pediatric nursing - continuation from n.u.r. online review
TRANSCRIPT
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CARDIOPULMONARY RESUSCITATION
CPCR = cardiopulmonary and cerebral resuscitation
5 minutes of 02 deprivation will cause irreversible brain damage
Priority: Airway, Breathing, Circulation
AIRWAY
Clear the airway Shake the baby
If no response, call help
Immediately do 1 minute CPR before calling for help
Flat on bed, put a board if the bed is soft
Head tilt chin lift maneuver
No head tilt for suspect of cervical damage
Overextension may cause occlusion
BREATHING
Ventilating the lungs
Check breathlessness
If breathless = give 2 breaths
If newborn = mouth and nose If child = mouth and pinch the nose
Force = puff only
Use one way mask to prevent contact with the secretion
CIRCULATION
By cardiac compression
Check if pulseless
Use brachial pulse = children
No breath + No pulse = CPR
Infant = 1 finger breadth below nipple line, 2 finger
1 year old = heal of the palm
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RESPIRATION
Normal Values = 30 60 bpm irregular
Either abdominal or diaphragmatic breathing with short period of apnea without cyanosis
Normal apnea in newborn is 15 seconds or less
Age Rate
Newborn 40 901 year old 20 40
2 3 years old 20 30
5 years old 20 25
10 years old 18 22
15 and above 12 20
Breath Sounds Heard on AuscultationVesicularNormal
Soft, low pitched, heard over periphery oflungs, aspiration is longer than expiration
BronshovesicularNormal
Soft, medium pitched heard over majorbronchi, inspiration equals expiration
Bronchial
Normal
Loud, high pitched, heard over the trachea,
expiration is longer than inspirationRonchiNormal
Snoring sound made by air moving throughmucus in bronchi
RalesAbnormal
Crackles (like Cellophane) made by air movingthrough fluid in alveoli
Denotes pneumonia, fluid in the lungs orpulmonary edema
WheezingAbnormal Whistling on expiration made by air beingpushed through narrowed bronchi
Denotes children with asthma or foreign bodyairway obstruction
Stridor Crowing or roster like sound made by air being
pulled through a constricted larynx Indicative of Respiratory Obstruction
Resonance Loud, low tone, percussion sound over normallung tissue
HyperResonance
Louder, lower sound than resonance,percussion sound over hyperinflated lung tissue
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1. RESPIRATORY DISTRESS SYNDROME Lack of surfactant within 24 hours of life
Aka Hyaline Membrane Disease
Common in preterm babies
The alveoli cannot expand properly
Signs and symptoms
o
Present within 4 hours of lifeo Using the Silverman Anderson Scoring to determine RDSo Increased RR with retraction (1st sign of RDS)o Expiratory Grunting (major sign)o Xiphoid retractiono Flaring nasal flareso Cyanosiso Respiratory acidosis
Managemento Head elevatedo Proper suctioningo O2 administration with increased humidityo Client placed on
o
CPAP Continuous Positive Airway Pressureo PEEP Positive End Expiratory Pressureo Purpose id to maintain the alveoli partially open and prevent alveolar
collapseo Monitor for acidosiso Surfactant replacement
2. LARYNGOTRACHEO BRONCHITIS (LTB) Most common form of croup
Viral infection of the larynx, trachea and bronchi
Signs and symptomso BARKING or CROUPY COUGH = outstanding signo Inspiratory Stridor
o
Respiratory acidosiso Cyanosiso Death
Diagnostic Examso Throat swab for c & so ABGo Chest and x-ray to rule out epiglottitis
Managemento Racemic Epinephrine bronchodilatoro Humidified Oxygen
3. BRONCHIOLITIS Inflammation of the bronchioles characterized by production of tenacious mucus
FLU LIKE SYMPTOMS outstanding sign Increased RR
Causative Agent: Respiratory Syncitial Virus
Drug: Antiviral Ribavirin
LTB and Bronchiolitis ends with Epiglottitis
4. EPIGLOTITIS Inflammation of the epiglottitis
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Sudden onset
The child always assume the tripod position
Less than 18 months cannot cough must be placed on mist tent or Croup tie makesure that the edges are tucked in
o Provide washable plastic toys or materialso Avoid toys that crate frictiono
Avoid toys that are hairy or furry
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Blood Pressure
Newborn 80 46 mmHg
After 10 days 100/ 50 mmHg
BP taking begins by 3 years old
SKIN If cyanotic after the first cry suspect Transposition of the Great Arteries
1. Acrocyanosis body is pink, extremities are blue2. Generalized Mottling due to the immaturity of the circulatory system3. Birthmarks
a. Mongolian Spots Slate gray or bluish discoloration/ patches commonly seen across the sacrum or
buttock
Related to increased melanocyte which is common in Asian newborn
Usually disappear by 1 5 years old (preschool)b. Milia
Plugged or unopened sebaceous glands usually seen as a white pinpoint patches
at the nose, chin and cheeks and will disappear by 2 4 weeksc. Lanugo
Fine downy hair which is common in pretermd. Desquamation
Peeling of the newborns skin within 24 hours characterized by extreme drynessthat begin in the sole and palm, common in post term babies
e. Stork Bites (Talengeiclasis Nevi) Pink patches at the nape, never disappears
f. Erythema Toxicum (Flea Bite Rash) First self limiting rash to appear sporadically and unpredictably as to time and
placeg. Harlequin Sign
Dependent part is pink, independent part is blue because of the immaturity of
circulation, the RBC settles downh. Cutis Memorata
Transitory mottling of the neonates skin when exposed to coldi. Hemangiomas
Vascular tumors of the skin
Types:o Nevus Flammeus/ Port Wine Stain
Macular purple or dark red lesions usually seen on the faceor thigh, disappears and be removed surgically
o Nevus Vasculosus/ Strawberry Hemangioma Dilated capillary in the entire dermal or subdermal area
continuing to enlarge but disappear after 10 years oldo Cavenous Hemangiomas
Consist of communicating network of venules in thesubcutaneous tissue that never disappear with age
j. Vernix Caseosa White cream cheese like substance that serves as skin lubricant
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SKIN COLOR AND THEIR SIGNIFICANCE
1. Blue = cyanosis , hypoxia2. White = edema3. Gray = infection4. Yellow = jaundice or carotinemia
5.
