Compilation of Pedia Notes

PEDIATRIC NURSING
I. A. GROWTH AND DEVELOPMENT
Definition of Terms:
Growth – increase in physical size of a structure or whole quantitative structure
2 Parameters of Growth
1. Weight
- Most sensitive especially in low birth weight
- Weight doubles by 6 months
- Triples by 1 year
- Quadruples by 2 ½ year
2. Height
- Increase by 1 inch per month during first 6 months
- And ½ inch per month from 7 – 12 months
Development – increase in the skills or capacity to function qualitative change
How to Measure Development?

1. by simply observing a child doing specific task
2. by noting parent’s description of the child’s progress
3. by DDST (Denver Developmental Screening Test), MMDST (Metro Manila
Developmental Screening Test)
4 Main Rated Categories
1. Language – for communication
2. Personal Social
3. Fine Motor Adaptive – pre tensile ability (ability to use hand movement)
4. Gross Motor Skills – ability to use large body movement
Maturation – synonymous with development (readiness)
Cognitive Development – is the ability to learn and understand from experience, to

acquire and retain knowledge to respond to a new situation and to solve problems
I. B. BASIC DIVISION OF LIFE

1. Pre-Natal – begins at conception and ends at birth
2. Period of Infancy
- Neonatal (first 28 days or first 4 weeks)
- Formal Infancy (from 29th day to 1 year)
3. Early Childhood
- Toddler (1 – 3 years)
- Pre-School (4 – 6 years)
4. Middle Childhood – school age 7 – 12 years
5. Period of Adolescent 1
- Pre-Adolescent/Late childhood (11 – 13 years)
- Adolescent (12 – 21 years)
Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

I. C. PRINCIPLE OF GROWTH AND DEVELOPMENT
1. Growth and Development is a continuous process that begins from

conception and ends with death.
Principle: womb to tomb
2. Not all parts of the body grow at the same time or at the same rate.
Patterns of Growth and Development
1. Renal, digestive, circulatory, Musculo-skeletal (childhood)
2. Neurologic Tissue
- Grows rapidly during 1 – 2 years of life
- Brain (achieve to its adult proportion by 5 years)
- Central Nervous System
- SC
3. Lymphatic System
- Lymph nodes, Spleen, Thymus
- Grows rapidly during infancy and childhood (to provide protection
against infxn)
- Tonsils is achieved in 5 years
4. Reproductive Organ – grows rapidly during puberty
3. Each child is unique
2 Primary factors affecting Growth and Development

A. Heredity
Race
Intelligence
Sex
Nationality
B. Environment
Quality of nutrition
Socio-Economic status
Health
Ordinal position in family
Parent-Child relationship
4. Growth and Development occurs in a regular direction reflecting a

definite and predictable patterns or trends
A. Directional Trends – occurs in a regular direction reflecting the
development of neuromuscular functions: these apply to physical, mental,
social and emotional developments and includes:
a. Cephalo - caudal (head to tail)
- It occurs along bodies’ long axis in which control over head, mouth
and eye movements and precedes control over upper body torso and
legs.
b. Proximo – distal (centro distal)
- Progressing from the center of the body to the extremeties 1
c. Symmetrical
- Each side of the body develop on the same direction at the same
time at the same rate

d. Mass – specific (differentiation)
- In which the child learns from simple operations before complex
function or move from a broad general pattern of behavior to a more
refined pattern.
B. Sequential – involves a predictable sequence of growth and development
to which the child normally passes.
a. Locomotion
b. Language and Social skills
C. Secular – refers to the worldwide trend of maturing earlier and growing

larger as compared to succeeding generations.
5. Behavior is a most comprehensive indicator of developmental status
6. Play is the universal language of a child
7. A great deal of skill and behavior is leaned by practice
8. There is an optimum time for initiation of experience or learning
9. Neonatal reflexes must be lost first before development can proceed
 Persistent Primitive Infantile Reflex (suspect Cerebral Palsy)
I. D. THEORIES OF DEVELOPMENT
Development Tasks is a skill or growth responsibility arising at a particular time in

the individual’s life. The successful achievement of which will provide a foundation
for the accomplishments of the future tasks.
THEORISTS
1. Sigmund Freud (1856-1939) – an Austrian neurologist, Founder of
psychoanalysis
PHASE OF PSYCHOSEXUAL THEORY

a. Oral Phase (0 – 18 months)
- Mouth is the site of gratification
- Biting, crying or sucking for enjoyment and to release tension
- Provide oral stimulation even the baby is NPO, offer pacifier
- Never discourage thumb sucking
b. Anal Phase (18 months – 3 years)

- Anus
- May show toilet training
- Elimination, defecation
- Principle of
- Holding on (child wins, hard headed, anti social and stubborn)
- Letting Go
- Mother wins (kind, perfectionist, obedient, obsessive – compulsive)
c. Phallic Phase (4 – 6 years)

- Genitals
- May show exhibitionism 1
- Accept the child fondling his own genital area as the normal area of exploration
- Answer the child’s question early

d. Latent Phase (7 – 12 years)
- Period of suppression
- Because there is no obvious development
- Child’s energy or libido is diverted to more concrete type of thinking
- Help child achieve positive experiences
e. Genital Phase (12 – 18 years)

- Achieved sexual maturity
- Learn to establish satisfactory relationship with opposite sex
- Give an opportunity to relate with opposite sex
2. Eric Erickson
- Trained in psychoanalysis theory
- Transits the importance of culture and society to their development of ones society
STAGES OF PSYCHOSOCIAL THEORY
Trust vs. Mistrust (0 – 18 months)
- Trust is the foundation of all psychosocial task
- To give and to receive is the psychosocial theme
- How trust is developed:
- Satisfy needs on time
- Care must be consistent and adequate
- Give and experience that will add to security (touch, hugs and kisses, eye to
eye contact, soft music
Autonomy vs. Shame and Doubt (18 months – 3 years)
- Autonomy is independence or self governance
- How autonomy is developed
- Give an opportunity for decision making such as offering choices
- Encourage the child to make decisions rather than judge
Initiative vs. Guilt (4 – 6 years)
- Learns to do basic things
- Activity recommended are modeling clay, finger painting
- Develop creativity and imagination to facilitate fine motor development
- How initiative is developed:
- Give an opportunity of exploring new places and events
Industry vs. Inferiority (7 – 12 years)
- Learn how to do things well
- How industry is developed:
- Give an opportunity no short assignment and projects
Identity vs. Role Confusion (12 – 20 years)
- Learn how he/she is or what kind of person he/she will become by adjusting to new
body image
- Seeking emancipation or freedom from parents
Intimacy vs. Isolation (20 – 40 years)
- Focus on career or looking for lifetime partners
1
Generativity vs. Stagnation (40 – 60 years)
Ego Integrity vs. Despair (65 and above)

3. Jean Piaget – a Swiss psychologist
STAGES OF COGNITIVE DEVELOPMENT

A. Sensorimotor (0 – 2 years)
- Practical intelligence because words and symbols are not applicable
- Babies are communicating through sense and reflex
SCHEMA AGE BEHAVIOR

Neonatal Reflex 1 month - All reflexes
Primary Circular Reaction 1 – 4 months - Activities related to bodies
repetition of behavior (thumb
sucking)
Secondary Circular Reaction 4 – 8 months - Activity not related to body
- Discover object or persons
code and code memory arises
- Anticipate familiar events
Coordination of Secondary 8 – 12 months - Exhibit goal directed
behavior
Tertiary Circular Reaction 12 – 18 months (1 – 1 ½ year) - Increase sense of
separateness
- Use trial and error to
discover change of places
and events
- Code and Code invention of
Invention of new means thru 18 – 24 months new means
mental combination - Capable of space and time
perception
B. Preoperational Thought 2 – 7 years old - Transitional phase to
SCHEMA AGE operational period
Pre-conceptual 2- 4 years
BEHAVIOR
- Egocentric (unable to view
another point of view)
- Their thinking is basically
concrete and static
Intuitive 4 – 7 years - Their concept of time is only
now and their concept of
distance is only as far as they
can see
- Not yet aware of the
concept of reversibility
- Concept of animism
(inanimate object is alive)
C. Concrete Operational (7 – 12 years)

- Can find solutions to everyday problems with systemic reasoning
- They have concept of reversibility
- Activity recommended is collecting and classifying
D. Formal Operational (12 and above)

- Period when cognition has achieved its final form
- They are capable
- Can find scientific reasoning (can deal with the past, present and future)
- Capable of abstract and mature thought
- Do abstraction by talk time that will sort

4. Kohlberg (1984) – recognized the theory of moral development as considered closely to
approximate cognitive stages of development
STAGES OF MORAL DEVELOPMENT
INFANCY
Age (Year) Description
Preconventional Stage
2-3 (Level I)
1 Punishment/obedience orientation
(“heteronomous morality”). Child does right
because a parent tells him/her to and to
4-7 avoid punishment.
2
Individualism. Instrumental purpose and
exchange. Carries out action to satisfy own
needs rather than
society. Will do something for another if that
person do something for the child
Conventional (Level II)

7-10 3 Orientation to interpersonal relations
of mutuality. Child follows rules because of a
need to be a “good” person in own eyes and
10-2 4 the eyes of others.
Maintenance of social order, fixed rules and
authority. Childs finds following rules
satisfying.
Follows rules of Authority figures as well as
parents in an effort to keep the “system”
working
Postconventional (Level III)

Older than 12 5 Social contract, utilitarian law-making
perspectives. Follows standards of society for
the good of all people
6 Universal ethical Principle orientation.

