep blood moving forward not back to nasopharynx 2. apply pressure to the side of the nose with your fingers, may have ice compress
3. Ask the child to stop crying because crying increases pressure in the blood vessels of the head and prolonged bleeding 4. control of bleeding, can give epinephrine (1:1000) to constrict blood vessels 5. can put nasal packing for continuous pressure on the site of the ruptured blood vessel
SINUSITIS
rare in children younger than 6 years of age frontal sinuses and sphenoidal (6 - 8y) occurs as secondary infection in older children
ETIOLOGY
Streptococcal Staphylococcal H. Influenza type B
SIGNS AND SYMPTOMS

1. fever 2. purulent nasal discharge 3. headache 4. tenderness over the affected sinus
TREATMENT
1. antipyretic 2. analgesic 3. antibiotic for specific infection 4. nasal spray- Oxymetazoline HCl shrinks the edematous mucus membrane and allow infected material to drain 5. warm compress
COMPLICATION
1. otitis media 2. osteomyelitis (involving facial bone)
Laryngitis
- inflammation of larynx - occurs as complication of pharyngitis or from excessive use of voice - s/sx: voice hoarseness
MANAGEMENT
1. sips of fluid to offer relief from annoying tickling sensation 2. rest the voice for at least 24 hrs
CROUP (LTB) Acute Laryngotracheobronchitis

- Inflammation & narrowing of the larynx, trachea, and major bronchi. Most common form of croup & usually affects children younger than 5 years old. - one of the most frightening diseases of early childhood for both parents and children. Tends to occur at night & recur with respiratory tract infections. - common cause is viral infection usually parainfluenza virus, influenza virus.
signs and symptoms

1.Gradual onset from upper respiratory tract infection which progresses to signs of distress. 2. Hoarseness 3. low grade fever 4. barking cough at night 5. inspiratory stridor 6. Retractions 7. Severe respiratory distress 8. Restlessness& Irritability 9. Wheezing, rales, rhonchi, & localized areas of diminished breath sounds
Assess for airway obstruction by evaluating respiratory status. Note color, respiratory effort, evidence of fatigue, & VS. Provide warm, moist environment-give o2 to alleviate hypoxia Keep emergency equipment ( tracheostomy & intubation tray) near the bedside. Give corticosteroids & epinephrine (nebulizer) - reduce inflammation and bronchodilation Intravenous hydration Nursing Dx: Ineffective Airway Clearance related to
MANAGEMENT
Health Teachings 1. When the child awakens with a barklike cough, tell the parents to place the child in the bathroom & to run hot water to produce steam.
2. Instruct the parents to stay in the bathroom with the child to prevent accidental injury.
Epiglotitis
>an acute , severe inflammation of the epiglottis.( flap of tissue that covers the opening to larynx to keep out food and fluids) > it is considered an emergency because the swollen epiglottis is not allowing the airway to open. > this emergency situation occurs most commonly in children between 3 and 6 years of age.
Causes:
1. H. Influenza type B 2. pneumococci, streptococci - most common cause 3. echovirus 4. respiratory syncitial virus
Sign and symptoms:

1. begins as mild URTI 2. restlessness & anxiety 3. hyperextension of the neck, drooling, & severe sore throat with refusal to drink 4 rapid, thready pulse 5. characteristic tripod position: child sits in upright position, with chin thrust out & tongue protruding. 6. sudden onset of high fever, lethargy, & dyspnea & dysphygia 7. Red & inflamed throat with large , cherry red,
edematous epiglottis.
NURSE ALERT!!! Never illicit gag reflex-may cause complete obstruction

Laboratory findings: Leukocytosis ( 20,000-30,000 mm3) with high proportion of neutrophils
MANAGEMENT:
1. Closely monitor respiratory status to ensure patent airway. If a child presents with sx of epiglottitis, ensure that appropriate personnel perform a throat examination & that emergency equipment is at hand.
2. Prepare for emergency hospitalization = after dx is confirmed, an endotracheal intubation or tracheostomy is performed to maintain a patent airway. Swelling usually decreases after 24 hours & the child is extubated by the third day.
3. After the child is intubated, monitor closely &
maintain a patent airway by suctioning as needed & providing oxygen therapy as prescribed. 4. Administer prescribed medications ( antibiotics, anti-inflammatories.) 5. Recommend that all children receive H. Influenzae type B ( Hib) conjugate vaccine beginning at 2 months of age, because H.Influenzae is the most common cause of epiglottitis.
6. Provide warm, moist environment

7. O2 therapy 8. Intravenous therapy
Foreign Body Aspiration

> inhalation of foreign objects into the upper airway > common in infant and toddlers > the severity of foreign body aspiration is determined by the location & extent of obstruction & the type of object aspirated. Objects such as PEANUTS, & popcorn not only swell when wet, increasing obstruction but are coated with oil, which adds to the risk of development of lipid pneumonia.
> Common aspirates besides peanuts & popcorn, include hotdogs, candy, grapes, cookies, carrots, coins, bullets, nails, & small toy parts. > The right bronchus is usually the site of bronchial obstruction because it is shorter &
straighter than the left bronchus.
s/sx:
1. Initially, foreign body aspiration causes choking & coughing. 2. Universal Distress signal
Management: 1. Assess s/sx of choking 2. Perform emergency measures a. Heimlich Maneuver (subdiaphragmatic abdominal thrusts) for children older than 1 yr ( stand behind the child and place a fist just under the child diaphragm). b. Back blows & chest thrusts for children younger than 1 year of age. 3. Encourage prevention of aspiration: a. do not allow small children access to small objects.
b. do not use adhesive bandage on small children.

c. spread peanut butter on bread, do not allow the child to eat it from a spoon because it can obstruct the airways & stick to the mucus membranes.
*if the child is lying on his back at the time of aspiration, stand at the head of the table or bed, place hand under child diaphragm and exert inward and upward thrust* * for infants, use back thrust to dislodge an aspirated object. Turn the infant prone over your arm and administer up to 5 quick back blows forcefully bet. the infants shoulder blades using the heel of the hands*
Bronchial obstruction
> obstruction on the bronchus (commonly on the right) > common in child younger than school-age
Sign and symptoms: 1. violent cough 2. hemoptysis 3. fever
4. purulent sputum 5. localized wheezing 6. dyspneic Laboratory findings: 1. radioopaque finding on chest Xray 2. leukocytosis Complication: 1. pneumothorax 2. atelectasis 3. lipid pneumonia
Management: 1. bronchoscopy removal of foreign body 2. close observation after bronchoscopy, frequent V/S monitoring 3. maintain on NPO after procedure, assess for gag reflex
Influenza
> inflammation and infection of the major airway > causes by orthomyxoviruses influenza types A, B, C Signs and symptoms: 1. cough 2. fever 3. fatique 4. myalgia/arthralgia 5. sore throat 6. GIT symptoms-diarrhea, vomiting
incubation period: 1-5 days
Management: 1. antipyretic 2. antiviral drugs( tamiflu) 3. influenza vaccine( yearly given) Complication: 1. bronchitis 2. pneumonia
Bronchitis
> inflammation of major bronchi and trachea > affect preschool and school age Sign and symptoms: 1. fever 2. cough 3. nasal congestion
causes:1. influenza virus 2. adenovirus 3. mycoplasma pneumoniae Course of disease: 1-2 weeks Sign and symptoms: 1. fever 2. dry hacking cough 3. on auscultation can hear rhonchi and rales 4. On chest x-ray finding-diffused alveolar hyperinflation and some marking on hilus of lungs
Management:-1. aim in relieving the

respiratory symptoms 2. antipyretic 3. adequate hydration 4. antibiotic therapy 5. cough syrup supress coughing
Viral
Etio
Bronchitis
Bacterial
Rhinovirus,Influenza, RSV, Parainfluenza adenovirus, paramyxovirus Rhinitis, cough, malaise, chills, mild fever, sore throat Clinical Xray normal
S. pneumoniae, S. aureus, H. Influenzae, M. Catarrhalis higher fever and a more prod cough Elev c-reactive protein Up to 2 weeks
amoxicillin tetracycline, erythromycin
S/sx
Dx
Course Mild & self-limiting Rx supportive
Bronchiolitis
Viral infection with inflammation & swelling of bronchioles w/ mucous in airways. Usually follows an upper respiratory tract infection. RSV, parainfluenza, Adenovirus, influenza Rare in children older than 2 yo, usually occurs between 2 months & 12 months; peak 6 mos old transmitted via droplets
Pathophx: mild upper respiratory infection > edema of airway and accumulation of mucus > airway narrowing > hypoxemia / hypercapnia S/sx:wheezing, tachypnea, wet hoarse cough, fever, poor appetite, difficulty sucking, restless sleep, retractions
Dx: cxr, pulse oximetry, throat culture
Nsg Dx: Impaired Gas Exchange r/t bronchiolar obstruction, atelectasis and hyperinflation Parental anxiety r/t respiratory distress in child Management nebulization hydration O2 positioning TSB Monitor VS esp RR support
Inflammation of lung parenchyma ( bronchioles, alveolar ducts & sacs, alveoli) Bacterial and atypical pathogens: NB GBS, Gr (-) bacilli, chlamydia Children S. pneumoniae, H. Influenzae, M. catarrhalis Adolescents S and M Pneumoniae, M. catarrhalis Hospital acquired Pseudomonas, Klebsiella, E. Coli, Enterobacter sp Viral Pneumonia - RSV, Parainfluenza,
Pneumonia
Pathophx: aspiration/hematogenous/inhalation alveoli inflammation hypoxemia S/sx: = high fever, chills,non productive to productive cough with whitish sputum, irritability, poor feeding, restlessness, headache, GI sx, tachypnea, use of accessory muscles, decreased BS, crackles, dullness on percussion, chest retractions, N & V, diarrhea, anorexia
Dx: cxr may reveal diffused or patchy infiltrates; blood and sputum c/s may reveal the causative organism; cbc may reveal elevated wbc count
Nsg Dx: Ineffective breathing pattern r/t physiologic effects of Pneumonia - O2, monitor VS, CPT, encourage coughing and deep breathing
Risk for deficient fluid volume r/t diminished oral intake and increased insensible fluid losses sec to diaphoresis, dyspnea and fever - weigh and monitor daily, sips of fluid,
Activity Intolerance r/t effects of Pneumonia and Tachypnea - rest periods, O2, small frequent feedings, gradual increase in activity, support and contact with family
MX:
1. Assess for respiratory distress
2. Administer prescribed medications

- antibiotics for bacterial pneumonia ( Penicillin)
3. Promote adequate oxygenation & a normal breathing pattern.