Pale = anemia
BURN MANAGEMENT
First Aido Put out the flames by rolling the child on a blanketo Immerse the burned part on cold watero Removed burned clothing (sterile material)o Cover burned part with sterile dressing
Maintenance of patent airwayo Suction PRNo O2 administration with increased humidityo Endotracheal Intubationo
Tracheostomy Prevention of shock and fluid and electrolyte imbalances
o Colloids to expand blood volumeo Isotonic saline to replace electrolyteo Dextrose in water to provide calories
Booster dose of Tetanus Toxoid
Relief pain such as IV analgesic (morphine sulfate)
Prevention of wound infectiono Cleaning and debriding the woundo Open or close method of wound careo Whirl pool therapy
Skin graftingo 3rd degree burn
o
get skin from buttocks or pig skin (xenograft) or from frozen cadaver Diet = increase CHON and calories
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BLEEDING DISORDERS/ BLOOD DYSCARIAS
Hemophilia
Sex linked (X) Recessive disorders
The mother is the carrier
The son is affected
The father transmits to daughter Deficiency in clotting factor
o Hemophilia A factor 8 classic hemophiliao Hemophilia B Factor 9 Christmas diseaseo Hemophilia C Factor 11
OMPHALAGIA earliest signo >300 cc loss of blood during cutting of the cord
the maternal clotting factor is present in the new born that is why there is a delayed diagnosisof hemophilia
in toddlers sudden bruising
HEMARTHROSIS major sign repeated bleeding, bleeding of the synovial membrane
Diagnostic exam: PTT
Nursing Diagnosis: High Risk for Injury
Goal: Prevention of injury Health Teaching
o Avoid contact sportso Determine the case before doing any invasive procedure
In immunization change the needle into a smaller oneo In case of fracture/ injury
Immobilize and elevateo Cold compresso Gentle pressureo Blood transfusion of cryoprecipitate
Leukemia
Group of malignant disease characterized by rapid proliferation of immature RBC
Ratio is 500 RBC : 1 WBC The client is immunocompromised
Classification of Leukemiao Lympho affects the lymphatic systemo Myelo affects the bone marrowo Acute/ Blastic affects the immature cellso Chronic/ cystic affects the mature cells
Acute Lymphocytic Leukemia
Most common in children
Increase immature WBC
Signs and Symptomsa.Infection
i.
Feverii. Poor wound healing
b.Bone weakness and causes fracturesc.Signs of bleeding
i. Blood in the urineii. Emesisiii. Petechiaeiv. Epistaxis
d.Signs of anemia
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i.Pallorii. Body malaiseiii. constipation
e.Invasion of the organsi. Hepatomegaly abdominal painii. Spleenomegaly
2.Diagnostic examinationsa.Peripheral Blood Smear reveals immature WBCb.CBC reveals anemia and thrombocytopenia; neutropeniac.Lumbar Puncture
i. To determine CNS involvementii. Fetal position without flexion of the neck because it will cause airway
obstructioniii. C position or shrimp position
d.Bone Marrow Aspirationi. Determines the presence of blast cellsii. Site of bone marrow aspiration iliac Crest post op : prevent hemorrhageiii. Lie on affected site
e.Bone Scan determines the degree of bone involvementf. CT Scan determine the degree of organ involvement
3.Management Triada.Surgeryb.Irradiationc.Chemotherapyd.Bone marrow transplant
4.4 Levels of Chemotherapya.Induction
i. To achieve remissionii. Drugs
IV VincristineL AsparagineOral Prednisone
b.Sanctuaryi.
