GROWTH AND DEVELOPMENT

GROWTH - Increase in physical size - QUANTITATIVE CHANGE TWO PARAMETERS OF GROWTH 1. Weight most sensitive measure of growth, especially low birth rate a. Weight doubles 6 mos b. Triples 1 year c. Quadruples - 2 - 2 years 2. Height increase by 1 inch per month during 1st 6 mos - Half inch per month by 7 mos - Average increase in height 1st year = 50% - Increase in height coincide with eruption of wisdom tooth DEVELOPMENT - increase skills or capability to function - QUALITATIVE CHANGE HOW TO MEASURE DEVELOPMENT 1. By simply observing a child doing specific task 2. By noting parents description of the childs progress 3. By DDST Denver Development Screening Test measures mental MMDST (Phil.) Metro Manila Developmental Screening Test 4 MAIN RATED CATEGORIES OF DDST 1. Language communication 2. Personal social interaction 3. Fine motor adaptive ability to use hand movement; pre Hensile activity 4. Gross motor skills large body movement MATURATION synonymus with development readiness COGNITIVE DEVELOPMENT ability to learn and understand from experience - To acvquire and retain knowledge - To respond to a new situation and to solve problems IQ TEST test to determine cognitive development Mental Age/Chronological Age x 100 = IQ Average IQ = 90-100 Gifted Child = >130 Genius = over 140

BASIC DIVISIONS OF LIFE

STAGES:
I.PRENATAL STAGE -from conception to birth II.PERIOD OF INFANCY 1. Neonatal 1st 28 days of life or 1st 4 weeks of life 2. Formal Infancy 29th day 1 year III. MIDDLE CHILDHOOD 1. Toddler 1-3 years 2. Preschool 4-6years IV.MIDDLE CHILDHOOD 1. School age 7-12 years V.LATE CHILDHOOD (Adolescent Period) 1. Pre adolescent 11-13 years 2. Adolescent (12 18 21) overlapping of age

PRINCIPLES OF GROWTH AND DEVELOPMENT

1. Growth and development is a continuous process - Begins from conception and ends in death - Womb to tomb principles 2. Not all parts of the body grow at the same time or at same rate - Asynchronism or asynchronous growth PATTERNS OF GROWTH AND DEVELOPMENT A. RENAL, DIGESTIVE, CIRCULATORY, MUSCULOSKELETAL grows sparely smoothly during childhood B. NEUROMUSCULAR TISSUE (CNS, BRAIN, SPINAL CORD) -grow rapidly 1-2 years of life -brain achieved its adult proportion by 5 years SIGNIFICANCE: Food for the brain POTATO C. LYMPHATIC SYSTEM -Lymph nodes -Spleen grows rapidly -Infancy and childhood to provide protection -Infection -TONSIL ACHIEVE ITS ADULT PROPORTION BY 5 YEARS D. REPRODUCTIVE ORGAN grows rapidly at puberty RATES OF GROWTH AND DEVELOPMENT 1. Fetal and infancy most rapid growth and development 2. Adolescent rapid growth and development 3. Toddler- slow growth and development

4. School age slower growth FETAL AND INFANCY prone to develop anemia

3. Each child is unique 2 PRIMARY FACTORS AFFECTING GROWTH AND DEVELOPMENT A. Heredity R-ace I-ntelligence N-ationality S-ex Females are born less in weight than males by 1 oz Females are born less in length than males by 1 inch B. Environment Q-quality of nutrition S-ocio economic status H-ealth O-rdinal position in family P-arent child relationship Eldest- skillful in language and social skills Younger toilet trained self 4. Growth and development occurs in a regular direction reflecting a definitive and predictable patterns or trends A. Directional trends occur in a regular direction reflecting the development of neuromuscular function; these apply to physical, metal, social and emotional developments and includes: 1. Cepahalocaudal (head to tail) - it occurs along bodies long axis in which control over head, mouth and eye movements and proceeds control over upper body torso and legs 2. Proximo-distal (centro distal) - progressing from center of body extremities 3. Symmetrical at side of body develop on same direction at same time and same rate 4. Mass specific differentiation in w/c the child learns from simple operations before complex functions or move from a broad general pattern of behavior to a more refined pattern B. Sequential involves a predictable sequence of growth and development to which the child normally passes. 1. Locomotion- ex: creep then walks, sit then stand, walk the run 2. socio and language skills- ex: solitary games, parallel games

C. Secular refers to the worldwide trend of maturing earlier and growing larger as compared to succeeding generations. 5. Behavioral is the most compressive indicator of developmental status : Act at your stage 6. Great deal of skill and behavior is learned by practice. Practice makes perfect 7. Universal language of child PLAY 8. There is an optimum time for initiation of experience or learning 9. Neonatal reflexes must be lost before one can proceed. Rooting Reflex disappear by 6 weeks Plantar reflex - disappear before baby can walk; 8-9 mos Moro reflex - disappear before baby can roll; 4-5 mos : protects himself from the attacker Persistent primitive infantile relexes suspect case of cerebral palsy

THEORIES OF GROWTH AND DEVELOPMENT

Developmental tasks - Different form chronological age - Skills or growth responsibility arising at a particular time in the individuals life.

Theorists 1. SIGMUND FREUD 1856 - 1939 Austrian neurologists. Founder and Father of
psychoanalysis - offered personality development

Psychosexual theory
A.) ORAL PHASE 0 - 18 MONTHS - Mouths site of gratification - activity of infant- biting, sucking crying. - why do babies suck?- enjoyment and release of tension. - provide oral stimulation even if baby was placed on NPO. Significance: Offer pacifier - never discourage thumb sucking. B.)ANAL - 18 MONTHS - 3 YEARS - Site of gratification- anus Obsessive Compulsive -anal phase - Activity: elimination, retention or defecation of feces may occur * toilet training * - Principle of holding on or letting go enters - Mother wins or child wins - Child wins - stubborn, hardheaded anti social. (anak pupu na, child holds pupu,child wins) Impacted stools Letting Hold

- Mother wins - obedient, kind, perfectionist, meticulous Letting GO Significance: help child achieve bowel and bladder control even if child is hospitalized. C.) PHALLIC 4 - 6 YEARS - Site of gratification-genitals - Activity - may show exhibitionism - Increase knowledge of a sexes- accept child fondling his/her own genitalia as normal exploration - answer Childs question directly Right age to introduce sexuality preschool D.)LATENT 7 - 12 YEARS - Period of suppression - no obvious development (slower growth) - Childs libido or energy is diverted to more concrete type of thinking Significance: helps child achieve (+) experience so ready to face conflict of adolescence E.)GENITAL 12 - 18 YEARSOPPOSITE SEX - Site of gratification genitals - achieve sexual maturity and satisfactory - learns to establish relationships with opposite sex. Significance: give an opportunity to relate to opposite sex.

2. ERIK ERICKSON- trained in psychoanalysis theory

- Stresses important of culture and society to the development of ones personality Importance a. environment b. culture

Stages of Psychosocial
A.)TRUST VS. MISTRUST 0 - 18 MONTHS Alert! -Foundations of all psychosocial task -to give and receive is the psychosocial theme To know to develop trust on baby 1. satisfy needs on time breastfeed 2. care must be consistent and adequate - both parents - 1st 1 year of life 3. give an experience that will add to security- touch, hugs and kisses, eye to eye contact, soft music.

B.)AUTONOMY VS. SHAME AND DOUBT 18 MONTHS - 3 YEARS -independence / self government To develop autonomy on toddler 1. give an opportunity of decision making like offer choices. 2. encourage to make decision rather then judge. 3. set limits moral obligations of the parent C.) INITIATIVE VS. GUILT 4 - 6 YEARS - learns how to do basic things well To develop: - give opportunities to explore new places and events Activities recommended: -modeling clay, finger painting will enhance imagination and creativity and further enhances fine motor development D.)INDUSTRY VS. INFERIORITY 7 - 12 YRS - child learns how to do things well To develop: - give opportunity on short assignments and projects E.)IDENTITY VS ROLE CONFUSION OR DIFFUSION 12 - 18 YRS - learns who he/she is or what kind of person he/ she will become by adjusting to new body image and seeking emancipation or freedom from parents F.)INTIMACY VS. ISOLATION 20 40 YEARS UP TO 45 YEARS OLD - looking for a lifetime partner and career focus G.)GENERATIVELY VS. STAGNATION 40 45 60 65 YEARS OLD H.)EGO INTEGRITY VS. DESPAIR 60 65 YEARS OLD AND ABOVE

3. JEAN PAGET- Swiss psychologists;

- Cognitive- develop reasoning power

Stages of Cognitive Development

A. SENSORY MOTOR 0-2 YEARS - practical inteliigence words and symbols not yet available - baby communicates through senses and reflexes

SCHEMA

AGE

BEHAVIOR

1.Neonate Reflex 2.Primary Circular Reaction 3.Secondary Circular Reaction

1 month 1-4 mos

4-8 mos

4.Coordination of Secondary Reaction 5.Tertiary Circular Reaction

8-12 mos 12-18 mos

6.Invention of New Means thru mental combination

18-24 mos

ALL REFLEXES -Activity related to body -Repetition of behavior Ex: thumb sucking -Activity not related to body -Discovers object and persons permanence -memory traces are present -Anticipate familiar events -Exhibit goal directed behavior -Increase of separateness (will search of lost toys, knows mom) -Use trial and error to discover characteristics of places and events -invention of new means -Capble of space and time perception (hits fork, spoon on table or drops fork) -Transitional phase to the pre operational thought period.