4. Recommend the pneumococcal vaccine for children 2 yo & older 5. Provide child & family teaching.
Asthma
> chronic, reversible , obstructive airway disease, characterized by wheezing. It is caused by smooth muscle spasm w/ hypertrophy of the bronchial tubes, or swelling of the bronchial mucosa, after exposure to various stimuli. Hypersecretion of mucus Most common chronic disease in childhood. Most children experience their first sx by 5yo exercise, nocturnal occurrence, seasonal, hx of allergy, stress
Etiology:
1. Commonly results from hyperresponsiveness of the trachea & bronchi to irritants. Common irritants include: 1. Allergens = dust mites, molds, animal danders 2. Viral infections 3. Irritants = air pollution, smoke, perfumes, laundry detergents 4. Certain foods ( food additives, sea foods etc.)
5. Rapid changes in environmental factors

6. Exercise 7. Psychological stress
Pathophysiology:
* Release of inflammatory mediators from bronchial mast cells, epithelial cells, & macrophages >>> activation of inflammatory cells >>>bronchial spasm >>> inflammation >>> edema of the mucosa >>> production of thick mucus>>> inc. airway resistance >>>closure of airways >>>dyspnea & wheezing
Clinical Assessment of Asthma

MILD MOD SEVERE
breathless talks in Alertness

RR accessory wheeze pulse
walking sentences may be agitated inc (-) audible

<100
talking phrases usually agitated inc (+) audible

100-120
at rest words agitated

>30 (+) audible w/o steth >120
Asthma
Ndx: Ineffective breathing pattern r/t bronchospasm, edema and accumulation of mucus Fear r/t sudden onset of Asthma attack Activity intolerance r/t imbalance between O2 supply and demand Health seeking behaviors r/t prevention and treatment for asthma attack
Management B2 agonists ( Bronchodilators), Theophylline, Steroids( anti inflammatories), Cromolyn Na, O2 Orthopneic position Monitor VS, hydration Adequate nutrition and non allergenic diet Environmental modification Health education
Status Asthmaticus
Progression of acute, severe, prolonged asthma attack unresponsive to therapy Preceding upper respiratory tract infection, allergen, cigarette smoke HR and RR inc, decrease breath sounds, cyanosis Mx: B2 agonist and IV steroid, O2, coughing, fluids, monitor I and O
Sudden Infant Death Syndrome

>sudden, unexpected death of any infant for whom a postmortem exam fails to determine the cause of death > Death occurs during sleep >most common cause of death (1 mo-1 year old, peaks 2-4 mos) Preterm / infants with apneic episodes, with prenatal drug exposure, siblings of infants who died of SIDS, exposed to smoking, infants of adolescent mothers, infants of closely spaced pregnancies, underweight the victim seems healthy sleeping on prone position Theories of causation: abnormalities in the brain and metabolic disorder
Maternal risk factors - cigarette smoking during pregnancy, maternal age < 20 yo, poor prenatal care, low weight gain, anemia, use of illegal drugs and alcohol, low socioeconomic status Newborn risk factors cyanosis, tachycardia, respiratory distress, irritability, hypothermia, poor feeding
Nsg Dx: Dysfunctional grieving r/t loss of a child

Management assist psychologically - intense grief and guilt for parents
Tuberculosis High incidence in infancy and adolescence Primary Complex based on xray; first encounter of a child w/ TB; Ghons tubercle w/ lymphangitis and regional (hilar) lymphadenopathy Primary Pulmonary TB clinical TB
d/t Mycobacterium Tuberculosis

Dx: exposure, s/sx (2 or more), PPD, cxr
Classification of TB
Class I TB exposure (+) exposure Class II TB infection (+) exposure and PPD Class III TB disease active TB or 3 or more of criteria - Exposure, s/sx, (+) tuberculin test, xray, sputum exam, culture Class IV TB inactive (+/-) hx of prev TB, (+/-) hx of prev hx of chemotherapy, (+)
S/sx: fever, wt loss, cough, anorexia, night sweats, painless lymphadenopathy Tx: SCC Intensive INH, Rifampicin, PZA x 2 mos Maintenance INH, Rifampicin x 4 mos
Respiratory Distress Syndrome

Preterm, infants of diabetic mothers, C/S, hx of asphyxia S/sx: inc RR, chest retractions, nasal flaring,expiratory grunt, cyanosis, HPN, hypothermia Dx: ABG, Xray Mgmt: surfactant replacement, O2, ventilation, supportive care
Decreased surfactant lungs collapse Inc pulmonary resistance
blood shunts through F.O. and D.A.

poor lung perfusion and gas exchange further decrease in surfactant hypoxia
Mastery Exam
1. A teenager with chronic asthma asks the nurse How come I make so much noise when I breathe? The nurses best reply is: a. It is the sound of air passing through fluid in your alveoli
b. It is the sound of air passing through fluid in your bronchus.

c. It is the sound of air being pushed through narrowed bronchi on expiration. d. It is the sound of air being pushed past a narrowed larynx on inspiration.
2. Chest physiotherapy is done for the treatment of chronic
asthma. When should the nurse administer the childs bronchodilator in conjunction with postural drainage? a. One hour before postural drainage b. During postural drainage c. One hour after postural drainage
d. Between postural drainage treatments

3.Which school related activity might the school nurse prohibit for a child with asthma? a. Swim team b. Pet show & tell c. The Band d. Art class
4. An infant has laryngotracheobronchitis. On assessment, which one should the nurse anticipate?
a. Barking cough & inspiratory stridor
b. Low grade fever

c. Cherry red epiglottis d. Drooling 5. When performing postural drainage, how much time should the nurse generally plan to allow for this procedure? a. 10-15 mins b. 20-30 minutes c. 30-45 minutes d. one hour
6.Immunization of children with the H Influenza B ( Hib) vaccine decreases the incidence of which of the following conditions? a. Laryngotracheobronchitis b. Epiglottitis c. Pneumonia d. Bronchiolitis
7. Which of the following infants is LEAST likely to develop SIDS?
a. An infant born premature

b. A sibling of an infant who died premature
c. An infant with prenatal drug exposure

d. An infant who sleeps on his back
8. Which of the following respiratory conditions is always considered a medical emergency?

a. Laryngotracheobronchitis (LTB) c. Asthma
b. Epiglottitis
d. Otitis media
9. An acute , severe, prolonged asthmatic attack that is unresponsive to usual treatment is referred to as which of the ff.? a. Intrinsic asthma b. Reactive airway disease c. Status asthmaticus d. Extrinsic asthma
10. After the child finally awakens after tonsillectomy, the mother asks the nurse for something for her child to eat or drink. Which of the ff would be best for the child initially? a. Chocolate milk
b. Red kool aid
c. a yellow popsicle
d. vanilla pudding
11. After tonsillectomy, in what position should the child be put on to prevent aspiration?
a. Trendelenburg b. Supine c. Prone d. Lithotomy
12. The nurse concludes that the parents of a post tonsillectomy pt. understand the discharge instructions when they state that medical attention should be sought for which of the following occurrences? a. Low grade fever
b. Frequent swallowing
c. Slight ear pain

d. Objectionable mouth odor
Cardiovascular Disorders
Fetal Circulation
placenta provides the exchange of gas and nutrients four shunts in fetal circulation:
Placenta Ductus venosus Foramen Ovale Ductus arteriosus
Congenital Heart Defects

-CHD are structural defects of the heart, great vessels, or both that are present at birth. -Children with CHD are more likely to have associated defects such as tracheoesophageal fistula. - CHD is second only to prematurity as a cause of death in the first year of life.
1.Acyanotic Heart Disease L R shunt high pressure to low pressure oxygenated to unoxygenated blood
2. Cyanotic Heart Disease R L shunt
4 Classifications of Congenital Heart Defects: 1. Defects with increased pulmonary blood flow: a. Atrial Septal Defect (ASD) b. Ventricular Septal Defect (VSD) c. Patent Ductus Arteriosus (PDA) d. Atrioventricular Canal Defect ( AV ) 2. Defects with Decreased pulmonary blood flow: a. Tetralogy of Fallot (TOF) b. Tricuspid Atresia ( TA)
3. Obstructive Defects: a. Coarctation of the Aorta ( COA) b. Aortic stenosis ( AS) c. Pulmonic stenosis ( PS) 4. Mixed Defects: a. Transposition of the Great Vessels ( TOGV) b. Truncus Arteriosus c. Hypoplastic left Heart Syndrome ( HLHS)
Factors associated with Increased incidence of CHD:

1. Fetal & Maternal Infection during the first trimester, especially rubella 2. Maternal alcoholism, drugs with teratogenic effects 3. Maternal age over 40 years 4. Maternal dietary deficiencies 5. Maternal insulin dependent induced diabetes
6. Sibling, parent with CHD

7. Chromosomal abnormality such as Down Syndrome.
ACYANOTIC HEART DISEASE

1. Atrial Septal Defect
Opening between 2 atria Atrial septal tissue does not fuse properly during embryonic development S/sx: cyanosis(CHF), dyspnea on exertion, fatigue, failure to thrive, split S2 Mx: Abx, surgery 1-3 yo Cx: endocarditis, heart failure Postop: monitor arrhythmia, administer antibiotics
Pathophysio:
Pressure is higher in the left atrium than the right >>>blood shunts from the left to the right >>>RV & pulmonary artery enlarge ( they are handling more blood). Notes:
>Most infants asymptomatic until early childhood; many defects close spontaneously by 5 yo.
DX: Echocardiography reveals enlarged right side of the heart & inc. pulmonary circulation. MX: defects are repaired in girls due to possibility of blood clots during child bearing years.
2. Ventricular Septal Defect Opening in ventricular

septum, most common S/sx: respi infections, failure to thrive, dyspnea, fatigue, pansystolic murmur Mx:close spontaneously otherwise surgery <2 yo Cx: pulmonary HPN, endocarditis, heart failure Postop: monitor arrhythmia, administer antibiotics
3. Patent Ductus Arteriosus

Aorta to pulmonary artery Fetal ductus arteriosus fails to close after birth Common in prematurity, high altitude, maternal rubella females S/sx:clubbing, dyspnea, machine like murmur (2nd3rd ICS) Cx:heart failure, endocarditis, pulmonary artery stasis/HPN Mx: Indomethacin, surgery
4. Atrioventricular Canal Defect

-Results from the incomplete fusion of endocardial cushions. -Consists of a low atrial septal defect that is continuous with a ventricular septal defect & clefts of the mitral & tricuspid valves, creating a large central AV valve that allows blood to flow between all heart chambers.
S/SX:
1.Children usually have severe to moderate CHF

2. Child may have a mild cyanosis that increases with crying. 3. A characteristic murmur exists. DX: Echocardiography confirms the dx MX: 1. Repair involves surgical patch closure of septal defects, possible mitral valve replacement & reconstruction of AV valve tissue. 2. Palliative repair for sxmatic infants
CYANOTIC HEART DISEASE
1. Tetralogy of Fallot Localized narrowing of the aorta. TOF consists of 4 major anomalies: VSD Right Ventricular Hypertrophy Pulmonic Stenosis Aorta overriding the VSD
Pathophysio:
PS impedes flow of blood to lungs>>>inc pressure in the rt ventricle ( causes hypertrophy)>>>forces deoxygenated blood thru the septal defect to the left ventricle >>>overriding aorta receives blood from both rt & left ventricles.
S/sx:
1.Acute episodes of cyanosis ( Tet spells). Tet spells are characterized by irritability, pallor & blackouts or convulsions. Cyanosis occuring at rest as PS worsens clubbing, exertional dyspnea, fainting, fatigue slowness due to hypoxia Squatting,( a characteristic posture of older children that serves to decrease the return of poorly oxygenated venous blood from the lower extremities & to increase systemic vascular resistance, which increases pulmonary blood flow & eases respiratory effort.) Systolic murmur
DX: Echocardiography shows enlarged rt chamber & dec in pulmonary artery size > Cardiac catheterization & Angiography allows definitive evaluation Cx: thromboembolism,CVA Mx: 1. Surgical repair when infant is 1 yo Blalock Taussig: anastomose SC and pulmonary artery - avoid BP and venipuncture in right arm 3. O2, knee chest position
2. Tricuspid Atresia
- Tricuspid valve fails to develop -Without the tricuspid valve, there is no communication between the right atrium & the right ventricle -Involves complete mixing of oxygenated & unoxygenated blood on the left side of the heart resulting in pulmonary obstruction. Blood flows thru a patent foramen ovale to the left side of the heart & thru the VSD, to the right ventricle & to the lungs.
S/S:
1. Cyanosis in NB 2. Chronic hypoxia, clubbing in older children DX: Echocardiography
MX:
1. Palliative procedures such as pulmonary to systemic artery anastomosis ( for children w/ CHF) 2. Corrective surgery may be performed using the hemi-Fontan procedure.
Mixed Defects
1. Transposition of the Great Vessels

