PEDIATRIC NURSING - The first social relationship for the infant

- Entrainment: child-mother bonding

- Engrossment: child-father bonding
NEONATES • Provide Proper Nutrition
• Birth to 28 days of life • Exclusive breastfeeding starts from proper latching on
• Neonatal period is a period of adjustment to external life • Purposes: Bonding, Involution, Breastfeeding Stimulation
• Delivery Room Setting: • Prevent Infection & Injury
- Assess for breathing or if baby is crying - Cord Care
Check for AVA
UNANG YAKAP Ensure air drying
Do not put anything on the cord
• “Essential Newborn Care” DOH AO 2009-0025 If with infection refer to MD
• Soon as the baby is out, the baby is put on mother’s chest - Eye Prophylaxis (Crede’s)
• Priority: Intervene that the newborn is kept warm Erythromycin Eye Ointment
• Unnecessary Procedures: Half a grain of rice to prevent infection
- Routine Suctioning: if the baby is crying there is no need Even if CS, the baby needs this
- Early Bathing: Hypothermia > Death - Skin Care
- Footprinting: Not all babies have a deep crease in their foot & may cause Bathing the baby after 6 hrs
infxn
- Giving sugar water or formula: Breastmilk is best for babies
- Use of bottles or pacifiers: EO 51 does not recommend since it may cause
breastfeeding to fail
- Application of alcohol, medicine and other substance on cord: Keep the cord
dry, this delays drying
- Bandaging cord stump or abdomen: Baby is not able to breathe and cord
does not dry
• Ensure Quality Time-Bound Interventions
- Happens at the first 30 minutes of life
- Objectives:
Dry & provide warmth and prevent hypothermia
Facilitate bonding mother and baby through skin-to-skin contact to
reduce likelihood of infection and hypoglycemia
Reduce the incidence of anemia in term NB and intraventricular
hemmorhage in preterm NB by delayed cord clamping
Prevent Opthalmia Neonatorum by applying erythromycin eye
ointment
• Provide Optimum Temperature
- Newborns are Prone to Cold Stress
- NBs do not shiver > Brown Fat produces heat > Acidosis > Possible brain
problems > death
- Primary Intervention: Heat/Temperature Regulation
- Primary Assesment: Breathing
- Warm Chain should not be broken!
Warm Delivery Room > Immediate drying > Skin to Skin Contact > • Non-Immediate Interventions
warm resuscitation > bathing and weighing postponed > breastfeeding - Vit K Injections
> Appropriate clothing > mother and baby together > Warm To prevent Prothrombenemia and Bleeding Problems
transportation > training of health care providers GI Tract is Sterile (Bacteria is the one that synthesizes blood clotting)
- Heat is lost by Convection, Evaporation, Radiation and Conduction 0.5 ml / 1 mg injected
• Prevent causes of Heat Loss Vastus Lateralis: Largest formed muscle
- Postpone the bath until temp is stable - Hepatitis B and BCG Immunization
- Minimum of 6hrs s/p delivery (because brain has establish temperature Hepa B is the most common blood transmitted disorder
regulation then) BCG: Intradermal @ right shoulder
- Evaporation: Dry Immediately BCG prevents Extrapulmonary TB
- Radiation: keep crib away from cold wall or use heating devices (radiant - Examination of the Newborn
warmer, drop lights) Assessment is necessary but not immediate
- Conduction: use pre-warmed padded crib - Cord Care
- Convection: Avoid cold air currents • Initial Assessment of the Newborn
- Rooming In Act: RA 7600 - Done on the 1st minute after birth: Low score
- Make sure baby has a bonnet since the head is the biggest part of the baby - 5 minutes after 1st: higher than 1st
• Establish & Maintain Respiration - 10 mins: stable
- A crying is a breathing baby - Tool: APGAR score (not required)
- if the baby is not crying after delivery, still put on mother’s chest to be able - Goal: Determine adaptation to Extrauterine Life
rub the back and loosen secretions - Heart Rate (PULSE):
- Suction only as neccessary Most importatnt and last to absent
Suction mouth first (neonates are nasal breathers until 4 mos) Neonates: 120-160
Avoid very deep suctioning (Vagal stimulation may cause brady) you may listen by putting stet at umbilical cord (but warm first)
Be gentle and intermittent - Reflex Irritability (GRIMACE)