Follows internalized standards of conduct.
I. E. DEVELOPMENTAL MILESTONE
PERIOD OF INFANCY
a. Play
- Solitary play
- Non interactive
- Priority is safety
- Age who appreciate teddy bears
- Attitude: proper hygiene
b. Fear
- Stranger anxiety
- Begin at 6 – 7 months
1
- Peak at 8 months
- Diminish by 9 months
c. Milestones

E.I Neonate
- Largely reflex
- Complete head lag
- Hands fisted
- Cry without tears (due to immature larcrimal duct)
- Visual fixation of human face
1 MONTH
- Dance reflex disappears
- Looks at mobile objects
2 MONTHS
- Holds head up when in prone
- Social smile
- Baby “coos”
- Cry with tears
- Closure of posterior fontanel by 2 – 3 months
- Head lag when pulled to a sitting position
3 MONTHS
- Holds head and chest when in prone
- Follow object past midline
- Grasp and tonic neck reflex are fading
- Hand regards (3 months)
4 MONTHS
- Turns from front to back
- Head control complete
- Bubbling sounds
- Needs space to turn
- Laugh aloud
5 MONTHS
- Roll over
- Turn both ways
- Teething rings
- Handles rattle well
- Moro reflex disappear by 4 – 5 months
6 MONTHS
- Reaches outs in anticipation of being picked up
- Handle bottle well
- Sits with support
- Uses palmar grasp by 6 months
- Eruption of first temporary teeth (2 lower incisors)
- Says vowel sounds “Ah, ah” 1
7 MONTHS
- Transfer objects hand to hand

- Beginning fear of stranger
- Likes objects that are good sized
8 MONTHS
- Sits with support
- Peak of stranger anxiety
- Plantar reflex disappear
9 MONTHS
- Creeps/crawl
- Needs space for creeping
- Pincer grasp reflex
- Combine two syllables “Papa, Mama”
- Priority: safety
10 MONTHS
- Pull self to stand
- Understand word “No”
- Respond to own name
- Peak – a – boo
- Pat a cake since they can clap
11 MONTHS
- Cruises
- Stand with assistance
12 MONTHS
- Stand alone
- Take first step
- Walk with assistance
- Drink from a cup
- Cooperate in dressing
- Says the 2 words “Mama, Papa”
- Toys: pots and pans, pull toy and learn nursery rhymes
E.2. TODDLER
a. Play
- Parallel (2 toddlers playing separately)
- Provide two similar toys (squawky squeeze toy)
- Waddling duck to pull, pull truck, building block and pounding peg
b. Fear
- Separation anxiety
- Do not prolong goodbye, say goodbye firmly
- 3 Phases of separation anxiety
a. Protest
b. Despair
c. Denial
1
c. Milestones
15 months
- Plateau stage

- Walks alone (delay in walking maybe a sign of mental retardation)
- Puts small pellets into small bottle
- Scribbles voluntarily with pencil
- Holds a spoon well
- Seat self on chair
- Creep upstairs
- Speaks 4 – 6 words
18 months
- Hide of possessiveness
- Bowel control achieved
- No longer rotates a spoon
- Run and jump in place
- Walk up and down stairs holding on (typically places both feet on one step before
advancing)
- Able to name body part
- Speaks 7 – 20 words
24 months
- Can open doors by turning doorknobs
- Unscrew lids
- Walk upstairs alone by still using both feet on the same step at same time
- Daytime bladder control
- Speak 50 – 200 words
30 months
- 3 year old do tooth brushing with little supervision
- 2 – 3 year old is the right time to bring to the dentist
- Temporary teeth complete and last temporary teeth to appear is the posterior
molars
- 20 deciduous teeth by age 2 ½ years
- Can make simple lines or stroke for crosses with a pencil
- Can jump down from the stairs
- Knows full name
- Copy a circle
- Holds up fingers
36 months
- Trusting three
- Able to unbutton
- Draw a cross
- Learns how to share
- Full name and sex
- speak fluently
- Right time for bladder control (night time control)
- Able to ride a tricycle
- Speak 300 – 400 words 1
- Clues for toilet training
a. Can stand, squat and walk alone
b. Can communicate toilet needs

c. Can maintain himself dry with interval of 2 hours
d. Character Traits
- Negativistic likes to say no (it is their way to search independence)
- Limit questions and offer options
- Temper tantrums (stomping feet and screaming)
- Ignore the behavior
- Rigid ritualistic: stereotype
- Cause: mastering
- Protruded abdomen
- Cause:
- Under development of abdomen
- Unsteady gait
- Physiologic anorexia (give foods that last for a short period of time)
E.3. PRE-SCHOOL
a. Play
- Associative play, Cooperative play
- Play house
- Role playing
b. Fear
- Body mutilation or castration fear
- Dark places and witches
- Thunder and lighting
c. Milestone
4 years
- Furious four (noisy and aggressive)
- Able to button
- Copy a square
- Lace shoes
- Know the 4 basic colors
- Vocabulary of 1500 words
5 years
- Frustrating five
- Copy a triangle
- Draw a 6 part
- Imaginary playmates
- 2100 words
d. Character Traits
- Curious
- Creative
- Imaginative 1
- Imitative
- Why and How

e. Behavior Problems
- Telling tall tales (over imagination)
- Imaginary friends (purpose: release their anxiety and tension)
- Sibling rivalry (jealousy to a newly delivered baby)
- Bed wetting
- Baby talk
- Fetal position
- Masturbation is a sign of boredom and should divert their attention
E.4. SCHOOL AGE (7 YEARS)

a. Play
- Competitive play
- Tug – o – war
b. Fear
- School phobia
- To prevent phobia orient child to new environment
- Displacement from school
- Significant person is the teacher and peer of the same sex
- Loss of privacy
- Fear of death
c. Significant Development
- Prone to bone fracture (green stick fracture)
- Mature vision
d. Milestones
6 years
- Temporary teeth begins to fall
- Permanent teeth begins to appear (first molar)
- Year of constant motion
- Clumsy movement
- Recognizes all shapes
- Teacher becomes authority figure that may result to nail biting
- Beginning interest with God
7 years
- Age of assimilation
- Copy a diamond
- Enjoys teasing and play alone
- Quieting down period
8 years
- Expansive age
- Smoother movement
- Normal homosexual
- Love to collect objects 1
- Count backwards
9 years

- Coordination improves
- Tells time correctly
- Hero worship
- Stealing and lying are common
- Takes care of body needs completely
- Teacher find this group difficult to handle
10 years
- Age of special talents
- Writes legibly
- Ready for competitive sports
- More considerate and cooperative
- Joins organization
- Well mannered with adults
- Critical of adults
11-12 years
- Pre adolescent
- Full of energy and constantly active
- Secret language are common
- Share with friends about their secrets
- Sense of humor present
- Social and cooperative
e. Character Traits
- Industrious
- Love to collect objects
- Cant bear to loose they will cheat
- They are modest
SIGNS OF SEXUAL MATURITY
Girls Boys
Increase size of breast and genetalia Appearance of axillary and pubic hair
Widening of hips Deepening of voice
Appearance of axillary and pubic hair Development of muscles
Menarch (last sign) Increase in size of testes and scrotum (1st
- telarch is the 1st sign of sexual maturity sign)
Production of viable sperm (last sign)
E.5. ADOLESCENT PERIOD

- They have distinctive odor because of the stimulation of apocrine gland
- They have nocturnal emission (wet dreams) the hallmark for adolescent
- Testes and scrotum increase in size until age 17
- Sperm also viable
- Breast and female genetalia increase until age 18
a. Fear
- Acne
1
- Obesity
- Homosexuality
- Death

- Replacement from friends
b. Significant Person
- Peer of opposite sex
c. Significant Development
- Experiences conflict between his needs for sexual satisfaction and societies
expectations
- Core concern is change of body image and acceptance from the opposite sex
d. Personality Trait
- Idealistic (parent-child conflict begins)
- Rebellious
- Very conscious with body image
- Reformer
- Adventuresome
e. Problems
- Vehicular accident
- Smoking
- Alcoholism
- Drug addiction
- Pre marital sex
IMMEDIATE CARE OF THE NEWBORN