Pulmonary artery leaves the L ventricle, Aorta exits the right ventricle. No communication bet systemic & pulmonary circulations This defect results in 2 separate circulatory patterns. Rt heart systemic circulation Left heart pulmonary circulation.
** To sustain life, the child must have an associated defect ( VSD, ASD, PDA)- which permits oxygenated blood into the systemic circulation, but cause increased workload. S/SX: 1. In infants w/ no associated defects, severe respiratory depression & cyanosis 2. In infants w/associated defects, less cyanosis but may have sx of CHF Mx: PGE for PDA, Balloon catheter to create ASD, Arterial switch procedure- surgical procedure of choice done at 1 wk-3 mos
Total Anomalous Pulmonary Venous Return

Pulmonary v. drain to SVC or R atrium PDA or foramen ovale essential S/sx:cyanosis, fatigue CX: R heart failure Mx:PGE, surgery
Obstructive Defects
1. Coarctation of the Aorta

males Constriction of aorta S/sx: asymptomatic HPN, irritability, headache, epistaxis, dyspnea, claudication, higher BP in upper extremities, dec femoral and distal pulses,systolic murmur Cx:chronic HPN Mx:surgery 2 yo Postop: monitor abdominal pain, antihypertensives
Ndx: Ineffective cardiopulmonary and peripheral tissue perfusion related to impaired cardiac function Proper positioning to maintain respiration Conserve energy to promote rest Quiet activities and stimulation Anticipate needs Administer prescribed drugs
Activity intolerance r/t effects of congenital heart defect and dyspnea Rest periods Adequate nutrition small frequent feedings iron supplementation
2. Aortic Stenosis
-Involves an obstruction of the ventricular outflow of the blood
S/SX: faint pulse, hypotension, tachycardia, poor feeding, exercise intolerance, chest pains
DX; ECG, Echocardiography reveals left ventricular hypertrophy. MX:
-Surgical aortic valvutomy or prosthetic valve replacement.

- Balloon Angioplasty to dilate the narrow valve.
3.Pulmonic Stenosis
- Obstruction of blood flow from the right ventricle
Before puberty, peaks 4 yo S/sx:spiking fever x 5 days, bilateral conjunctivitis, reddened pharynx, dry lips, strawberry tongue, cervical lymphadenopathy, peripheral edema, erythema and desquammation, truncal rash, arthritis Patho: Respi infection immune complex systemic vasculitis aneurysm and MI Dx:clinical Mx: Salicylates and Immunoglobulins
Kawasaki Disease/ Mucocutaneous Lymph Node Syndrome
Risk for ineffective peripheral tissue perfusion related to inflammation of blood vessels - Observe for chest pain, color changes, vomiting Pain r/t swelling of lymph nodes and inflammation of joints - Comfort measures, administer pain medications
Other Measures: Protect edematous areas Record intake and output Offer soft food Administer prescribed medication
Rheumatic Fever
Autoimmune Grp A Beta hemolytic strep 6-15 yo, peaks 8 yo 1-3 wks after untreated infection Dx: 5 major criteria polyarthritis, carditis, subcutaneous nodules, erythema marginatum, sydenhams chorea minor fever, polyarthralgia, hx of RF, inc ESR, antecedent strep infection
J.
N. E. S.
S/SX:
1. Carditis sx include tachycardia, cardiomegaly, murmur, muffled heart sounds, precordial pain.
2. Polyarthritis consists of swollen, hot, painful joints

3. Syndenham Chorea or St. Vitus dance demonstrated by sudden,aimless, irregular movements pf the extremities, involuntary facial grimaces, speech disturbances. 4. Erythema marginatum clear centered,transitory, nonpruritic macules w/ defined borders. 5. Subcutaneous nodules non tender lesions
MX:
1. Child may receive monthly injections of benzathine penicillin, 2 daily oral doses of penicillin ( to prevent recurrent strptococcal infections
Cx: mitral valve insufficiency and myocarditis To diagnose, either 2 major or 1 major and 2 minor present
Mgmt: salicylate, penicillin

Ndx: Risk for noncompliance r/t knowledge deficit about importance of long term therapy - prevent initial and recurrent attacks Decreased cardiac output r/t disease process - bed rest, comfort and appropriate
Nursing Care Monitor vital signs Provide adequate nutrition Promote safety to prevent chorea related injuries
MASTERY EXAM
1. Which of the following disorders leads to cyanosis from deoxygenated blood entering the systematic arterial circulation?
a. Patent ductus arteriosus

c. Coarctation of tha aorta
b. tetralogy of pallot
c. aortic stenosis
2. While assessing a child with coarctation of the aorta, the nurse would expect to find which of the following? a. Absent or diminished femoral pulses b. cyanotic (tet) episodes c. Squatting posture d. severe cyanosis at birth
3. When developing a teaching plan for the parents of a child with pulmonic stenosis, the nurse would keep in mind that this disorder involves which of the following? a. Return of the blood to the heart without entry into the left atrium b. Obstruction of blood flow from the right ventricle c. Obstruction of blood from the left ventricle d. A single vessel arising from both ventricles
4. Which of the following represents an effective nursing intervention to reduce cardiac demands and decrease cardiac workload?
a. Scheduling care to provide for uninterrupted rest periods b. Developing an implementing a consistent plan of care c. Feeding the infant over long periods of time
d. Allowing the infant to have her way to avoid conflict
5. Which of the following are defects associated tetralogy of fallot? a. Coarctation of the aorta, aortic valve stenosios, mitral valve stenosis and patent ductus arteriosus b. Ventricular septal defect, overriding aorta, pulmonic stenosis, and right ventricular hypertrophy
c. Tricuspid valve atresia, artial septal defect, ventricular septal defect and hypoplastic right ventricle
d. Aorta exits from the right ventricle, pulmonary artery exits from the left ventricle, and two noncommunicating circulations.
6. Which of the following instructions would the nurse include in a teaching plan that focuses on initial prevention of rheumatic fever (RF)? a. Using corticosteroids to reduce inflammation b. Treating streptococcal throat infections with antibiotics c. Providing antibiotics before dental work d. Giving penicillin to patients with RF
7. In assessing a child with kawasakis disease, the nurse should recognize that the childhood communicable disease that poses the greatest danger for this child is:
a. Measles b. Mumps c. Rubella
d. chickenpox
8. Which nursing intervention is most effective in preventing rheumatic fever in children? a. Refer children with sore throats for a throat culture b. Include an ECG in the childs yearly physical examination
c. Assess the child for a change in the quality of the pulse

d. Assess the childs blood pressure 9. A common goal for children with cardiac disease is to reduce the workload of the heart to conserve energy. Attainment of this goal can best be evaluated by: a. Vital signs that are within normal limits
b. Intake that equals output

c. Weight stabilization d. Pink nailbeds and warm extremities
10. Which is most beneficial in achieving the goal of preventing infection in a child with cardiac disease? a. Give the child extra immunizations b. Keep the child on prophylactic antibiotics
c. Keep the child away from others who are ill

d. Place the child in protective isolation 11. A 3-year-old child undergoes a diagnostic cardiac catheterization. On conclusion on this procedure, the nurses first action should be to assess: a. The IV site for patency
b. Peripheral pulses and observe incision site

c. Body temperature d. Pain status
12. The nurse is instructing the parents of a two-month-old infant with congenital disease how to administer digoxin to the infant at home. Which statement reflects a lack of knowledge on the nurses part? a. In case the baby spits up, give the digoxin 1 hour before or 2 hours after feeding to avoid a dose of being lost b. do not change the amount or timing of the dose without specific instructions from your pediatrician
c. always use the same measuring device each time so the dose given remains consistent
d. take the apical pulse before giving the drug and do not give it if the pulse is below 80 beats per minute
13. A newborn with patent ductus arteriosus is scheduled to receive indomethacin. The nurse administers this medication to: a. Open the ductus arteriosus b. Close the ductus arteriosus
c. Enlarge the ductus arteriosus

d. Maintain the present size of the ductus arteriosus 14. Which congenital heart defect necessitates that the nurse take upper and lower extremity blood pressure readings? a. Coarctation of the aorta b. Tetralogy of fallot
c. Ventricular septal defect

d. Patent ductus arteriosus
15. An infant with tetralogy of fallot becomes hypoxic following a prolonged bout of crying. The nurses first action should be to: a. Administer oxygen b. Administer morphine
c. Place the infant in knee-chest position

d. Comfort the infant 16. The parents of an infant with tetralogy of fallot ask the nurse why their infants fingers and toes appear clubbed. The nurse should inform the parents that clubbing is: a. Part of the anomaly
b. Occurs because the infants extremities are in a dependent position

c. The result of extra capillaries forming in the tips of the extremities
17. Tetralogy of fallot is the most frequently occuring type of congenital heart disease in children. The four anomalies associated with this defect are:
a. Artial septal defect, pulmonary stenosis, left ventricular hypertrophy, overriding aorta b. Ventricular septal defect, aortic stenosis, mitral stenosis, right sided aorta
c. Tricuspid stenosis, right ventricular hypertrophy, pulmonary stenosis, artial septal defect
d. Ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, overriding aorta
18. You see a school-age child in an ambulatory setting because of rheumatic fever. Which of the following would you expect to find revealed by the health history? a. Knee pain, abdominal rash, subcutaneous nodules b. An elevated temperature, back pain, loss of hair 19. Coarctation of the aorta demonstrates few symptoms in newborns. Which of the following is an important assessment to make on all newborns to reveal this condition? a. Observing for excessive crying b. Assessing for presence of femoral pulses c. Recording an upper extremity blood pressure d. Auscultating for a cardiac murmur
Gastrointestinal Disorders
Cleft Lip and Palate

failure of fusion of maxillary and median nasal process hereditary unilateral/bilateral males Mx: surgery - Cheiloplasty Rule of 10s-10 wks, 10 lbs, Hgb 10 gm
Cleft Palate
midline opening of palate usually w/ Cleft lip Female surgery 6-18 mos - allow anatomic changes <1 yo ie formation of palatine arch and tooth buds
Ndx: Risk for imbalanced nutrition, less than body requirements r/t feeding problems Risk for ineffective airway clearance r/t oral surgery Risk for infection during post op period
Nursing mx: Adequate nutrition; sips of fluid btw feeding in semiupright position; use rubber tipped syringe Direct the formula away from the cleft & toward the side & back of the mouth to prevent aspiration. Provide special nipples or feeding devices ( ex. Soft pliable bottle with soft nipple with enlarged opening) Feed the infant slowly & burp frequently to prevent excessive swallowing of air & regurgitation. Prevent ear and upper respiratory tract infection Address body image and speech concerns Reassurance to parents
Pre-op:
1. Surgical correction of the cleft lip usually occurs at 1-3 mos. Repair of the cleft palate is usually performed between 6-18 mos. Repair of the cleft palate may require several stages os surgery as the child grows.
2. Early correction of the CL enables development ofmore normal speech pattern

3. Delayed closure or large defects may require the use of orthodontic appliances ** Provide mouth care to prevent infection**
Nursing Care
Postop monitor respiratory distress d/t edema, hemorrhage Use mist tent , if prescribed, to minimize edema, liquefy secretions & minimize distress. Suction mucus and blood gently dropper feeding 1st 3 weeks; regular feeding after Use elbow restraints to maintain suture line integrity. Remove them every 2 hours Position side lying or back in cleft lip to avoid injury to the operative side; prone in cleft palate to facilitate drainage.
Tracheoesophageal Fistula
> Communication of the esophagus and trachea > maternal hydramnios and prematurity S/sx:coughing, choking, cyanosis, dyspnea, excessive secretion, abdominal distention Dx: Ba swallow
Ndx: Risk for imbalanced nutrition, less than body requirements r/t inability for oral intake Risk for infection r/t aspiration or seepage of stomach contents into lungs Risk for impaired skin integrity r/t gastrostomy tube insertion site
Nursing care
Preop Suction regularly Elevate the head Gastrostomy feeding hydration O2 Postop 1. Observe for respiratory distress 2. Proper positioning avoid hyperextension of neck 3. Continue suction 4. Prevent wound infection
Hirschprungs Disease
Hirschsprung disease ( Aganglionic Megacolon) is a congenital anomaly characterized by absence of nerves( innervation) to a section of the intestines ( usually the rectosigmoid)
4x more common in boys ( esp. with Downs syndrome)

It can be acute & life threatening or chronic familial, congenital
> Results from failure of the craniocaudal migration of ganglion nerve cell precursors along the GI tract bet the 5th & 12th weeks of gestation.
No peristalsis in the affected area.