B. PREOPERATIONAL THOUGHT 2-7 YEARS SCHEMA AGE BEHAVIOR Preconceptual -Thinking basically complete literal and static 2-4 -Egocentric- unable to view on others view point years -Concept of TIME is only now -Concept of distance is only as far as they can see -Concept of animism inanimate object is alive (animism is the main reason why they are afraid in the dark places) -Not aware of concept of reversibility- in every action there is an opposite reaction or cause and effect Initiative -Beginning of causation 4-7 years C. CONCRETE OPERATIONAL THOUGHT 7 - 12 YEARS 1. able to find solution to everyday problems with systematic reasoning. 2. have concept of reversibility- cause and effect ( in every action there is anopposite reaction) 3. have concept of conservation constancy despite of transformation. Activity Recommended:-collecting and classifying Such as in collection of stamps, stationeries, dolls, rubber band markers. D. FORMAL OPERATIONAL THOUGHT 12 AND UP

1. Cognition achieved its final form 2. can deal with past present and future 3. have abstract and mature thoughts. 4. can find solutions to hypothetical problems with scientific reasoning Activity: will sort out opinions and current events

4. KOHLBERG - recognized the theory of moral development as considered toclosely

approximate cognitive stages of development (sabay with cognitive development ) STAGES OF MORAL DEVELOPMENT Infancy pre-moral, pre-religious, amoral stage AGE STAGE DESCRIPTION Pre LEVEL I conventional 2-3 years 1 Punishment/ Obedience orientation (heteronomous morality) child does right because a parent tells him or her to and to avoid punishment 4-7 years 2 Individualism. Instrumental purpose and exchange. Carries out action to satisfy own needs rather than society. Will do something for another if that person does something for the child Conventional LEVEL II 7-10 years 3 Orientation to interpersonal relations of mutuality. Child follows rules because of a need to be a good person in own eyes and eyes of others 10-12 years 4 Maintenance of social order fixed rules and authority. Child finds following rukes satisfying. Follows rules of authority figures as well as parents in an effort to keep the sytem working. Post LEVEL III Conventional Above 12 years 5 Social contract, utilitarian level making perspectives. Follows standards of society for good of all people 6 Universal ethical principle orientation. Follows internalized standards of conduct

DEVELOPMENTAL MILESTONES
means major markers of growth and development 1. Period of infancy-universal language of child - play a.) Play- Infancy- solitary plays - solo, non interactive example: rattles, mobiles, teeters, music box - facilitate motor and sensory development Note: In choosing toys: safety - important age appropriate b . ) F e a r of Infancy - stranger anxiety begin Alert:begins at 6 - 7 months; peak - 8 months ; diminishes - 9 months c.) Milestone Neonate largely reflex; complete head lag; hands fisted; cry without tears; visual fixation for human face 1 month - dance reflex disappears looks at mobile 2 months - holds head up when in prone, - social smile, - baby coos doing sound - cry with tears - closure of posterior fontanel 2 - 3 months - head lag when pulled to sitting position - holds head and chest up when prone - follows object past midline - grasp and tonic neck reflex fading - hand regard (looks at hand) - turns form front to back - Head control complete - needs space to turn - Laugh aloud, bubbling sounds - turn both ways roll over - teething rings - handles rattle well - moro reflex disappears ( 4 - 5 months) - reaches out in anticipation of being picked up

3 month

4 months

5 months

6 months

- sits with support- uses palmar grasp -eruption of 1st temp teeth 6-8 months 2 lower central incisors - say vowel sounds ah, oh, eh - handles bottle well 7 months beginning fear of strangers (6 7 months) - transfer object hand to hand - likes object that are good size - sits without support - peak of stranger anxiety - plantar reflex disappears 8 - 9 months in preparation for walking - creeps or crawls - neat finger grasp reflex - combine 2 syllables mama and dada - needs space for creeping pull self to stand - understands the word no - responds to own name - peak a boo, pat a cake since they can clap - cruises - stand with assistance - stand alone take 1st step - walk with assistance - drink from cup, cooperate in dressing - says 2 words mama and dada - pots and pans, pull toy, nursery rhymes

8 months

9 months

10 months

11months

12 months

2. Toddler -parallel play- 2 toddlers playing separately a. Play - provide with similar toys Examples: -squeaky frog to squeeze -waddling duck to pull -trucks to push- push pull toy ( best parallel toy) -building blocks, pounding peg -toys to ride on b. Fear -separation anxiety begin 9 months

peak 18 months

3 phases of separation anxiety (in order) 1. P - protect 2. D -despair 3. D -denial How to prevent separation anxiety: - dont prolong goodbye - say goodbye firmly to develop trust - say when you will be back c. Milestones 15 months plateau stage - walks alone Alert: lateness in walking- mild mental retardation - puts small pellets into small bowl - holds spoon well- seats self on chair - creep up stairs- 4 - 6 words - scribbles voluntarily with pencil 18 months -height of possessiveness - favorite word- mine - bowel control achieved (bowel control 1st before bladder control) - no longer rotates spoon- can run and jump in place - walks up and down stairs holding on to persons hand or railing - 7 - 20 words - name, body part - typically places both feet on 1 step before advancing. - also known as the terrible two - can open doors by turning door knob or unscrew lids - can walk upstairs alone, still using both feet on same step at same time - 50 - 200 words ( 2 words sentences) - daytime bladder control achieved (daytime 1st - next nighttime bladder control) makes simple lines or stroke or crosses with a pencil - can jump down from chairs - knows full name - copy a circle- holds up finger to show age - temp teeth complete ( last temporary teeth to appear posterior molars ) ( 20 deciduous teeth )- beginning of toothbrush 2 2 years - tooth brushing with little assistance 3 years

24 months

30 months or 2 years

- tooth brushing alone 6 yrs - right time to bring to dentist- when temp teeth complete ( 2 2 1/2 years old ) 36 months or 3 years trusting 3 - unbutton buttons (unbutton before learn to button) - draw a + - learns how to share - knows full name and sex (gender identity) - speaks fluently - nighttime bladder control achieved - 300 - 900 words - ride a tricycle

d. Character Traits of toddler 1.) Negativistic - NO! - way to search for independence limit questions; offer options modify questions to a statement 2.) Rigid, Ritualistic and Stereotype ritualism - for mastering 3.) Temper tantrums- head banging, screaming, stamping feet, holds breath What to do: ignore behavior Slightly protruding - scaffold abdominal - due to underdeveloped/immaturity of the abdominal muscles physiologic anorexia- due to preoccupation with environment- food jagthat last for short period of time loves rough and tumbling play steady gait love to stay with daddy loves toilet training failure of toilet training unreadiness

Clues of toilet readiness: 1.) can stand, squat walk alone 2.) can communicate toilet needs 3.) can maintain dry for an interval of 2 hours

4. School Age a. Play -competitive play Example: Tug of war, track and field, basketball, volleyball, softball
b. Fear:

1.) school phobia orienting the child to a new environment 2.) displacement from school - teacher and peer of same sex 3.) loss of privacy - wants bra 4.) fear of death 7- 9 years death is personified death permanent loss of life Preschooler - death is sleep age 9 have the same height age 12 girls are taller than boys

c. Significant Development a.boys - prone to bone fracture * greenstick fracture b.mature vision 20/20

d. Milestone 6 years - temporary teeth begin to fall - permanent teeth appear -1st molar * 1st temporary teeth - 5 months * 1stpermanent teeth - 6 years (1stmolar) - year of constant motion- clumsy movement - recognize all shapes - 1st grade teacher becomes authority figure - nail biting - begin interest in God. 7 years - assimilation age - copy a diamond - enjoys teasing and playing alone - quieting down period

8 years

- expansive age - smoother mouth - loves to collect objects - count backwards* homosexual normal coordination improves - tells time correctly - hero worship - stealing and lying are common - takes care of body needs completely - teacher finds this group difficult to handle - age of special talent

9 years

10 years

- writes legibly - ready for competitive games - more considerate and cooperative - joins organizations: girl scouts/boy scouts - well mannered with adult- critical of adults 11 - 12 years pre adolescents - full of energy and constantly active - secret language are common - share with friends secrets - sense of humor present - social and cooperative

e. Character Traits School Age 1. industrious 2. modest 3. cant bear to lose- they will cheat 4. love collections stamps Signs of sexual maturity GIRLS: I-increase size of breast and genitalia Alert: Menarche - 1st sign sexual maturity in girls W-widening of hips A-appearance axillary, pubic Alert: (adrenarch) M-menarche- last sign sexual maturity in Girls BOYS: A-appearance axillary, pubic hair Alert: ( 1st sign sexual maturation) D-deepening voice D- development of muscles I -increase in size of testes and penis P- production of viable spermAlert: ( last sign sexual maturity) 5. Adolescent Period significant others and peers a. Fear 1. obesity 2. acne 3. homosexuality 4. death 5. replacement from friends b. Significant Person opposite sex

c. Significant Development 1. Experiences conflict between his needs for sexual satisfaction and societies expectation 2. They change of body image and acceptance of opposite sex 3. Nocturnal emission wet dreams; hallmark of adolescent 4. Distinctive odor- due to stimulation apocrine glands 5. Sperm is viable by age 17 years Alert: . testes & scrotum increase until age 17 breast and female genitalia increase until age 18 d. Personality Traits Adolescents 1.idealistic 2.rebellious 3.reformers 4.conscious with body image 5.adventuresome e. Problems: 1. vehicular accident Due to peer pressure: 2. smoking 3. alcoholism 4. drug addiction 5. pre marital sex II. IMMEDIATE CARE OF NEWBORN 1st days of life A. The 8 Priorities of the Newborn in the first days of life: 1.Initiation and maintenance of respiration 2.Establishment of extra uterine circulation 3.Control of body temperature 4.Intake of adequate nourishment 5.Establishment of waste elimination 6.Prevention of infection 7.Establishment of an infant-parent relationship 8.Developmental care that balances rest and stimulation for Mental Development 1.)Initiation and maintenance of respiration Alert: 1. 2nd stage of labor- initial airway 2. Initiation of airway is a crucial adjustment among the newborn 3. Most neonatal deaths with in the first 24 hours is primarily causedby inability to initiate airway 4. Lung function begins only after birth How to initiate airway: A. Remove secretions bulb syringe