• O2 Therapy Tested thru: gentle slap on foot/passing cath thru the nose
- If remaining cynotic give O2 as ordered reaction: crying
- More than 40% give O2 concentration may cause blindness (retrolental - Color (APPEARANCE)
fibroplasia/retinopathy of prematurity) with acrocyanosis
- Use pulseox attatched to the soles of the foot - Respirations
• Ensure Mother-Child Bonding/Attachment 30-60/min
- Skin to Skin Contact is helpful - Muscle tone (ACTIVITY)
1! of 9! DE JESUS, M.B.
 Normal: flexed position for warmth • Plantar Surface
if flaccid check if premature or dead • Breast
- 0-3: Poor Condition • Eye/Ear
Resuscitation needed • Genitals (Male/Female)
- 4-6: Fair but guarded, possible problems present. Prep for Dx tests • Measurement
These babies go to NICU or is prepared for transport PRN
- 7-10: Good Condition Measurement Normal Abnormal Implication
Regular Nursery Care
• Newborn Screening Birthweight 3000 gms SGA >10% in the Diabetic Mom
- RA 9288 6.5 lbs IUGC
- Heel Punctures (done after 24hrs s/p delivery) LGA >90% in
- To detect genetic disorders IUGR
- PKU, Hypothyroidism, Galactosemia, G6PD, CAH, Maple Syrup Urine DS
- Universal Hearing Screening RA 9709 Birth Length 50 cm or 19-20
Philhealth Circular 2018-0021 (Enhancement of Newborn Care Package) inches
•
- EINC
- Hearing Screening Head 33-35 cm Microcephaly Mental
- Expanded newborn screening test panel of 31 disorders Retardation
Endocrine Disorders
Macrocephaly Hydrocephalus
Amino Acid Disorders
Fatty Acid Disorders Chest 31-33 cm
Prganic Acid Circumference
Urea Cycle Defect
Cystic fibrosis Abdominal
Henoglobinopathies Circumference
Biotinidase Deficiency
Others (Galactosemia G6PD) • VItal Signs
• Identification RR 30-60 RPM
- Footprints, like thumbprints can never be the same
- Name tags/bracelets that include: name of newborn, Mother’s name, Manner
Cardiac Rate 120-160 bpm
of delivery, attending MD
• Emergency Baptism
- Pour Holy Water or plain clean water on head BP 80/45 - 100/50 mmHg
- Invoke: I baptize thee (Y/N), in the name of the Father, the Son and the Holy
Spirit. Amen. Temp 36.5 - 37.5
- If in doubt, whether alive or dead: If thou art alive, I baptize thee…
• Newborn Resuscitation Respirations: Thoraco-abdominal and irrular with periods of apnea less than
- if NB is completely floopy or is not breathing or is grasping after 30 seconds 10 secs/episode
of drying - PR: with normal murmurs, higher when crying lower when sleeping
- Start resuscitation ASAP
- Clamp cord ASAP • Skin
- Call for help - Pre-term: Thin, Translucent, veins clearly seen
- Transfer to a clean, Dry surface, keep warm - Term: Thick, pinker, cutis marmorata
• Discharge Instructions - Post term: Thick parchment like with peeling
- Advise mother to return or go to the hospital ASAP if: - Acrocyanosis
Jaundice of the soles > Abnormal always (even if physiologic) > - Harlequin Sign: by gravity the blood drains downward
Kernicterus - Pallor
Difficulty feeding
Convulsions • Jaundice (Forehead or Soles)
Movement only when stimulated
Physiologic Jaundice Pathologic Jaundice
Fast or slow or difficult breathing (severe chest indrawing)
Temp more than 37.5 orless than 36.5 Celsius
- Advise mother on routine check-up at the ff sched: Term Babies: 3rd until 7th day If noticed at birth or baby is less than
Postnatal visit 1: 48-72 hrs of life Preterm: 2nd Day until 10th day 24 hrs old
Postnatal visit 2: 7 days of life
Immunization visit 1: 6, 10, 14 weeks Caused by normal accumulation of Biliary Atresia
bilirubin due to expected hemolysis Blood incompatibiliy
after birth
HEAD-TO-TOE ASSESSMENT
- Phototherapy as ordered
• General Appearance - Nursing Considerations during phototherapy:
- Flexed Adequate hydration
- Generaly Pink with Acrocyanosis Position
- Frequent bouts of crying Cover the eyes; genitals (males)
• Assess for maturity by using the Ballard’s Scoring System VS
• Neuromuscular Maturity I&O
• Posture Temp
• Square Window (Wrist) Bilirubin levels
• Arm recoil Signs of bilirubin encepalopathy
• Popliteal Angle - Lethargy
• Scarf Sign - Hypotonia
• Head to Ear - Poor Suck
• Physical Maturity - High Pitched Cry
• Skin - Seizures
• Lanugo - Coma