Pathophysiology: 1. Absence of ganglion cells in one segment of the colon >>> lack of innervation >>> absence of propulsive movements >>> accumulation of intestinal contents & distention of the bowel proximal to the defect >>> enterocolitis ( inflammation of the small bowel & colon leading cause of death in children with hirschsprung)
S/SX:
1. Newborns failure to pass meconium, reluctance to ingest fluids, abdominal distention, bile stained emesis. 2. Infants failure to thrive, constipation, abdominal distention, vomiting& episodic diarrhea 3. Older children anorexia, chronic constipation, foul smelling & ribbon like stools, abdominal distention, visible peristalsis, palpable fecal
mass, anemia
Rectal exam reveals a rectum empty of stool, a tight anal sphincter, & stool leakage.
Ominous sign signifying enterocolitis include explosive, bloody diarrhea, fever, & severe prostration. DX : > Barium enema reveals megacolon > Rectal biopsy reveals absence of ganglionic cells which confirms the diagnosis.
Ndx: Constipation r/t reduced bowel function Imbalanced nutrition, less than body requirements r/t reduced bowel function
Nursing Care Preop 1. Daily cleansing enemas w/ 0.9% NaCl *Tap/hypotonic water will cause cardiac congestion or cerebral edema 2. Manual dilatation of the anus 2. Minimal residue diet w/ vitamin supplementation 3. Position semi fowlers to relieve dyspnea from distended abdomen Postop 1. Observe for abdominal distention 2. Small frequent feedings after NGT removal 3. Colostomy care 4. Assist parents to cope with childrens feeding problems
Surgery is done in 3 Stages:

1.Temporary colostomy before definitive surgery to allow the bowel to rest & the child to gain weight.
2. Reanatomosis by means of abdominoperineal pull-through about 9-12 mos later. 3. Closure of the colostomy about 3 mos after the pull through procedure.
Intussusception
Intussusception - invagination or
telescoping of one portion of the intestine into an adjacent portion, causing obstruction. One of the most frequent causes of intestinal obstruction in children ages 3 mos to 5 yrs, most commonly bet 3-12 mos of age. If tx is delayed for longer than 24 hrs, bowel strangulation may occur, leading to necrosis, hemorrhage, perforation, peritonitis, & shock. If untreated, intussusception is incompatible with life.
Cause: > unknown

> maybe associated with viral infections, intestinal polyps,lymphoma
Pathophysiology:
Invagination because of hyperperistalsis in an intestinal segment usually the ileocecal valve >>>peristalsis continues to pull the invaginated segment along the bowel >>> intestinal edema >>>obstruction occur >>> blood supply is cut off ( necrosis)
Ndx: Pain r/t abnormal abdominal peristalsis Risk for deficient fluid volume r/t bowel obstruction DX: Barium enema for dx & therapeutic treatment tool ( reduction by hydrostatic pressure) Sonogram reveals coiled spring MX: surgery
S/Sx:
1. Severe paroxysmal abdominal pain, causing the child to scream & draw his knees to the abdomen. 2. Vomiting of gastric contents
3. Tender, distended abdomen with palpable sausage shaped mass.

4. Currant jelly stoolscontaining blood & mucus 5. Bile stained or fecal emesis, & shocklike syndrome which may progress to death.
Nursing Care
1. Provide comfort measures - pacifier for infants 2. NPO 3. Adequate hydration via IV therapy 4. Promote parent-infant bonding
Pyloric Stenosis
Pyloric Stenosis is the narrowing of the pyloric sphincter at the outlet of the stomach d/t hypertophy. > Common in males
Cause: unknown ; may be hereditary
Pathophysiology:
Pylorus narrows bec of hyperplasia/ hypertrophy>>>obstruction of the pyloric sphincter >>>gastric distention >>> dilatation >>>hypertrophy
S/SX:
1. Projectile vomiting 2. Non bile stained emesis 3. No signs of anorexia, good appetite & feeding patterns. 4. No evidence of pain, weight loss, upper abdominal distention
5. Palpable olive shaped mass in the epigastrum (RUQ) just to the right of the umbilicus.
6. Visible gastric peristalsis moving from left to right across the epigastrum.
7. Decreased frequency & volume of stools. 8. Signs of malnutrition & dehydration DX: x-ray string sign, USG. Endoscopy MX: Surgery
Ndx: Risk for deficient fluid volume r/t inability to retain food Risk for infection at site of surgical incision r/t danger of contamination from feces d/t proximity of incision to diaper area
Nursing care
Hydration Pacifier may give thickened feedings on upright position then NPO just before surgery Monitor I and O, weight, and vomiting Postop 1. dropper feeding 4-6 hrs after surgery 45 min- 1 hr duration; oral rehydration soln then half strength breastmilk/formula at 24 hr interval 2. Side lying position 3. Monitor weight and return of peristalsis 4. Wound care 5. Pacifier for oral needs
Diaphragmmatic Hernia
Herniation of intestinal content into the thoracic cavity Left side S/sx:respiratory difficulty, cyanosis, retractions, (-) breath sounds affected side, scaphoid abdomen Cx: pulmonary HPN Mx:E surgery
Ndx: Risk for ineffective airway clearance r/t displaced bowel Risk for imbalanced nutrition, less than body requirements, r/t NPO status
Nursing Care
Preop Elevate head Low intermittent suction Postop 1. Semi-fowlers 2. Maintain warm, humidified envt lung fluid drainage 3. Suction prn 4. Chest pptx 5. NPO prevent pressure on diaphragm
Necrotizing Enterocolitis
- Bowel develops necrotic patches, interfere w/ digestion, lead to paralytic ileus, peritonitis and perforation - D/t ischemia sec shock or hypoxia, infection, immature GIT immune protection S/sx: abdomen tense and distended, stool (+) for occult blood, > 2 ml gastric residual, bradycardia, apnea Dx: abdominal xray Mgmt: d/c feeding, IV or TPN, Antibiotic, colostomy, surgery for perforation
Celiac Disease/Gluten sensitive enteropathy/Celiac sprue

Malabsorption syndrome that occurs when the mucosa of the proximal small intestine is sensitive to gluten. (wheat, rye, oats, barley) inability to absorb fat, thus steatorrhea, def fat soluble vitamins, malnutrition and distended abdomen S/Sx appears bet 1-5 yo after introduction of gluten in the diet. S/sx:diarrhea, wt loss, anorexia, irritable, anemic (Fe deficiency)
Pathophysiology:
Intolerance for or inability to digest gluten >>>accumulation of the amino acid glutamine>>>toxic to intestinal mucosal cell>>> intestinal villi atrophy >>>reduction of absorptive surface of the small intestine.
CELIAC CRISIS (due to ingestion of gluten, infections, prolonged fasting) = acute vomiting and diarrhea & may lead to F & E imbalance & rapid dehydration. Dx: Biopsy of the jejunum reveals the mucosal surface with hyperplastic villus atrophy. ( Definitive diagnosis of celiac disease). This characteristic lesion return to normal after dietary restriction of gluten which helps confirm the dx.
Mx: hydration, gluten free diet, vitamin & Fe supplementation , avoid cereals, bread, cake, cookies, spaghetti, pizza, instant soup, some chocolates, some ice cream, donuts, pies,
Foods allowed:
1. Meats: beef, pork, poultry & fish 2. Eggs 3. Milk & dairy products: milk, cheese, cream 4. Fruits & veg: all 5. Grains: rice, corn, gluten free wheat flour, corn flakes, corn meal & gluten free pre-cooked cereals
Inguinal Hernia
Protrusion of a bowel through the inguinal ring males S/sx:painless lump in the groin Cx:bowel strangulation Mx:surgery <1 yo Post op Nursing care: wound care assess circulation in the leg
Mastery Exam
1. While assessing a newborn with cleft lip, the nurse would be alert that which of the ff will most likely be compromised? a. Sucking ability b. Respiratory status c. Locomotion d. GI function
2. When providing post op care for the child with a cleft palate, the nurse should position the child: a. Supine b. Prone c. In an infant seat d. Semi fowlers
3. While assessing a child with pyloric stenosis, the nurse is most likely to note which of the ff ?
a. Regugitation c. Projectile vomiting
b. Steatorrhea
d. currant jelly stools
4.Discharge teaching for a child with celiac disease would include instructions about avoiding which of the ff ? a. Rice b. Milk c. Wheat d. Chicken
5. Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea? a. Notify the physician immediately b. Administer antidiarrheal medication c. Monitor child every 30 minutes d. Nothing, this is characteristic of Hirschsprung disease 6. A newborns failure to pass meconium within the first 24 hours after birth may indicate which of the following? a. Hirschsprung disease c. Intussusception b. Celiac disease d. Abdominal
7. When assessing a child for possible intusussception, which of the following would be least likely to provide valuable information? a. Stool inspection c. Family History b. Pain pattern d. Abdominal palpitation 8. Which evidence provides the nurse worth essential evaluation criteria needed to establish the diagnosis the diagnosis of pyloric stenosis? a. Hematest-positive stool b. Hematest-positive urine c. Non-bile stained vomitus d. Bile-stained vomitus
9. A 10-month-old infant is admitted to the pediatric unit to rule out Hirschsprungs disease. The nurse should expect the infants stool to be: a. Watery, green in appearance b. Currant-jellylike in appearance c. Steatorrhic in appearance d. Ribbonlike in appearance 10. The ultimate goal of nursing care for a child with Hirschsprungs disease is to: a. Reduce the trauma induced by daily traumas b. Teach the family how to plan an age-appropriate, lowfiber diet c. Prepare the child and family for surgical removal of the affected portion of bowel d. Assist the child and family in accepting the permanent need for colostomy
11. Following a rectal biopsy that confirms the diagnosis of Hirschsprungs disease, a child is to begin on dailt enemas. Which selection, made by the childs parents, indicates that they have inderstood the nruses teaching regarding the type of solution to be administeres? a. Tap water c. Soap suds b. Normal saline d. Pediatric Fleet preparation 12.The nurse should suspect intussusception in an infant who experiences: a. Constipation b. Bloody diarrhea c. Projectile vomiting and an olive shaped mass in the epigastric area. d. Sudden onset of vomiting an severe, crampy abdominal pain
13. A 6-month-old infant with suspected intussusception passes a currant jelly stool. The nurses first action is to: a. Note this finding in the patients chart b. Notify the pediatrician c. Hematest the stool d. Ask the parents to sign a surgical consent form for an immediate abdominal exploration. 14. Which statement made by the parents of an infant with intussusception indicates that they have understood the nurses teaching regarding the rationale for a barium enema as a treatment modality? a. The pressure of the barium enema may return our babys bowel back to its normal position b. The barium enema will relieve our babys constipation c. The pressure if the barium enema will stop our babys bowel from bleeding d. The barium enema will prevent our baby from needing abdominal surgery
15. Which finding, when a diaper check is performed, should alert the nurse that an infant with intussusception is successfully passing the barium left in the infants bowel following a barium enema? a. A green, watery stool c. A black, tarry stool b. A bulky, greasy stool d. A grayish-white stool 16. Which of the following methods would the nurse use to feed an infant after surgical repair of cleft lip? a. Gastric gavage b. Intravenous fluids c. A rubber-tipped medicine dropper
17. The child is eventually admitted to the hospital for repair of the cleft palate. Which of the following eating utensils would be most appropriate for the child on the second day after the surgery? a. Cup b. Drinking tube c. rubber-tipped Asepto syringe d. Large-holed nipple 18. Which of the following types of restraints would be best for the nurse to use for the child in the immediate postoperative period after cleft palate repair? a. Safety Jacket c. Wrist restraints
Endocrine Disorders
Cystic Fibrosis
Autosomal recessive Chronic multisystem disorder of the exocrine glands characterized by abnormally thick pulmonary secretions. Affects lungs, pancreas, intestines and sweat glands, salivary glands, reproductive tract.
S/SX: GI - meconium ileus, rectal prolapse,( most common GI sign); loose, bulky, fatty stools (steatorrhea,) malnutrition ( vit ADEK deficiency), failure to thrive; marked tissue wasting; distended abdomen thin extremities. Respiratory wheezing, recurrent infection,cough, dyspnea, clubbing, cyanosis, atelectasis, generalized obstructive emphysema, chronic sinusitis, bronchitis, ear, nose, throat problems.
Reproductive
Female delayed puberty & decreased fertility ( from decreased viscosity of cervical mucus which blocks the entry of sperm)
Male infertile, sterility is due to blockage of the vas deferens with abnormal secretions.
Cardiovascular Cor Pulmonale, right sided heart enlargement, CHF d/t obstruction of pulmonary flow
S/SX of hyponatremia rapid IV electrolyte replacement to prevent circulatory collapse.
Integumentary
> Increased concentrations of sodium & chloride in sweat; parents report salty taste when they kiss their babies. > Failure to thrive may result in hypoalbuminuria, which causes edema.
Dx: > Sweat test (Chloride 2-5x the normal), > absence of pancreatic enzymes, >immunoreactive trypsinogen in blood > stool analysis steatorrhea > xray patchy atelectasis & generalized obstructive emphysema. Mx: chest physiotherapy, antibiotics, pancreatic enzymes, vitamins, lung or pancreas transplant
Ndx: Imbalanced nutrition, less than body requirements r/t inability to digest fats Ineffective airway clearance r/t inability to clear mucus from the respiratory tract
Nursing Care
1. Hi calorie, Hi CHON, moderate fat diet 2. Nebulization and physiotherapy 3. Frequent Position changes when in bed 4. Oral care 5. Adequate rest and comfort
Musculoskeletal Disorders
Clubfoot (Talipes)
Ankle-foot disorders Types: Varus inward rotation Valgus outward rotation Calcaneous upward rotation or dorsiflexion Equinas downward rotation or plantarflexion
Males
Unilateral more common Talipes Equinovarus (plantar flexion and medial deviation) 95% S/sx: foot cannot be manipulated by passive exercises into correct position Mx: cast and splint, surgery then casting and corrective shoes
NDx: Risk for impaired skin integrity r/t corrective devices Nursing Care Exercise Cast and brace care Skin care Restraints if necessary Diversional activities Health teaching
Congenital Hip Dysplasia