B. Proper Suctioning with a Catheter 1.) place head to side to facilitate drainage of secretion 2,) suction mouth 1st before nose - neonates are nasal breathers / obligatory nasal breather 3.) period of time - 5 - 10 seconds suctioning, gentle and quick prolonged and deep suctioning can lead to: a.hypoxia b laryngo spasm c.bradycardia due to stimulation vagal nerve located near the esophagus and anus 4.) evaluate for patency - cover one nostril and when the baby struggles theres a need for q additional suctioning C. If not effective, requires effective laryngoscopy to open airway After deep suctioning an endotracheal tube can be inserted and oxygen can be administered by an (+) pressure bag and mask with 100% oxygen at 40 60 bpm Nursing Alert: 1. No smoking for it can facilitate combustion 2. Always humidify to prevent drying of mucosa (Mask should cover thenose/mouth not including the eyes) 3. Over dosage of oxygen can lead to scarring of retina leading toblindness ( retro lentalfibroplasia or ROP - retinopathy of prematurity) 4. When mecomium stained (greenish) never administer oxygen with pressure (O2 pressure will push mecomium inside) to preventatelectasis

2.) Establishing extra uterine circulation Nursing Alert: circulation is initiated by lung expansion or pulmonary ventilation and completed by cutting of cord. FETOPLACENTALCIRCULATION Placenta (simple diffusion) oxygenated blood is carried by the umbilical vein passes liver ductus venousus Inferior Vena Cava Right Atrium 70% bloodis shunted to Foramen Ovale Left Atrium Mitral Valve Left Ventricle Aorta Lower Extremities. The remaining 30% Tricuspid Valve RightVentricle Pulmonary Arteries Lungs (for nutrition) vasoconstriction of lungs pushes blood to the ductus arteriousus to the aorta to supply upper extremities. The two arteries carry the unoxygenated blood back to the placenta for oxygenation. Alerts: Increase Pressure to the left side closure of foramen ovale SHUNTS shortcuts Ductus Venosus - shunts from liver to Inferior Vena Cava Foramen Ovale - shunts between 2 atrias Ductus Arteriosus - from pulmonary artery to aorta

What will initiate lung circulation- lung expansion What will complete circulation- cutting of cord A. 2 way to facilitate closure - of foramen ovale a.) Tangential Foot slap - slap foot of baby to make the baby cry Alert: -never stimulate the baby to cry if secretions not fully drained to prevent aspiration - check characteristic of cry normal cry- strong, vigorous and lusty cry UHA cri-du-chat syndrome-chromosomal obliteration / cat like cry or meowlike cry b.) Proper Positioning- right side lying position - will increase pressure on left and foramen ovale will close Foramen Ovale and Ductus arteriosus will begin to close within 24 hours

Obliteration - means complete closure

STRUCTURE

1.FORAMEN OVALE 2.DUCTUS ARTERIOSUS 3.DUCTUS VENOSUS 4.UMBILICAL ARTERIES 5.UMBILICAL VEIN

APPROPRIATE TIME OF OBLITERATION 1 year 1 month 2 months 2-3 months

STRUCTURE REAMINING Fossa Ovalis Ligamentum Arteriosum Ligamentum venosum 1.Lateral umbilical ligament 2.Interior iliac artery Ligamentum teres (round ligament of liver)

FAILURE TO CLOSE Arterial Septal Defect (ASD) Patent Ductus Areteriosus PDA)

2-3 months

Position of infant immediately after birth: NSD trendelenberg / T position for drainage contraindication of trendelenberg position - increase ICP CS - supine or crib level position Signs of increased ICP 1.) abnormally large head 2.)bulging and tense fontanel 3.)increase BP and widening pulse pressure Cushing Triad of ICP 4.)Decreased Respiratory Rate, decreased Pulse Rate hypo-brady-brady 5.) projective vomiting - sure sign of cerebral irritation 6.)high deviation diplopia sign of ICP older child 4 - 6 months - normal eye deviation > 6 months - lazy eyes or indication of ICP 7.) High pitch shrill cry - late sign of ICP or hypoglycemia

3.) Temperature Regulation Alerts: - goal in temperature regulation is to maintain it not less than 97.7% F (36.5 C) -maintenance of temperature is crucial on preterm and SGA (small for gestational age) babies prone to hypothermia or cold stress A.Factors Leading to the development of HYPOTHERMIA 1.preterms are born per kilo thermic - means cold blooded-babies easily adapt to temperature of environment due to immaturity of thermo regulating system of body Hypothalamus 2.inadequate Subcutaneous tissue

3.new born is not capable of shivering 4.babies are born wet

B. PROCESS OF HEAT LOSS 1.evaporation body to air (TSB) 2.conduction body to cold solid object (cold compress) 3.convection body to cooler surrounding air (aircon) 4.radiation body to cold object not in contact with the body earliest sign of hypothermia -increase in Respiratory Rate C. Effects of Hypothermia ( Cold stress) 1.) Hypoglycemia - 45 - 55 mg/dl normal - 40 borderline 2.) metabolic acidosis catabolism (breaking down) of brown fats (best insulator of newborns body) leading to formation of ketones 3.) high risk for kermicterus body - bilirubin in brain leading to irreversible braindamage such as cerebral palsy 4.) additional fatigue to a stressful heart D. Prevent Hypothermia 1.dry and wrap baby 2.mechanical pressure radiant warmer i.pre-heated first isolette (or square acrylic sided incubator) 3.prevent an necessary exposure cover the areas that is not being examine 4.cover baby with tin foil or plastic 5.embrace the baby - known as kangaroo care 4. Establish Adequate Nutritional Intake CS- breastfeeding after 4 hours NSD- breastfeeding as soon as possible Alerts: A. Physiology breast milk production As you deliver baby, decrease Estrogen, decrease Progesterone- -Anterior Posterior Gland (APG) releases prolactin acts on acinar cells (or alveoli) produce foremilk stored in lactiferous tubules ( or collecting tubules of the breast ) where breast milk is produced alveoli posterior pituitary gland SuckingPPEoxytocincontraction of smooth muscles of lactiferoustubulesmilk ejection reflexlet down reflex. B. Advantages of Breastfeeding 1.Very Economical 2.Always available 3.Facilitates Bonding 4.It facilitates rapid involution

5.Decrease incidence of breast cancer. 6.has antibodies IgA 7.Breastfed babies have higher IQ than bottle fed babies 8.Has lactobacillius bifidus- interferes with attack of pathogenic bacteriain GastroIntestinalTract 9.Has macrophages engulfs bacteria Store milk - plastic storage container Store milk good for 6 months from freezer - put room temp - dont heat Disadvantages: 1.Possibility of transfer HEP B, HIV, cytomegalo virus(CMV) 2.No iron 3.Father cant feed & bond as well C. Stages of Breastmilk: 1. Colostrum 2 - 4 days present content: decrease fatsincrease IgA decrease CHO increase CHON increase minerals increase fat soluble vitamins 2. Transitional milk - 4 14 days content: increase lactose increase water soluble vitamins increase minerals 3. Mature milk - 14 days & up content: Increase Fats (linoleic acid) cause for higher IQ ( responsible for the development of the brain &integrity of skin ) Increase CHO - lactose easily digested, that iswhy the baby not constipated ( responsible for sour milk smelling odor of stool ) Lactose intolerance - deficiency of enzyme LACTASE that digest LACTOSE protein lactoallbumin D. Cows milk increase fats Contents: Decrease CHO that is why we need to add a little sugar Increase CHON casein has curd thats hard to digest that is why baby is constipated Increase Minerals traumatic effect on kidneys of babies. Can trigger stone formation in the kidney Increase Phosphorus reverse proportion in Calcium E. Health Teachings: 1. Proper hygiene - proper hand washing Care of breast - cotton balls with lukewarm water inner to outer