2! of 9! DE JESUS, M.B.
 Sneezing & Coughing
Yawning
• Head
- Proportianately large 1/4 total length - Others
- Cranium is large, face small Moro/Startle
• Fontanels Doll’s Eyes
- Anterior: diamond-shaped, closes at 12-18 mos Tonic-Neck Reflex
- Posterior: triangular shaped, closes at 2-3 mos Palmar Grasp
• Variations: 7. Senses
- Molding: • Vision: follows bright light; focuses on b&w
Brow presentation: Prominent forehead • Hearing: able to hear in utero
Vertex: flattened • Smell: Least Developed
CS operation: spherical • Taste: Sweets acceptable; acidic, bitter resisted
• Touch: most developed at birth; most acute on the lips, tongue, ears, forehead
SYSTEMS REVIEW
BE OBSERVANT FOR THE FOLLOWING CONDITIONS
1. Respiratory System
• In Utero, lung is filled with 20ml/kg pulmonary surfactamt
• initial breath stimulated by: cold receptors, noise, light, low O2 • Hypoglycemia
• Periodic Apnea - CHO reserves are low; glucose is the main source of energy
• obligatory Nose Breathers Causes S/Sx Tx
• Crackles
• Sign of Atelectasis or possible lung collapse Prematurity, post- jittery, apnea,tense, oral glucose, keep
• Asymmetric Lung Expansion maturity,inadequate bulgin fontanels, warm, administer
• Lack of One Lung or Only one lung is expanding intake, stresses absent moro reflex ordered 10%-25% IV
• Grunting glucose
2. Cardiovascular System
• Change from fetal to neonatal circulation • Hypoprothrombinemia
• PMI: 4th-5th ICS MCL
Causes S/Sx Tx
• Dextrocardia: Heart of the Right side
• Murmurs: caused by incomplete or functional or fetal shunt
Low level of Vit K, Mucocutaneous Vit K Admin 0.5-1.0
3. GI System necessary for the bleeding (GI), mg/IM
• Gastric Capacity 60-90 ml formation of clotting Intracranial
• with limited capacity to digest fat and starch factors VII, IX, X Hemorrhage,
• regurgitates easily resulting in prolonged Ecchymosis
• sucking pads (brownfat deposits in each cheeks) coagulation or PT
• Stools:
- 1st 24 hrs: Meconium • Anemia
- 2-3rd day: Transitional Stool
- 4th Day: Causes S/Sx Tx
- Breast fed: 3-4x/day golden light yellow loose
- Formula fed: 2-3x/day soft but formed excessive blood Pale skin, Sluggish, • Mild: No tx
• Variations: loss; inadequate flow Poor Feedin or required
- Bright Green: s/p phototherapy > High Bilirubin of blood from te cord getting tired while • Oral Iron
- With Mucus: Milk Allergy/Other Irritants into the infant at feeding; tachycardia Supplements
- Gray/Clay: with bile duct obstruction birth; low Fe stores; and tachynea when • Rapid Blood Loss:
- Black, tarry stool: with intestinal bleeding blood incompatibility resting IV Therapy and
• Digestion, absorption and metabolism is adequate but limited Blood transufions
• Immature Liver (Jaundince, Hypoglycemia, Bleeding and edema after birth) • Blood
• No saliva until 2-3 mos Incompatibility r/t
• Small Volume of the Colon > Frequent Stooling to hemolysis >
Exchange
4. Urinary System transfusion
• If not able to uinate w/i 24 hrs, inspect observe for force of urinary stream:
• Kidneys do not concentrate urine well, thus urine is light color and odorless THE PREMATURE
• 1-2 days = 30-60 ml, pink or dusky
• 1 wk = 300 ml
• Signs of Prematurity
- Small size with a disproportinately large head
5. Autoimmune System - Lanugo covers much of the body
• NBs have difficulty forming Antibodies until 2 mos - Low Body Temp
• Placental Antibodies: IgG - Labore breathing or in Respi Distress
• Breastmilk Antibodies: IgA - Lack of reflexes for sucking and swallowing
6. Neuromuscular System • Surfactants
- decreases tension in the alveoli so the baby can breathe well
• Reflexes - Orogastric Tube inserted > Connected to Asepto Syringe
- Feeding - Enotracheal Tube > Connected to Mech Vent
Rooting: Place finger on the side of the mouth baby will follow
Sucking • Complications
- Breathing
Swallowing - Heart
Spitting up/Extrusion: “tinitikman” whatever is placed on the mouth - Brain
- Protective - Temp Control
Blinking
3! of 9! DE JESUS, M.B.
 - GI - Lungs are immature
- Blood • RDS (Hyaline Membrane DSE)
- Metabolism - High insuling secretion interfere with cortisol release
- Immune System - Lecithin pathways do not mature rapidly