To treat the leukemic cells that has invaded the testes and CNS
ii. Drugs intrathecal methotrexate via spinecytocinearabinase steroids irradiation
c.Maintenancei. To continue remissionii. Drugs
oral methotrexateoral 6-mecaptopurinecytarabine
d.Reinductioni. Give anti-gout agent Toii. To treat leukemic cells after relapse occursiii. Treat hyperurecemic neuropathy
Alopurinol or zylorene5.Nursing Management
a.Assess for common side effects of chemotherapy nausea and vomitingb.Assess for stomatitis ulceration and abscess of oral mucosa
i. Oral care
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ii. Alcohol free mouthwashiii. Cotton pledglets
c.Diet give food according to childs preferenced.Alopecia temporary side effect of chemotherapy
HEMOLYTIC DISORDERS
Rh Incompatibility
Rh = monkey foreign body
Mother (-) no antigen; no protein factor
Fetus (+), Father (+) has antigen and protein factor
4th baby is severely affected
Erythroblastocis Fetaliso hemolysis/ destruction of RBC leading to O2 carrying capacity leading to IUGR with
pathologic jaundice w/in 24 hours
ALERT! Baby is small and yellowish
Managemento RHOGAM
Vaccine given to Rh(-) mothers within the first 24 hours or within 72 hours Given once If pregnancy was aborted and the mother undergo D & C, RHOGAM must be given
w/in 24 hours, if not given within 24 hours, mother will produce antibody Action: destroys RBC preventing antibody formation
Diagnostic TestCoombs Test
ABO Incompatibility
Mother Type O; Fetus Type A most common
Mother Type O; Fetus Type B most severe
Hydrops Fetaliso Common in abo incompatibilityo Newborn is edematous, on lethal state, accompanied by pathologic jaundice w/in 24
hours Difference from Rh Incompatibility
o First pregnancy is affectedo NB is yellow and edematous
Managemento Initiation of breastfeeding, then temporary suspension of breastfeeding after 4 days (
breastfeeding releases prenanediole causing kernicterus)o Pregnanediole delays actions of Glucoonyl transferase ( liver enzyme that converts
indirect bilirubin into direct bilirubin) Indirect bilirubin
Fat soluble
Cant be excreted by kidneysCauses hyperbilirubinemia causing jaundice
Direct Bilirubin Water soluble Can be excreted by the kidneys
o Use phototherapyo Exchange transfusion for Rh and ABO affectations that tend to cause a continuous
decrease in hemoglobin during the first 6 months because the bone marrow fails toproduce erythrocytes in response to the continuous hemolysis
Hyperbilirubenemia
More than 12mg of indirect bilirubin among full terms
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Normal Indirect Bilirubin Level: 0 3 mg/dl
Kernicterus/ Bilirubin Encephalopathy
Irreversible brain damage
> 20 mg/dl of indirect bilirubin among full terms
> 12 mg/ dl of indirect bilirubin among preterm because of immaturity
Physiologic Jaundice Pathologic Jaundice Breastfeeding JaundiceNormalWithin 48 72 hoursMx:Expose to early morningsunlight
Within 24 hoursYellow upon birth
Possible Rh/ ABOincompatibility
Within 6t 7t dayDue to glucoronyl transferase
Assessment of Jaundice
blanching of forehead, nose and sternum
yellow skin, sclera
light stool
dark urine
Management
Phototherapy/ Photooxygenationo Nursing Responsibilities
Cover the eyes prevents retinal damage Height of light from baby 18 20 inches Increase Fluid intake Cover genitalia prevent priapism ( painful continuous erection Change position Avoid lotion and oils Monitor I&O best way is to weigh the baby Monitor VS
Bronze Baby Syndrome Transient bronze discoloration of the skin
Minor side effect of phototherapy
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HEAD
of its length
Structureso sutureso fontanels
anterior/ bregma 3 x 4 12 18 mos
posterior/ lambda - 1 x 1 2 3 mos Noticeable structures of the Head
o Craniotabes Localized softening of the cranial bone common to first bone child due to early
lightening If present in older children, sign of rickets or Vit. D deficiency
o Seborrheic dermatitis/ Cradle Cap Scaling, greasing, appearing salmon colored patches Usually seen at the scalp, behind ears and umbilicus Usually caused by improper hygiene Management
Application of baby oil the night before shampooing the childo Caput Succedaneum
Edema of the scalp due to prolonged pressure at birth Present at birth
Crosses the suture line Disappears 2 3 days Disappears without treatment
o Cephalhematoma Collection of blood due to rupture of capillaries of poriosteal capillaries Present after 24 hours Does not cross the suture line Disappears after 4 6 weeks Disappears without treatment
o Hydrocephalus Excessive accumulation of CSF Types
Communicating/ extraventricular hydrocephalus
No-communication/ intraventricular hydrocephalus/ obstructivehydrocephalus caused by tumor
Signs and symptoms
Signs of increased ICPo Diplopia eye deviation @ 6th mos and aboveo Management
Low semi fowlers (30 degrees) best position
Frontal bossing 9 prominent forehead)
Sunset eyes
Prominent scalp vein Therapeutic management
Osmotic Diuretico Mannitolo Diamox / acetazolamide
Seizure precautions
Surgery Shuntingo AV Shunt - atrioventricularo VP shunt ventriculoperitonial most common
Best time to shave the head just before the surgery prevent infection Post VP Shunt management
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Position sidelying on non-operated side ( applicable to all eyes andhead surgeries)
Sign of good shunting sunken fontanel
Sign of blocked shunting bulging fontanel
Catheter is changed as the child is growing
Child with BP shunt is prone to infection
SENSES
Sense of Sight
Sclerao Normal light blueo Later Color dirty white
Pupilso Normal round and adult size