Caked colostrums - dry colostrums on breast 2. Best position in breastfeeding upright sitting - avoid tension! 3. Stimulate & evaluate feeding reflexes a.) Rooting reflex - by touching the side of lips/cheeks then baby will turnto stimulus. Disappear by 6 weeks- by 6 weeks babycan focus. Reflex will be gone **Purpose rooting: to look for food. b.)Sucking Reflex when you touch middle of lips then baby will suck - Disappears by 6 month - When not stimulated easily disappear **Purpose: to take food c.) Swallowing - when food touches posterior of tongue then it will beautomatically swallowed d.)Extrusion/ Protrusion reflex - when food touches anterior portion of tongue then food will be automaticallyextruded or protruded **Purpose: to prevent from poisoning Disappear by 4 months & baby can already spit out by 4 months. Extrusion no force Spitting Up with force 4. Criteria Effective Sucking a.)Babys mouth is hike up well to areola b.)That Mom experiences after pain. c.)Other nipple is also flowing with milk. 5. To prevent from crack nipples & initiate proper production of oxytocin. - begin 2 - 3 minutes at each breast ( 5 7 minutes other authors )to initiate production of oxytocin - increase 1 minute / day until reaching 10 minutes at each breast or 20 minutes / feeding. 6. For proper emptying & continuous milk production / feeding- feed baby on last breast that you feed her with alternately ( if not emptied - mastitis) Problems experienced in Breastfeeding : Changes in breast post partum: a.) Engorgement - feeling of fullness & tension in the breast. - sometimes accompanied by fever known as MILK FEVER. Management:Warm compress - for breastfeeding mom Cold compress for bottle feeding & wear snug supportive bra . When is involution of breast? - 4 weeks b.) Sore nipple cracked, wet and painful nipple

Management: 1.) exposure to air remove bra & wear dress 2.) expose to 20 Watt bulb 3.) avoid wearing plastic liner bra prevent air toenter - will create moisture, cotton only c.) Mastitis- inflammation of breast, cause by staphylococcus aureus Factors: 1. Improper breast emptying 2. Unhealthy sexual practices - contraindicated for breast feeding - manually express inflamed breast - feed on unaffected breast - give antibiotics can still feed on unaffected breast Contra Indications in Breast Feeding: Maternal Conditions: 1.HIV 2.CMV 3.Hepatitis B 4 .Coumadin Newborn Condition - Inborn errors of metabolism 1. Erythrobastosis Fetalis Rh incompatibility 2. Hydrops Fetalis 3. Phenylketonuria (PKU) 4. Galactosemia 5. Tay Sachs disease 5. Establish of waste elimination A. Different Stools A.1.Meconium - physiologic stool - black green, sticky, tar like, odorless because of Sterile intestine -will pass with in 24 36 hours failure to pass mecomium after 24 hour - GastroIntestinalTract obstruction ex: 1. Hirschsprungs disease 2. Imperforate anus 3. Mecomium ileus due to Cystic Fibrosis A.2. Transitional stool - green loose & slimy that may appear to be like diarrheato the untrained eye A.3. Breastfed stool - golden yellow, soft, mushy with sour milk smelling odor frequently passed -recurring almost nearly every feeding

A.4. Bottlefed stool - pale yellow, formed hard with typical offensive odor - seldom passed, 2 3 times a day - with food added - brown & odorous B. Indication of Stool Changes Jaundice baby light stool Undergoing phototherapy bright green Mucus mixed with stool milk allergy Clay colored stool obstruction to bile duct Chalk clay stool after barium enema Black stool GIT bleeding (melena) Blood flecked stool anal fissure. Currant jelly stool intussusceptions Ribbon like stool hirschsprung disease Steatorrhea stool fatty, bulky foul smelling odor stool Malabasorption Syndrome 1.celiac disease or 2.cystic fibrosis Cult blood stool exam III Assessment for Well being A. APGAR SCORE Dr. Virginia Apgar Special Considerations: 1st 1 minute determine general condition of baby Next 5 minute - determine babys capabilities to adjust extra uterinely (most important ) Next 15 minute dependent on the 5 minute Newly Born Baby: A- appearance - color slightly cyanotic after 1st cry baby becomes pink. P- pulse rate apical pulse left lower nipple G- grimace reflex irritabilitySubcomponents: tangential foot slap, catheter insertion A activity degree of flexion or muscle tone R respiration New Delivered Baby: Baby cry within 30 seconds Failure to cry after 30 seconds asphyxia near the neotorium Respiratory Depression due mom given Demerol. Administer Naloxone

APGAR SCORING CHART Heart rate Respiratory rate Muscle tone Reflex irritability Catheter Tangential foot slap Color 0 Absent Absent Flaccid extremities No response No reaction Blue/ Pale 1 <100 Slow, irregular, weak Some flexion Grimace Griamace Acrocyanosis (bodypink extremitiesblue) 2 >100 Good strong cry Well flexed Cough, sneeze Cry Pinkish

APGAR result 0 3 = severely depressed, need CPR, admission NICU 4 6 = moderately depressed, needs additional suctioning & Oxygen Administration 7 - 10 = good / healthy Cardio Pulmonary-Resuscitation Cardio pulmonary resuscitation or CPR other name Cardio pulmonary cerebral resuscitation (CPCR) Basic Life Support ( BLS ) Airway ( Clear Airway) 5 minutes no Oxygen irreversible brain damage 1. Shake, no respiration, call for help 2. Flat on head 3. Head tilt chin lift maneuver [except spinal cord injury] over extension mayocclude airway Breathing ( ventilating the lungs ) 4. Check for breathlessness 5. If breathless, give/administer 2 breaths- ambu bag use one mask * infant mouth and nose > 1 year old- mouth to mouth, pinch nose < 1 year mouth to nose Force different between baby & child infant puff Circulation ( by cardiac compression ) 6. Check for pulslessness :carotid- adult Brachial infants up to 1 year old CPR breathless/pulselessCompression infant 1 finger breath below nipple line or 2 finger breaths or thumb

CPR infant 1 : 5 Adults 2 : 15 7. Assessment tool determines respiration of baby TOOL USE: Silvermann Anderson Index B. RESPIRATION EVALUATION LOWEST SCORE BEST CRITERIA 0 1 Chest movement Synchronized Lag on respiration Intercostal No retraction Just visible Retraction Xiphoid Retraction None Just visible Nares dilation Minimal Expiratory grunt None Heard on stet only Interpretation result: 0 - 3 normal, no Respiratory Distress Syndrome 4 6 moderate Respiratory Distress Syndrome 7 10 severe Respiratory Distress Syndrome C. Assessment of Gestational Age Tool Used: Ballards & Dobouitz FINDINGS LESS 36 WEEKS (PRETERM) Sole creases Anterior transverse crease only Breast nodules 2 mm Scalp hair Fine & fuzzy Ear lobe Pliable Testes and scrotum Testes in lower canal Scrotum small few rugae

2 See saw Marked Marked Marked Heard on naked ear

37-38 WEEKS Occasional creases 2/3 inch 4 mm or 3.5 mm Fine & fuzzy Some cartilage Some intermediate

39 and UP Sole covered with creases >5 or 7 mm Coarse & silky Thick cartilage Testes pendulus Scrotum full Extensive rugae

Signs of Preterm Babies Born after 20 weeks, after 37 weeks - frog leg or laxed positon - hypotonic muscle tone - prone to respiratory problem - scarf sign elbow passes midline - square window wrist 90 degrees angle of wrist - heel to ear sign - abundant lanugo

Signs of Post term babies: > 42 weeks - classic sign old mans face - desquamation peeling of neonate skin - long brittle finger nails - wide & alert eyes IV. Neonate in Nursery * Special and Immediate Interventions: 1. Upon receiving baby - proper identification - foot printing, affixing mother thumb print 2. Take anthropometric measurement Normal Length - 19.5 21 inches or 47.5 53.75 cm Average = 20 inches Average = 50 cm Head Circumference 33- 35 cm or 13 14 inches Average = 34 cmHydrocephalus - >14 inches Chest : 31 33 cm or 12 13 inches Abdomen 31 33 cm or 12 13 inches Note: Head is bigger than the chest/abdomen 3. Bathing - oil bath initial - to cleanse baby & spread vernix caseosa Function of vernix caseosa 1.insulator brown fats 2. bacterio static Alert: 1. Babies of HIV + mom immediately give full bath; to lessen transmission of HIV ; 13 39 % possibly of transmission of HIV 2. Full Bath - safely given when cord falls 4. Dressing the Umbilical Cord * follow strict asepsis to prevent tetanus neonatorium by giving tetanous toxoid three cleans in community: 1. Clean hand 2. Clean cord 3. Clean surface Note: Betadine or Povidone Iodine - used for cleaning the cord Umbilical Granulation after 2 weeks, umbilical cord does not fall. * Check for three vessels Alert: 1. If 2 vessel cord suspect kidney malformation 2. Leave about 1 inch of cord * If Blood Transfusion or IV infusion leave 8 inches of cord best access no nerve

* Check cord every 15 minutes for 1st 6 hours bleeding > 30 cc. of blood hemorrhage to the new born * Bleeding of cord with pus Omphalitis suspecthemophilia/blood dyscrasia * Best access for IV transfusion Umbilical cord * Cord turns black on 3rd day & fall 7 10 days * Faiture to fall after 2 weeks- Umbilical granulation Management: silver nitrate or catheterization -clean with normal saline solution not alcohol -dont use bigkis air - persistent moisture-urine, suspect patent uracus fistula between the bladder and normal umbilicus Diagnostic Examination: Nitrazine paper test yellow urine Management: Surgery 5. Credes Prophylaxis Dr. Crede - prevent opthalmia neonatorum or gonorrheal conjunctivitis - how transmitted mom with gonorrhea/ Chlamydia Drug: Erythromycin Ophthalmic Ointment- inner to outer silver nitrate (used before) 2 drops lower conjunctiva (not used due to staining) 6. Vitamin K to prevent hemorrhage Related To physiologic hypoprothrombinemia - Aquamephyton, phytomenadione or konakion - .5 1.5 ml IM, vastus lateralis or lateral anterior thigh - 5 ml preterm baby Vitamin K synthesized by normal flora of intestine Vitamin K medication is synthetic due intestine is sterile 7.Weight-Taking: Normal weight: 3.000 3400 grams ; 3 3.4 kg 6.5 - 7.5 lbs Arbitrary lower limit 2500 grams Low birth weight baby delivered < 2500g Small for gestational age (SGA) < 10th% rank or born small Large for gestational age > 90th% rank or macrosomia > 4000 g Appropriate for Gestational Age within 2 standard deviation of mean Physiologic weight loss 5 10% wt loss few days after birth Small Gestational Age < (less) 10 Large Gestational Age > (more) 90