A. THE 8 PRIORITIES OF THE NEWBORN IN THE FIRST DAY OF LIFE
1. Initiation and Maintenance of respiration
2. Establishment of extra uterine circulation
3. Control of body temperature
4. Intake of adequate nourishment
5. Establishment of waste elimination
6. Prevention of infection
7. Establishment of an infant-parent relationship
8. Development care that balances rest and stimulation for mental development
1. Initiation and Maintenance of respiration
Alerts
- Second stage of labor initiate airway
- Initiation of airway is a crucial adjustment among newborn
- Most neonatal deaths with in the first 24 – 48 hours is primarily the inability to
initiate airway
- Lung function begins only after birth
How
A. Removal of secretions by proper suctioning
B. Proper Suctioning of catheter 1

- Place baby’s head to side to facilitate drainage
- Suction nose first because neonates are nasal obligates

- Suction for 5 – 10 seconds and should be gentle and quick because prolong deep
suctioning may result to hypoxia, bradycardia (caused by vagal nerve stimulation)
and laryngospasm
C. If not effective, requires effective laryngoscopy to open the airway. After deep
suctioning, an endotracheal tube can be inserted and oxygen can be administered by
a positive pressure bag and mask with 100% oxygen at 40 – 60 b/min.
Nursing Alerts:
- No smoking sign to prevent combustion
- Always humidify to prevent drying of mucosa
- Mask should cover nose and mouth
- Overdosage of oxygen may lead to scaring of retina which may lead to blindness
called
RETROLENTAL FIBROPLASIAS (retinopathy of prematurity)
- When meconium stained never administer oxygen because pressure will force
meconium to the alveolar sac and cause atelectasis
2. Establishing extrauterine circulation

Alerts: circulation is initiated by pulmonary ventilation and is completed by cutting
of cord
THE FETO-PLACENTAL CIRCULATION

Placenta (via simple diffusion) – oxygenated blood is carried by the vein – liver –
Ductus venosus
Inferior vena cava – right atrium – 70% shunted to Foramen ovale - left atrium –
mitral valve – left ventricle – aorta – lower extremities.
The remaining 30% - tricuspid valve – right ventricle – pulmonary artery – lungs (for
nutrition) – vasoconstriction of the lungs pushes the blood to the Ductus arteriosus
to aorta to supply the extremities. The two arteries carry the unoxygenated blood
back to the placenta for reoxygenation.
Alerts: Increase pressure on the left side of heart causes closure of foramen ovale
SHUNTS
1. Ductus Venosus – shunt from umbilical vein to inferior vena cava
2. Foramen Ovale – shunt between 2 atria (begin to close within 24 hours)
3. Ductus Arteriosus – shunt from pulmonary artery to aorta (begin to close within
24 hours)
A. 2 Way to facilitate Closure-of Foramen-ovale

1. Tangential foot slap
- So baby will cry to expand lungs
- Never stimulate baby to cry when not yet properly suctioned
- Check characteristics of cry (strong vigorous and lusty cry) 1
- Cri – du – chat (meow cry)
2. Proper Positioning

- Right side lying
STRUCTURE APPROPRIATE TIME STRUCTURE FAILURE TO CLOSE
OF OBLITERATION REMAINING
Foramen Ovale 24 hours complete by Fossa Ovalis Atrial Septal Defect
1 year
Ductus Arteriosus 24 hours complete by Ligamentum Patent Ductus
1 month Arteriosum Arteriosus
Ductus Venosus 2 months
Umbilical Arteries 2 – 3 months Ligamentum
Venosum
Lateral Umbilical
Umbilical Vein 2 – 3 months Ligament
Inferior Iliac Artery
Lateral Umbilical
Ligament
Inferior Iliac Artery
Ligamentum Teres
(round ligament of
liver)
B. Best position immediately after birth:

NSD – trendelendberg
CS – supine or crib level position
Signs of increase ICP

1. Abnormally large head
2. Bulging and tense fontanel
3. Projectile vomiting (surest sign of cerebral irritation)
4. Increase blood pressure but widening pulse pressure
5. Decrease respiratory rate
6. Decrease pulse rate
7. High pitch shrill cry (late sign)
8. Diplopia (sign of ICP from 6 months – 1 year)
3. Temperature Regulation
Alerts:
- The goal in temperature regulation is to maintain it not less than 97.7 oF – 36.5 oC
- Maintenance of temperature is important for preterm and SGA because it may lead
to hypothermia or cold stress
A. Factors Leading to the development of Hypothermia
1. Preterm are born poikilothermic (cold blooded) they easily adapt to temperature
of environment due to immaturity of thermo regulating system of body
2. Inadequate subcutaneous tissue
3. Newborns are not yet capable of shivering (increase basal metabolism)
4. Babies are born wet
B. Process of Heat Loss
1. Evaporation – body to air
2. Conduction – body to cold solid object
1
3. Convection – body to cooler surrounding air
4. Radiation – body to cold object not in contact with body
C. Effects of Hypothermia (Cold Stress)

1. Hypoglycemia – due to utilization of glucose (40 – 45 gm/dl is the normal blood
sugar of a newborn)
2. Metabolic Acidosis – due to catabolism of brown fats (best insulator of a newborn)
3. High risk for KERNICTERUS (bilirubin in brain)
4. Additional fatigue to already stressful heart
D. Prevention of Cold Stress

1. Dry and wrapped newborns
2. Mechanical measures
- Radiant warmer
- Isolette (square acrylic sided incubator, must be pre heated first)
3. Prevent unnecessary exposure – cover areas not being examined
4. Use tin foil in absence of electricity
5. Embrace baby (called kangaroo care)
4. Establish Adequate Nutritional Intake

Alerts: Breastfeed immediately for NSD and after 4 hours for CS (Colostrum is
present on the 3rd trimester)
A. Physiology of Breast milk Production

- Decrease in level of estrogen and progestin, stimulates the anterior pituitary
gland, that stimulates the prolactin of the acinar cells (alveoli) to produce the
foremilk stored in lactiferous tubules
B. Advantage of Breastfeeding
- Very economical
- Always available
- Promotes bonding
- Helps in rapid involution
- Decrease incidence of breast cancer
- Breast fed babies has higher IQ
- It contains anti body (IgA) lactobacillus bifidus that interfere attack of pathogenic
bacteria in GIT
- Contains macrophages (store in plastic container, good for 6 months when stored in
freezer)
- Disadvantages of breast milk and cow’s milk
- Both has no iron
- Possibility of transfer of HIV, Hepatitis B
- Father cannot feed or bond as well
C. Stages of Breastmilk
1. Colostrum – available 2 – 4 days after delivery
Contents:
- Low fats
- Low carbohydrates
- High protein
- High immunoglobulin 1
- High minerals
- High fat-soluble vitamins
2. Transitional – covering 4 – 14 days

Contents:
- High lactose
- High minerals
- High water soluble vitamins
3. Mature milk – 14 days and above

Contents:
- High fats (linoleic acid responsible for integrity of skin and development of skin)
- High carbohydrates (lactose, easily digested, responsible for sour milk smelling odor
of stool)
- Low protein (lactalbumin)
D. Cow’s milk
Contents:
- High fats
- Low carbohydrates (add sugar)
- High protein (casein) has a curd that is hard to digest
- High minerals, has traumatic effect on kidneys of baby
- High phosphorus that may cause inverse proportion with calcium
E. Health Teachings
1. Proper Hygiene
- Importance of hand washing
- Removal of caked colostrum
2. Position
- Upright sitting avoid tension to properly empty breast milk
3. Stimulate and evaluate feeding reflexes
a. Rooting
- touch side of lips or cheek and baby will turn to the stimulus
- purpose: to look for food
- disappear at 6 weeks because baby can already focus
b. Sucking
- by touching the middle of lips then baby will suck
- purpose: take in food
- disappear at 6 months
- easily disappear when not stimulated
c. Swallowing
- food touches posterior portion of tongue automatically swallowed
- never disappear cough, gag, sneeze
d. Extrusion/Protrusion reflex
- food touches anterior portion of tongue and tongue automatically
extruded/protruded
- purpose: prevent from poisoning
- disappear by 4 months because baby can already spit out
4. The criteria of effective sucking
a. baby’s mouth is hike well up to areola 1
b. mother experiences after pain
c. other nipple is flowing with milk