o Coloboma key hole pupils part of the iris is missingo Congenital N Cataract whiteness/ opacity of the lens
Corneao Normal round and adult size
o
Congenital Glaucoma larger than normal
Test for BlindnessAge Common Test
NewbornCan see @ a distance
of 10 12 inches withvisual acuity of 20/200to 20/ 800
General appearanceCheck ability to follow object pass midlineDOLLS EYE TEST done at approximately 10th dayGLADELLAR TEST test for blink reflex, not blinking is a sign ofblindness
Infant and children ALLENS CARD test for visual acuity- familiar pictures are flashed 20 ft away from the child
ISHIARA PLATE test for color blindness
3 years old School age Cover testing test for strabismus
School age adult Snellens test
RETINOBLASTOMA
malignant tumor of the eye
signs and symptomso cats eye reflex (whitish glow of pupil)o red, painful eye usually accompanied by glaucoma
Managemento Surgery innucleation - removal of the eyeballo Irradiationo Therapy
SENSE OF SMELL
Normal nasal membrane - pinkish
Check for sense of smell
Check for nasal flaring
Sign of Cocaine User
Ulceration and abscess of nasal mucosa
Absence of hair
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Epistaxis
Nose bleeding
Managemento Position, upright, sitting, head tilted, slightly forwardo Gentle pressureo
Cold compresso Epinephrine last resort
SENSE OF HEARING
Normal should be aligned with the outer canthus of the eye
Low Set Ears is a sign ofo Kidney malformation
Renal agenesis
Absence of kidneyo Chromosomal Abnormalities
Due to advance maternal age - >35y/o
Typeso Nondisjunction (uneven division)
Trisomy 21
Down Syndrome
Most common type
Extra chromosome 21
47xx + 21/ 47xy + 21
can be related to advance paternal age
signs and symptomso broad noseo protruding tongueo low- set ears
o
puppys necko hypotonia prone to URTIo simian crease single traverse line in palmo mental retardation ranging from educable to
institutionalization
Trisomy 18
Has 3 numbers of 18 chromosomes
Severely cognitively impaired SGA
Low set ears, small jaw, CHD, index finger crosses over the otherfingers, rounded soles of feet
Trisomy 13
Pataus syndrome
Extra chromosome 13
Severely cognitively impaired
Signs and symptomso Microcephalyo Micropthalmiao Cleft-lip and palateo Low-set earso VSDo Do not survive
Turners
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Gonadal Dysgenesia
One functional x chromosome
Short in stature
Neck appear to be webbed and short
COA and kidney problems
Only 1 streak (nonfunctional) gonads
Secondary sex characteristic does not develop except for pubic hair Lack ovarian function sterility
Cognitively challenged but mostly normal intelligence
Klinefelters syndrome
Males with a XXY chromosome pattern
@ puberty child has poorly developed secondary characteristics andsmall testes that produces ineffective sperm
boys tend to develop Gynecomastiao Deletion Abnormalities
Cri du chat Syndrome
Result of a short arm on chromosome 5
Cats cry
Small head, wide set eyes, downward slant to the palbepral fissure of
the eyes
Severe cognitive impairment
Fragile X Syndrome
X linked pattern
One arm of x chromosome is weakened
Most common cause of cognitive impairment in boys
Before puberty, boys typically have maladaptive behavior likehyperactivity and autism
Large head, long face with high forehead, prominent lower jaw, largeprotruding ears
o Translocation abnormalities
Balance translocation Carrier
Unbalanced Translocation Syndromeo Others
Mosaicism
A situation wherein the nondisjunction of chromosome occurs duringmitotic cell division after fertilization resulting to different cellscontains different numbers of chromosome
Isochromosomes
A situation wherein the chromosome instead of dividing vertically itdivides horizontally resulting to chromosomal mismatch
Otitis Media
Inflammation of the middle ear
Common to children due to wider and shorter Eustachian tube
Predisposing factorso Bottle proppingo Cleft lip/ palate
Signs and symptomso During otoscopic exam, reveals bulging tympanic membraneo Observe for passage of purulent, foul smelling odor discharge
Managemento Positioning sidelying on the affected sideo Supportive care
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Medical managemento Massive dosage of antibioticso Mucolyticso Ear drops
< 3 y/o down and back >3 y/o up and back
o Surgery Myringectomy slight incision of tympanic membrane to prevent hearing loss
Side effect bacterial meningitis
MOUTH AND TONGUE
Check for symmetry
Bells palsy/ Facial Nerve Paralysis
7th CN injury
usually related to forceps delivery
risk for URTI
Signs and symptomso
Continuous drooling of salivao Inability to open one eye and close the other
Managemento Artificial tearo Self limitingo Refer to PT for rehabilitation
TEF/ TEA
No connection between esophagus and stomach
There is a blind pouch
Hydramnios earliest sign intrauterine
Signs and symptoms
o
Coughingo Chockingo Cyanosiso Continuous drooling
Managemento Emergency surgery
Epstein Pearls
White glistening cyst
Usually seen on palate, gum
Related to hypercalcemia
Natal Tooth
Tooth at the moment of birth Related to hypervitaminosis
Managemento Manual extraction if rootless
Neonatal Tooth
Appearance of tooth within 28 days of life
Oral Thrush
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White cheese-like, curd like patches
Usually seen in mouth and on tongue
Causative agent C. Albicans fungi
Managemento Do not remove can cause woundo Wash with cold, bottled water
o
Medical Mycostatin/ Nystatin
Kawasaki Disease
Discovered in Korea
Strawberry tongue
Common in Asian countries
Criteria for diagnosiso Fever lasting for more than 5 dayso Bilateral conjunctivitiso Changes in lips and oral cavity