V. Physical Exam and Deviations from Normal

A. Important Considerations: 1. if client is new born, cover areas not being examined 2.if client is infant the 1st yr of life - the first vital sign to take * from the least intrusive to the most intrusive area take Respiratory Rate 1st 3. if client is a toddler and preschool, let them handle an instrument like: - play syringe or stethoscope, security blanket favorite article. Let baby hold it. 3.if the client is school age and adolescent, explain procedure and respect their modesty B. Components: 1. Vital Signs: * Temperature rectal - newborn to rule out imperforate anus -take it once only, 1 inch insertion Imperforate anus 1.atretic no anal opening 2.agenetic no anal opening 3.stenos has opening 4.membranous has opening Earliest sign: 1. no mecomium 2. abdominal distention 3. foul odor breath 4. vomitous of fecal matter 5. can aspirate respiratory problem Management: Surgery with temporary colostomy * Cardiac rate: 120 160 beats per minute newborn Apical pulse left lower nipple Alert: Radial pulse normally absent. If palpable present PDA( Patent Ductus Arteriosus ) Femoral pulse normal present. If absent- COA( Coartation of Aorta )

CONGENITAL HEART DISEASE

* Common in girls : 1. PDA (Patent Ductus Arteriousu) 2. ASD (atrial septal defect) * Common in boys: 1. TOGA ( transportation of great arteries) 2. TA ( tricuspid atresia)3. TOF (tetralogy of fallot)

Causes: 1 . f a m i l i a l 2.exposure to rubella (german measles) 1st month 3.failure of structure to progress Two Major Types: 1. acyanotic Left to Right 2. cyanotic Right to Left Two Major Types: A.ACYANOTIC HEART DEFECTS LEFT TO RIGHT SHUNTING * with increase Pulmonary Blood Flow 1.VENTRICULAR SEPTAL DEFECT - OPENING BETWEEN 2 VENTRICLES Signs & Symptoms: 1. systolic murmurs at lower border of sternum and no other significant signs 2.cardiac catheterization reveals increased oxygen saturation at the Right sideof the heart 3.ECG reveals hypertrophy of the right ventricle or Right side of the heart 50% - goes to the Upper/Lower extremities 50% - right side of the heart causing hypertrophy of the right ventricle Nursing Care: Cardiac catheterization: common site Right femoral vein 1. NPO 6 hours before procedure 2.protect site of catheterization. PROTECTION OF Femoral Vein: a.Avoid flexion of joints proximal to site. b.Observe for the signs and symptoms of complications 3.assess for complication 1. infection 2.thrombus formation possible embolism 4.check pedal pulse ( dorsalis pedis) Management: 1.)self limiting 2.)open heart surgery 2. ATRIAL SEPTAL DEFECT failure of foramen ovale to close within 24 hours(closure) Position: right side lying position

Signs and Symptoms: 1.systolic murmur @ upper border of sternum 2.result of cardiac catheterization & ECG same with Ventricular Septal Defect Management: - open heart surgery 3.ENDOCARDIAL CUSHION DEFECTS also known as atrium ventricular (AV ) canal between the atria and ventricles ; affects both tricuspidand mitral valve Signs and Symptoms: confirmed by cardiac catheterization Management: -open heart surgery 4. PDA PATENT DUCTUS ARTERIOSUS - failure of ductus arteriosus to close - should close within 24 hours - complete close 1 month Signs and Symptoms: 1.continuous machinery like murmurs 2. prominent/ presence radial pulse 3.ECG- hypertrophy Left ventricle Management: 1.Endomethazine prostaglandin inhibitor - facilitate closing of PDA 2.Ligation of PDA by 3 - 4 years old 3.thoracotomy procedure- nakadapa child * with decrease Pulmonary Blood Flow 1. PULMONARY STENOSIS - narrowing of valve of pulmonary artery Signs &Symptoms: 1. typical systolic ejection murmur 2. S2 sound widely split 3. ECG - Right ventricular hypertrophy 2. AORTIC STENOSIS narrowing of valve of aorta Signs and Symptoms: 1. inactive, symptoms same with angina

2. typical murmur 3. rough systolic sound and thrill 4. ECG- Left ventricular hypertrophy * If active the child may exhibit signs of Angina Management: Pulmonary Stenosis & Aortic Stenosis 1.)balloon stenostomy 2.)surgery recurrent so the least important 3. DUPLICATION OF AORTIC ARCH - doubling of arch of aorta causing compression to trachea and esophagus Signs&Symptoms: 1. dysphagia 2. dyspnea 3. left ventricular hypertrophy ECG Management: close heart surgery 4.COARTATION OF AORTA narrowing/ congestion of arch of aorta Outstanding Symptom : absent femoral pulse *Blood Pressure higher on upper extremities and decreased on lower extremities * ECG hypertrophy Left ventricle Management: close heart surgery B. CYANOTIC HEART DEFECTS Right to Left * with increase Pulmonary Blood Flow 1.TRANSPORTATION OF GREAT ARTERIES (TOGA) - a situation wherein aorta arising from Right ventricle pulmonary artery arising from Left ventricle Outstanding Symptoms: 1.cyanosis after the 1st cry (due to no oxygenation) Mechanism to decrease polycythemia increased RBC = compensatory mechanism to decrease Oxygen supply = viscous blood causing =thrombus = embolus = stroke(complications 2.ECG cardiomegaly Management: Palliative repair rashkind procedure Complete repair mustard repair

2.TOTAL ANOMALOUS PULMONARY venous return pulmonary vein instead of entering Left atrium, enters Right atrium or Superior Vena Cava Increased pressure on Right so blood goes to Left (open foramen Ovale) Right to Left Shunting supplying the body mixture with blood Outstanding Sx: Open foramen ovale Mild to moderate cyanosis Polycythemia = thrombus = embolus = stroke Asplenia - absent spleenManagement: Restructuring of heart 3.TRUNCUS ARTERIOUSUS - aorta & pulmonary artery is arising from 1 single vessel or common trunk with VSD Signs & Symptoms: 1. Cyanosis 2. polycythemia thrombus = embolus = stroke Management: Restructuring of Heart 4.HYPOPLASTIC LEFT HEART SYNDROME non-functioning Left ventricle * Function of the left ventricle is to pump oxygenated blood to aorta Signs and Symptoms: 1. cyanosis 2. polycythemia thrombus = embolus = stroke Management: heart transplant 5.TRICUSPID ATRESIA failure of tricuspid valve to open Signs and Symptoms: 1. open foramen ovale(R to L shunting goes to Lt atrium) 2. cyanosis 3. polycythemia Management:Fontanprocedure open tricuspid valve 6.TETRALOGY OF FALLOT Four Anomalies Present: P pulmonary stenosis V ventricular Septal Defect O overriding or dextroposition of aorta

R Right ventricular hypertrophy Signs & Symptoms: 1.Right ventricular hypertrophy 2.high degree of cyanosis 3.polycythemia 4.severe dyspnea only relieve by squatting position inhibit venous return - facilitate lung expansion. 5.growth retardation due no O2 6.Tet Spell or blue spells - short episodes of hypoxia 7.syncope or fainting 8.clubbing of fingernails due to chronic tissue hypoxia 9.mental retardation due decreased O2 in brain Management: 1.Oxygen 2.no valsalva maneuver , fiber diet laxative 3.morphine hypoxia 4. propranolol (Inderal) decrease heart spasms 5.palliative repair BLT blalock taussig procedure - Brock procedure complete repair

ACQUIRED HEART DISEASE

1.RHD Rheumatic Heart Disease - inflammatory disease followed by an infection acquired/caused by group A Beta hemolytic strepto coccus Affected body parts : 1. cardiac muscles and valves 2. musculoskeletal 3. CNS 4. Integumentary * From initial Sorethroat before RHD Tonsillitis (children because they love sweets) * Aschoff Bodies rounded nodules with multinucleated cells and fibroblasts that staysand occludes mitral valve. Signs and Symptoms: JONES CRITERIA MAJOR 1. Polyarthritis multi joint pain 2. Chorea syndenhamms chores or st. vetaus dance purposeless involuntary hand and movements of shoulder accompanied by grimacing 3. Carditis tachycardia

MINOR 1.arthralgia joint pain 2.low grade fever

3. all lab results = elevated increase antibody

4. Erythema marginatum muscular rashes SQ nodules

Increase C reactive protein Increase erythrocyte Sedimentation rate Sedimentation anti-streptolysin O titer (ASO)

Criteria: Presence of 2 major signs, or 1 major and 2 minors + history of sore throat willconfirm the diagnosis Diagnostic Tests: 1 . A n t i b o d y 2.C-reactive protein 3.Erythrocyte Sedimentation Rate 4.Anti Streptolysin O titer (ASO) Nursing Care: 1.Complete Bed Rest 2.Avoid contact sports 3.throat swab prepare culture and sensitivity 4.antibiotic management to prevent recurrence 5.aspirin anti-inflammatory. Low grade fever dont give aspirin. Side Effects of aspirin: * Reyes syndrome encephalopathy accompanied by fatty infiltration of organs such as liver and brain

