Pedia Notes

Physiologic wt loss – 5 – 10% wt loss few days after birth

Small GA < (less) 10

Large GA > (more) 90

Physical Exam and Deviations fr Normal

1. if client is new born, cover areas not being examined

2. if client is infant – the 1st yr of life - get VS – take RR 1st

- begin fr least intrusive to the most intrusive area

3. if client is a toddler and preschool, let them handle an instrument like:

- play syringe or stet, security blanket – favorite article. Let baby hold it.

4. Explain procedure and respect their modesty - school age and adolescent

V/S:

Temp: 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 opening3. stenos – has opening4. membranous – has opening

Earliest sign:

1. no mecomium

2. abd destention

3. foul odor breath

4. vomitous of fecal matter

5. can aspirate – resp problem

Mgt:

Surgery with temporary colostomy

Cardiac rate: 120 – 160 bpm newborn

Apical pulse – left lower nipple

Radial pulse – normally absent. If present PDA

Femoral pulse – normal present. If absent- COA - coartation of aorta

Congenital Heart Dse

Common in girls – PDA, ASD atrial septal

Common in boys – TOGA ( transportation of great arteries)

TA – tronchus arteriosus

TOF – tetralogy of fallot

Causes:

1. familial2. exposure to rubella – 1st month 3. failure of strucute to progress

acyanotic L to R

cyanotic R – L

Acyanotic heart defects L to R

1. ventricular septal defect - opening between 2 ventricles

S&Sx 1. systolic murmurs at lower border of sternum and no other significant sign

2. cardiac catheterization reveals increased o2 saturation @ R side of heart3. ECG reveals hypertrophy of R side of heart

Nsg Care:

Cardiac catheterization: site – Rt femoral vein

1. NPO 6 hrs before procedure2. protect site of catheterization. Avoid flexion of joints proximal to site.3. assess for complication – infection, thrombus formation – check pedal pulses

( dorsalis pedis)

Mgt.

1. long term antibiotic – to prevent subacute bacterial endocarditis2. open heart surgery-

2.) ASD – failure of foramen ovale to close

S&SX

1. systolic murmur @ upper border of sternum 2. result of cardiac catheterization & ECG same with VSD

Mgt: open heart surgery

3.) endocardial cushion defects - atrium ventricular (AV) - affects both tricuspid and mitral valve

Dx – confirmed by cardiac catheterization

Mgt: - open heart surgery

Antibiotics to prevent subacute bacterial endocarditis

4.) PDA - failure of ductus arteriosus to close

- should close within 24 h -complete close – 1 month

S&Sx

1. continuous machinery like

murmurs 2. prominent radial pulse 3. ECG- hypertrophy Left ventricle

Drug:

1. endomethazine – prostaglandin inhibitor - facilitate closing of PDA2. ligation of PDA by 3-4 yo3. thoracotomy procedure- nakadapa child

5.)Pulmunary Stenosis- narrowing of valve of pulmo artery

S &Sx: 1.) typical systolic ejection murmur

2. S2 sound widely split

3. ECG- Lt ventricular hypertrophy

6.)Aortic Stenosis – narrowing of valve of aorta

S & Sx: 1. inactive, sx sme with angina

2. typical murmur

3. rough systolic sound and thrill

4. ECG- Left ventricular hypertrophy

cardiac catheterization-

Mgt Pulmo Stenosis & Aortic Stenosis

1. balloon stenostomy2. surgery

Duplication of Aortic Arch- doubling of arch of aorta causing compression to trachea and esophagus

S&Sx : 1. dysphagia 2. dyspnea

3. left ventricular hypertrophy

Mgt: - close heart surgery

8.) Coartation of Aorta – narrowing of arch of aorta

outstanding Sx : absent femoral pulse

BP increased on upper extremities and decreased on lower extremities

ECG – hypertrophy Lft ventricle

Mgt: close heart surgery

CYANOTIC HEART DEFECTS R to L

1. Transportation of Great Arteries (TOGA) - aorta arising from Rt ventricle

pulmo artery arisin

g form Lt ventricle

Outstanding Sx:

1. cyanosis after 1st cry (due no exygenation) 2. polycythemia

– increased RBC =compensatory due to O2 supply=viscous blood

=thrombus = embolus = stroke

3. ECG – cardiomegaly

Cardiac cath – decreased O2 saturation

Palliative repair – rashkind procedure

Complete repair – mustard repair

2.) Total Anomalous Pulmonary

venous return – pulmo vein instead of entering Lt atrium, enters Rt atrium or SVC

Increased pressure on Rt so blood goes to Lft

Outstanding Sx: Open foramen ovale

Mild to moderate cyanosis

Polycythemia = thrombus = embolus = stroke

asplenia- absent spleen

Mgt: restructuring of heart

3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 1 single vessel or common trunk with VSD