Dry red fissure lips Strawberry tongue Diffuse erythema of mucus membrane
o
Changes in the peripheral extremities Erythema on the palms and soles Erythema on the hands and feet Membranous desquamation from fingertips
o Polymorphous rash (primarily at trunk)o Acute non purulent swelling of the cervical lymph nodes to > 1.5 cm in diameter
Drug of Choice : ASPIRIN
Cleft Lip
Failure of the median maxillary nasal process to fuse
Common to boys
Surgery cheiloplasty
o
Done w/in 1 3 monthso To save sucking reflex
Signs and symptomso Evident at birtho Milk from nostrils spillso Cold is commono Frequent URTI and otitis media
Post cheilo sidelying
Nutrition use rubber tip syringe
Cleft Palate
Failure of the palate to fuse
Common to girls
Surgery Uranoplastyo Done w/in 4 6 monthso To save speech
Signs and symptomso Evident at birtho Milk from nostrils spillso Cold is commono Frequent URTI and otitis media
Post cheilo prone
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Nutrition use paper cup/ plastic cup/ soup spoon
Condition to consider for suspension of operation
If child has a cold/ nasopharyngitis may lead to general septicemia
General management
Maintenance of patent airway Proper nutrition
o NPO 4 hours post opo Clear liquid
Popsicle except red and brown in color Flavore gelatin No ice cream
Observe for bleedingo Frequent swallowing
Protect suture lines specially LOGAN BARo Clean using hydrogen peroxide, bubbles traps microorganism, more bubbles more
microorganism trappedo Prevent crying by attending to needs
Therapeutic Management
Emotional support
Proper Nutrition
Cleft lip nipple (long tip, made by silicon)
Prevent Colico Burp frequentlyo One at the middle of the feedingo Another at the end of the feedingo Upright sitting positiono Pat at the back lower to uppero Prone positiono Right sidelying position facilitates gastric emptying
Educate parents Apply elbow restraints so the baby can easily adjust post op
NECK
Check for symmetry
Congenital Torticollis/ Wryneck
Birth injury of sternocleidomastoid due to excessive traction during cephalic delivery
A case of incompetence to the one giving birth
Managemento Passive stretchingo Exercise daily
o
Surgery Complication
o Scoliosis
Congenital Cretinism/ Congenital Hypothyroidism
Absence or non functioning thyroid gland
Causeso Due to delayed diagnosis, thyroid is covered by sternocleidomastoid muscleo Hypothyroidism
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o Thyroid dysgenesis (absence of thyroid)o Baby receive maternal thyroxin
Earliest Signs and Symptomso Change in suckingo Change in cryingo Excessive sleeping (16-20 hours/ day)o
Constipationo Edema moon faced babyo Mental retardation late sign
Diagnostic Testo Radioimmunoassay Testo Protein bound iodine
Treatmento Synthroid / sodium levothyroxine for life
CHEST
Witch Milk
Transparent Liquid coming out from newborns breast related to hormonal changes
ABDOMEN
Abdominal Assessment
Inspection
Auscultation
Percussion
Palpation
Diaphragmatic Hernia
Protrusion of stomach contents through a defect in diaphragm due to failure of pleuroperitonealcanal to close
Signs and Symptomso Sunken abdomeno Signs of RDSo Right to left Shunting
Treatment diaphragmatic repair w/in 24 hours
Omphalocele
Protrusion of stomach content between the junction of abdominal wall and umbilicus
If small surgery
If large suspend surgery
Apply wet dressing
GASTROINTESTINAL SYSTEM
Functionso Assist in maintaining fluid and electrolytes and acid and base balanceo Processes and absorbs nutrients to maintain and support growth and developmento Excrete wasted products from the digestive process
Supplementary Feeding
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Begin 4 6 months
As early as 4 months
Usually at 6 months
Principleso Solid food are often according to the following sequence
Cereals rich in iron
Fruits
VegetablesMeat
o Begin with small quantitieso Finger food are offered @ 6 monthso Soft table food is offered @ 1 yearo Diluted citrus/ fruit juices @ 6 monthso Offer new food one at a time with an interval of 4 7 days or 1 weeko Never offer half cooked egg may lead to gastroenteritis/ salmoneliosis
Major Concepts of Fluid and Electrolyte Balance
Distribution of Body Fluidso Fluids are greater in ECF in infant and childreno
Newborns are candidate for dehydrationo Total Body fluid is 65 85% of their body weight in infants and children
Acid Base Imbalance
Depending upon the followingo Chemical bufferso Renal and respiratory system involvemento Dilution of strong acids and bases in blood
Imbalance of Acido Respiratory Acidosis
Carbonic acid excess LTB RDS Hypoventilation COPD
o
Respiratory Alkalosis Carbonic acid deficit Hyperventilation Fever, encephalitis
o Metabolic Acidosis Base bicarbonate deficit Diarrhea Severe malnutrition and dehydration celiac
o Metabolic Alkalosis Base bicarbonate excess due to uncontrolled vomiting NGT aspiration Gastric lavage Pyloric stenosis
Conditions that Produce Fluids and Electrolyte Imbalance
Vomiting
Forceful expulsion of stomach content
Signs and symptomso Nauseao Abdominal crampingo Flushing of face
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o Watery eyes
Assessmento Frequencyo Forces
Projectile increase ICP/ Pyloric stenosis Non projectile
Alertso Vomiting is an initial symptom of GI Obstructiono Vomitus of upper GI can be blood tinged but bot bile streakedo Vomitus of lower GI is biliouso Projectile vomiting is a sign of increased ICP or GI Obstructiono Abdominal distention is the major symptom of lower GIT obstruction
Managemento Bananao Rice cerealo Apple sauceo Toast