• Prevention of Premature Delivery • Assessment:

- Difficult to initate respirations at first
Maternal Assessment Management - Subtle signs of low body temp, nasal flaring, retractions, Tachypnea
- Grunting
Intact Fetal Membranes Tocolytics • Hyperglycemia ASAP after birth then Glucose levels begin to fall
• WOF severe hypoglcemia
(-) bleeding Bed Rest - tremors, restlessness and irritability
- Mgmt:
Good Fetal Heart Sounds Hydration IV infusion of glucose but do not administer in bolus
Formula feeding
• Polycythemia
Cervix is not dilated > 3-4 Betamethasone - Timing of cord clamping is crucial
c,

Effacement not > 50% Fetal assessment/ THE BABY OF DRUG ADDICTED MOTHERS
monitoring
• Common Causes
- Narcotics
• If Labor cannot be stopped - Mathadone
- Analgesics given with caution - Heroin
- Do not perform artificial rupture of membranes - Cocaine
- Episiotomy - Infant is not breastfed by the drug addicted mother
- Clamp the cord • Nursing Considerations
- Assess for withdrawals sx
If baby is premature, CLMAP THE CORD ASAP - Cluster Care
you dont need the blood because if it breaks down it will only add the bilirubin that - Dec. CNS stimulating activities
will be difficult to breakdown for the baby
INFANT WITH FAS
POST MATURE
• Causes • Alcohol crosses the placenta in the same concentration that it is present in the
- Faulty due dates maternal blood stream
- Long Menstrual Cycles
- Trigger initiating labor did not work • 2 oz of alcohol a day
- Increased does of salicylates (severe sinus headaches/rheumatoid arthritis) • Long Term Effect:
- Mental Retardation
- Myometrial Quiescence - Behavioral Probs, Hyperactivity in school
• Postmature Syndrome
- SGA, loss of weight
- Dry, Cracked, almost, leather-like skin GROWTH AND DEVELOPMENT
- Absence of vernix
- Fingernails have grown beyond the ends of the fingertips • Growth: inc in physical size
- Alert (like a 2 week old baby) • Development: progressive inc in skills and capacity to function
- Less amniotic fluid during delivery • Maturation: Increase in comptence and adaptability
• Factors influencing G&D
• Maternal Assessment - Heredity
- Ultrasound
- Serum Estriol Levs - Neuroendocrine Factors
- Determine adequacy of fetal-placental unit - Nutrition
- Interpersonal Relationship
Falsely High: impaired renal function
Mothering Person: single most influential person (early infancy)
Low: anencephalic fetus
Parents: helps child on sex-role behavior
Low: GDM mother - Socioeconomic Level
- Amniocentesis
- Disease
• If the child is term upon assessment: - Environmental Hazards
- Induction of labor
- Prostaglandin gel • Developmental Task: tasks that arises at certain periods in life
- Oxytocin • Critical Periods in life: Points at which the maximal capacity for an aspect is
- Close fetal heat rate monitoring present

INFANT OF A DIABETIC MOTHER PSYCHOSEXUAL FREUDIAN THEORY

• Etiology: Unknown • Oral (0-1 Year)

• Probs cause by inadequate insulin respons to carbohydrate or from excessive
- The child receives stimulations and pleasure through his mouth
resistance to insulin - Answering their cry helps develop trust
• Probs caused by prescence of human placental lactogen and high levels of
- Behaviours to observe:
cortisol, progesteron and cathecolamines Attempts to put everything into mouth
• Appearance Receives pleaure from sucking
- LGA Tension reduced by sucking and biting
- Congenital Anomaly Differentiate self from mother
- Caudal Regression Syndrom • Anal (18 months to 31/2 years)
Hypoplasia of the lower Extremities - The child’s interest is focused on the anal region
- Lethargic and limp during the first days of life - Finds pleasure in holding on and letting go
- Often immature/born premature Letting go comes first
4! of 9! DE JESUS, M.B.
 Focus: Learning how to hold on - birth weight doubles by 4-6 mos
• Phallic (4-7 years) - 6-12 mos
- The Oedipal Phase weekly gain 3-5 ounces
- Both parents have to be present so that the child knows what to do - monthly 0.5 inch
- Child turns toward the parent of the opposite sex - bt wt triples by 1 y/o
- Fears the same sex parent
- Behaviors to observe: • Growth and Development Progressions
Exhibits interest on sex differences - Cephalocaudal - Head to Tail
Exhibits preoccupation with loss of body parts and bodily injury infants gain control of the head before the trunk and extremities
Asks many questions related to sexuality - Proximo-Distal- Center to Out
• Latency (7-11 years)
- The sexual drive (libido) is controlled and repressed during this
period. Interest on same sex only (Normal Homosexuals)
- Behaviours to observe:
- Emphasis during this period is on the development of skills and
talents and socialization outside home
- Achievement oriented years
• Genital
- Resurgence of sexual drives
- Behaviours to Observe
- Learns independence from parents
- Responsibility for self
- Develops relationships with memebers of the opposite sex