S & Sx 1. cyanosis

2. polycythemia – thrombus = embolus = stroke

Mgt: Heart transplant

4.) Hypoplastic Left heart syndrome – non fx Left ventricle

1. cynosis

2. polycythemia – throm, emb, stroke

Mgt: heart transplant

 

5.) Tricuspid atresia – failure of tricuspid valve to open

S&SX: open foramen ovale

(R to L shunting – goes to Lt atrium)

cynosis, polycythemia

Mgt: fontan procedure – open tricuspid valve

6.) Tetralogy of Fallot

P – pulmonary stenosis

V – ventricular SD

O – overriding or dextroposition of aorta

R – Rt ventricular hypertrophy

S &Sx:

1. Rt ventricular hypertrophy 2. high degree of cyanosis3. polycythemia4. severe dyspnea – squatting position – relief , inhibit venous return facilitate lung expansion. 5. growth retardation – due no O26. tet spell or blue spells- short episodes of hypoxia7. syncope8. clubbing of fingernails – due to chronic tissue hypoxia9. mental retardation – due decreased O2 in brain

10. boot shaped heart – x-ray

Mgt:

1. O2 2. no valsalva maneuver , fiber diet laxative3. morphine – hypoxia4. propranolol – decrease heart spasms5. palliative repair –

BLT blalock taussig procedure

Brock procedure – complete procedure

 

ACQUIRED HEART DSE

1. RHD Rheumatic Heart Disease

- inflammation disease ff an infection acquired by group A Beta hemolytic strepto coccus

Affected body – cardiac muscles and valves , musculoskeletal , CNS, Integumentary

Sorethroat before RHD

Aschoff – rounded nodules with nucleated cells and fibroblasts – stays and occludes mitral valve.

 

 

 

Jones Criteria

Major Minor

1. polyarthritis – multi joint pain 1. arthralgia – joint pain

2. chorea – sydenhamms chores or

st. vetaus dance-purposeless involuntary hand and shoulder with grimace

2. low grade fever

3. carditis – tachycardia 3. all lab results

erythema marginatum - macular rashes

SQ nodules

increase antibody

" C reactive protein

" erythrocyte sedimentation rate

" anti streptolysin

o titer (ASO)

Criteria:Presence of 2 major, or 1 major and 2 minor + history of sore throat will confirm the dx.

Nsg Care:

1. CBR 2. throat swab – culture and sensitivity 3. antibiotic mgt – to prevent recurrence 4. aspirin – anti-inflammatory. Low grade fever – don’t give aspirin.

S/E of aspirin:

Reyes syndrome – encephalopathy- fatty infiltration of organs such as liver and brain

Respiration

Newborn resp – 30-60 cpm, irregular abd or diaphramatic with short period of apnea without cyanosis.

< 15 secs – normal apnea –newborn

Resp Check

Newborn – 40 – 90

1 yr - 20 – 40

2-3yr 20 – 30

5 yrs 20 – 25

10 yrs 17 – 22

15 & above 12- 20

BREATH SOUNDS HEARD DURING ASCULTATION:

1.) VESICULAR – soft, low pitched, heard over periphery of lungs, inspiration longer then expiration -Normal

2.) BRONCHOVESICULAR- soft, medium pitched, heard over major bronchi, inspiration equals exp. 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. Normal

5.) RALES-or crackles – like cellophane – made by air moving through fluid in alveoli.

Abnormal- asthma, foreign body obstruction.

6.) WHEEZING- whistling on expiration made by air being pushed through narrowed bronchi .Abnormal – asthma, foreign body obstruction

7.) STRIDOR- crowing or ropster life sound – air being pulled through a constricted larynx. Abnormal – resp obstruction

Asthma- pathognomonic sign – expiratory wheezing

Pet – fish. Sport – swimming

Drugs – amynophylline – monitor bp, may lead to hypotension

Laryngo Tracheo Bronchitis LTB

- inspiratory stridor – pathognomonic sign

RDS respiratory dist synd or hyaline membrane dis

Cause- lack of surfactant – for lung expansion

Hypotonia, Post surgery, Common to preterm

Fibrine hyaline

Sx – definite with in 1st of life

Increase RR with retraction

Inspiratory grunting – pathognomonic

7 – 10 severe RDS (silvermenn Anderson index)

cyanosis due to atelectasis

Mgt:

1. surfactant replacement and rescue 2. pos- head elevated 3. proper suctioning

4. o2 with increase humidity- to prevent drying of mucosa 5. monitor V/S skin color , ABG6. CPAP- continuous + a/w pressure7. PEEP - + end expiratory pressure

Purpose of #6-7- to maintain alveoli partially open and alveoli collapse

LARYNGOTRACHEOBRONCHITIS

LTB – most common Creup -viral infection of larynx, trachea & bronchi

outstanding sx - croupy cough or barking

pathognomonic - stridor

labored resp resp acidosis end stage – death

Lab:

1. ABG 2. neck and throat culture3. dx- neck x-ray to rule out epiglotitis

Nsg Mgt:

1. bronchodilators

2.increase o2 with humidity

3. prepair tracheostomy set

BRONCHOLITIS- Inflammation of bronchioles – tenatious mucus

Causative agaent – RSV - Resp sincytial viruses

Sx: flu like sx

Increased RR

Drug: Antiviral – Ribavirin

End stage – epiglotitis

 

EPIGLOTITIS - infl of epiglottis

- emer. Condition of URTI

Sx: sudden onset

Tripod position – leaning forward with tongue protrusion

never use tongue depressor

prepare tracheotomy set

< 5 yo – unable to cough out, put on mist tent (humidifier o2) or croupe tie

Nsg Care: check edges tucked on mist tent

Provide washable plastic material

No toys with friction due O2 on

No hairy toys – due moist environment medium for bacterial growth

BP – 80/46 mmHg newborn

BP after 10 days- 100/50

BP taking begins by 3 yo

COA – take BP on 4 extremities

SKIN:

Acrocyanosis

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 yr old

2. MIlla – plugged or unopened sebaceous gland . white pin point patches on nose, chin or cheek.3. Lanugo – fine, downy hair – common preterm 4. Desquamation – peeling of newborn, extreme dryness that begin sole and palm. 5. Stork bites (Talengeictasi nevi) – pink patches nape of neck

hair will grow as child grows old

1. Erythema Toxicum – (flea bite rash)- 1st self limiting rash appear sporadically & unpredictably as to time & place.

2. Harlequin sign – dependent part is pink, independent part is blue

(side lying – bottom part is dependent pink)

3. Cutis Marmorato – transitory mottling of neonates skin when exposed to cold. 4. Hemangiomas – vascular tumors of the skin

3 types Hemangiomas

a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can be removed surgically

b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. Enlarges, disappears at 10 yo.

c.) Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear with age. - MOST DANGERIOUS – intestinal hemorrhage

Skin color blue – cyanosis or hypoxia

White – edema

Grey – inf

Yellow – jaundice , carotene

Vernix Caseosa – white cheese like for lubrication, insulator

BURN TRAUMA – injury to body tissue caused by excessive heat.

 INFANT 5-9 yo

 ANTERIOR POSTERIOR Ant Post

Head 9.5 9.5 6.5 6.5

Neck 1 1 1 1

Upper arm 2 2 2 2

Lower arm 1.5 1.5 1.5 1.5

Hand 13 1.25 1.25 1.25

Trunk 13 

13 

Back 13 

13 

Genital 1 

1 

@ buttocks

2.5@ 

2.5 @ 

Thigh 2.75 2.75 4 4

Leg 2.5 2.5 3 3

foot 1.75 1.75 1.75 1.75

 

DEPTH

1st degree – partial thickness – superficial epidermis - erythema, dryness, PAIN

-sunburn, heals by regeneration from 1 – 10 days

2nd degree – epidermis & dermis- erythema, blisters, moist, extremely painful

o scalds

3rd degree – full thickness- epidermis, dermis, adipose tissue, fascia, muscle & bone

o lethargy, white or black, not painful – nerve endings destroyed o ex. lava burns

Mgt:

1.) 1st aid a.) put out flames by rolling child on blanket

b.) immerse burned part on cold H2o

c.) remove burned clothing of with sterile material

d.) cover burn with sterile dressing

2.) a/w

a.) suction PRN, o2 with increased humidity

b.) endotracheal intubation

c.) tracheostomy

3.) Preventiuon of shock & F&E imbalance

a. colloids to expand bld volume

b. isotonic saline to replace electrolytes

c. dextrose & H2o to provide calories

4.) Tetanus toxoid booster

5.) Relief of pain – IV analgesic MORPHINE SO4 – needed for 2nd degree – very painful

6.) 1st defense of body – intact skin

prevention of wound infection

a. cleaning & debriding of woundb. open or close method of wound carec. whirlpool therapy – drum with solution

7.) skin grafting – 3rd degree – thigh or buttocks (autograft), pigs/ animals – xenograft

frozen cadaver – hallow graft

8,) diet – increase CHON, increase calories.

ATOPIC DERMATITIS- infantile eczema (galis)

Papulo vesicular erythematus lesions with weeping & crusting

Cause – food allergies: milk, citrus juice, eggs, tomatoes, wheat

Sx: - extreme pruritus, linear excoriation, weeping crusting; scaly shiny and white – lechenification

Goal of care: decrease pruritus – avoid food allergens

Diet: Prosobi or Isomil

Hydrate skin, borow solution 1% hydrocortisone cream

Prevent infection – proper handwahsing, trim nails

IMPETIGO- skin disease.