5. To prevent from crack nipples and initiate proper production of oxytocin
- begin 2 – 3 minutes per breast
- increase 1 minute per day each breast until you reach 10 minutes each breast or 20
minutes per feeding
6. For proper emptying and continuous milk production per feeding
- feed baby on the last breast that you fed him
PROBLEMS EXPERIENCED IN BREASTFEEDING

a. Engorgement
- soft and non tender (1 day)
- feeling of tension and fullness of breast
- while feeding warm compress
- bottle feeding cold compress and wear supportive bra
b. Sore nipple
- cracked, wet and painful nipple
- exposure to air is the management or 20 watt bulb
- avoid wearing plastic liner bra, instead wear cotton bra
c. Mastitis
- inflammation of breast
- causative factor: staphylococcus aureus
- improper breast emptying
- unhealthy sexual practices
- breast feed on unaffected breast
- express your breast on affected side
- take antibiotic
- increase 500 calories when breastfeeding
- involution of breast is 4 weeks
CONTRAINDICATIONS IN BREASTFEEDING
Maternal Conditions
- HIV, Hepatitis B, CMV, comadin/warfarin sulfate intake
Newborn Conditions
- erythroblastosis fetalis
- hydrops fetalis
- phenylketonuria (PKU)
- galactosemia
- tay-sachs disease
5. Establishment of waste-elimination
A. Different stools
1. Meconium
- Physiologic stool
- Blackish green
- Sticky 1
- Tar like
- Odorless (because of sterile intestines)
- No bacteria

- Passed with in 24 – 36 hours
- Failure to pass meconium suspect GIT obstruction
a. hirschsprung
b. imperforate anus
c. meconium ileu (cystic fibrosis)
2. Transitional
- Become green, loose and slimy that may appear to be a slight diarrhea to the
untrained eye
3. Breastfed stool
- Golden yellow, soft, mushy with sour milk smelling odor frequently passed occurring
almost nearly every feeding
4. Bottle-fed stool
- Light yellow, formed, hard with a typical offensive odor seldom passed 2 – 3 times a
day
5. With supplementary foods added

- Brown and odorous
B. Indication of Stool Changes

- Light stool: jaundice baby
- Bright green: phototherapy
- Mucous mixed with stool: allergy
- Clay colored: obstruction to bile duct
- Chalk clay/whitish clay: barium enema
- Black stool: GIT hemorrhage
- Blood flecked: anal fissure
- Curant jelly: intususeption
- Ribbon like: hirschsprung
- Steatorrhea: fatty, bulky, foul smelling – suspect malabsorption a case of cystic
fibrosis or celiac disease
ASSESSMENT FOR WELL-BEING

A. APGAR SCORING
Special Considerations
- Taken on first 1 minute, shows the general condition of baby
- 15 minutes is optional
- Taken again after 5 minutes, to determine baby’s capability to adapt/ adjust
extrauterinely
Components
Appearance
- Color: slightly cyanotic, after first cry baby becomes pinkish
Pulse rate
- Apical pulse (left lower nipple)
Grimace
- Reflex irritability (foot slap, catheter insertion)
1
Activity
- Degree of flexion (muscle tone)
Respiration

APGAR SCORING CHART
Score
Criteria 0 1 2
Heart rate Absent Less than 100 More than 100
Respiratory effort Absent Slow irregular weak Good strong cry
cry
Muscle tone Flaccid extremities Some flexion Well flexed
Reflex irritability
Catheter No response Grimace Cough or sneeze
Tangential Footslap No response Grimace Cry
Color Blue/Pale Acrocyanosis Pink
(body and
extremities blue)
Interpretation of APGAR Result

0-3: severely depressed, need CPR, admission to NICU
4-6: moderately depressed, additional suction and oxygen administration
7-10: good/healthy
CARDIO PULMONARY-RESUSCITATION
Airway (Clear Airway)
1. Shake, no response call for help
2. Place flat on bed
3. Head tilt – chin lift maneuver
- Contraindicated to spinal cord injury
- Over extension may occlude airway
Breathing (Ventilating the lungs)
4. Check for breathlessness
5. Administer 2 rescue breaths
Circulation (by cardiac compression)
6. Check for pulselessness
7. Do CPR (when breathless and pulse less)
B. RESPIRATION EVALUATION
SILVERMAN ANDERSON INDEX CHART
Score
Criteria 0 1 2
Chest movement Synchronized Lag on respiration See saw
Intercostal retraction No retractions Just visible Marked
Xiphoid retraction None Just visible Marked
Nares dilation None Minimal Marked
Expiratory grunt None Stethoscope Naked ear
Interpretation of Result
0 – 3: Normal no respiratory distress syndrome
4 – 6: Moderate RDS
7 – 10: Severe RDS
C. ASSESSMENT OF GESTATIONAL AGE

1
BALLARD AND DOBOWITZ CLINICAL CRITERIA
Gestational Age (Weeks)
Findings Less THAN 36 37-38 39 and up
Sole creases Anterior transverse Occasional creases in Sole covered with

crease only 2/3 creases
Breast nodule (dm.) 2 mm 4mm or 3 – 5 mm 7 mm – 7.5 mm
Scalp hair Fine and fuzzy Fine and fuzzy Coarse and silky
Ear Lobe Pliable Some Thick
Testes Scrotum Testes and scrotum Intermediate Testes pendulous,
in lower canal, scrotum full with
scrotum is small with extensive rugae
few rugae
PRE TERM BABIES

- 28 – 32 weeks
- Frog leg or lax position
- Hypotonic muscle tone
- Scarf sign (elbow passes the midline)
- Square window wrist (90o angle)
- Heel to ear sign
- Abundant lanugo
- Prominent labia minora and clitoris
POST TERM BABIES

- More than 42 weeks
- Old mans face (classic sign)
- Desquamation (peeling of neonate skin characterized by extreme dryness than
begin from sole and palm within 24 hours
D. Neonate in the Nursery

*Special and Immediate Interventions
1. Upon receiving
- Proper identification (foot print with mothers thumb print)
- Take antropometric measurement
2. Then take anthropometric measurements

a. Length = 19.5 – 21 inches/47.5 – 53.75 cm average of 50 cm
b. Head Circumference = 33 – 35 cm average of 34 cm/13 – 14 inches
c. Chest Circumference = 31 – 33 cm average of 32 cm/12 – 13 inches
d. Abdominal Circumference = 31 – 33 cm average of 32 cm/12 – 13 inches
3. Bathing Baby
- Normal oil bath
- Cleanse and spread vernix
- Babies of HIV positive mothers are given full bath to lessen transmission of infection
- Insulator
- Bacteriostatic
- Full bath is safely given when cord falls
4. Dressing the umbilical cord

- Follow strict asepsis to prevent infection/tetanus
- Use Povidone iodine
- Check for 3 vessels (2 arteries and 1 vein)
- AVA (2 vessel cord suspect kidney malformation)
- Leave about 1 inch of cord
- 8 inches if anticipating IV or BT
- Check for the cord q 15 minutes for the first 6 hours
- For bleeding: 1
- 30 cc is bleeding to newborn
- Hemophilia is excessive bleeding
- Ompalagia is bleeding of the cord

- Cord turns black on the third day
- Falls by 7th – 10th day
- Failure to fall is umbilical granulation (silver nitrate)
- Use saline to clean
5. Credes Prophylaxis
- Purpose: prevent opthalmia neonatorum (use erythromycine ophthalmic ointment)
6. Administration of Vitamin K
- Action: prevent hemorrhage
- Related to physiologic hypoprothrombinemia
- Give Aquamephyton, phytomenadione, konakoib (.5 – 1.5 mg, IM)
7. Weight-taking
Normal Weight: 3000 – 3400 grams/3 – 3.4 kg/6.5 – 7.5 lbs
Arbitrary Lower Limit: 2500 grams
Low Birth Weight: below 2500 grams
Small for Gestational Age: less 10 percentile rank
Large for Gestational Age: more than 90 percentile rank
Appropriate for Gestational Age: within the 2 standard deviation of the mean
Physiological Weight Loss: 5 – 10 percent occurs a few days after birth
E. PHYSICAL EXAMINATION AND DEVIATIONS FROM THE NORMAL

A. Important Considerations
a. If the client is new born, cover areas that is not being examined
b. If the client is infant, the first vital sign to take is RR (due to fear of stranger)
- Begin at east intrusive to the most intrusive
c. If the client is toddler and preschool, let them handle an instrument play syringe,
stethoscope,
d. If the client is school age and adolescent explain procedure
COMPONENTS:
1. Vital signs
- Temperature is taken rectally to rule out imperforate anus and thermometer is
inserted 1 inch
- Don’t force insertion because it may lead to pruritus
- Types of imperforate anus
a. Atretic – no anal opening, causing failure to pass meconium
b. Agenetic
- no anal opening, causing failure to pass meconium
- abdominal distention
- foul smelling stool
- vomitus of fecal materials
- respiratory problems
- Management: surgery with temporary colostomy
c. Membranous
CARDIAC RATE 120-160/min

- Irregular
- Radial pulse is absent, if present suspect PDA 1
CONGENITAL HEART DISEASES
*Common in girls: PDA, ASD
*Common in boys: TOGA (transposition of great arteries), Truncus Arteriosus