Imperfect hip development affecting femoral head and acetabulum Female Unilateral more common Inc frequency w/ breech delivery
A. Lower right leg B. asymmetric skin

fold
A. Normal hip B. subluxated hip C.Dislocated Hip
S/sx: limited abduction of affected hip shortening of leg on affected side (Galeazzi/Allis sign) asymmetric thigh and gluteal folds buttocks on affected side will flatten on prone pelvis dips on normal side when standing on affected leg (Trendelenburg) palpable click (Ortolanis click) Mx: maintaining hip in abduction
A. Ortolanis test
B. Barlows Test
A. Frejka splint
B. Pavlik Harness
C. Hip abduction for subluxation
NDx: Impaired physical mobility r/t immobilization device Nursing Care Maintain proper positioning-keep legs abducted Adequate nutrition Diversional activities Regular exercise Ensure adequate circulation Provide comfort Maintain cast, traction, splint
SCOLIOSIS
- Lateral curvature of the spine, spinal rotation & thoracic hypokyphosis. -Most common spinal deformity Cause: -Results from leg length discrepancy, hip or knee contractures, neuromuscular disorders or congenital malformations -- autosomal dominat trait, usually idiopathic
S/SX:
1. Presence of spinal curve 2. Assymetry of scapula & extremities 3. Unequal distance between the arms & waist DX: 1. Xray reveals degree & location of the curvature
NMX:
1. Prevent emotional & physical trauma r/t wearing a brace.
> Boston brace or Milwaukee brace are the most commonly used braces. > type of brace & wearing schedule depends on the age of the child, the nature of the curve
a. Worn 23 hours a day. Removed for 1 hour for bathing.
2. Prevent complications r/t surgery.

> surgical technique consists of realignment & straightening with internal fixation & instrumentation combined with bony fusion. a. Instrumentation includes Harrington, Cotrel-dubouset > prevent neurologic deficit by monitoring motor, sensory, & neurologic status particularly in extremities. > promote adequate bowel & bladder elimination.
1. When assessing a newborn for developmental dysplasia of the hip, the nurse would expect to assess which of the following? a. Symmetrical gluteal folds b. Trendelenburg sign
c. Ortolani sign
d. Characteristic limp 2. Which of the following would the nurse do to best assess a mothers ability to care for her child who requires the use of a pavlik harness? a. Have the mother verbalize the purpose for having the device
b. Request a home health care nurse visit after discharge

c. Have the mother remove and reapply the harness before discharge d. Demonstrate to the mother how to remove and reapply the device
3. Which of the following is the priority nursing action for a child immediately following the application of a spica cast? a. Perform neurovascular checks b. Elevate the cast
c. Cover the perineal area

d. Keep the cast clean and dry 4. The long term plan of a care for a child with myelomeningocoele must include: a. Speech therapy b. Dietary counseling c. Bowel & bladder training d. Emotional guidance
5. Which is the most critical nursing goal for an infant with an unrepaired myelomeningocoele? a. Maintenace of hydration status b. Maintenance of nutritional status
c. Prevention of contractures
d. Prevention of infection 6. In which position should the nurse place an infant with an unrepaired myelomeningocoele? a. Prone b. On right side c. Semi fowlers in an infant seat d. On left side with head elevated
7. What is the nurses primary rationale for keeping the sac of an infant such as unrepaired myelomenigocoele moist via application of sterile normal saline? a. Prevent the sac from rupturing
b. To aid in delivering additional fluids to the infant
c. To prepare the sac for surgical removal

d. To prevent cerebral spinal fluid from leaking into the surgical incision site.
8. The parents of a newborn with clubfoot asks the nurse why did this happen? The nurses best response is:
a. It was caused by a viral infection during the pregnancy b. It is related to the effects of smoking while pregnant c. It is unknown what causes clubfoot d. It is related to the age of the mother at the time of conception.
9. The most critical element to teach the parents of a newborn who has clubfoot and bilateral short leg casts, is: a. Neurovascular assessment of the toes b. General cast care c. Cast removal before scheduled weekly orthopedic clinic appointments d. Skin assessment on removal of the casts 10. The parents of an infant with a newly repaired cleft lip question the nurse about the purpose of the Logans bow. The nurses best reply is: a. It prevents aspiration during feedings. b. It prevents trauma to the suture line. c. It prevents the baby from sucking on his fingers or a pacifier d. It prevents the baby from vomiting
11. The parents of an infant with a repaired cleft lip ask the nurse to explain what a Breck feeder is/ The nurses best responses is: a. It is a special type of spoon b. It is another name for an Asepto syringe c. It is a standard type of nipple d. It is a large syringe with soft rubber tubing 12. The parents of an infant with a cleft palate ask when the defect will be repaired. The nurses best response is: a. Before teeth erupt b. When the child is drinking from a cup. c. Before speech develops d. When the child is able to separate easily from the parents.
13. The parents of an infant with an unrepaired cleft palate ask why their baby has frequent ear infections. The nurses best response is: a. The babys poor nutrition predisposes her to infection. b. The baby's Eustachian tubes become clogged with formula. c. The baby is in a high-risk age groip for ear infections. d. The cleft palate causes ineffective functioning of the eustachian tubes and improper drainage of the middle ear.
14. Which of the following statements by the mother would indicate that she understands pyloric stenosis? Pyloric stenosis is caused by: a. an enlarged muscle below the stomach sphincter b. a telescoping of the large bowel into the smaller bowel. c. giving the baby more formula than is necessary. d. the babys taking the formula too quickly.
15. A 6-month child is brought to the clinic for suspected celiac disease. Which of the following by the mother would support the diagnosis of celiac disease? a. His urine seems so dark in color. b. His stools are large and smelly. c. His belly is so small. d. He has never been sick. 16. Then nurse teaches the mother about the childs diet. Which of the following foods should not be included in a gluten-free diet? a. Wheat, oats, rye, and barley b. Milk, yogurt, cheese, and butter c. Rice, corn sorghum, and soybeans d. Lemons, limes, oranges, and bananas
17. Which of the following diet plans would be appropriate for this 6-month-old with suspected celiac disease? a. Cows milk formula and oatmeal cereal b. Cows milk formula and barley cereal c. Breast milk and rice cereal d. Breast milk and mixed cereal 18. After clubfoot deformity is overcorrected by serial casting, the client is to wear a Denis Browne splint. The nurse should explain to the parents that the splint is applied to a. assess the strength of calf and thigh muscles b. help maintain the feet in the desired position c. prevent kicking d. Prevent possible bone deformities
16.
S/sx: headache, vision changes, vomiting, enlarging head circumference, papilledema, lethargy, ataxia, nystagmus, personality changes, seizures, lethargy, coma Dx: skull films, bone scan, CT scan, Lumbar puncture, MRI, angiography Mx: surgery, chemotx
1. 2. 3. 4. 5.
Preop Stool softeners Dexamethasone Dilantin Shave head Prepare patient and family psychologically
Postop 1. Proper position low fowlers 2. Anticipate needs 3. Saline eye drops as needed 4. Monitor VS and NVS 5. Regulate IV 6. Observe head dressings 7. Provide comfort and opportunity for self expression
Benign Febrile Seizure

6 mos - 5 years fever >/= 38.5C generalized tonic-clonic rarely persist > 10 minutes Postictal stage 30-40 % recurrence (+) family history
NURSING CARE
Turn child to side & allow to drool Do not restrain Do not put anything in the mouth Dec temp Refer if: sx persist another sx occurs delirious/difficult to rouse after sx
Seizure
Paroxysmal involuntary disturbance of brain function Epilepsy: recurrent seizures unrelated to fever or to acute cerebral insult
Generalized Seizures Absence Seizures/Petit Mal:

- staring spell that lasts a few seconds - 100x a day - appear as if daydreaming
Generalized/Grand Mal/Tonic-Clonic 4 stages

Prodrome: mood or behavioral changes; precede attack by hours
Aura: immediately before seizure and will localize the attack to its point of origin within the nervous system
Tonic phase (10 secs) eyes open. Elbows flexed. Arms pronated. Legs extended. Teeth clenched. Pupils dilated. Breath held- cyanosis. Bowel or bladder control may be lost at the end of this phase Clonic phase (1-2 min) tremor gives way to violent generalized shaking. Eyes roll backwards and forwards. Tongue may be bitten, tachycardia develops. Breathing commences at the end of phase.
Partial Seizures
Simple partial: with motor and sensory symptoms Complex partial/psychomotor: simple partial developing into a complex seizure, consciousness impaired at onset Partial seizure with secondary generalization discharges spread from their point of origin and excite other structures
Mx: Acute Attack Provide O2 Position properly Turn head to side Promote safety Do not restrain
Prevention Health teaching Supervise activities Antiepileptics Generalized Tonic-Clonic, Focal Phenobarbital, Phenytoin Absence Ethosuximide, Valproate
Erb Duchennes Paralysis

Damage on C5-C6 due to birth trauma Unilateral S/sx: shoulder adducted, internally rotated, elbow extended, forearm pronated and the wrist flexed waiters tip, (-) moro reflex Mx: PT, surgery Nsg care: advise exercise and frequent follow up
Cerebral Palsy
Damaged motor function d/t anoxic brain injury secondary to infection, perinatal asphyxia, metabolic disorder Nonprogressive TYPES: Spastic Dysphagia most common; hypertonicity Athetiodidyskinetic worm-like Ataxic wide based gait w/ repetitive mvmt Mixed
S/sx: spasticity/rigidity, difficulty feeding, delayed speech and motor devt, mood swings, impulsive, short attention span, irritable Dx: Clinical Mx: antispastics, antibiotics, surgery, nutrition, prevention of injury, PT NDx: Risk for injury r/t neuromuscular impairment Self care deficit r/t neuromuscular impairment - ensure safety, assist in ADL, ensure adequate nutrition, assist children achieve maximum potential
Hydrocephalus
Impaired circulation and absorption of CSF 2 TYPES: 1. Obstructive/Noncommunicating w/n ventricular system 2. Nonobstructive/Communicating obliteration of SA cisterns or malfunction of arachnoid villi S/sx: head enlargement, ant fontanel wide and bulging, scalp veins dilated, broad forehead, sclera shows above iris, brisk tendon reflexes, spasticity, irritability, lethargy, poor appetite, cracked pot sound on percussion
Ndx:
Risk for ineffective cerebral tissue perfusion related to increased intracranial pressure - monitor vs, head circumference, I and O - O2 - position flat or head 30 deg - do not lie on operative site
Risk for imbalanced nutrition, less than body requirements, related to increased intracranial pressure - NPO until bowel sounds return - position head w/o flexion - observe for constipation - note how child sucks - IV fluids - obtain daily weight
Spina Bifida
Collective term for all SC disorders Spina Bifida Occulta posterior laminae fail to fuse - dimpling, abnormal tufts of hair Meningocoele - meninges herniate through unformed vertebrae; protrusion covered by a layer of skin - usually occurs in the lumbar region - protrusion is covered by a skin layer or only the clear dura mater
Myelomeningocoele SC and meninges protrude through the vertebrae defect
- absent motor and sensory function

- flaccidity, lack of sensation in LE - loss of bowel and bladder control - may be accompanied by hydrocephalus Dx: sonography
Risk for infection r/t rupture or bacterial invasion of the neural tube sac - position side lying or prone - keep sac moist - place under radiant warmer - post op prone until site is healed Risk for ineffective cerebral tissue perfusion r/t increased intracranial pressure - measure head circumference - assess for s/sx of inc ICP
Risk for impaired skin integrity r/t required prone positioning - reposition head every 2 hrs if w/ hydrocephalus - change diapers frequently Impaired physical mobility r/t neural tube d/o - passive exercises - may use leg braces, crutches - inspect lower extremities and buttocks for irritation or possible infection Risk for impaired elimination r/t neural tube d/o - intermittent catheteriazation - surgery
Meningitis
Inflammation of meninges Bacterial, Tuberculous, viral S/sx: opisthotonus, neck rigidity, irritability, high pitched cry Dx: Lumbar puncture, Bld C/S, Ct scan, MRI NDx: Risk for infection r/t presence of infective organism Tx: Abx
Hematologic Disorders
Iron Deficiency Anemia

Infants iron supply 4-6 mos Anemia 9-24 mos S/sx: pallor, tachycardia, irritability, Hg < 9 g/dl, susceptible to infection Mgmt: iron fortified formula, iron rich diet and vitamins Nsg care: give iron w/ vit c, use w/ dropper at the back of the mouth, expect black stools, provide iron rich food
Hemophilia A
Inherited interference w/ blood coagulation Factor VIII Sex linked recessive S/sx: excessive bleeding NB apparent Pre-school accidents/falls School age bleeding between joints Adolescent ulcers, hematuria Mx:factor 8
NDx: Acute pain r/t bleeding into joints

Nursing Care Promote safety Watch out for bleeding rest area, ice compress, elevate body part Monitor transfusion reaction Passive ROM Assist in gaining control of situation
Acute Lymphocytic Leukemia

Uncontrolled proliferation of WBC Lymphoblast
Most frequent CA in children

2-16 yo Males
S/sx: pallor, low grade fever, lethargy, petechiae, bleeding, vomiting, anorexia, bone pain, painless lymphadenopathy
Dx:WBC variable w/ blasts, low platelet and hematocrit, anemia BMA > 25% blast cells
Mx: chemotherapy
Cx: CNS s/sx, renal failure NDx: Risk for infection r/t decreased immune function Activity intolerance r/t reduced oxygen carrying capacity of blood
Nursing Care
Prevent infection monitor bleeding and transfusion reactions Provide comfort and pain alleviation Health teaching Emotional and psychological support
Beta Thalassemia
B chain defect Heterozygous Thalassemia minor Homozygous Thalassemia major 4-6 mos old S/sx: anemia Dx: peripheral blood smear Tx: blood transfusion - pRBC
Sickle Cell Disease

-Group of chronic, severe, genetic hemolytic disease associated with Hemoglobin S ( Hgb S) which transforms RBCs into a sickle(crescent) shape when blood oxygenation is decreased. -Hemoglobin SS ( sickle cell anemia) predominant with African ancestry, mediterannean, Caribbean, South & Central America, Arabia & East India. - Sickle cell trait benign, carrier state of the disorder.
Pathophysiology:
Abnormal hemoglobin ( Hgb S) replaces all or part of normal Hgb A >>>inc.O2 tension * lowered pH >>> RBCs change from round to sickle or crescent shape >>>clumpimg, thrombosis, arterial obstruction, inc blood viscosity, hemolysis >>> tissue ischemia & necrosis
S/SX:
1. Enlarged spleen from congestion with sickled cells 2. Enlarged liver fromblood stasis
3. Hematuria, Inability to concentrate urine,dactylitis.

4. Other problems: CVA, MI, Growth retardation, delayed sexual maturation, decreased fertility Sickle Cell Crisis- usually precipitated by infection but possibly by dehydration, fever, cold exposure, hypoxia, strenuous exercise, extreme fatigue,extreme changes in altitude.
A.Vaso- occlusive crisis most common & most painful form. Sickled cells obstruct blood vessels causing fever, acute abdominal pain, dactylitis, priapism, & arthralgia.
TX: hydration, electrolyte replacement, bed rest, broad spectrum antibiotics. Transfusions & O2 are used in severe cases. DX: Hgb S is present from conception but fetal hemoglobin ( Hgb F) inhibits sickling, making diagnosis difficult before 3 mos of age. > Sickledex screen most widely used test ( presence of Hgb S
>Chorionic Villi sampling may reveal sickle cell disease

CBC reveals a dec RBC count & ^ WBC & paletelet counts
Genitourinary Disorders
Females ( because of their shorter urethral structure) Bacterial origin (E coli) Ascending infection S/Sx:infants mimic GI d/o; dysuria, frequency, hematuria, low grade fever, abdominal pain and bedwetting Dx: urine culture (suprapubic any amount) clean catch > 100,000/ml Mx: antibiotic ( Penicillin, Sulfonamides, Cephalosporins ) > hydration
Urinary Tract Infection
Acute Glomerulonephritis
Inflammation of glomeruli or kidney Follows infection with strep10-14 days 5-10 yo, peak 6-7 yo Males Etiology : Poststreptococcal infection ( usually of the skin- impetigo or upper respiratory tract.
S/SX: >history of infection about 10 14 days before the onset of sx. >irritablity, fatigue & lethargy >anorexia, pallor , hypertension > sudden onset of edema ( periorbital) and hematuria ( urine is brown (tea or cola colored) Dx: urinalysis and 24 hour urine hypoalbuminemia inc ESR, BUN, Crea, antistreptolysin O
Mx: semi fowlers diuretics, antibiotics, O2 antihypertensives calcium channel blockers, B- blockers, ACE inhibitors ( Angiotensin converting enzyme) Nsg Care: quiet play activities diet normal CHON, mod salt restriction, fluid restriction daily weight and output
Nephrotic Syndrome
Altered glomerular permeability(autoimmune); inc permeability to albumin 3 yo Males Minimal change syndrome S/sx: proteinuria, edema-periorbital area, hypoalbuminemia, hyperlipidemia Dx:urinalysis and 24 hr CHON, inc ESR
Mx:steroids, immunosupressant NDx: Risk for decreased fluid volume r/t CHON and fluid loss Imbalanced nutrition: less than BR r/t CHON and fluid loss
Nsg care: Adequate nutrition, proper diet dec salt Weigh daily, monitor I and O Protect edematous areas Administer prescribed drugs Health teaching
Wilms Tumor
Malignant tumor of the kidney Associated with other anomalies 6 mos-5 yo, peaks 3-4 yo Good prognosis S/sx:abdominal mass, hematuria, low grade fever, anemia, wt loss Dx: CT scan Mx: Nephrectomy, radiotherapy avoid abdominal palpation
Hypospadia/Epispadia
A. Hypospadia
B. Epispadia
C. Hypospadia w/ chordee
Hypospadias - common - chordee - fibrous band Mx: surgery Nsg care: Post op pain relief assist parents in coping
Chryptorchidism
Failure of one or both testes to descend Descend up to 6 weeks at birth May be d/t dec testosterone S/sx:right testis more common Mx:chorionic gonadotrophin hormone Orchiopexy 1 yo
Other Diseases
2 mos-3 yo R/t food allergy S/sx: papular and vesicular skin eruptions w/ erythema, pruritus, dry,flaky scales upon healing Mx: reduce allergen, topical steroids NDx: Impaired skin integrity r/t eczematous lesion Nsg care: Reduce allergen Prevent skin dryness and pruritus
Atopic Dermatitis
Otitis Media
Inflammation of the middle ear 6-36 mos, 4-6 yo S. Pneumoniae, H. Influenzae, M. Catarrhalis Follows URTI S/sx:pain in affected ear, fever Cx:hearing impairment Mx: antibiotics, analgesics, antipyretics NDx: Acute pain r/t inflammatory process - provide comfort, reinforce completion of antibiotic, offer liquids and finger food (prev pain when chewing)
Diarrhea
Viral Rotavirus, Adenovirus Bacterial Shigella, Salmonella, Cholera Protozoan Amoeba TYPES: Mild: fever, irritable, 2-10 episodes/day, dry mucous membranes, tachycardia - 2.5-5% wt loss Mx: oral rehydration
Severe: fever, tachycardia, tachypnea, pale and cool skin, apprehensive/lethargic, obvious s/sx of dehydration, UO scanty, several episodes of loose stools -5-15% wt loss Cx:dehydration Mx:fluid and electrolyte replacement Dx:Stool exam and culture Electrolyte determination NDx: deficient fluid volume r/t fluid losses in stools - promote hydration and comfort, Record I
Protein Energy Malnutrition