Causative agent – grp A beta Hemolytic streptococcus

papulovesicular surrounded by localized erythema –becomes purulent , oozes a honey colored crust

Pediculosiscapitis –"KUTO"

Mgt: proper hygiene – wash soap and H2o, oral penicillin – bactroban ointment

Can lead to acute glomerulonephritis AGN

ACNE- adolescent problem

self limiting infl dis – sebaceous gland comedones – sebum causing white heads sebum- lipids causing acne bulgaris

Mgt: - proper hygiene- mild soap or sulfur soap- antibacterial retin A or tretinoi

 

 

ANEMIA-pallor

Causes:

1.)early cutting of cord – preterm – cut umb cord ASAP

fullterm – cut umb cord when pulsation stops

2.) Bleeding disorders – blood dyscrasias

HEMOPHILIA – deficiency of clotting factor. X linked recessive – inherited

If mom – carrier, son – affected

If father carrier- transmitted to daughter

Hemophilia A – deficiency of coagulation component factor 8

Hemophilia B –or christmas disease, deficiency of clotting factor 9

Hemophilia C – deficiency of clotting factor 11

Assessment:

umphalagia – earliest sign newborn receive maternal clotting factor newborn growing – sudden bruising on bump area- marks earliest sign continuous bleeding – hematrosis – damage or bleeding synovial membrane

Dx test :

PTT. Partial thromboplastin time – reveals deficiency in clotting factor

Long Term Goal- prevention of injury

Nsg Dx- increase risk of injury

HT: avoid contact sport, swimming only, don’t stop immunization – just change gauge of needle

Falls – immobilized , elevate affected part, apply pressure-not more then 10 min

cold compress

-determine case before doing invasive procedure

LEUKEMIA- grp of malignant disease

rapid proliferation of immature WBC WBC – protection from infection, soldiers of body

Classification :

1. Lympho – affects lymphatic system 2. Myelo – affects bone marrow 3. acute / blastic- affects immature cells 4. chronic/ cystic- affects mature cells

MOST COMMON CANCER – (ALL) – Acute Lymphocytic Leukemia

S&Sx:

1. from invasion of bone marrow

signs of infection

a. fever b. poor wound healingc. bone weakness & causes fracture

signs of bleeding

a. petecchiae-small, round, flat, dark red spot b. epistaxisc. blood in urine/ emesis

signs of anemia

a. pallor , body malaise , constipation

2. from invasion of body organ- hepato spenomegaly – abd pain ,

CNS affectation, increase ICP

Dx Tests:

1. PBS- peripheral blood smear – determine immature RBC

2. CBC – determine anemia, leukocytosis, thrombocytopenia neutropenia 3. lumbar puncture (LP) – determine CNS involvement. Before LP, fetal pos.- avoid flexion of neck

– will cause a/w obstruction."C" position or shrimp position only. 4. bone marrow aspiration – determine blast cells,

common site- iliac crest post BMA s/effect –

bleeding apply pressure. Put pt on affected side to prevent hemorrhage

1. Bone scan – determine bone involvement 2. CT scan – determine organ involvement

Therapeutic Mgt:

TRIAD:

1. surgery 2. irradiation 3. chemotheraphy

Focus Nsg Care: prevent infection

4 LEVELS OF CHEMOTHERAPHY

1. induction – goal of tx; to achieve remission

meds: IV vincristine

L- agpariginase

Oral predinisone

2. Sanctuary- treat leukemic cells that invaded testes & CNS

give: methotrixate- adm intrathecally via CNS or spine

cytocine, Arabinoside, steroids with irradiation

3. maintenance- to continue remission

give: oral methotrisate – check WBC

-adm of methotrisate – do weekly WBC check

4. Reinductin – treat leukemic cells after relapse occurs. Meds – same as induction

- give antigout agents: allopurinol or Zyloprim- treat or prevent hyperurecemic nephropathy.

Nsg mgt: Outstanding nsg dx: alteration in nutrition less body requirement.

Based on Maslow’s heirarchy

S/Effect of Chemotherapy

1. N/V – adm antiemetic drugs 30 mins before chemo until 1 day after chemo

2. Ulcerations / stomatitis / abscess of oral mucosa- (alteration nutrition less body req)

- oral care – alcohol free mouthwash , betadine mouthwash

- don’t brush – use cotton pledgets

- topical xylocaine before meals

diet- soft, bland diet according to child’s preference

Temporary S/E of chemo:

Alopecia – altered body image

Hirsutism – hair

-give emotional support to parents

ABO incompatibility –

Most common incompatibility – ( mom) O – ( fetus) A

Most severe incompatibility (Mom) O– (Fetus) B

Can affect 1st pregnancy

 

 

 

 

 

 

Hydrops (h20) Fetalis – edematous on lethal state with pathologic jaundice

Within 24 h

Mgt:

1. initiate breastfeeding to get colostrum 2. Temp suspension of breastfeeding

content breast milk pregnanedioles – that delays action of glucoronil transferees

liver enzymes converts in direct bilirubin to become direct bilirubin

1. Needs phototherapy 2. needs exchange therapy

Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term

Normal – 0-3 mg/dL

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 h (2-3 days) expose morning sunlight

Pathologic Jaundice – within 24h. Jaundice during delivery.