Diarrhea
Exaggerated excretion of intestinal contents Acute diarrhea is associated with the following
o Gastroenteritis/ salmonelliasiso Antibiotic use penicillin, tetracyclineo Dietary indigestion
Chronic non specific diarrheao Food intoleranceo CHO/ CHON malabsorptiono Excessive fluid intake
Assessmento Frequencyo Consistency (best criteria)o Appearance of green colored stool
Complicationso Mild dehydration 5% weight losso Moderate dehydration 10% weight losso Severe dehydration 15% weight loss
Signs of dehydrationo Tachycardia earliest signo Tachypneao Hypotensiono Increase tempo Sunken fontanelo Sunken eyeballo Poor skin turgoro Absence of tearso
Scanty urineo Oliguria severe dehydrationo Weight losso Prolonged capillary refill time
Managemento NPOo IV infusiono KCl given by doctors
Assess child for ability to void before giving KCl may lead to hyperkalemia Normal K Value 3.5 5.5
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o Order Na Bicarbonate, administer slowly to prevent cardiac overload
Gastric Motility Disorders
Hirschprungs Disease/ Congenital Aganglionic Megacolon
Absence of ganglion cells needed for peristalsis
Assessmento Neonatal Period
Abdominal distention Failure to pass meconium within 24 hours
o Early childhood Ribbon like stool Constipation Foul smelling stool Diarrhea Vomitus of fecal materials
Diagnostic Procedureso Barium enema reveals narrowed portion of the bowelo Rectal biopsy reveals absence of ganglion cellso Abdominal x- ray reveals dilated loops on intestineso Rectal manometry reveals failure of intestinal sphincter to relax
Therapeutic Managemento NGT Feeding
NGT Measurement
Infant nose-ears middle of xiphoid process and umbilicus
Adult nose ears xiphoid processo Surgery
Temporary colostomy Anastomosis and pull through procedure
o Diet Increase CHON Increase Calorie
residue diet pasta foods no raisin/ prunes
Gastroesophageal Reflux
presence of stomach content on esophagus
Assessmento chronic vomitingo failure to thrive syndrome organico esophageal bleeding manifested by melena and hematemesis
Complicationso esophagitiso aspiration pneumoniao esophageal cancer
Diagnostic Procedureo barium esophogramo esophageal manometry reveals lower esophageal pressureo intraesophageal pH content reveals pH of distal esophagus
Medicationso anticholinergics
bathanechol/ urecholine
esophageal tone and peristaltic activity Methachlopromide (Reglan)
esophageal pressure by relaxing pyloric and duodenal segments
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peristalsis without stimulating secretions H2 Blocker/ histamine Receptor Antagonist
gastric acidity and pepsin secretion Maalox/ Cimetidine (Tagamet)/ Ranitidine (Zantac)
Neutralizes gastric acid between feedings
Surgery: Nissen Fundoplication
Dieto Thickened feeding with rice cereal prevents vomitingo Feed slowlyo Burp often every 1 ozo Positioning
< 9 mos infant sit/ infant supine > 9 mos prone with head on mattress slightly elevated on a 30 angle
Obstructive Disorders
Pyloric Stenosis
hypertrophy of the muscle of pylorus causing narrowing and obstruction
Assessment
o
Projectile vomitingo Failure to gain weighto Metabolic alkalosiso Peristaltic wave visible from left to right across epigastrumo Palpation of olive shaped mass
Diagnostic Procedureo ABGo Serum Electrolyte - Na and K, Clo Ultrasoundo X-ray of upper abdomen with barium swallow
Managemento Pyloromyotomy/ Fredet Ramstedt Operation
Intussusception Telescoping or invagination of one portion of the bowel into the other
Peritonitis danger of intussusception
Emergency for URT epiglottitis
Emergency for GIT peritonitis
Signs and symptomso Acute paroxysmal abdominal paino Currant jelly stool caused by inflammation and bleedingo Sausage shaped mass
Non congenital
Caused by fast eating and positioning
Managemento Hydrostatic reduction with barium enema
o
Surgery Anastomosis
Inborn Errors of Digestion
Phenylketonuria/ PKU
Deficiency of the liver in Phenylalanine Hydroxylase Transferase (PHT)
PHT is a liver enzyme that coverts protein into amino acid
9 Essential Amino Acidso Tyrosine / phenylalanine
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o Histidineo Isoleucineo Leucineo Lysineo Methionine/ cysteineo Threonineo Tryptophano Valine
Tyrosine or Phenylalanine responsible for the melanin production
Signs and Symptomso Fair complexiono Blond hairo Blue eyeso Infantile eczemao Mousy/ musty odor urineo Seizure due to Phenyl Pyruvic Acid goes to braino Mental retardation
Guthrie Testo Specimen Bloodo Preparation Increase Fluid Intake
Managemento Diet
phenylalanine diet indefinitely Chicken, meat, peanuts, milk, legumes, cheese contraindicated Lofenalac special formula
Celiac Disease/ Malabsorption Syndrome; Gluten Induced Enteropathy
Sensitivity or immunologic response to protein
Assessmento Early signs
Diarrhea, failure to regain weight following diarrheal episode Constipation Vomiting Abdominal pain Steatorhea
o Late signs Behavioral changes: irritability and apathy Muscle wasting and loss of subcutaneous fats
o Celiac Crisis Development of infection by a child having a celiac disease Acute vomiting and diarrhea
Diagnostic Procedureo Stool analysiso Serum antiglandin and antireticulin antibodieso Sweat test
Therapeutic managemento Vitamin supplementso Mineral supplementso Steroid
Poisoning
Common accident in toddlers poisoning
Common accident in infants falls
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Principleso Determine the substance taken and assess LOCo Unless poisoning was corrosive, caustic (strong alkali, such as lye) or hydrocarbon,