PSYCHOSOCIAL - ERICKSON’S THEORY

• Trust vs. Mistrust

- Ensure that the child has parents who can answer the cries of the
baby
- When you establish trust it must be consistent
- Consistent implementation of care is neccessary for newborns
- Failure of development in Oral Stage most likely leads to
development of Mistrust
• Autonomy vs. Shame & Doubt
- Learning how to be independent to be able to practice what you
have learned (talking, walking, toileting, etc.)
- Risk Takers had a good development in this stage
- Learning in this stage is quite fast
• Initiative vs. Guilt
- Initiative is developed if the child is allowede to initiate small
activities and ask questions.
- Guilt Develops if the child is made to feel that his activities is bad or
wrong
- Teachers are crucial in this stage
- Give children a few challenges that they are able to overcome
- Behaviours to Observe:
Starts many tasks but completes few
Very Imaginatice
Engages in Fantasy Play
Very curious, asks many questions
Boastful
• Industry vs. Inferiority
- Industry develops if permitted to do things by himseld and prepare
for the reults.
- Inferiority develops if the child’s activities are seen as a neusance
- Behavours to observe
Wants to learn to do things well and completely
participates in activites in school
Take pride in accomplishments
• Identity vs. Role Confusion
- Identity: develops if there is feeling of belonginess and acceptance
- Role Confusion: develops when not sure who he is and what he can do. • Language Dev’t
• Intimacy vs. Isolation - 9 mos-10 mos: “ma-ma”, “da-da”; Understand NO
- establish relationship with partner • Language
- 12 mos: responds to own name
- 15 mos: names familiar objects