RESPIRATION
Newborn respiration: 30 - 60 breaths per minute, irregular abdominal or diaphragmatic with short period of apnea (absence of breathing) without cyanosis < 15 seconds normal apnea newborn Respiratory Check: Newborn 40 90 1 year - 20 40 2 3 years - 20 30 5 years - 20 25 10 years - 17 22 15 years & above - 12 20 BREATH SOUNDS HEARD DURING ASCULTATION: 1.) VESICULAR soft, low pitched, heard over periphery of lungs, inspiration longer than expiration. Normal 2.) BRONCHOVESICULAR - soft, medium-pitched, heard over major bronchi,inspiration equals expiration. Normal 3.) BRONCHIAL SOUNDS - loud high pitched, heard over trachea, expiration longer than inspiration. Normal

4.) RHONCHI snoring sound made by air moving through mucus in bronchi. Normal5.) RALES - or crackles ( like cellophane ) made by air moving through fluid in alveoli.Abnormal : denotes pneumonia or pulmonary edema which is fluid inalveoli 6.) WHEEZING - whistling on expiration made by air being pushed through narrowed bronchi .Abnormal: seen in children with asthma or foreign-bodyobstruction. 7.) STRIDOR - crowing or rooster like sound made by air being pulled through aconstricted larynx. Abnormal : seen in children with respiratoryobstruction 8.) R ESONANCE Loud , low tone, percussion sound over normal lung tissue 9.) HYPERRESONANCE Louder. lower sound than resonance, a percussion soundover normal lung tissue ASTHMA pathognomonic sign expiratory wheezing Pet fish. Sport swimming Drugs Amynophylline Monitor blood pressure, may lead to hypotension

RDS (RESPIRATORY DISTRESS SYNDROME OR HYALINE MEMBRANE DISEASE) Cause: lack of surfactant ( Lecithin) for lung expansion Hypotonia, Post surgery, Common to preterm

FIBRINE HYALINE Symptoms: 1.definite with in 1st 4 hours of life 2.RETRACTION: EARLIEST SIGN Increase RR with retraction 3.Inspiratory grunting pathognomonic 7 10 severe RDS (silvermenn Anderson index)cyanosis due to atelectasis 4.flaring alaenacy Management: 1.surfactant replacement and rescue 2. position: head elevated 3. proper suctioning 5 10 seconds 4.oxygen with increase humidity - to prevent drying of mucosa 5.monitor Vital Signs, skin color , ABG 6.CPAP- continuous positive airway pressure 7.PEEP - positive end expiratory pressure Purpose of # 6-7- to maintain alveoli partially open and alveoli collapse

LARYNGOTRACHEOBRONCHITIS LTB most common Croup refers to the viral infection of larynx (inflamed),trachea & bronchi outstanding symptoms:croupy cough or barking pathognomonic -stridor = signs of carbon dioxide retention ( RespiratoryAcidosis)

-labored respiration -respiratory acidosis -end stage death Laboratory: 1.ABG 2.throat culture 3.diagnosis - neck 4.Chest x-ray to rule out epiglotitis Nursing Management: 1. bronchodilators ( Racemic Epinephrine ) 2. increase oxygen with humidity 3. prepare tracheostomy set

LARYNGO TRACHEO BRONCHITIS LTB -inspiratory stridor pathognomonic sign

BRONCHOLITIS - Inflammation of bronchioles tenacious mucus Causative agent RSV Respiratory sincytial viruses Symptoms: flu like symptoms/cold like symptoms Increased Respiratory Rate Drug:Antiviral Ribavirin End stage epiglotitis

EPIGLOTITIS - inflammation of epiglottis - emergency condition of Upper Respiratory Tract Infection Symptoms: sudden onset Tripod position leaning forward with tongue protrusion

Management: Avoid/never use tongue depressor prepare tracheotomy set < 5 years old unable to cough out, put on mist tent (humidifier o2) or croupette Nursing Care: check edges tucked on mist tent Provide washable plastic material toys for mist tent No toys with friction due Oxygen No hairy toys due moist environment medium for bacterial growth

Drug of Choice: RIBAVIRIN Blood Pressure Cuff should cover 2/3 or 50 75% of the upper arm More than 2/3 = low Blood Pressure Below 2/3 = False high blood pressure * Blood Pressure 80/46 mmHg newborn * Blood Pressure after 10 days - 100/50 * Blood Pressure taking begins by 3 years old COA coartation of aorta take Blood Pressure on 4 extremities

2. SKIN: Acrocyanosis Body : pink - Extremities: blue BIRTHMARKS: 1.Mongolian spots stale gray or bluish discoloration patches commonly seen across the sacrum or buttocks due to accumulation of melanocytes. Disappear by 1 year old . Common in Asiannew borne 2.Milla plugged or unopened sebaceous gland . white pin point patches on nose, chin or cheek. Disappear without treatment by 2 -4 weeks 3.Lanugo fine, downy hair common preterm 4.Desquamation peeling of newborn skin within 24 weeks post term- extreme dryness that begin sole and palm. 5.Stork bites (Talengeictasi nevi) pink patches at the nape of the neck - hair will grow as child grows old 6.Erythema Toxicum (flea bite rash) - 1st self limiting rash appear sporadically & unpredictably any time & place. 7.Harlequin sign dependent part is pink, independent part is blue (side lying bottom part is dependent pink) 8.Cutis Marmorato transitory mottling of neonates skin when exposed to cold. 9. Hemangiomas vascular tumors of the skin

3 types Hemangiomas A.) Nevus Flammeus port wine stain macular purple or dark red lesions usually seen on the face or thigh. NEVER disappear but\as the child grows it can be removed surgically B.) Strawberry hemangiomas nevus vasculosus dilated capillaries in the entire dermal or subdermal area continuing to enlarge but disappears after 10 years old. C.) Cavernous hemangiomas consists of communicating network of venules in subcutaneous tissue that never disappear with age. MOST DANGERIOUS internal hemorrhage

10. Vernix Caseosa white cheese like for : 1. lubrication 2. insulator Significance 3. bacterio static Skin color and their significance: blue cyanosis or hypoxia Pale skin anemia White/Shining edema Grey infection ellow jaundice , carotenimia - carotene in the skin * BURN TRAUMA is an injury to body tissue caused by excessive heat. INFANT ANTERIOR POSTERIOR 9.5 9.5 1 1 2 2 1.5 1.5 13 1.25 13 13 1 2.5 @ 2.75 2.75 2.5 2.5 1.75 1.75 5-9 YEARS OLD ANTERIOR POSTERIOR 6.5 6.5 1 1 2 2 1.5 1.5 1.25 1.25 13 13 1 2.5 @ 4 4 3 3 1.75 1.75

Head Neck Upper arm Lower arm Hand Trunk Back Genitals @ Buttocks Thigh Leg Foot

Assessment: 1. DEPTH 1st degree-

(partial thickness) involves only the superficial epidermis characterized byerythema, dryness and PAIN example:sunburn, heals by regeneration from 1 10 days (partial thickness) involves the entire epidermis & portion of dermis, characterized by erythema, blisters, moist from exudates which isextremely painful example: scalds (full thickness) involves both skin layers, epidermis and dermis/ may involve adipose tissue, fascia, muscle & bone. It is leathery, white or black and not sensitive to pain since nerve endings had been destroyed.

2nd degree

3rd degree

Example: lava burns; flames

Management: 1.) 1st aid a.) put out flames by rolling child on a blanket b.) immerse burned part on cold water c.) remove burned clothing of with sterile material d.) cover burn with sterile dressing 2.) Maintenance of a patent airway a.) suction if necessary (PRN) b.) administration of oxygen with increased humidity c.) endotracheal intubation d.) tracheostomy 3.) Prevention of shock & Fluid and Electrolyte imbalance a. colloids to expand blood volume b. isotonic saline to replace electrolytes c. dextrose & H2o to provide calories 4.) A booster dose of Tetanus toxoid 5.) Relief of pain such as IV analgesic MORPHINE SO4 needed for 2nd degree very painful 6.) Prevention of wound infection 1st defense of body intact skin a.)cleaning & debriding of wound b.)open or close method of wound care c.)whirlpool therapy drum with solution 7.) Skin grafting 3rd degree thigh or buttocks (autograft) (common in children) pigs/ animals xenograft frozen cadaver hallow graft 8.) Diet increase/high CHON, increase calories *ATOPIC DERMATITIS-INFANTILE ECZEMA (HIKA NG BALAT) Papulo vesicular erythematus lesions with weeping & crusting Cause food allergies: milk, citrus juice, eggs, tomatoes, wheat Symptoms: extreme pruritus, linear excoriation, weeping and crusting; scalyshiny white lechenification Goal of care: decrease pruritus avoid food allergens Diet: Isomil or Nutramigen Hydrate skin with a borow solution topical steroid such as 1% hydrocortisone cream Prevent infection proper handwashing, trim nails: cut it short

* IMPETIGO - skin disease. Causative agent cause by group A beta Hemolytic streptococcus characterized by Papulo-vesicular surrounded by localized erythema becoming purulent and oozes forming a honey colored crust *PEDICULOSISCAPITISKUTO Management: proper hygiene wash soap and water Sequelae: oral penicillin bactroban ointment Can lead to acute glomerulonephritis AGN