vomiting is the most effective way to remove the poison from the body Strong acid poisoning give weak acid to neutralize strong acid
o Syrup of ipecac oral antiemetic to cause vomiting after drug overdose or poisoning
15 ml adolescent, school age and preschool 10 ml infanto Universal Antidote
Activated charcoal Milk of magnesia Burned toast
Charcoal absorbs toxic substanceo Never administer the charcoal before ipecac because giving charcoal first will absorb
the effect of ipecaco Antidote for acetaminophen poisoning : Acetylcysteine (mucomyst)o Kerosine/ Gasoline poisoning: Give mineral oil to coat the intestine and prevent poison
absorption
Tracheostomy set will be at bed side
Lead Poisoning
Pencil, paint, crayon Lead
Destruction of RBC Functioning
Hypochromic Microcytic Anemia
Destroys Kidney Function
Accumulation of ammonia
Leading to Encephalitis (Late stage)
Severe mental retardation
Assessmento Beginning symptoms of lethargyo Impulsiveness and learning difficultyo As lead , severe encephalopathy with seizure and permanent mental retardation
Diagnostic procedureo Blood smearo Abdominal x-rayo Lone bone
Managemento Chelation binds with the lead and excreted via kidneyso Ca EDTA/ BAL/ Dimercapro
Nephrotoxic
ANOGENITAL
Female
Pseudomenstruationo Slight vaginal bleeding related to hormonal changes
Rape/ Child Abuseo If the client came with a laceration and bleeding at the perineumo Report rape within 48 hours
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o Preschool are proneto rape because of their innocenceo CBQ Report rape cases to barangay chairman first or bantay bata
Male
Cryptorchidismo Undescended testes or empty scrotum or ectopic testes
Common in preterm babies Testes is palpable at lower quadrant
Surgery: Orchioprexy
Preop warm the room and hands
Epispadiaso Urinary meatus is located at the dorsal or above the glans penis
Hypospadiaso Urinary meatus is located at the ventral or below the glans peniso Hypospadias is usually accompanied by Chordee ( A fibrous band causing penis to
curved downward)o Both are manage by surgery
Phimosiso Tight foreskino
This will cause infectiono Circumcision as management
Hydroceleo Fluid filled scrotumo Flashlight/ transillumination test to determine
Varicoceleo Enlarged vein of the epididymis
RENAL DISORDERS
RenalDisorder
Causes Assessment Findings Treatment Nursing Care
Nephrotic
Syndrome
Infection Anasarca
Massive proteinuriaMicroscopic or nohematuria serum CHON serum lipidNormal or BPFatigue
Prednisone Skin Care
Weigh the client dailywith the same clothing CHON(Normal Diet) Na K
AcuteGlomerulonephritis
AutoimmuneGroup A betahemolyticstreptococcus
Primary peripheralperiorbital edemaModerate ProteinuriaGoss hematuria(smokey urine) serum K
FatigueHPN
AntiHPNHydralazineApresoline
ComplicationHypertensive
Encephalopathy
Monitor weightSkin CareMonitor BP andneurological status K Fe
Na
BACK
Check for flatness and symmetry of the back
Spina Bifida Occulta
Failure of the posterior lamina or vertebral to fuse
Sampling of the lower back
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Abnormal tufts of hair
Spina Bifida Cystica
With Sac
Typeso Meningocele protrusion of CSF and Meningeso
Myelomeningocele CSF, Meninges and Spinal cordo Ecephacele
cranial meningocele - CSF and meninges Myelomeningocele - brain, CSF , meninges
Common Complicationo Infectiono Rupture of Sac
Treatmento Surgery to prevent infection: post op prone position
Scoliosis
Lateral curvature of the spine, common in school age because of heavy bags
Uneven hemline Tell the child to bend forward, one hip higher than at the other and one shoulder is most
prominent
Typeso Structuralo Postural
Managemento Conservative
Exercise Avoid obesity
o Preventive Milwaukee Braces worn 23 hours a day
o Corrective: Surgery
EXTREMITIES
Count the number of digits
Digits
Syndactyl webbing of the digits (foot ginger like foot)
Polydactyl extra digits
Olidactyl lacks digits
Erb Duchennse Paralysis/ Brachial Plexus Injury
Birth injury of breech delivery
Signs
o
Inability to abduct the arm from the shoulder, rotate the arm extremely and supinatethe forearm
o Asymmetrical or absence of moro reflex
Managemento Abduct the arm from the shoulder with the elbow flexed
Congenital Hip Dislocation
Congenital hip dysplasia
When the head of the femur is outside the ascetabulum
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2 typeso subluxated most commono dislocated
Signs and Symptomso Shortening of the affected lego Assymetrical gluteal foldo
Limited movement earliest signo + ortolanis sign abnormal clicking of during abductiono when able to walk the child limps (Trendelenburg sign) late sign
Management facilitate abductiono Triple the diapero Carry the babyo Frejka Splinto Pavlik Harnesso Hip Spica Cast
Talipes
Club foot
4 typeso
Equinos plantar rotation/ horse foot (most common)o Calcenuous dorsiflexion/ the heel is held lower than the foot/ the anterior portion of
the foot is flexed towards the anterior lego Varus foot turns ino Valgus foot turns out
Assessmento Make a habit of straightening the legs and flying it to the midline position
Managemento Corrective shoes : Dennis Brown Shoeso Spica Cast
For immobilization Maintain bone alignment Prevent muscle spasm
If there is a blood mark on the cast mark a pen to determine whether there isa hemorrhage Neurovascular check
Circulation
Motion
Sensation
CRUTCHES
Wait is on the palm not the axilla
Exercise squeeze ball
Different Crutches and Gait
Swing Through
Advance both crutches
Lift both feet/ swing forward/ land feet in front of crutches
Advance both crutches
Lift both feet/ swing forward/ land feet in front of crutches
Swing To
Advance both crutches