CARE OF THE INFANT • Play

- Solitary
• Weight and Height
- Ex: Mobiles (Sound,Sight and Touch stimulated)
- 0-6 mos • Bathing
weekly gain 5-7 ounces - Cleanliness
monthly gain 1 inch - A chance to exercise
- Time to play and observe G&D
5! of 9! DE JESUS, M.B.
 - Done anytime convinient to mother (not immeditely after feeding) Better to use pacifier than fingers
- Include scalp care to prevent cradle cap Does not cause malocclusion unless done beyond 4 years old or if
• Dentition with permanent teeth
- Physiologic process and should not cause fever. diarrhea and other serious Should not replace actual feeding or suckling
upset Dependency may cuase social and speech problem
- Begins at 6-7 mos with milk/temporary/deciduos teeth = 20 Consider safety against aspiration
- Complete by around 2-3 y/o - Aspiration
- Dentition begins with the 2 lower central incisor Asphyxiation by foreign materials
- Formula for # of teeth: Age in mos less 6 Milk, Solid food items, Buttons, Pacifiers, Baby Powder
- Introduce infant to tooth brushing when dentition begins Heimlich Maneuver
- First dental visit when dentition is complete should be a “friendly” visit ontl - Suffocation
- Sheds off at 6-7 y/o Covering of the airway, pressure on the throat or exclusion of air by
• Sleep and Exercise entrapment
- Amount depends upon his need Crib Hazards: Blankets, MAttress, Crib Slats
- Nutrition
- Breastfeeding/bottlefeeding/mixed - Falls
- Weaning started 2nd half of first year Most common after 4 mos (Roll Over)
- If not Breastfeeding > Drink from cup
- Supplementary or complementary feeding at 6 completed mos (One at a CARE OF THE TODDLER
time!) • Growth slows down
- Caloric Requirement: 45cal/lb/bwt/day - gains 4-6 lbs/year
- Mineral Supplement: Ca, Fe, F - gains ht 3inches/year
• Health Supervision - Quadruples weight by 2 1/2 y/o
- Well baby-checkup to monitor growth and EPI • Pot-Bellied: appearance because of less developed abdominal muscles and
• Common Health Problems short legs
- Colic • Sensory Changes
Managment: - Visual Acuity: 20/40
If Milk Allergy: change formula casein hydrosylate (Nutramigen, - With full binocular Vision
Alimentu, Pregesmil), Milk Free Diet - Other senses increasingly well developed
Drugs: Sedatives, Antispasmodic, Antihistamine, Antiflatulent - Has Taste preferences
Comfort Measures: Prone with hot water bottle, Massage, • Gross Motor Development
Swaddling, Car Ride - 12-15 mos: walks alone
- Diarrhea: - 15 mos: walks well alone and can stoop
Poor Hygiene - 18: walk balkward and up and down the stairs
Caused by Rotavirus, Salmonella, Shigella - 2 y/o: runs
Major goal treatment is replacement of fluids and electrolyte losees - end of 2 y/o: step on tiptoe
- Constipation • Fine Motor Development
Caused by more milk than water in milk - 15 mos: developing fine motor coordination and can scribble
Add fibers to diet - By the end of toddlerhood, the child has rudimentary drawing skills, can
- Respi Infection wash and dry hands and
Common Colds • Spiritual Development
Breastfeed - Vague Idea about God
- Skin Problems - Routines such as prayers can be comforting
Miliaria - By the end of toddlerhood, may already be influenced by religous teachings
Diaper Rash: Keep Diaper Dry and reward of punishment
Cradle Cap
• Concerns
- Separation Anxiety CARE OF THE PRE-SCHOOLER
4-6 mos
Protests when Mom leaves
- Stranger Anxiety ABNORMAL PEDIATRICS
Fear of strangers as they are unable to distinguis familiar and
unfamiliar people • Planning for interventions
- Maternal Sepanx “Anaclytic Depression” • Anticipate guidance
Phases: Protest, Despair, Denial or Detachment • Encourages to reach maximum developmental potential
- Limit Setting and Discipline • Stressors of Hospitalization
Set safe limits to protect the child
- SepAnx: Greatest stress imposed on early childhood
Set Time-out safely in the crib
- Loss of Control
Provide safe alternatie instead of discouraging exploration
- Bodily Injury and Pain
- Burns
Scalding from hot bath water, microwaved formula
Sunburn
Electrical outlets
- Drowning
Bathtub, Toilet
Swimming Pools
- Bodily Damage
Sharp Pbjects
Small Objects into Body Orifices
Excessive noise from toys
Constriction injuries-Tight clothes
Animal Attacks
- Thumb Sucking and Pacifier Use
Benefits of Non-Nutritive Sucking
6! of 9! DE JESUS, M.B.
Physical Differences bet Adult and Children
CNS
Cardiovascular System
Pulmonary
Hematologic
F&E
PAIN IN CHILDREN
SENSORIMOTOR
PREOPERATIONAL
CONCRETE OPERATIONAL
THOUGHT
FORMAL THOUGHT OPERATION
• Pain Assessment- QUESTT
- Q: Question the Child
- U: Use a pain rating scale
- E: Evaluate behavioral and physiologic changes
- S: Secure parent’s involvement
- T: Take cause of pain into account
- T: Take action and evaluate results
• Wong-Baker Paing Scale
NEONATES WITH NEURAL TUBE DEFECTS
• Neural Tube: Embryonic structure that matures to form the CNS
• Forms first as a flat plate in utero
• Folic Acid: Can be found in vegtables and supplements
1. Spina Bifida
• Occurs because of lack of fusion of the posterior surface of the embryo in early
intrauterine life
• Common at 5th lumbar or 1st sacral level
• Spina Bifida Occulta
- With Sac
- Intervention neccessary