* ACNE- adolescent problem (common) -self limiting inflammatory disease that involves sebaceous gland -comedones sebum causing white heads -sebum - composed of lipids/cholesterol causing acne bulgaris Management: proper hygiene- mild soap or sulfur soap Body Acne - antibacterial Retin A or Tretinol

* ANEMIA - pallor Possible Causes: 1.) early cutting of cord preterm cut umbilical cord ASAP fullterm cut umbilical cord when pulsation stops 2.) Bleeding disorders blood dyscrasias

* HEMOPHILIA- deficiency of clotting factor. - X linked recessive inheritance * If mom carrier, son affected * If father carrier - transmitted to daughter Hemophilia A deficiency of coagulation component factor 8 (Classic) Hemophilia B or Christmas Disease, deficiency of clotting factor 9 Hemophilia C deficiency of clotting factor 11 Assessment: -umphalagia earliest sign ( excessive bleeding of the cord or after Circumcision -newborn receive maternal clotting factor (no bleeding) -newborn growing easy bruising on bump area marks earliest sign

-continuous bleeding hematrosis damage or bleeding s ynovial membrane Diagnostic test : PTT. Partial thromboplastin time reveals deficiency in clotting factor Long Term Goal- prevention of injury Nursing Diagnosis: increase risk of injury Health Teaching: 1. avoid contact sport, swimming only 2. dont stop immunization just change gauge of needle Falls immobilized , elevate affected part, apply gentle pressure - not more then 10 minutes - cold compress 3. determine case before doing invasive procedure Alert: NO ASPIRIN

* LEUKEMIA - group of malignant disease characterized by rapid proliferation of immature White Blood Cell (5,000 10,000 cucmm3) WBC protection from infection, soldiers of body Classification : 1.Lympho affects lymphatic system 2.acute / blastic- affects immature cell Acute Lymphocytic Leukemia Modst common cancer)* 3.Myelo affects bone marrow Leukemia 4.chronic/ cystic- affects mature cells (Most common Cancer) Signs & Symptoms: 1. from invasion of bone marrow signs of infection a.)fever b.)poor wound healing c.) bone weakened & causes fracture *signs of bleeding a.) petechiae - small, round, flat, dark red spot b.)epistaxis nose bleeding c.)hematuria - blood in urine/ emesis blood in vomiting *signs of anemia a.)pallor b.)easy fatigability 2. from invasion of body organ - hepato spenomegaly abdominal pain , CNS affectation, increase ICP

Diagnostic Tests: 1.PBS - peripheral blood smear determine immature RBC 2.CBC determine anemia, leukocytosis, thrombocytopenia, neutropenia 3.lumbar puncture (LP) determine CNS involvement. * Before Lumbar Puncture , fetal position - avoid flexion of neck will cause airway obstruction.C position or shrimp position only. 4.bone marrow aspiration determine blast cells - COMMON SITE : ILEAC CREST -Post BMA: side effect : - bleeding - apply pressure. Put patient on affected side to prevent hemorrhage 5. Bone scan determine bone involvement 6. CT Scan determine organ involvement

Therapeutic Management: TRIAD: for CANCER 1.surgery 2.irradiation 3.chemotherapy Focus Nursing Care: prevent infection 4 LEVELS OF CHEMOTHERAPHY 1.For Induction goal of treatment: to achieve remission Medications: IV vincristine L- agpariginase Oral prednisone 2. For Sanctuary - treat leukemic cells that invaded testes & CNS Give: 1. Methotrixate - administer intrathecally via CNS or spine 2. Cytocine 3. Arabinoside, steroids with irradiation 3. For maintenance - to continue remission Give: oral methotrisate check WBC - administration of methotrisate do weekly White Blood Cell check-up oral 6 Mercaptopurine; Cytarabine 4. For Reinduction reduce leukemic cells after relapse occurs. Medications: same as induction 5. Antigout Agents: allopurinol or Zyloprim - treat or prevent hyperurecemic nephropathy.

Nursing Management: 1. Assess the common side effects of chemotherapy Outstanding nursing diagnosis: alteration in nutrition less body requirement. Based on Maslows hierarchy Physiologic always the first priority Side Effect of Chemotherapy: 1. Nausea and Vomiting administer antiemetic drugs 30 minutes before chemotherapy and continue until 1 day after chemotherapy 2. Ulcerations / stomatitis / abscess of oral mucosa- (alteration nutrition less than body requirement) oral care: 1. alcohol free mouthwash 2. betadine mouthwash 3. dont brush 4. use cotton pledgets 5. topical xylocaine before meals soft, bland diet according to childs preference

diet:

Temporary Side Effects of chemotherapy: a. Alopecia altered body image b. Hiesuitism hair Health Teaching: - Give emotional support to parents -

HEMOLYTIC DISORDERS
-destruction of RBC a. Rh Incompatibility Rhesus Monkey Foreign Body CHON Mother (-) = no antigen (no protein factor) Father (+) = has antigen (protein factor) Erythroblastosis Fetalis Hemolysis - oxygen carrying IUGR with pathological jaundice within 24 hours Rhogan a vaccine given to Rh (-) given to mother within 72 hours to destroy fetal RBChence preventing Rh sensitization after 72 hours should not be given

ABO incompatibility Most common incompatibility ( mom) O ( fetus) A,B,AB Most severe incompatibility (Mom) O (Fetus) B Can affect 1st pregnancy O universal donor ; AB universal recipient Hydrops (h20) Fetalis edematous on lethal state with pathologic jaundice Within 24 hours ( most common ABO incompatibility) Management: 1. Initiate feeding 2. Temporary suspension of breastfeeding glucoronil transferase content breast milk pregnanedioles that delaysaction of glucoronil transferase glucoronil transferase is a liver enzymes converts indirect bilirubin (FAT SOLUBLE) to become direct bilirubin (water soluble) * Life span of RBC 20 days 3.Use of phototherapy 4.Exchange transfusion for Rh or ABO affectations that tend to cause continuous decrease in hemoglobin during the first 6 months because the bone marrow failsto produce erythrocytes in response to continuing hemolysis. Yellow Jaundice Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term Normal 0 - 3 mg/dL (indirect bilirubin) -bilirubin encephalopathy -Kemicterus - > 20 mg/dL among full term & >12 mg /dl of indirect preterm = can lead to cerebral palsy Physiologic jaundice jaundice within 48 -72 hours (2-3 days) expose morning sunlight - also known as Icterus Neonatorium ( Yellow Baby) Pathologic Jaundice within 24 hours. Jaundice during delivery. Icterus Gravisneonatorium ( Baby Yellow na) Breastfeeding jaundice caused by pregnanediole delayed reaction of glucoronil transferase; present 6 -7 days Assessment of Jaundice : 1. Blanching neonates forehead, nose or sternum ( normal cyanotic ) 2. yellow skin & sclera 3. color of stool light stool 4. color of urine dark urine Management: Phototherapy photo oxygenation Nursing Responsibilities:

1.cover eyes prevent retinal damage 2.cover genitals prevent priapism painful continuous erection 3.change position regularly even expose to light 4.increase fluid intake due prone to dehydration 5.monitor Input & Output weigh baby weigh diaper 1gm = 1cc 6.monitor Vital Signs avoid use of oil or lotion , due to heat at phototherapy side effects: bronze baby syndrome - transient Side Effect of phototherapy 18 inches 20 inches= height of phototherapy light 3. Head largest part of baby ; of its length Craniostenosis or craniosinustosis premature closing of anterior fontanel Hydrocephalus ant fontanel open after 18 months Microcephaly small growing brain - due to alcohol & HIV positive mom withdrawal syndrome Anencepahly absence of cerebral hemisphere Noticeable Structures of the Head: 1. Craniotabes localized softening cranial bone. Common to the 1st born child - due to early lightening (2 weeks prior to EDD) Rickets of Vitamin B deficiency soft craniotabes in older children 2. Caput Succedaneum edema of scalp due prolonged pressure at birth Characteristics: 1.present at birth 2.crosses suture lines 3.disappear after 2 - 3 days

3. Cephalhematoma - collection of blood due to rapture of periosteal capillaries Characteristics : 1. present after 24 hours 2.never cross suture line 3.disappear after 4 - 6 weeks 4. Seborrheic Dermatitis craddle cap Scaling, greasy appearing salmon colored patches usually seen on scalp the behind ears and umbilicus Cause: - improper hygiene Management: 1.proper hygiene 2.application of baby oil before shampooing the child 5. Hydrocephalus excessive accumulation of CerebroSpinalFluid 1.communicating extra ventricular hydrocephalus

2.non-communicating- intraventricular hydrocephalus or obstructive hydrocephalus mainly due to tumor obstruction Symptoms: ICP abnormally large head, bulging fontanel -cushings triad : Blood Pressure ; Respiratory Rate with widening ; high pitched cry older children diplopia eye deviation - projectile vomiting -fontanel bossing prominent forehead -prominent skull vein -sunset eyes Management: Position to lessen ICP low semi-fowlers 30 degrees angle Administer - osmotic diuretic: Mannitol/ Osmitrol , Diamex- Azetam To decrease CSF production Surgery Shunting AV shunt or VP shunt (ventriculoperitoneal shunt) Shave hair just before the surgery in OR to prevent growth of micro organism

Nursing Care: 1.) post VP shunt

side lying on non operated site - to prevent increase ICP or increase IOP monitor for good drainage - sign sunken fontanel bulging fontanel blocked shunt