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Lift both feet/ swing forward/ land feet next to crutches
Advance both crutches
Lift both feet/ swing forward/ land feet next to crutches
Three point gait
Advance left foot and both crutches
Advance right foot Advance left foot and both crutches
Advance right foot
Four Point Gait
Advance right crutch
Advance left foot
Advance left crutch
Advance right crutch
Two Point Gait
Advance left foot and right crutch
Advance right foot and left crutch
Advance left foot and right crutch Advance right foot and left crutch
Other Crutch Maneuvering Technique
To Sit Down
Grasp the crutches at the hand pieces for control
Bend forward slightly while assuming a sitting position
Place the affected leg forward to prevent weight bearing and flexion
To Stand Up
Move forward to the edge of the chair with the strong leg slightly under the seat
Place both crutches in the hand on the side of the affected extremity
Push down on the hand piece while raising the body to a standing position
To Go Downstairs
Walk forward as far as possible to the step
Advance the crutches to the lower step. The weaker leg is advanced first and then the strongerleg. In this way, the stronger extremity shares the work of raising and lowering the patientsbody weight with the arms
To Go Upstairs
Advance the stronger leg first up to the next step
Then advance the crutches and the weaker extremity (strong leg goes up first and comes downlast.)
A memory device for the patient is UP WITH THE GOOD, DOWN WITH THE BAD
WALKER
A walker provides more support than cane and crutches
The patient is taught to ambulate with a walker as followso Patient must hold the walker on the hand grips for stabilityo Lift the walker, placing it in front of you while leaning your body slightly forwardo Walk into the walker, supporting your body weight on your hands while advancing the
weaker leg, permitting partial weight bearing or non weight bearing leg as prescribed
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o Balance yourself on your feeto Lift the walker and place it in front of you again and continue the pattern of walking.
CANE
Used to help patient walk with greater balance and support and to relieve the pressure on the
weight bearing joints by redistributing the weight. Quad Cane (four footed cane) is hold on the hand of affected extremity.
METHODS OF TRANSFERRING A PATIENT FROM THE BED TO A WHEELCHAIR
Weight bearing transfe4r from bed to chair. The patient stands up, pivots his back is oppositethe new seat and sits down.
(Left) Non-weight bearing transfer from chair to bed. (Right) With legs braced.
(Left) Non-weight bearing transfer combined method. (Right) Non-weight bearing transfer, pullup method.
THERAPEUTIC EXERCISEExercise Description Purpose ActionPassive carried out by the
therapist or the nursewithout assistancefrom the patient
To retain as muchjoint range of motionas possibleTo maintaincirculation
Stabilize the proximaljoint, and support thedistal part. Move thejoint smoothly, slowlyand gently through itsfull rang of motionAvoid producing pain.
Active Assistance Carried out by thepatient with the
assistance of thetherapist or the nurse
To encourage normalmuscle function
Support the distal partand encourage the
patient to take thejoint actively throughits ROM. Give no moreassistance than isnecessary toaccomplish the action.Short periods ofactivity should befollowed by adequaterest periods.
Active Accomplished by thepatient withoutassistance, activitiesinclude turning fromside to side and fromback to abdomen andmoving up and down inbed
To increase musclestrength
When possible, activeexercise should beperformed againstgravity. The joint ismoved through fullROM withoutassistance. (make surethat the patient doesnot substitute anotherjoint movement forthe one intended)
Resistive An active exercisecarried out by the
To provide resistanceto increase muscle
The patient moves thejoint through its ROM
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patient workingagainst the resistanceproduced by eithermanual or mechanicalmeans
power while the therapistresist slightly at firstand the progressivelyincreasing resistance.Sandbags and weightscan be used and are
applied at the distalpoint of the jointinvolved. Themovement should beperformed smoothly.
Isometric/ MuscleSetting
Alternately contractingand relaxing a musclewhile keeping the partin fixed position;performed by thepatient
To maintain strengthwhen a joint isimmobilized
Contract or tighten themuscle as much aspossible withoutmoving the joint. Holdfor several seconds,and then let go andrelax. Breathe deeply.
TRACTION
Use to reduce dislocation
Principles of Traction
The client should be in dorsal or supine position
For every traction, there is always a counter traction
Line of pull should be in line with deformity
For traction to be effective it must be continuous
Weight must be freely hanging
Types of Traction
Straight traction weight of the body serves as counter pull
Skin traction applied directly to the skino Bryants Traction
use to immobilize for < 2 years old at a 90 angle with buttocks off the bedo Bucks extension
For > 2 years old
Halo traction immobilize the spine
Skeletal tractiono Nursing responsibilities
Assess for circulatory and neurology impairment It can lead to HPN
Be careful to carry out nursing functions by not moving the weights
AUTOIMMUNE SYSTEM
Types of Immunityo Passive Natural
Developed via exposure to a diseaseo Active Natural
Transplacental transfer, IgA from breastmilko Passive Artificial
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Vaccinationo Active Artificial
Anti Rabies Serum