• Myelomeningocele: sac-like cyst of meninges filled with spinal fluid
7! of 9!
- Motor and sensory function absent beyond the point of protrusion
- Flaccidity and lack of sensation of the LE
Not Fully Mature - Loss of Bowel and Bladder Control
Certain Reflexes Absent
Unstable temperature regulation • Delivered via CS to avoid pressure and injury
• Observe for movement specially at LE and bowel and bladder activity
CO,BP, BV differ from adults • Encephalocele: Cranial meningocele; Herniation of the brain and meninges
through a defect in the skull - Most Dangerous!
• Meningomyelocele: Protrusion of a sac-like cyst containing meninges, spinal fluid
Intercostal muscles are not fully and spinal cord with its nerves. Parallysis of LE, Clubbed foot-talipes
developed equinovarum
Irregular Respiration
• Assessment: Movement of the LE
Smaller Trachea
• Overall Goal: Protect the sac against pressure, injury and infection
Shorter RBC Lifespan (90 days) • Management:
Surgical closure w/i 24-48 hrs s/p delivery to prevent local infxn and trauma
to the tissues
Infants 70-80% bwt Prone position
Bladder cannot expel all the contents due to decreased innervation to te
detrusor muscle: Catherization every 4-6 hrs (intermittent cath procedures,
straight cath causes high risk for infection if with retention)
During feeding carry the baby but don’t put pressure on the sac
don’t put diapers on
Violation of basic needs
2. Arnold Chiari Deformity
• Overgrowth of the neural tube in weeks 16-20 of fetal life
• Concept of Illness • Projection of cerebellum, Medulla Oblongata and 4th ventricle of the cervical
- Phenominism canal
- Contagion • Upper motor neuron involvement
• Concept of Pain • No gag and Swallowing Reflex
- Physical concrete Experience
- Believes that pain will magically 3. Hydrocephalus
disappear • Communicating hydrocephalus or Extraventricular Hydrocephalus
- Punishment - Passage of fluid between the ventricles & the SC
- Hold someone accountable • Obstructive or Intraventricular or Non-Communicating Hydrocephalus
- Block in the passage of fluid
• Concept of Illness
- Contamination • Hydrocephalus > enlarged ventricles > brain pushed against the cranium >
increased pressure > baby still has fontanels, can expand > able to accomodate
- Internalization the swelling
• Concept of Pain • Too much produced CSF
- Fears harm and mutilation
- Punishment • Shunting Procedures
• Causes of Excess CSF:
- Overproduction
• Concept of Illness - Obstruction
- Physiologic
- Psychophysiologic • Assessment:
- Fontanels widen and appear tense
• Concept of Pain - Suture lines may separate
- Able to give reason for pain
- Perceives several types of - Enlarge Head Diameter
- Shiny Scalp
psychologic pain - Sunset Eyes
- Has limited life experiences
- Fears losing Control - Brow Bulges
- Prominent Scalp Veins
- Hyperactive Reflexes
- Shrill High-Pitched Cry
• Management
- Acetazolamide: to prevent production CSF
- Ventriculo-Peritoneal Shunting
- Morphine to decrease pain
- Position: Side-lying
- HCOD: Head Circumference of the Day
• Surgical Management
- Ventriculostomy to relieve pressure
- Insertion of shunt to bypass point of ostruction
CARE OF CHILD WITH PROBLEMS IN OXYGENATION RELATED TO
RESPIRATORY DYSFUNCTION
• Common in infants and children - due to lack of antibodies
• Causes in and out of hospital CP arrest
• Upper Respi Tract
- Oropharynx
- Pharnyx
- Larynx
- Upper Part of Trachea
• Lower Respi Tract
- Lower Trachea
- Main stem bronchi
DE JESUS, M.B.
 - Segmental bronchi - Post-op
- Subsegmental bronchi Position: Prone/Lateral
- Terminal brionchioles WOF bleeding (Frequent swallowing, restlessness and stopping
- Alveoli down)
• 4 Signs of Respi Distress - Signs of Hemorrhage
- Tachypnea Increased pulse
- Grunting Pallor
- Retractions Frequent clearing of throat
- Nasal Flaring - Post op Nursing Mgmt
• Nursing Interventions for Children w/ DOB With bleeding: Elevate HOB, turn to sides
- Position px UPRIGHT Check ability to swallow, gag reflex
- kept calm and quiet as possible (prevent generation of turbulent airflow > Avoid suctioning, throat clearing, blowing of nose
increased WOB) Analgeesics (rectally or IV)
• Factors leading to Respi Illness in Children - Critical periods post-surgery:
- Infectious Agents first 24 hrs: clot formation
- Age 5-7 days: Clots begin to lyze or dissolve
- Size - Diet
- Resistance Cold, Clear non irritating drinks
- Seasonal Variations Soft foods 1-2 days post op
No Dairy
1. Common Colds - Nasopharyngitis yes ice pops
- Toddlers: 10-12 colds a year 4. Croup syndrome
- School age to adolescent: 4-5 yearly - A symptoms complex characterized by:
- Prevention: protext px from exposure, avoid contact Hoarseness of voice
- Management resonant cough (barky, croupy, brassy)
Home management Varying degrees of inspiratory stridor
Antipyretics for fever Varying degrees of respi distress
Saline nose drops (liquefy and drain) - Acute Epiglottitis: Acute, Severe inflammation of the epiglottis
Suction with bulb syringe Cause: Virus, Bacteria
Decongestion Manifestation:
Bedrest Excessive drooling
- Nursing Management Cherry red epiglottis
Elevate head of bed Wheexe inspiratory stridor
Maintain adequate fluid intake - Diagnostics
prevent dehydration Throat culture