Marasmus Low calorie, low CHON 0-2 yo (-) edema all skin and bone (+) growth retardation Apathetic, quiet Good appetite Infrequent skin/hair changes Anemia uncommon Kwashiorkor
Low CHON 1-3 yo (+) edema Wasting variable Growth retardation variable Irritable, moaning Poor appetite (+) skin and hair changes (+) anemia
Poisoning
Usually 2-3 yo Soap, cosmetics, detergents, drugs Males>females children Females>males adolescent Mx: 1. Determine age, wt, type of poison swallowed, time of ingestion, route of poisoning, amt ingested, present condition of child
2.Use syrup of ipecac to induce vomiting except: caustic, corrosive, hydrocarbon, px is comatose 3. Activated charcoal then syrup of ipecac 4. Monitor VS 5.refer to hospital/poison control center
Acetylsalicilic acid (Aspirin) S/sx:nausea, vomiting, fever, profuse sweating, flushing, hyperthermia, hyperventilation, convulsions, coma Mx:stabilize airway and breathing Fluid and electrolyte replacement Activated charcoal Alkalinization of urine hemodialysis
Burns
Assessment A airway - check nose, face and neck (priority) singed and sooty hair of the nose, give high flow 02 B breathing C circulation - if there is no breathing and circulation start CPR D check for disability and manage accordingly E expose or determine extent of injury
Kinds of Burn: Flame gasoline, kerosene, petroleum Chemical acid or alkali Electrical most fatal Radiation sunlight
< 1 yo scalding Pre school reaches up a stove, spills coffee Older children flame burns
TBSA Parkland Formula (4ml x TBSA x BWkg) 1st 8H give , 2nd 8H give and for the 3rd 8H give the last part)
0-1 yo Head Neck Ant trunk Post trunk r. Buttock L buttock Genitalia r. Upper arm l. Upper arm 19 2 13 13 2.5 2.5 1 4 4
1-4 yo 5-9 yo 10-14 yo 17 13 11 2 2 2 13 13 13 13 13 13 2.5 2.5 2.5 2.5 2.5 2.5 1 1 1 4 4 4 4 4 4
15 yo 9 2 13 13 2.5 2.5 1 4 4
0-1 yo 1-4 yo 5-9 yo 10-14 yo 15 yo r. Lower arm l. Lower arm r. Hand 3 3 2.5 3 3 2.5 3 3 2.5 3 3 2.5 3 3 2.5
l. Hand
r. Thigh l. thigh
2.5
5.5 5.5
2.5
6.5 6.5
2.5
8 8
2.5
8.5 8.5
2.5
9 9
r. Leg
l. leg r. Foot l. foot
5
5 3.5 3.5
5
5 3.5 3.5
5.5
5.5 3.5 3.5
6
6 3.5 3.5
6.5
6.5 3.5 3.5
Classification 1st degree partial thickness (painful, no blisters, erythematous); epidermis 2nd degree deep partial thickness (painless, with blister, blanch); epidermis and dermis 3rd degree full thickness (painless, leathery, whitish/charred) 4th degree bones and visceral organs are affected
Hospitalization recommended
- Total burns > 10% of BSA or > 2% FTB *halved if < 2 yrs old - Hands, feet, face or genitalia involved - Inhalation injury - Associated injuries present - Burn is inflicted - Infected burn - Prior medical illness - comatose
Management: - 1st 24 hrs - D5LR - 8-24 hrs post burn - colloid - Give TIG or TAT and TT - Prophylactic antibiotic - Sterile dressing for wound
Small minor burns dressings, soap and water More extensive burns antibacterial cream/ointment, thick/thin dressings and
Downs Syndrome
Trisomy 21 Maternal age >35 yo, paternal age >55 Features:nose is broad and flat, eyelid have an extra fold of tissue at the inner canthus, palpebral fissure slants upwards, white specks in iris, tongue protrudes, back of the head is flat, neck is short, extra fat pad, low set ears, poor muscle tone, short thick fingers, simian crease, cognitively challenged
Poor immune function Congenital heart diseases Cataract ALL occurs 20x more
Mx: early education and play opportunities prevention of infection counseling and support
Child Abuse
Non accidental injury inflicted by an adult Physical, emotional, sexual Children grow up to be abusers themselves and are violent Nsg Resp: treat injury, report to DSWD, NGO, Bantay
Substance Abuse
Use of chemicals Improve mental state Induce euphoria Peer pressure Feel more confident Adolescent rebellion
TYPES OF ABUSED SUBSTANCES

Tobacco - sign of maturity Alcohol - most frequent - no stigma Amphetamines sense of well being, alertness, self esteem and wt loss

Anabolic steroids improves athletic ability Marijuana stress reliever bec gives a sense of well being, altered sensory perception

Hallucinogens distortions in vision, smell or hearing Opiates physiologic craving
Cocaine inc VS, dec appetite, cardiovascular arrest, euphoria, excitement, hallucinations
ASSESSMENT OF SUBSTANCE ABUSE Failure to complete homework

Poor reasoning ability Decreased school attendance Frequent mood swings Deteriorating physical appearance Recent change in peer group Negative perception of parents
Nursing Intervention
Caution against drug abuse Provide counseling refer to rehab facilities
Thank you!
Parameter Bacterial Age Onset Fever Toxicity Inc RR Any Abrupt High Toxic
Viral Any Variable
Atypical 5-15 yo Insidious
Variable Low-grade Variable Non-toxic
Common Common Uncommon
Perimeter Cough Assoc sx
Bacterial Productive Mild coryza
Viral Non prod Mild coryza
Atypical Non prod Bullous myringitis, pharyngitis Fine crackles, wheezing Uncommon
PE
(+) consolidation few crackles common
variable
Inc WBC
variable
Julie C. Yu-Santos
Diarrhea in Children: Basic and Newer Concepts

DEHYDRATION: Loss of Fluid and Electrolytes A. Non GIT Loss
a. Skin b. Third space loss
Renal Cardiac Systemic Infections Septic Shock
Diarrhea in Children: Basic and Newer Concepts

DEHYDRATION: Loss of Fluid and Electrolytes B. GIT Losses
a. Third Space Hepatic Intestinal Obstruction b. Diarrhea - Gastroenteritis
DEHYDRATION PLASMA LOSS

Hct Hr
ADH
Aldosterone
C.O. GFR
USG
Na / Water Retention
Anuria
Concentrated Urine
Anuria
Hypovolemic Shock Acute Renal Failure
DEHYDRATION ELECTROLYTE BASE LOSS
SODIUM
POTASSIUM
GLUCOSE
BICARBONATE
RBS
CO2 RR
SEIZURES METABOLIC INTRACELLULAR ARRYTHMIA HYPOTONIA ACIDOSIS EDEMA OR ILEUS SHRINKAGE BRAIN CELLS ENCEPHALOPATHY ENCEPHALOPATHY
Diarrhea
Passage of >4 loose stools per day Compensatory flushing out of pathogens DIARRHEA is physiologic DEHYDRATION is pathologic
Causes of Diarrhea
A. Non infectious Malabsorption
1. 2. 3. 4. 5. 6. 7. Enzyme deficiencies Hepatobiliary disease Pancreatic disease Short GUT syndrome Immune deficiency Drug induced Chemotherapy Viral Bacterial Protozoan Fungal
B.
Infectious Mucosal Injury

1. 2. 3. 4.
INFECTIOUS DIARRHEA
TOXIGENIC Vs.
SITE Ileal
ENTEROINVASIVE
Colonic
S/S
Stool
Initial Vomiting
Watery
Tenesmus
Bloody Mucoid
Enteritis
Colitis
Clinical Spectrum of Infectious Diarrhea

Type Acute Watery Acute Bloody (Dysentery) Persistent Diarrhea (>14 days) Diarrhea with severe malnutrition (Marasmus or Kwashiorkor) Incidence 80% 10% Risk Dehydration Dehydration, sepsis, malnutrition Dehydration, septicemia, severe malnutrition Dehydration Sepsis Multiple vitamin deficiencies
10%
Magnitude of the Problem

Global Trends:
Top ten in infant mortality / morbidity Annual Death Rate (Under Five) 1979 4.5 million 1993 3.2 2002 1.6 2003 1.87
Philippine Data:
2001 5th cause of death (infants) 2nd cause of death (Older age) 2002 2nd cause of death (all ages)
Magnitude of the Problem

Incidence: 2-3 episodes / child /year Prevalence: 6 months to 2 years Peek January to February June to August Risk Factors: A. Host Nutrition / Immune Status - Gastric Acidity B. Etiologic Agent C. Environment
The Pathogens
Enterotoxigenic Strains: A. Rotavirus
Age Incidence Incubation Endemicity Profile : : : : 6-24 months 24-72 hours Sporadic Initial vomiting episodes associated with low grade fever, watery voluminous stools peaking on the 3rd day Self limiting 3-5 days Stool examination is not helpful Electron microscopy and ELISA test are done for research purposes
Prognosis Laboratory
: :
The Pathogens
B. Enterotoxigenic Bacteria
1. E. coli Different Strains (EPEC / ETEC) Age Incidence : Newborn / Infants Travelers (ETEC) Incubation : 12-72 hours Stools : Cholera like for ETEC Slimy for EPEC Endemicity : Sporadic Treatment : Fluid / Electrolytes Antimicrobials for <2 mos old Stool Exam : Not helpful
The Pathogens
B. Enterotoxigenic Bacteria
2. Vibrio Cholera Age Incidence Incubation Stools Other S/S Endemicity Prognosis
Treatment : : : : : : : 2-10 y/o Hours to 5 days Rice water stools Washerwomans Hands Epidemic Guarded risk of shock Fluid / Electrolytes Antibiotic
The Pathogens
C. Enteroinvasive Bacteria
Dysenteric stools Associated abdominal cramps / tenesmus Note: Please do a rectal examination to rule out other causes of bloody stools
Differential Diagnosis of Hematochezia: Intussusception Bleeding Meckels Diverticulum Bleeding polyp Anal fissures Cows milk allergic colitis
Common Etiologic Agents of Dysentery

Shigella
Prevalence (%) Age Incubation (Hrs) Onset Fever Toxemia Dehydration Tenesmus Stool Exam WBC RBC 40 All 24-72 Acute Present Present Present Present >20 / hpf (+)
Amoeba
1-5 Older 2-4 weeks Insidious Absent Present 10-20 / hpf (+) Hematophagous Trophozoites Fluid / Electrolytes Antiamoebic
Treatment Supportive Definitive
Fluid / Electrolytes Antimicrobial
Basic Concepts
Pathophysiology of Infectious Diarrhea: a. Mucosal injury Villus Atrophy (malabsorption) b. Stimulation of the cyclic amp - Secretion / secretory MALABSORPTION OVERSECRETION
ABSORPTION
SECRETION
Overview of Sodium Movement Across the Intestines