Breastfeeding jaundice – caused by pregnanediole

Assessment of Jaudice :

1. Blanching neonates forehead, nose or sternum

- yellow skin & sclera

- color of stool – light stool

- color of urine – dark urine

Mgt: Phototheraphy – photo oxygenation

Nsg Resp:

1. cover eyes – prevent retinal damage 2. cover genitals – prevent priapism – painful continuous erection 3. change position regularly – even exposed to light 4. increase fld intake – due prone to dehydration 5. monitor I&O – weigh baby 6. monitor V/S – avoid use of oil or lotion due- heat at phototherapy

= bronze baby syndrome-transient S/E of phototherapy

weigh diaper 1gm = 1cc

Head – largest part of baby

¼ of its length

Craniostenosis or craniosinustosis – premature closing of fontanel

Hydrocephalus – ant fontanel open after 18 mos

Microcephaly – small growing brain due- alcohol & HIV mom

Anencepahly – absence of cerebral hemisphere

Craniotabes – localized softening cranial bone. Common – 1st born child

-due early lightening (2 weeks prior to EDD)

Rickets of Vit B deficiency – soft cranial bone in older children

Caput Succedaneum – edema of scalp due prolonged pressure at birth

Char:

1. present at birth2. crosses suture lines 3. disappear after 2-3 days

 

 

Cephalhematoma- collection of blood due to rapture of pericostal capillaries

Char :

1. present after 24 h2. never cross suture line 3. disappear after 4-6 weeks 4. monitor for developing jaundice

Seborrheic Dermatitis – ‘craddle cap"

Scaling, greasy appearing salmon colored patches – seen on scalp behind ears and umbilicus

Cause: - improper hygiene

Mgt:

1. proper hygiene

2. put oil night before shampoo

baby oil

Hydrocephalus – excessive accumulation of CSF

1. communicating – extra ventricular hydrocephalus2. non-communicating- intraventricular hydrocephalus or obstructive hydrocephalus

due to tumor obstruction

Sx – ICP – abnormally large head, bulging fontanel

cushings triad high pitched cry

older child – diplopia – eye deviation, projectile vomiting

fontanel bossing – prominent forehead - prominent skull vein sunset eyes

Mgt: position to lessen ICP – low semi-fowlers 30 degree angle

Administer- osmotic diuretic Mannitol/ Osmitrol , Diamex- Azetam

Decrease CSF production

Shunting – AV shunt or Vp shunt (ventriculoperitoneal shunt)

Shave hair – in OR – to prevent growth of micro org.

Nsg Care:

1.) post VP shunt – side lying on non operated site - to prevent increase ICP

monitor for good drainage - sign – sunken fontanel

bulging fontanel – blocked shunt

change fontanel as child is growing

SENSES

EYES: Assessment

1. check for symmetry 2. sclera – normal color – light blue then become dirty white

pupil – round- adult size

coloboma- part of iris is missing

sign: key hole pupil

whiteness & opacity of lens congenital cataract

cornea – round & adult size

large – congenital glaucoma

Test for blindness common tests

1. newborn – general appearance

- can only see 10 – 12 "

- visual acuity 20 /200 to 20/ 800

Doll’s eyes test- test for blindness

done 10th day pupil goes opposite to direction when head is moved

Globellars test – test for blink reflex. Points near nose – baby should blink

 

2. Infant & children

- appearance

- ability to follow object past midline

3. 3 yrs – school age

- general appearance

Allen cards – test for visual acuity. Show picture 20 ft away

Ishiharas plates – test for color blindness

Prechool E chart - test for stereopsi 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 : oat’s eye reflex-whitish glow of pupil

red painful eye blindness

surgery – Enucliation – removal of eyeball put artificial aye

NOSE:

1. flaring alenase – case of RDS 2. cyanosis at rest – choanal atresia - post nares obstructed with bone or membrane

Sx:

1. resistance during catheter insertion 2. emer. Surgery within 24 h

normal color nasal membrane – pinkish

rhinitis – presence of creases & pale

check sense of smell – blindfold – smell

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

most developed sense of newborn – sense of touch

1st sense to develop & last to disappear – hearing

EARS:

1. Properly aligned with outer cantus of eyes

low set ear – kidney malformation

ex. Renal aginesis – absence of kidney

sign in uterus : oligohydramnios

sign in newborn: 2 vessel cord

failure to void within 24 h

Mgt: kidney transplant

 

 

 

 

 

 

Chromosomal aberrations : -advance maternal age

1. non disjunction – uneven division

Trisomy 21 - down syndrome - extra chromosome

47xx + 21 - related to advance paternal age

Sx:

Mongolian slant

Broad flat nose

Protruding neck

Puppy’s neck

Hypotonic – prone to resp problem

Simean crease – single transverse line on palm.