2. Pharyngitis: Infection and inflammation of the throat, often accompanied by CHILDREN WITH CARDIAC PROBLEMS
common cold
- Causative Agents: Virus, GABHS • Classification
- Diagnostics: Throat Culture - Congenital
- Manifestations: Tonsils and pharynx inflammed and covered with exudate Idiopathic
- Complications: Sinusitis, Parapharyngeal peritonsillar or retro pharyngeal Infection
abscess Alcoholism
- Nonsupportive complications: Acute Nephrits Maternal Age
- Treatment Diabetes
Oral Penicillin (10 days) > First line Parent or sibling with CHD
Erythromycin (oral) if allergic Down Syndrome
Intramuscular Benzathine Penicillin G Born with other congenital defect
- Nursing Management • Factors
Cold or warm compress (Neck part) - Teratogenic Agents
Warm saline gargles - Maternal Factors
Dont force children to eat solids Maternal Medical Conditions
Complete antibiotic treatment Maternal Age
Warm compress at the injection site - Family History
change of toothbrush • Physical Assessment
- Height and Weight: Short and Thin
3. Tonsilitis - Inc. HR and RR
- most common tonsils removed: palatine and adenoids - Displaced Apex beat
- Management - Heart murmur
Antipyretics - Hepatomegaly
Antibiotics - Easily Fatigued
- Nursing Mgmt - Faint peripheral pulses
Promote comfort (Soft, non-irritating diet) - Frequent epistaxis
- Surgical Management - Cyanosis/Polycythemia
Tonsillectomy - Absent Femoral Pulses/Pain in legs
Adenoidectomy • General Appearance
- Contraindications - Clubbing
Cleft palata - Slow Capillary Refill
Acute infections - Cyanosis
Uncontrolled systemic disease or blood dyscrasias - Ruddy complexion
- Pre-op - Prominence of the left side and obvious heart movement
Check for bleeding and clotting time - Murmurs
CBC and Urinalysis for general status of health, check for infxns
Dental status
8! of 9! DE JESUS, M.B.
 A7: Congestive Heart Failure
Left Sided Failure Right Sided Failure • Prevention:
- Improve CO: Digoxin
- Promote elimination of excess fluids
Pulmonary congestion Systemic congestion ACE inhibitors
symptoms symptoms Diuretic
Early symptoms: Hepatojugular reflux
- Low Na Diet
- Refusal to feed
- Promote Nutrition
- Profuse scalp sweating while
- Decrease O2 Demand
nursing Cluster Care
Control of environment temperature
Decrease stress and anxiety
• Diagnostics SFF
- ECG Prevent respi infection
- Echocardiography
- Exercise training (Stress test) C1: Tetralogy of Fallot
- Blood Tests • Vetricular Septal Defect
- Cardiac catherterization • Pulmonary Stenosis
• R Ventricular Hypertrophy
A1: Atrial Septal Defects • Overriding of the Aorta
• Hole between the R Atria and L Atria • “Tet Spells”
• Slow weight gain - Supplemental O2
• Frequent LRTI - Morphine Sulfate
• Hyperdynamic precordium - Wasoconstrictors
• CXR: Cardiomegaly & Pulmonary Artery enlarged - B-Blockers
• Increased pulmonary vascularity - Volume administration
- Let the child squat
A2: Vetricular Septal Defect • Treatment
• Hole between the L Ventricle and R Ventricle - Phlebotomy: 10-20 ml removed
• Normal pulmonary artial pressure - Blalock-Taussig Shunt
- Growth failure - Closure of the VSD and pulmonary valvotomy
- CHF
- Chronic LRTI C2: Transposition of the Great Vessels
• Increase pulmonary arterial pressure • Surgical Emergency
- SOB • Aorta and pulmonary artery are switched
- dyspnea on exertion • When the baby is delevered he is immediately cyanotic > Prostagalandin
• Management: administered to keep Ductus Arteriousus open
- Close the Hole via open heart surgery • The Ductus Arteriousus keeps the baby alive
- Insert a septal occluders
C3: Truncus Arteriousus
A3: Patent Ductus Arteriosus • management:
• Connection between Pulmonary Artery and Aorta - Improve cardiac function - Ace Inhibitors, B-Blockers, Cardiac Glycosides
• Treatment: Indomethacin - Remove accumulated fluid and Na - Diuretics
• Surgery: Ligation - Decrease cardiac Demands
- Improve oxygenation and decrease O2 demands
A4: Coarctation of the Aorta
• Narrowing beyond the blood vessels of the aorta THE CHILD WITH GASTROINTESTINAL PROBLEMS
• Higher pressure on the UE compared to LE
• Manifestations: 1. Cleft Lip and Cleft Palate
- Different pulses • Cleft Palate: Males
- Frequent Pulses • Cleft Lip: Females
- Headaches • Vit A, Intake of Anticonvulsants, Hereditary
- UE HTN • Can cause problems with airways
- Ruptured Aorta • Cleft palate: speech, defects in air, hearing problem
- Aortic Aneurysm • Surgery is a priority
- Stroke • Will have coping problems as they grow up
• Treatment: Ballon Angioplasty, End to End Anastomosis • Rule of Ten
- 10 weeks
A5: Aortic Stenosis - 10 lbs
• Masikip ang Aorta - 10 gms of hemoglobin
• Lessen the diameter of the Aorta so that blood could pass through - Less than 10,000 WBC
• Manifestations: • Surgery
- Decreased CO - Cheiloplasty/Z-Plasty
- Hypotension Cleft Lip Repair
- Tachycardia Usually done 3 times
- Poor Feeding Not urgent procedure, not life threatening
- Pulmonary Edema Delayed until they are no longer surgically at risk
- LVH • Post-op Care
• Treatment: Open Surgical Valvotomy, Balloon Valvuloplasty - Position: Never on Prone to prevent tension on suture
A6: Pulmonary Stenosis
• Stenosis of the Pulmonary Artery

9! of 9! DE JESUS, M.B.