1. 2. 3. 4. Na H2 exchange Active transport (camp) Solvent drag Na substrate (glucose) link
Only mechanism intact during acute diarrheas Water is absorbed three fold in a sugar-salt mixture Physiologic basis of ORT
Oral Rehydration Therapy

Adopted by WHO / UNICEF in 1970s (>25 years) Medical breakthrough of the century (Lancet)
Oral Rehydration Therapy

Meta analysis of 14 trials
No difference between IVF Vs. ORS in weight gain
Diarrhea duration Hypo / hypernatremia Total fluid intake
Length of stay significantly shorter in ORT group 1 in 25 children in ORT group treated with IVP Deaths 6 in IVF Vs. 2 in ORT ORT is first line therapy
Bellemare BMC 2004 Ali M. Indian Med Ass 2003 Spandorfer Pediatrics 2005
Search for Improved ORS

Outcome Desired: Minimized treatment failure / need for IV Decreased stool output duration Decreased vomiting
Reduced Osmolality ORS (mmol/liter)

Sodium Chloride Glucose Potassium Citrate Osmolality
(* STD ORS)
75 65 75 20 10 245
(90)* (80) (111) (20) (10) 311

-WHO / UNICEF 2004 -NASPGHAN - 2002
In the Clinics
Assessing the Diarrhea Patient: A. Dehydration Fluid Plan B. Nutrition Feeding Plan C. Other Problems D. Referral, Other drugs
Persistent Electrolytes Systemic Infection Bloody Stools Surgical Abdomen
Pertinent Diarrhea History

1. 2. 3. 4. 5.
Duration Stool frequency / consistency Systemic signs: Fever Last urine Past illness
Previous diarrhea 2-4 fold increased risk to chronicity Measles 30% risk to chronicity
Antidiarrheals risk of ileus
6. Measures done 7. Feeding History
Major Key Signs of Dehydration

1. Sensorium restless, irritable, lethargy, floppy 1. Thirst eager - poor intake 3. Skin pinch very slow retraction (>2 sec)
Other Signs of Dehydration

Mild Moderate Dry mucous membranes Increased thirst Sunken eyeballs Sunken fontanelle Loss of skin turgor Rapid therapy pulse Cyanosis Tachypnea Delayed capillary refill Lethargy Coma
Severe
Note: The major signs are carefully selected clinical signs that form Guidelines for Urgency; incorporated in the IMCI.
A
Assessment Basis Treatment Goal : : : : No signs of dehydration Normal P.E. Wt. loss <5% Plan A Prevent dehydration (Maintenance)
Treatment Plan A
Fluid Plan ORS Sugar / Salt Solution Broth Rate For every BM, give: <2 y 50-100 cc (1/2 cup) >2 y 100-200 cc (1 cup) >10 y Adlib
Treatment Plan B
Assessment : Mild to moderate dehydration (Some) >5 10% weight loss Thirst Irritable Fluid : ORS 75 cc/kg in 4 hours Monitor : Hourly for urine output Stool frequency Intractable vomiting Others problems IIeus Full Reassessment: 4th hour (+) urine (-) thirst Puffy eyelids ? Weight gain
Case Scenario
5 kg mild to moderately dehydrated child needing 400-600 cc ORS
Plan B
200 cc
Vomiting Cold extremities I0 2 3 4
Plan C
I
0 1 HR Active PE: Normal Refuses ORS Go to Plan A and Feed
II
Plan B
0 1
400 cc
Treatment Failure
Indications for IV Therapy: 1. Shock 2. Uncontrolled vomiting 3. Anuria the past 3-4 hrs 4. Ileus 5. Fatigue
IV Therapy
A.
-
For non severe dehydration (IVT in Plan B)

75 cc/kg in 4 hours LRS
B.
-
Severe dehydration >10% weight loss

Note last urine output Plan C
Challenging Period: 30 min > 12 months 1 hour < 12 months
Use LRS
Age <12 mos Fluid Rate 30 cc/kg x 1 hr 70 cc/kg x 5 hrs 30 cc/kg x 30 min 70 cc/kg x 2 hrs Deficit Phase 6 HOURS
> 12 mos
3 HOURS
Principles of Fluid Rehydration

A. Deficit therapy prompt correction of deficit
1st 4-6 hours
B. Maintenance Therapy
Next 20 hours Replaces on-going losses Includes daily fluid requirement Provides for metabolic expenditure
Types of Dehydration
(Based on Sodium Loss) A. Isotonic
Most common type Serum sodium is normal More water loss Serum Na >145 mmol/L
B. Hypertonic / Hypernatremic
C. Hypotonic/hyponatremic
More sodium loss Serum sodium <135mmol/l
Fluid Access
1. Enteral NGT drip 20 cc/kg/hr ORS Oral intake 2. Venous Access - Central Vein - Peripheral 3. Intraosseous
Nutritional Therapy
Rationale: Food is trophic to the GIT
The Feeding Plan: 1. Continue regular milk
Do not dilute unless lactose Intolerance is suspected, then Shift to special formula
2.
3.
Breastfeed even during the deficit phase

Milk formula start during the maintenance phase
Provide potassium rich foods

Banana (~ 10 meq)
4.
5.
During convalescence
Add drops of oil to regular food Add extra meal / day
Monitor weight gain
The Home Instructions

Follow-up Plan: 1. For Plan A come back in 2 days 2. Follow-up immediately (during home therapy) when the following appears
a. b. c. d. e. f. Fever Persistent vomiting Poor intake Increased thirst Increased purging Blood in stools
Drug Therapy
Drug Therapy: 1. Antidiarrheals / antispasmodics / antimotility
a. No role in childhood diarrhea
2. Antimicrobials indications:
a. b. c. d. e. <3 months old Immunocompromised Malnutrition Dysentery Cholera
WHO Guidelines for Bloody Stools

1. Start antishigella 2. After 2 days reassess
a. If no response shift to another antishigella
3. After 2 days if still no improvement

a. Do stool exam and culture b. Start antiamebic
Antimicrobials for Specific Causes

(WHO) Cholera
Tetracycline 12.5 g/K QID x 3 days Erythromycin 12.5 g/K QID x 3 days
Shigella
Ciprofloxacin 15 mg/K BID x 3 days Ceftruixone 50-100 mg/K OD (IM) x 5 days
Amoeba Giardiasis
Metronidazole 10 g/K 3x/day x 5-10 days Tinidazole
Results of stool culture / sensitivity may be followed
Newer Concepts
A. Search for improved ORS (Super ORS) Replace glucose No effect with amino acids
Reduced osmolality Proven (75 Na . 75 Glu) Effective
Evidences of the Reduced Osmolality ORS Vs. Standard

Metaanalysis of the 12 RCTs
Hahn et al BMJ 2001
1. Reduced the need for unscheduled IVT 35% 2. Reduced episodes of vomiting 30% 2. Reduced stool output 20% 3. Hyponatremia risk Not significant
Meta-analysis of unscheduled intravenous infusion among children randomised to reduced osmolarity and standard WHO rehydration solutions
Consensus Statement : WHO UNICEF

Group of experts recommended that policy of a single solution be maintained This ORS must contain:
Sodium 75 meq/L Glucose 75 meq/L Osmolality 245 mOsm/L
B. Zinc Supplementation: (+) Impact of severity and duration of: 1. Diarrhea 20% 10-20 mg/day x 14 days 2. Lower stool frequency Fewer prolonged cases 3. Reduced use of antimicrobials
Polat TB Pediatrics 2003 Bhatnagar JPGN 2004 Baqui Nutri 2004 Brooks Lancet 2005 WHO Consensus 2004 UNICEF
C. Functional Foods in Diarrhea: Probiotics Reduced risk of diarrhea at 3 days (RR=0.66) Reduced duration by 30-48 hours Meta analysis showed: Usefulness in rotavirus and Antibiotic associated diarrhea
Cochrane Database 2004
D. Vitamin A Oral vitamin Dose: 12 mos-5 yrs - 200,000 U 6 mos-12 mos - 100,000 U
Prevention of Diarrhea
1. 2. 3. 4. 5. 6. 7. Breast feeding ( diarrhea 25x) Improved weaning practices Hand washing Potable water Sanitation facilities Waste disposal Immunization
a. Measles b. Rotavirus

Pedia Review Final Growth and Developement

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GROWTH & DEVELOPMENT

Maricel S. Jose MD;RN

C. Third Stage Early Childhood( 1-6 y/o)

FACTORS THAT AFFECT GROWTH AND DEVELOPMENT

FACTORS THAT AFFECT GROWTH AND DEVELOPMENT

THEORIES OF GROWTH & DEVELOPMENT

PSYCHOSEXUAL DIMENSION (FREUD)

Freuds Psychosexual Theory

Psychological Dimension ( Erickson)

ERIKSONS PSYCHOSOCIAL THEORIES

Trust vs Mistrust (Infancy)

Autonomy vs Shame and Doubt (Toddler)

Initiative vs Guilt (Preschooler)

Industry vs Inferiority (School-Age)

Identity vs Role Confusion (Adolescence)

Sensorimotor ( 0-2yr old)

Primary Circular Reaction (1- 4 months)

Secondary Circular Reaction ( 4-8 months)

Coordination of Secondary Reactions ( 8-12 months)

Tertiary Circular Reaction (12-18 months)

Preoperational ( 2-7yr old)

Concrete Operational ( 7-12yr old)

Formal Operational Thought (>12yr old)

Moral / Ethical (Kohlberg)

INFANCY (28 DAYS TO ONE YEAR)

I- PSYCHOSEXUAL STAGE ( FREUD): ORAL II PSYCHOSOCIAL STAGE ( ERICKSON):

TRUST VS. MISTRUST

III COGNITIVE STAGE( PIAGET) :

3. TO RELATE TO OBJECTS & PEOPLE

Best color: red

GROWTH & DEVELOPMENT

GROWTH AND DEVELOPMENT

F: 3 mos eyes past midline

S: 3 mos recognize, familiar faces

GROWTH & DEVELOPMENT

GROWTH AND DEVELOPMENT

voluntarily L: 5 mos - simple

GROWTH & DEVLOPMENT

GROWTH AND DEVELOPMENT

GROWTH & DEVELOPMENT

GROWTH AND DEVELOPMENT

G: pulls self to stand, creeps

GROWTH & DEVELOPMENT

GROWTH AND DEVELOPMENT

PS: holds arm or foot out in dressing

GROWTH & DEVELOPMENT

GROWTH & DEVELOPMENT

PLAY solitary play

10-12 mos Picture books Large blocks Nesting cups

- Thumb sucking until school age

Discomfort and pain Lack of stimulation Separation anxiety Disruption of routine

Soothing stimulation Toys from home Human contact Provide/Anticipate needs

** Best color for neonates: black & white

- INTRODUCTION OF REALITY PRINCIPLE; EGO DEVELOPMENT

** INSISTS ON WINDING A TOY & BREAKING IT.

3. TOILET TRAINING BEGIN TRAINING WHEN READY:

SPANKING, NEVER IN ANGER FOR THE CHILDS SAFETY.

IV COGNITIVE STAGE: ( PIAGET): STAGE 1

GROWTH AND DEVELOPMENTAL MILESTONES

PLAY Parallel Play TODDLERS

- Building blocks - Toys to ride on

EGOCENTRIC uses MINE for everything.

Sibling rivalry Discipline Separation anxiety

REACTION TO ILLNESS and NURSING INTERVENTIONS