Trisomy 18 – "endvard syndrome"

Trisomy 13- patau syndrome

Turner – Monosomy of X synd.

45x0 affected girls signs evident during puberty has poorly developed 2dary sexual char. Sterile

Klinefelters Syndrome- has male genitalia - 47 XXY

- poorly devt secpndary sexual characteristics

- no deepening of voice

-small testes, penis -sterile

Klinefelter – Calvin Kline – male

Turner – Tina Turner – female

 

Otitis Media – inflammation of middle ear. Common children due to wider & shorter Eustachian tube

Causes

1. bottle propping 2. Cleft lip/ cleft palate –

Sx: Otitis

1. bulging tympanic membrane, color – pearly gray 2. absence light reflex 3. observe for passage of milky, purulent foul smelling odor discharge 4. observe for URTI

Nsg Care:

1. position side lying on affected aside – to facilitate drainage 2. supportive care- bedrest, increase fld intake

Med Mgt:

1. Massive dosage antibiotic

Complication – bacterial meningitis

2. Apply ear ointment

School age – up and down

< 3 yo – down & back

> 3 yo – up & back

Small child – down & back ( no age)

surgery (to prevent permanent hearing loss)– otitis media – myringotmy with tympanostomy tube

post surgery – position affected side for drainage

both – put ear plug

if tympanous tube falls – healed na

Bells Palsy- facial nerve #7 paralysis R/T forcep delivery

Sx.

1. Continuous drooling saliva 2. inability to open , eye & close either eye

Mgt:

Refer to PT

TEF (Tracheoesophageal Fistula)-TEA- no connection bet esophagus and stomach

Outstanding Sx – Coughing

Choking

Continuous drooling

Cyanosis

Mgt:

Emergency surgery

Epstein pearl – white glistering cyst at palate & gums related to hypercalcemia

Hypervitaminosis

Natal tooth – tooth at birth. Move with gauze

Neonatal tooth – tooth within 28days of life

Moniliasis – oral candidiasis

white cheese like, curd like patches that coats tongue oral thrush Nsg Care – don’t remove, wash with cold boiled H2o

Meds – nystatin / Mysnastatin – antifungal

Kawasaki Dse--strawberry tongue - originated in Korea

- Dr. Kawasaki discovered it

- common in Japan

- "mucocutaneous Lymphnode Syndrome"

Sx:

-persistent fever – 5 days

-strawberry tongue ,

-desquamation of palm & sole

- lymph adenopathy > 1.5 cm

Drug: aspirin

Can lead to MI

LIPS- symmetrical

Cleft lip – failure of median maxillary nasal process to fuse by 5-8 wks of pregnancy

common to boys unilateral

Cleft Palate- Failed palate to fuse by 9 – 12 wks of pregnancy

common to girls unilateral or bilateral

Sx:

1. evident at birth 2. milk escapes to nostril during feeding 3. frequent colic & otitis media or URTI

Mgt:

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

Pre op care

1. emotional support especially to mom2. proper nutrition 3. prevent colic

feed – upright seating or prone pos

burp frequently 2x at middle and after feeding-lower to upper tap

4. orient parents to type of feeding

rubber tipped syringe – cheiloplasty

paper cup/ soup spoon/ plastic cup – urano plasty

5. apply restraints – elbow restraints

so baby can adjust post op

Condition that warrants suspension of operation

colds & pharyngitis = can lead to generalized infection – septicemia

Post Op Nsg Care :

1. airway – positon post cheilopasty – side lying for drainage

post uranoplasty (tonsillectomy)- prone

2. assess for RDS sx bleeding

3. assess for bleeding – freq 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 diet

regular diet

5. Maintain integrity of suture line such as:

Logan bar – wash ½ strength Hydrogen Peroxide & saline solution- Bubbling effect

traps microorganism

- prevent baby form crying

for pain- analgesic

 

NECK-

1. check symmetry

Congenital torticolis- " wryneck"-burn injury of sternocleidomsstoid muscle during

delivery – due to excessive traction at cephalic delivery

Mgt: passive stretching exercise , Surgery

Complication – scoliosis

THYROID gland – for basal metabolism

Congenial cretinism – absence or non functioning thyroid glands

reasons for delaying dx:

1. Thyroid glands covered by sternocleidomastoid muscles in newborn 2. baby received maternal thyroxine 3. baby sleeps 16 – 20 h 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

prognosis : mental retardation preventable when Dx is early

Dx:

1. PPI-protein 2. radioimmunoassay test 3. radioactive iodine uptake

Mgt: synthroid – sodium Levothyrosine -synthetic thyroid given lifetime

check pulse rate before giving synthroid tachycardia – Sx of hyperthyroidism

CHEST

1. symmetry 2. breast - transparent fluid coming out from newborn related to hormonal changes-

3. chest has retroactive – RDS

4. sternum sunken – pectus excavation

ABDOMEN (in order)

1. inspection I2. Auscultation A3. percussion P4. Palpation P = Will change bowel sounds, so do last

Normal contour of abd – slightly protruding

Sunken abd- diaphramatic hernia – protrusion of stomach content through a defective diaphragm due to failure of puroperitoneal canal to close.

Sx:

1. sunken abd2. Sx of RDS3. R to L shunting

Mgt:

Emergency surgery within 24h

Omphalocele – protrusion of stomach contents in between junction of abd wall and

umbilicus.

Mgt- very small surgery

If large – suspension surgery

Nsg Mgt: protect sac- sterile wet dressing

Gastrochisis – absence of abd wall

Nsg Mgt: sterile wet dressing

Fx of GIT

1. assists in maintaining F&E & acid base balance 2. Processes & absorbs nutrients to maintain metabolism & support G & D 3. excrete waste products from digestive process

Recommended Daily Allowance

Calories : 120 cal / Kbw/day (kilo body wt)

360 – 380 cal/ day

CHON_ 2.2g /Kbw/day

Principles in Supplementary Feeding

Supplementary Feeding usually – 6 mos

Supplementary feeding given – 4 mos.

a.) solid food offered to ff sequence!

1. cereals – rich in iron

2. fruits

3. veg

4. meat

b.) begin with small quantities

c,) finger foods – offered 6 months

d.) soft table food – "modified family menu" given 1 yr

e.) dilute fruit juices – 6 mos

f.) never give half cooked eggs – usually causes of salmoneliosis

g.) don’t give honey – infant botulism

h.) offered new food one at a time – interval of 4 – 7days or 1 week – determines food allergens

Total Body Fluids- comprises 65 - 85% of body wt of infants & children

Where fluids are greater in infants

Extracellular fld – prone to develop dehydration

Acid Base Balance dependent on the ff:

a. chemical buffersb. renal & resp system involvement c. dilution of strong acids and bases in bld

Resp Acidosis – carbonic acid excess

hypoventilation RDS COPD Laryngotracheobronchitis (LTB)

Resp Alkalosis – carbonic acid deficit

hyperventilation fever encephalopathy

Met. Acidosis – base HCO3 deficit

diarrhea severe dehydration malnutrition ciliac crisis

Met Alkalosis – base HCO3 excess

uncontrolled vomiting NGT aspiration Gastric lavage

 

 

 

 

PROBLEMS LEADIING TO F&E IMBALANCE

1. vomiting – forceful expulsion of stomach content

Sx:

1. nausea2. dizziness 3. facial flushing 4. abd cramping

assess: amt, freq, force

projectile vomiting= increase ICP or pyloric stenosis

Mgt: BRAT diet - banana, rice – cereal, apple sauce, toast

2. Diarrhea – exaggerated excretion of intestinal contents

Types:

Acute diarrhea – related to gastroenteritis, salmoneliosis

dietary indiscretions antibiotic use

Chronic non specific diarrhea

Cause:

1. food intolerance 2. excessive fld intake 3. CHO, CHON malabsorption

Assess: freq, consistency, appearance of given colored stool.

Best criteria to determine diarrhea : consistency

Complication = dehydration

Mild dehydration 5% wt loss

Moderate dehydration 10% wt loss

Severe dehydration 15 % wt loss

Earliest sx of dehydration

tachycardia increase temp weight loss

tachypnea sunken fontanel & eyeballs scanty urine

hypotension absence of tears

Severe dehydration:

Oliguria , Prolonged capillary refill time

Mgt:

Acute – NPO ( rest the bowel )

with fluid replacement – IV prone to Hypokalemia – give K chloride

before adm of K chloride – check if baby can void, if cant void – hypokalemia

Drug: Na HCO3 – adm slowly to prevent cardiac overload

 

Gastric Motility Disorder:

HIRSCHPRUNGS DISEASE – congenital aganglionic megacolon

Aganglionic – absence of ganglion cells needed for peristalis

Earliest sign

1. failure to pass mecomium after 24h2. abd distension

3. vomitus of fecal material

early childhood – ribbon like stool

foul smelling stool

constipations

diarrhea

Dx:

1. Barium enema – reveals narrowed portion of bowel 2. Rectal Biopsy – reveals absence of ganglionic cells3. abd x-ray – reveals dilated loops on intestine 4. rectal manometry – revels failure of intestine sphincter to relax