*Causes: TOF
1. Familial
2. Exposure to rubella (1st month for mother)
3. Failure of heart structure to progress
TWO MAJOR TYPES
A. ACYANOTIC HEART DEFECTS
Left to right shunting
WITH INCREASED PULMONARY BLOOD FLOW
1. Ventricular Septal Defect
- Opening between 2 ventricles
Signs and Symptoms
1. Systolic murmur at lower border of sternum and no other significant signs
2. Cardiac catheter reveals oxygen saturation at right side of heart
3. ECG reveals hypertrophy of right side of heart
Management
1. Long term antibiotic therapy to prevent development of sub acute bacterial
endocarditis
2. Open heart surgery
2. Atrial Septal Defect

- Failure of foramen ovale to close
Signs and Symptoms
1. Systolic murmur at upper border of sternum and no other significant signs
2. Cardiac catheter reveals increase oxygen saturation at right side of heart
3. ECG reveals hypertrophy of right side of heart
3. Endocardial Cushion Defects

- AV canal affecting both tricuspid and mitral valve
Signs and Symptoms
1. Only confirmed by cardiac catheter
Management
- Open heart surgery
4. Patent Ductus Arterious

- Failure of ductus arteriosus to close
Signs and Symptoms
1. Continuous machine like murmur
2. Prominent radial pulse
3. Hypertrophy of left ventricle upon ECG
Management
1. INDOMETHACIN (prostaglandin inhibitor that facilitate closure of PDA)
2. Ligation of PDA by 3 – 4 years old
WITH DECREASED PULMONARY BLOOD FLOW
1. Pulmonary Stenosis
- Narrowing of valve of pulmonary artery
Signs and Symptoms 1
1. Typical systolic ejection murmur
2. ECG reveals hypertrophy of right ventricle
3. S2 sound is widely split

2. Aortic Stenosis
- Narrowing of valve of aorta
Signs and Symptoms
1. Left ventricular hypertrophy
2. Typical murmur
Management
1. Balloon stenotomy
2. Surgery (last resort)
3. Duplication of aortic arch

- Doubling of arch of aorta causing compression to trachea and esophagus
Signs and Symptoms
1. Dysphagia
2. Dyspnea
Management
1. Close heart surgery
4. Coarctation of the Aorta

- Narrowing of arch of aorta
Signs and Symptoms
1. Blood pressure in upper extremities is increased
2. Blood pressure in lower extremities is decreased
3. Outstanding sign is absent femoral pulse
Management
1. Take blood pressure in 4 extremities
2. Close heart surgery
B. CYANOTIC HEART DEFECTS

Right to left shunting
WITH INCREASE PULMONARY BLOOD FLOW
1. Transposition of Great Arteries
- Situation where aorta is arising from the right ventricle and pulmonary artery of the
left ventricle
Signs and Symptoms
1. Cyanosis after 1st cry (outstanding sign)
2. Polycythemia (compensatory mechanism to decrease oxygen supply
3. Prone to thrombus leading to embolism resulting to stroke (complications)
Management
1. Palliative repair – kashkind procedure
2. Complete repair – mustard procedure
2. Total Anomalous Pulmonary Venous Return
- Pulmonary vein enters the right atrium or superior vena cava
Signs and Symptoms
1. Mixed blood supplying the body (oxygenated and unoxygenated)
2. Open foramen ovale 1
3. Aspleenia (absent spleen)
4. Mild to moderate cyanosis
Management

1. Restructuring of the heart
3. Truncus Arteriosus
- Pulmonary artery and aorta is arising from one common trunk or single vessel with
VSD
Management
1. Positive cyanosis and polycythemia
2. Restructuring of the heart
4. Hypoplastic Left Heart Syndrome

- Non functioning left ventricle
Signs and Symptoms
1. Cyanosis
2. Polycythemia
Management
1. Heart transplant
WITH DECREASE PULMONARY BLOOD FLOW

1. Tricuspid atresia
- Failure of tricuspid valve to open
Signs and Symptoms
1. Open foramen ovale
2. Cyanosis
Management
1. Fontan procedure
2. Tetralogy Fallot
- 4 Anomalies Present
Pulmonary stenosis
VSD
Overriding aorta
Right ventricular hypertrophy
Signs and Symptoms

1. High degree of cyanosis
2. Polycythemia
- Increase red blood
- Thrombus, embolus, stroke
- Mental retardation
- Clubbing of fingernails (chronic tissue hypoxia) late sign
- X-ray reveals boot shape heart
3. Severe dyspnea
- Relieved by squatting position
4. Growth retardation
5. Tet Spells
- Blue spells, short episode of hypoxia
1
Management
1. Morphine – for hypoxic episode
2. Propranolol (Inderal) – decrease heart spasm

3. Palliative Repair – BLALOCK TAUSSIG PROCEDURE
4. Complete Repair – BROCK PROCEDURE
ACQUIRED HEART DISEASE

Rheumatic heart Disease
- Inflammatory disease following an infection caused by Group-A beta hemolytic
streptococcus (thrives in aerobic environment)
Affected Body Parts
- Musculoskeletal – cardiac muscles and valves
- Integumentary
- CNS
- Aschoff bodies
- Rounded nodules containing of multi nucleated cells and fibroblasts that stays in
mineral valve
Signs and Symptoms
MAJOR MINOR
 Polyarthritis (multi joint pain)  Arthralgia (joint pain)
 Chorea (sydenhanns chorea) St.  Low grade fever
Vitus dance, purposeless/involuntary  Increase diagnostic tests
hand and shoulder movement a. Antibody
accompanied by grimace b. C-reactive protein
 Carditis c. Erythrocyte Sedimentation Rate
 Errythema marginatum (macular d. Anti-streptolysin O titer (ASO)
rash)
 - Subcutaneous nodules
Management
- CBR (avoid contact sports)
- Culture and sensitivity (throat swab)
- Antibiotic management (to prevent recurrence)
- Aspirin (anti inflammatory)
- Side Effects: Reye’s Syndrome
- Non recurring encephalopathy accompanied by fatty infiltration of organs such as
liver and brain
RESPIRATION
- Abnormal/diaphragmatic
- Short period of apnea without cyanosis
- Normal apnea of newborn is less than 15 seconds
Respiration Check
Newborn 40-90 5 years 20-25
1 year 20-40 10 years 17-22
2-3 years 20-30 15 and above 12-20
Breath Sounds Heard on Auscultation

Sound Characteristics
VESICULAR Soft, low pitched, heard over periphery of lungs, inspiration longer
than expiration, normal.
BRONCHOVESICULAR Soft, medium-pitched, heard over major bronchi, inspiration equals

expiration, normal.
BRONCHIAL Loud, high-pitched, heard over trachea, expiration longer than

inspiration, normal.
RHONCHI Snoring sound made by air moving through mucus in bronchi,
normal.
RALES
Crackles (like cellophane) made by air moving through fluid in
alveoli. Abnormal; denotes pneumonia or pulmonary edema which
is fluid in alveoli.
WHEEZING
Whistling on expiration made by air being pushed through
narrowed bronchi. Abnormal; seen on children with asthma or
STRIDOR foreign-body obstruction.
Crowing or rooster like sound made by air being pulled through a

RESONANCE constricted larynx, Abnormal, seen in infants with respiratory
obstruction.
HYPERRESONANCE
Loud, low tone, percussion sound over normal lung tissue.
Louder, lower sound than resonance, a percussion sound over

hyperinflated lung issue.

RESPIRATORY DISTRESS SYNDROME
- Hyaline membrane disease
- Cause: lack of surfactant
- Common in preterm infants
- Hypoxic
- Formation of hyaline
- Causing atelectasis
Signs and Symptoms
- Definite within 4 hours of life
1. Increase RR with retractions (early sign)
2. Expiratory grunting (major sign)
3. Flaring alae nassi
4. Xiphoid retractions
5. Intercoastal retractions
6. Respiratory acidosis
Management
1. Keep head elevated
2. Proper suctioning
- Oxygen administration
- Place on continuous positive airway pressure
- Positive end expiratory pressure (maintain alveoli partially open and prevent
collapse)
3. Monitor skin color, vital signs, ABG
4. Surfactant replacement and rescue
LARYNGOTRACHEOBRONCHITIS
- Infection of larynx, trachea and bronchi
Assessment
- Barking cough/croupy cough
- Respiratory acidosis
Laboratory Studies
a. ABG
b. Throat culture
c. CBC
Diagnostic Studies
a. Chest and neck x-ray (to rule out epiglotitis)
Management
1
a. Bronchodilators
b. Oxygen with increase humidity
c. Prepare tracheostomy set when necessary

Broncholitis
- Inflammation of bronchioles characterized by production of thick tenacious mucous
Signs and Symptoms
- Cold like/flu like symptoms
- Causative agent: respiratory syncitial virus
- Drug: Ribavirin (anti viral drug)
- End stage epiglotitis (emergency condition or URTI), sudden onset
Management
- Tripod position (leaning forward with tongue protrusion)
- Never use tongue depressor
- Prepare tracheostomy set
- Encircle age
- Mist tent “croup tent”, croupette
- Nursing management
a. Check edges if properly tucked
b. Washable plastic material
c. Avoid toys that cause friction and hairy and furry materials
BLOOD PRESSURE
- 80/46 mmHg after 10 days 100/50
- Normal blood pressure taking begins by 3 years old
Alerts
- BP cuff must cover 50 – 75% (2/3) of upper arm
- To large cuff results to false low BP
- To small cuff results to false high BP
SKIN
- Acrocyanosis (body pink extremities blue)
- Generalized mottling due to the immaturity of the circulatory system
BIRTHMARKS
1. Mongolian Spots – slate-gray-or-bluish discoloration/patches commonly seen
across he sacrum or buttocks
- Due to increase melanocytes
- Common in asian newborn
- Disappear by 1 year, preschool, 5 years old
2. Milia – plugged unopened sebaceous gland usually seen as white pinpoint patches
on nose, chin and cheek, disappears by 2 – 4 weeks
3. Lanugo – fine downy hair
4. Desquamation – peeling of the newborn skin within 24 hours, common among
post term
5. Stork bites (telengiectasis nevi) – pink patches at the nape of the neck 1
- Never disappear but is covered by hair
6. Erythema Toxicum (flea bite rash) – first self limiting rash to appear
sporadically and unpredictably as to time and place.