4. SENSES A. Sense of Sight (EYES): Assessment 1.check for symmetry 2.sclera normal color light blue then become dirty white 3. pupils round- adult size coloboma- part of iris is missing sign: key hole pupil whiteness & opacity of lens congenital cataract cornea round & adult size larger congenital glaucoma Test for blindness common tests 1.Newborn general appearance - can only see 10 inches 12 inches - visual acuity 20 /200 to 20/ 800 1.1. Dolls eyes test - test for blindness -done 10th day -pupil goes opposite to direction when head is moved 1.2. Globellars test test for blink reflex. Points near nose baby should blink (-) blink - - blind

2.Infant & children - general appearance - ability to follow object past midline 3.3 years school age - general appearance Allen cards test for visual acuity. Show picture 20 feet away Ishiharas plates test for color blindness Prechool E chart - test for stereoptist of depth perception Cover testing test cover 1 eye for 10 15 min. Then remove. Test for strabismus 4.School age adult - general appearance - snellens test Retinobastoma malignant tumor of retina Outstanding sign :oats eye reflex-whitish glow of pupil -red painful eye usually accompanied with glaucoma - b l i n d n e s s surgery Enucleation removal of eyeball put artificial eye Normal 4 6 months eye deviation > 6 months lazy eye: eye patch for covering the eyes B. Sense of Smell (NOSE): 1.flaring alenase case of RDS 2.cyanosis at rest choanal atresia - post nares obstructed with bone or membrane Symptoms: 1.resistance during catheter insertion Management: emergency Surgery within 24 hours * normal color nasal membrane pinkish * chronic rhinitis presence of creases & pale * check sense of smell blindfold smell * inflammation/infection red membrane * Hair in nose cilia Adolescent no hair with ulceration of nasal mucosa suspect cocaine user Epistasis nosebleed -sit upright, head slightly forward to facilitate drainage -cold compress , apply gentle pressure, epinephrine administration based on constriction * most developed sense of newborn sense of touch

* 1st sense to develop & last to disappear hearing C. Sense of Hearing (EARS): 1.Kidney Malformations : Properly aligned with outer cantus of eyes low set ear kidney malformation/ chromosomal aberrations example: Renal aginesis absence of kidney unilateral one kidney Bilateral two kidneys sign in uterus : oligohydramnios sign in newborn: 2 vessel cord failure to void within 24 hours (suspect renal aginesis) Management: kidney transplant 2. Chromosomal aberrations : related to advance maternal age A. Nondisjunction uneven division Classifications: 1.1.Trisomy 21- down syndrome - extra chromosome 47xx + 21 - related to advance paternal age 47xy + 21 Symptoms: Mongolian slant eyes; low set ears Broad flat nose Protruding tongue Puppys neck Simean crease (Hands) single transverse line on palm. Mental Retardation 1.2.Trisomy18 edward syndrome sole of foot is rounded called Rockers Bottom Foot 1.3. Trisomy 13 - patau syndrome - microptamia 1.4. Turners Monosomy of X syndrome -45 x 0- a f f e c t e d g i r l s -signs , evident during puberty -has poorly developed secondary sexual characteristics - S t e r i l e 1.5. Klinefilters Syndrome- has male genitalia - 47 XXY - poorly development secondary sexual characteristics - no deepening of voice - characteristics: small testes and penis sterile * Klinefelter Calvin Kline male * Turner Tina Turner female B. Deletion Abnormalities 1 . C r i - d u - c h a t S y n d r o m e - chromosomal obliteration / cat like cry or meow like cry

2.Fragile X Syndrome

C. Translocation Abnormalities 1.Balanced Translocation Carrier 2.Unbalanced Translocation Syndrome

D. Others 1.Mosaicism a situation wherein the nondisjunction of chromosomes occurs during the mitotic cell division after fertilization resulting to different cells contains different numbers of chromosomes. 2.Isochromosomes a situation wherein the chromosome instead of dividing vertically it divides horizontally resulting to chromosomal mismatch. *** Otitis Media inflammation of middle ear. Common children due to wider & shorter Eustachian tube Causes 1.)bottle propping 2.)Cleft lip/ cleft palate Symptoms: Otitis 1.bulging tympanic membrane, color pearl y gray 2.absence light reflex 3.observe for passage of milky, purulent foul smelling odor discharge 4.observe for URTI Nursing Care: 1.position side lying on affected aside to facilitate drainage 2.supportive care- bed rest, increase fluid intake Medications : 1. Massive dosage antibiotic Complication bacterial meningitis 2. Apply ear ointment * < 3 years old - down-back (small child) * > 3 years old - up-back (school age) Small child down & back ( no age) < 3 years old down & back >3 years old up & back School age up and down Surgery (to prevent permanent hearing loss) otitis media myringotmy with tympanostomy tube post surgery position affected side for drainage slight incision of both of both- put ear plug tympanic membrane if tympanous tube falls healed na

5. Mouth and Tongue a. Bells Palsy- facial nerve; #7 cranial nerve injury or paralysis R/T forcep delivery Symptoms. 1.Continuous drooling of saliva 2.inability to open one eye & close the other eye Management: Refer to Physical Therapist b. TEF (Tracheoesophageal Fistula) self limiting TEA (Tracheoesopageal Atresia ) -there is a pouch; no connection between the esophagus and stomach Outstanding Symptom: Coughing Choking Newborn Continuous drooling Cyanosis Management: Emergency surgery

Newborn 4 Cs

c. Epstein pearl white glistening cyst usually seen at/on palate & gums related to hypercalcemia * Hypervitaminosis d. Natal tooth tooth at birth. Move with gauze e. Neonatal tooth tooth within 28days of life f. Oral Moniliasis oral candidiasis ; oral thrush -white cheese like, curd like patches that coats the mouth and the tongue Nursing Care: dont remove, wash with cold boiled water Medications: nystatin / Mysnastatin antifungal * Kawasaki Disease -- strawberry tongue - originated in Korea - Dr. Kawasaki discovered it - common in Japan - mucocutaneous Lymphnode Syndrome

Criteria for diagnosis of Kawasaki Disease: 1. persistent fever lasting more than 5 days 2. Bilateral Conjunctivitis 3. Changes of lips and oral cavity a. dry, red fissure lips

b. strawberry tongue c. diffuse erythema of mucous membrane 4. Changes of peripheral extremities a. erythema of the palm & sole b. indurative edema of the hands and feet c. membranous desquamation from fingertips 5. Polymorphous rash ( primarily on trunk)

6. Acute nonpurulent swelling of cervical lymph node to > 1.5 cm in diameter * lymph adenopathy > 1,5 cm * Drug: aspirin ; administration of gamma globulin * May lead to MI

LIPS- symmetrical Cleft lip failure of median maxillary nasal process to fuse by 5 - 8 weeks of Pregnancy -common to boys -unilateral Cleft Palate - Failure of the palate to fuse by 9 12 weeks of pregnancy -common to girls -unilateral or bilateral By means of ULTRASOUND can be detected at once Symptoms: 1.evident at birth 2.milk escapes to the nostril during feeding 3.frequent colic 4.otitis media 5.URTI Management: 1. Surgery cleft lip repair Cheiloplasty = done 1 - 3 months to save sucking reflex (lost in 6 months ) Cleft Palate - uranoplasty = done 4 - 6 months to save speech (palatoplasty) Pre operation care: 1.emotional support for the parents especially to mom 2. proper nutrition - if unable to suck use medicine dropper - use cleft lip nipple 3.prevent colic feed upright seating or prone position burp frequently 2 times at middle and after feeding - lower to upper tap

Bootle feeding : every 3 -5 minutes Position: Right side lying position to facilitate gastric motility Post Operative Care: 1.orient parents to type of feeding rubber tipped syringe cheiloplasty (cleft lip) paper cup/ soup spoon/ plastic cup urano plasty (tonsillectomy) Position: Prone Position 2.. apply restraints elbow restraints (apply pre-operatve) so baby can adjust post operation Position: Prone Position Condition that warrants suspension of operation -Check for the presence of colds & nasopharyngitis = can lead to generalized infection septicemia

Post Operative Nursing Care : (Priority) 1. airway positon for post cheilopasty side lying for drainage post uranoplasty (tonsillectomy) prone 2. assess for RDS symptoms : bleeding 3. assess for bleeding frequent swallowing, 6 - 7 days after surgery bleeding 4. proper nutrition -clear liquids- (gelatin except red or brown color due may mask bleeding) -( popsicle - not ice cream) full liquid soft dietregular diet 5. Maintain integrity of suture line such as: Logan bar wash strength Hydrogen Peroxide & Saline Solution - Bubbling effect traps microorganism - prevent baby from crying for pain analgesic * gutom hungry * wet diaper NECK1.) check symmetry Congenital torticolis - wryneck- burn injury of sternocleidomastoid muscle during delivery due to excessive traction at cephalic delivery ( case of incompetence ) Management: passive stretching exercise Last Management: Surgery Complication: Scoliosis THYROID gland for basal metabolism Congenial cretinism absence or non functioning thyroid glands (Hypothyroidism) Thyroidismgenesis Reasons for Delaying Diagnosis:

1.Thyroid glands covered by sternocleidomastoid muscles in newborn 2.baby received maternal thyroxine 3. baby sleeps 16 20 hours a day Earliest sign: 1.change in crying 2.change in sucking 3.sleep excessively 4.constipation 5.edema moon face Late sign 1.mental retardation