Therapeutic Mgt/Nsg care

1. NGT feeding – measure tube fr nose to ear to midline of xyphoid & umbilicus 2. surgery

a. temp colostomy b. anastomosis & pull through procedure

Diet:

Increase CHON, increase calories , decrease residue – pasta

GER- Gastroesophageal Reflux

Chalasia – presence of stomach contents to esophagus

Will lead to esophagitis complication – aspiration pneumonia

 

 

 

Esophageal cancer

Assessment :

1. chronic vomiting 2. faiture to thrive syndrome 3. organic – organ affected 4. melena or hematemesis – esophageal bleeding

Dx procedure

1. barium esophogram – reveals reflux 2. esophageal manometry – reveals lower esophageal sphincter pressure3. intra esophageal pH content – reveals pH of distal esophagus.

Meds of GERD

Anti-cholinergic

a. Betanicol ( urecholine) – increase esophageal tone & peristaltic activity b. Metachloporomide (Reglam) – decrease esophageal pressure by relaxing pyloric & duodenal

segments

increase peristalsis without stimulating secretions

a. H2 Histamine Receptor Antagonist – decrease gastric acidity & pepsin secretion

Zimetidine, Ranitidine (Zantac) – take 30 min before meals

a. antacid – neutralizes gastric acid between feedings - Maalox

Surgery: Nissen funduplication :

Chronic vomiting –

thickened feeding with baby cereals - effective if without vomiting feed slowly, burp often every 1 ounce positioning

< 9 months – infant sit with infant supine

> 9 months – prone with head of mattress slightly elevated 30 degree angle

OBSTRUCTIVE DISORDERS

A. PYLORIC STENOSIS – hypertrophy of muscles of pylorus causing narrowing &

obstruction.

1.) outstanding Sx- projectile vomiting

- vomiting is an initial sx of upper GI obstruction

- vomitus of upper GI can be blood tinged not bile streaked. (with blood)

- vomitus of lower GI is bilous ( with pupu)

- projectile vomiting – increase ICP or GI obstruction

- abd distension – major sx of lower GIT obst

2.) met alk

3.) failure to gain wt

4.) olive shaped mass – on palpation

5.)serum electrolyte – increase Na & K, decrease chloride

6.) ultrasound

7.) x ray of upper abd with barium swallow reveal "string sign"

Mgt:

1. Pyleromyotomy 2. Fredet Ramstedt procedure

INSTUSSUSCEPTION- invagination or telescoping of position of bowel to another

Common site – ilio-secal junction

Prone pt: person who eats fat

Complication – peritonitis – emergency

Sx:

1. persistent paroxysmal abd pain 2. vomiting 3. currant jelly stool- dye bleeding & inflammation

palpate sausage shaped mass

Mgt:

1. Hydrostatic reduction with barium enema 2. Anastomosis & pull thru procedura

 

Inborn Errors of Metabolism- deficient liver enzymes

PHENYLKETONURIA (PKU) – deficiency of liver enzymes (PHT)

Phenylalaninehydroxylase Transferase – liver enzyme that converts CHON to amino acid

9 amino acids:

valine isolensine tryptophase

lysine phenylalanine

Thyronine – decrease malanine production

1. fair complexion 2. blond hair 3. blue eyes

Thyroxine – decrease basal metabolism

- accumulation of Phenyl Pyruvic acid

4.) Atopic dermatitis

5.) musty / mousy odor urine

6.) seizure – mental retardation

Test – GUTHRIE TEST – specimen – blood

preparation increase CHON intake test if CHON will convert to amino acid

specimen and urine

mixed with pheric chloride, presence of green spots at diaper a sign of PKU

DIET:

Low phenylalanine diet- food contraindicated- meats, chicken, milk, legumes, cheese, peanuts

Give Lofenalac- milk with synthetic protein

Galactosemia – deficiency of liver enzyme

GUPT – Galactose Urovil Phosphatetranferase Converts galactose to phosphate tranferace glucose

Galactose – will destroy brain cells if untreated – death within 3 days

Dx:

Beutler test – get blood -done after 1st feeding

presence of glucose in blood – sign of galactosemia

galactose free diet lifetime

neutramigen – milk formula

CELIAC DISEASE – gluten enteropathy

Common gluten food:

Intolerance to food with brow

B- barley

R- rye

O- oat

W- wheat

Early Sx:

1. diarrhea – failure to gain wt ff diarrheal episodes 2. constipation 3. vomiting

Late Sx:

1. abd pain – protruberant abd even if with muscle wasting 2. steatorrhea

Celiac Crisis- exaggerated vomiting with bowel inflammation

Dx:

1. lab studies – stool analysis2. serum antiglyadin – confirmatory of disease

gluten free diet – lifetime

all BROW – not allowed

ok – rice & corn

Mgt:

1. vitamin supplements2. mineral supplements3. steroids