7. Harlequin sign – dependent part is pink, independent part is blue (RBC settles
down)
8. Cutis marmorata – transitory motling of neonates skin when exposed to cold
9. Hemangiomas – vascular tumors of the skin
3 TYPES
a. Nevus Flammeus – macular purple or dark red lesions usually seen on the
face or thigh
- Portwine stain: never disappear but can be removed surgically
b. Strawberry hemangiomas (nevus vasculosus)– dilated capillaries in
the entire dermal or subdermal area continuing to enlarge but disappear after
10 years old.
c. Cavernous hemangiomas – Consist of communicating network of venules
in the subcutaneous tissue that never disappear with age.
- Dangerous type may lead to internal hemorrhage
10. Vernix Caseosa – white cheese like substance for lubrication; Color of vernix is
same as
amniotic fluid
SKIN COLOR AND THEIR SIGNIFICANCE
Blue – cyanosis/ hypoxia
White – edema
Gray – infection
Yellowish – jaundice/ carotinemia (increase carotin)
Pale – anemia
SKIN DISORDERS
BURN TRAUMA
- Is injury to body tissue cause by excessive heat
Assessment
Depth
1st (partial thickness)
Ex. Sunburn
Involves only the superficial epidermis characterized by erythema, dryness and pain
Heals 1 -10 days
2nd (partial thickness)
Ex. Scalds
Involves the entire epidermis, and portion of dermis characterized by erythema,
blistered and moist from exudates which is extremely painful.
3rd (full thickness)

Involves both skin layers, epidermis and dermis/may involve adipose tissue, fascia,
muscle and bone. It appears leathery, white or black and not sensitive to pain since
nerve ending had been destroyed.
Management
1. First Aid
a. Put out flames by rolling the child on a blanket
b. Immerse the burned part on cold water
c. Remove burned clothing
d. Cover burn with sterile dressing
2. Maintenance of a patent airway
a. Suction as needed
b. Oxygen administration 1
c. ET tube
d. Tracheostomy
3. Prevention of Shock and Fluid and Electrolyte Balance

a. Colloids to expand blood volume
b. Isotonic saline to replace electrolytes
c. Dextrose and water provide calories
4. A booster dose of tetanus toxoid
5. Relief of pain such as IV analgesic (morphine sulfate)
6. Prevention of wound infection
a. Cleaning and debriding of wound
b. Open/close method of wound care
c. Whirlpool therapy
7. Skin grafting
a. Big skin xenograft
b. Taken from cadaver
8. Diet
a. High protein
b. high calorie
ATOPIC DERMATITIS
- Infantile eczema
- Skin disease characterized by maculo vesicular errythematous lesion with weeping
and crusting
- Cause: allergens (main), milk, eggs, citrus juices, tomatoes and wheat
- Characterized by extreme pruritus
- Sign: linear excoriation, lichenified – scaling
Management
- Treat main cause
- Prosorbbee or Isomil (milk)
- Hydrate skin with burrow’s solution
- Prevent infection
- Cut short the nails
IMPETIGO
- Cause: group A beta hemolytic streptococcus
- Characterized by populo vesicular surrounded by localized errythema becoming
purulent and ooze forming a honey colored crust
- Pediculosis capitis (kuto)
- Give oral penicillin
- AGN complication
ACNE
- Self limiting inflammatory disease affects sebaceous glands common in
adolescence
- Signs: Comedones (sebum causing white heads)
- Sebum is composed of lipids
Management 1
- Proper hygiene
- Wash face with soap and water
- Use sulfur soap or mild soap

- Retin A
HEMATOLOGIC DISORDERS
PALLOR-ANEMIA
Possible cause of Anemia
1. Early cutting of cord
2. Bleeding Disorder/blood dyscracia
HEMOPHILIA
- Deficient clotting factor
- X link recessive inheritance
- Sex link
- Excessive bleeding upon cutting of cord or circumcision
- Carrier mother passed to son, when son becomes a father he will pass it to his
daughter
Hemophilia A (classic) – deficiency of the coagulation component (Factor VIII)

Hemophilia B (Christmas disease) – deficiency in clotting factor IX
Hemophilia C – deficiency in clotting factor XI
Assessment
- Newly delivered baby receive maternal clotting factor
- Sudden bruising of bumped area
- Continuous bleeding to hemarthrosis
- Bleeding or damage of synovial membrane
Diagnostic Test
- High risk for injury (prevent injury)
- Partial thromboplastin time
Management
- Avoid contact sports
- Significance: determine case before doing any invasive procedure
- No aspirin
- Immobilize and elevate upon injury
- Apply gentle pressure
- Cold compress
- Blood transfusion: cryoprecipitate, fresh frozen plasma
LEUKEMIA
- Group of malignant disease characterized by rapid proliferation of immature WBC
- WBC (soldiers of body)
- Ratio: 500 RBC:1WBC
Classification (depends on affected part)

Lympho – lymphatic system
Myelo – bone marrow
Acute/Blastic – immature cells
Chronic/cystic – mature cells
Acute lymphocytic – common among children 1
Signs and Symptoms

1. From the invasion of bone marrow

- Anemia (pallor, fatigue, constipation)
- Bleeding (bruising, petechiae, epistaxis, bleeding in urine, emesis)
- Infection
- Fever
- Poor wound healing
- Bone weakens and causes fracture
2. From the invasion of organs

- Hepatosplenomegaly
- CNS affectation (headache and signs of increase ICP)
Diagnostic Tests and Studies

1. PBS (peripheral blood smear) – determine immature WBC
2. CBC – anemia, neutropenia, thrombocytopenia
3. Lumbar Puncture – place in fetal position without flexion of neck, C position or
shrimp position
4. Bone Marrow Aspiration
- Site for aspiration is the iliac crest
- Put pressure after aspiration
- Place on affected side
5. Bone Scan – determine bone involvement
6. CT scan– determine organ involvement
Surgery
TRIAD
Irradiation Chemotherapy
Therapeutic Management
1. Medications
4 Levels of Chemotherapy
For Induction – achieve remission (main goal)
a. IV Vincristine
b. Laspariginase
c. Oral prednisone
For Sanctuary – treat leukemic cells that has invaded testes and CNS
a. Methothrexate (intrathecally via CNS/spine)
b. Cytocin
c. Arabinoside
d. Extra irradiation
For Maintenance – continue remission
a. Oral Methothrexate 1
b. Oral 6 mercaptopurine
c. Cytarrabine
For Reinduction – treat leukemic cells after relapse occurs

a. IV Vincristine
b. Laspariginase
c. Oral prednisone
Antigout Agents – treat/prevent hyperuricemic nephropathy
a. Allopurinol (Zyloprim)
b. Increase fluid intake
Nursing Management
- Assess for common side effects
- Nausea and vomiting
- Administration of anti emetics 30 minutes before chemo and continue until 1 day
after
- Check for stomatitis, ulcerations and abscess of oral mucosa
- Oral care (alcohol free mouthwash) no toothbrush
- Diet (soft and bland) according to child’s preference
- Alopecia (temporary side effects)
- Hirsutism
- To parents (always repeat instruction)
HEMOLYTIC DISORDER
a. Rh Incompatibility
- Mother negative, fetus positive
- 4th baby affected
- Mother negative, no antigen (no protein factor)
- Erythroblastosis fetalis: hemolysis leading to decrease oxygen carrying capacity
with pathologic jaundice within 24 hours
- Test: Comb’s Test
- Vaccine: Rhogam
- Given to RH negative mother within first 72 hours to destroy fetal RBC therefore
preventing antibody formation
b. ABO Incompatibility
- Mother is type O, fetus is type A, B, AB
- Most common is O, and A
- Severe O and B
- First pregnancy can be affected
Assessment
- Common is Hydrops fetalis, edematous on lethal state with pathologic jaundice
within 24 hours
Management
1. Initiation of feeding, temporary suspension of breast feeding to prevent
kernikterus
2. Pregnandiole – delays action of glucoronyl transferace (liver enzyme that
converts indirect bilirubin to direct bilirubin)
3. Use of Phototherapy
4. Exchange Transfusion of Rh or ABO affectations that tend to cause continuous 1
decrease in hemoglobin during the first 6 months because bone marrow fails to
produce erythrocytes in response to continuing hemolysis.

Yellow – Jaundice
Hyperbilirubinemia
- Normal: indirect bilirubin 0 – 3 mg/dl
- More than 12 mg/dl of indirect bilirubin in fullterm
Kernicterus
- Bilirubin encephalopathy more than 20 mg/dl indirect bilirubin in fullterm
- Less than 12 mg/dl in preterm because of immature liver
Physiological Jaundice
- Icterus neonatorum
- 48 – 72 hours
- Expose to sunlight
Pathological Jaundice
- Icterus gravis neonatorum
- Clinical jaundice within 24 hours
Breastfeeding Jaundice
- Pregnandiole
- 6 to 7 days
Assessment
- Blanching the neonates forehead , nose or sternum
- Yellow skin and sclera
- Light stool
- Dark urine
Management
Phototherapy
- Photo oxidation
- Height of 18 – 20 inches away from baby
Nursing Responsibilities
1. Cover the eyes – prevent retinal damage
2. Cover genitals – prevent priapism (painful continuous erection)
3. Change position – for even exposure to light
4. Increase fluid intake – to prevent dehydration
5. Monitor I & O – weigh baby 1 gram:1 cc
6. Monitor Vital Signs
- Avoid use of lotion or oil because it may result to bronze baby syndrome
HEAD
Structures
Sutures: 3
Fontanels: 12 – 18 months close
Anterior fontanel
- Craniostenosis/ craniosinostosis (premature closure of anterior fontanel)
Posterior fontanel
- 1 x 1 cm
- Closes by 2 – 3 months
Microcephaly 1
- Small/slow growing brain
- Fetal alcohol and HIV positive
Anencephaly

- Absence of cerebral hemisphere
Noticeable Structure of the head

1. Craniotabes
- Localized softening of cranial bones to 1st born child due to early lightening
- Ricketts in older children
2. Caput Succedaneum
- Edema of scalp due to prolonged pressure at birth
- Characteristics
- Present at birth
- Crosses the suture line
- Disappear after 2 – 3 days
3. Cephalhematoma
- Collection of blood due to rupture of periostial capillaries
- Characteristics
- Present after 24 hours
- Never cross the suture line
- Disappear after 4 – 6 weeks
4. Seborrheic Dermatitis
- Cradle cap
- Scaling, greasy appearing salmon colored patches usually seen on scalp, behind
ears and umbilicus
- Primary cause: improper hygiene
- Management: proper hygiene, apply oil the night before shampooing (use baby oil
or coconut oil)
5. Hydrocephalus
- Collection of CSF
2 types
a. Communicating – extra ventricular hydrocephalus
b. Non communicating – intra ventricular hydrocephalus also called obstructive
Signs and Symptoms
- Sign of increase ICP
- Sign of frontal bossing (prominent forehead)
- Prominent scalp vein
- Sunset eyes
- Place client in low semi fowlers position (30o)
- Osmotic diuretic
- Diamox (Acetazolamide) to decrease CSF production
- Seizure precaution
- Surgery (AV shunt, VP shunt) 1
- Shave just before surgery
- Place in side lying position on non operated side
- Monitor for good drainage

- Sunken fontanel is a good sign
- Mental retardation depend on extent of hydrocephalus
SENSES
a. Sense of Sight (Eyes)
Sclera – light blue becomes dirty white
Pupils – round and adult size
a. Coloboma – part of iris is missing
b. Congenital cataract – whiteness and opacity (caused by german measles)
Cornea – round and adult size, larger in congenital glaucoma
Test of blindness
AGE COMMON TEST
1. Newborn - General appearance
- See 10 – 12 inches
- Doll’s eye test done on 10th day
- Glabellars test blink reflex
2. Infant and children - General appearance

- Ability to follow object past midline
3. 3yr – school age - Pre school

- E chart test for stereosis or depth of
perception
- Allen cards for visual acuity
- Ishiharas plates for color blindness
- Cover testing for strabismus, eye deviation
4. School Age – Adult
- Snellen’s test
RETINOBLASTOMA
- Malignant tumor of retina
- Red painful eye often accompanied by glaucoma (pathognomonic sign: cat’s
eye reflex)
- Management: enucleation
b. Senses of Smell (Nose)

- Flaring or alae nasi (RDS)
- Pale with creases nasal membrane, chronic rhinitis
- Inflamed: infection
- Cocaine abuse:
- No hair
- Ulceration with abscess at the nasal mucosa
- Perforation of nasal septum
- Epistaxis:
- Nose bleed
- Sit upright with head tilted forward
- Cold compress
- Apply pressure
- Give epinephrine
c. Sense of Hearing (Ears) 1

- First to develop and last sense to disappear
- Properly aligned to outer canthus of eye

1. Kidney Malformation
- Low set ears
- Renal agenesis
- Unilateral/bilateral
- Oligohydramnios (sign of renal agenesis in utero)
- Failure to fade 24 hours
- Kidney transplant
2. Chromosomal Aberrations
- More than 35 years
A. Nondisjunction
1. Trisomy 21
- Down syndrome
- Extra chromosome 21
- 47 XX + 21 or 47 XY + 21
- Cause: advance paternal age
- Mongolian slant in eyes
- Low set ears
- Broad flat nose
- Protruding tongue
- Puppy’s neck
- Hypotonic (respiratory problem unable to cough out)
- Simian crease (single transverse line of palm)
- Educable
2. Trisomy 18
3. Trisomy 13
4. Turners
5. Klinefilters Syndrome
B. Deletion Abnormalities
1. Cri-du-chat Syndrome
2. Fragile X Syndrome
C. Translocation Abnormalities
1. Balance Translocation Carrier
2. Unbalanced Translocation Syndrome
D. Others
1. Mosaicism – a situation wherein the nondisjunction of chromosomes occurs during
the mitotic cell division after fertilization resulting to different cells contains different
numbers of chromosomes.
2. Isochromosomes – a situation wherein the chromosomes instead of dividing
vertically it divides horizontally resulting to chromosomal mismatch.
OTITIS MEDIA
- Inflammation of middle ear, common in children due to wider and shorter 1
eustachian tube
- Common with cleft lip and palate
- Bottle propping, may also result to dental caries

- Otoscopic: bulging tympanic membrane and absence of light reflex
- Observe for passage of milky, purulent and foul smelling odor discharge
- Observe for URTI
Management
- Side lying on affected side to facilitate drainage
- Supportive care (TSB, antipyretic)
- Massive dosage of antibiotic (may lead to bacterial meningitis)
- Apply ear ointment
a. below 3 years down and back
b. above 3 years up and back
- Mucolytics to shrink mucous
- Myringotomy: surgical procedure done by making a slight incision of the tympanic
membrane
- Place client on the operated side
- To prevent permanent hearing loss
MOUTH AND TONGUE

a. Bels Palsy
- Facial nerve paralysis
- VII cranial nerve injury
- Related to forcep delivery
Signs and Symptoms
- Continuous drooling of saliva
- Inability to open 1 eye and close other eye
Management
- Artificial tears
- Refer to PT (self limiting)
b. TEF/TEA
- Tracheo Esophageal Fistula. Tracheo Esophageal Atresia
- No connection between esophagus and stomach
- 4 C’s: coughing, choking, cyanosis, continuous drooling
- Emergency surgery
c. Epstein Pearls
- White glistening cyst usually seen on palate or gums related to hypercalcemia
d. Natal Tooth
- Tooth at moment of birth related to hypervitaminosis (rootless)
e. Neonatal Tooth
- Tooth within 28 days
f. Oral Thrush 1
- Oral moniliasis, white cheese/curd like patches that coats mouth and tongue
- Treat with anti fungal (Nistatin/Mycostatin)

g. Anodontia
- No eruption of temporary teeth
KAWASAKI DISEASE
- Common in Japan
- Mucocutaneous lymph node syndrome
- Drug of choice: Aspirin, Salicylates
Criteria for diagnosis of Kawasaki Disease

1. Fever lasting more than 5 days
2. Bilateral Conjunctivitis
3. Change of lips and oral cavity
a. Dry, red, fissure lips
b. Strawberry tongue
c. Diffuse erythema of mucous membrane
4. Changes of peripheral extremities
a. Erythema of the palms and sole
b. Indurative edema of the hands and feet
c. Membranous desquamation from fingertips
5. Polymorphous rash (primarily on trunk)
6. Acute nonpurulent swelling of cervical lymph node to > 1.5 cm in diameter
CLEFT LIP
- Failure of the median maxillary nasal processes to fuse by 5 – 8 weeks of pregnancy
- Common in boys
- Can be unilateral or bilateral
CLEFT PALATE
- Failure of the palate to fuse by 9 – 12 weeks of pregnancy
- Common in girls
Signs and Symptoms
a. Evident at birth
b. Ultrasound/3 dimensional UTZ
c. Milk escape to the nostril
d. Common URTI (otitis, cholic)
- Surgery
- Cleft lip: cheiloplasty done as early as 1 – 3 months to save sucking reflex
- Cleft palate: uranoplasty done 4 – 6 months to save speech
Nursing Responsibility
(Pre Op)
- Emotional support
- Proper nutrition
- Use Rubber tipped medicine dropper
- Prevention of cholic 1
a. Feed upright position
b. Burp twice
c. Prone position/on abdomen

- Orient parents to feeding technique
Cleft Lip
- Use rubber tipped syringe
Cleft Palate
- Use paper cup, plastic cup, soup spoon
- Use elbow restraints (pre op)
- So baby can easily adjust post op
(Post Op)
- Maintenance of airway
- Side lying (cheiloplasty)
- Prone (uranoplasty)
- Facilitate drainage
- Monitor for developing RDS
- Proper nutrition
- NPO 4 hours post op
- Check for colds or nasopharyngitis
- May cause septicemia
- Begin with clear liquid
- Observe for signs of hemorrhage (frequent swallowing)
- Usually happens 6 – 7 days post op
- Protect site of operation
- Maintain integrity of logan bar
a. Half strength hydrogen peroxide and saline
b. Prevent baby from crying
c. Prevent cholic
d. Check for wet diaper
NECK
- Check for symmetry
a. Congenital Torticolis
- Wry neck
- Birth injury of sternocleidomastoid muscle due to excessive traction during cephalic
delivery
- Management:
- Passive stretching exercises daily
- Surgery (last)
- Complication is scoliosis
b. Congenital Cretinism (congenital hypothyroidism) – absence or non-

functioning thyroid glands
Signs and Symptoms
1. Change in sucking (early sign)
2. Change in crying
3. Sleep excessively due to decrease metabolism 1
4. Constipation
5. Moon face baby
6. Mental retardation (late sign)

Diagnostic Exam
- Radio active iodine uptake
- Protein bound iodine
- radio immuno assay test
Reasons for delayed diagnosis
- Thyroid glands are covered by sternocleidomastoid
- Baby receive maternal thyroxine
- Sleep 16 – 20 hours a day
Management
- Synthroid (synthetic thyroid)
- Sodium Levothyroxine (given lifetime)
CHEST
- Check for symmetry
- Breast produces witch milk a transparent fluid related to hormone changes
ABDOMEN
- Inspection, Auscultation, Palpation, Percussion
A. Diaphragmatic hernia
- Protrusion of stomach contents through a defect in the diaphragm due to failure of
pleuroperitoneal canal to close
Signs and Symptoms
1. Sunken abdomen
2. Signs of RDS
3. Related to shunting
Management
- CPAP (continuous positive airway pressure)
- Diaphragmatic repair within 24 hours
B. Ompalocele
- Protrusion of stomach contents between junction of abdominal wall and umbilicus
- Small: surgery
- Large:
- Suspension of surgery
- Wrap with sterile wet dressing
- Apply silver sulfadiazine ointment to prevent infection
GASTROINTESTINAL SYSTEM
1. FUNCTIONS
a. Assists in maintaining fluid and electrolyte and acid/base balance
b. Processes and absorbs nutrients to maintain metabolism and support
growth and development
c. Excrete waste products from the digestive system
2. RECOMMENDED DAILY ALLOWANCE
a. Calories: 120 calories per kilo body weight per day (360 – 380 calories)
b. Fluids: 16 – 20 cc per kilo body weight
c. Protein: 2.2 grams per kilo body weight 1
3. SUPPLEMENTARY FEEDING 4 – 6 months

Principles

a. Solid food is offered to the following sequence
- Cereals: rich in iron (because at 6 months iron is completely catabolized)
- Fruits
- Vegetables
- Meat
b. Begin with small quantities
c. Finger food is deferred by 6 months
d. Soft table food/modified family menu by 1 year
e. Dilute fruit juices (6 months)
- Ratio: 1 oz. fruit to 4 oz. water
- Never give half cooked egg, may cause gastroenteritis/salmoneliosis diarrhea
- Avoid giving honey cause infant botulism
- Offer new food 1 at a time with interval of 4 – 7 days to determine food allergies
4. MAJOR CONCEPTS OF FLUID AND ELECTROLYTE BALANCE

Distribution of body fluid
- Total body fluids comprises of 65 – 85% body weight among infants and children
- Fluids are greater ECF compartment among infants and children (prone to
dehydration)
5. ACID-BASE BALANCE
Dependent on the following
a. Chemical buffers
b. Renal and respiratory system involvement
c. Dilution of strong acids and bases on blood
Imbalance of acid
a. Respiratory acidosis
- Carbonic acid excess
- Hypoventilation
- Asthma
- Pneumonia
- Emphysema
- Laryngo tracheo bronchitis
- RDS
b. Respiratory alkalosis
- Carbonic acid deficit
- Hyperventilation
- Fever
- Encephalitis
c. Metabolic acidosis
- Carbonate deficit 1
- Diarrhea
- Severe malnutrition
- Dehydration

- Celiac crisis
d. Metabolic alkalosis
- Carbonate excess
- Uncontrolled vomiting
- Gastric lavage
- NGT aspiration
- Pyloric stenosis
6. CONDITIONS THAT PRODUCE FLUIDS AND ELECTROLYTES IMBALANCE

A. Vomiting
- Forceful expulsion of stomach contents
Signs and Symptoms
a. Nausea
b. Dizziness
c. Abdominal cramping
d. Flushing of face
e. Teary eyes
Assessment
- Amount
- Frequency
- Force (projectile:IC, pyloric stenosis)
Management
Banana
Rice, cereal
Apple sauce
Toast
B. Diarrhea
- Exaggerated excretion of intestinal content
1. Acute diarrhea are associated with the following

a. Gastroenteritis, caused by salmoneliosis (half cooked egg)
b. Antibiotic use
c. Dietary indescretions
2. CNSD (Chronic Non Specific Diarrhea)
a. Food intolerance
b. Carbohydrates and Protein malabsorption
c. Excessive fluid intake
Assessment
- Frequency
- Consistency
- Appearance of green color stool
Complications
Dehydration
1. Mild – 5% weight loss
2. Moderate – 10% weight loss 1
3. Severe – 15% weight loss
Signs of dehydration
1. Tachycardia

2. Tachypnea
3. Hypotension
4. Increase temperature
5. Sunken fontanel and eyeballs
6. Poor skin turgor/dry skin and mucous membrane
7. Absence of tears
8. Scanty urine (mark oliguria sign of severe dehydration)
9. Weight loss
10. Prolonged capillary refill time
Management
1. Acute – NPO to rest bowel, IV infusion
2. Potassium Chloride – check if baby can void because it can lead to hyperkalemia
leading to cardiac arrest
3. Sodium Bicarbonate – metabolic acidosis, administered slowly to prevent cardiac
arrest
7. GASTRIC MOTILITY DISORDER

HIRSCHPRUNGS DISEASE
- Congenital gagnlionic mega colon
- Absence of gagliion cells for peristalsis
Assessment
1. Neonatal Period
- Failure to pass meconium after 24 hours
2. Early Childhood
a. Ribbon like stool
b. Constipation
c. Diarrhea
d. Foul smelling stool
Signs and Symptoms
- Foul odor breath with stool
- Vomitus of fecal materials
Management
- NGT feeding
- Surgery
a. Temporary colostomy (at 2 -3 months)
b. Anastomosis and pull through procedure
- Diet: high calorie and low residue (spaghetti and chicken)
Diagnostic Procedures
1. Barium Enema – reveals the narrowed portion of the bowel
2. Rectal Biopsy
3. Abdominal x-ray – reveals dilated loops on intestine
4. Rectal manometry – reveals failure of intestinal sphincter to relax
Therapeutic Management and Nursing Care
GASTROESOHAGEAL REFLUX (GER)

- Chalasia presence of stomach contents in esophagus
Assessment Findings
1
a. Chronic vomiting
b. Failure to thrive syndrome (organic)
c. Esophageal bleeding manifested by
Effects and complication

- Esophagitis
- Aspiration
- Carcinoma
Diagnostic procedures
1. Barium Esophogram
2. Esophageal Manometry – reveals lower esophageal sphincter pressure
3. Intraesophageal pH content – reveals pH of distal esophagus
Medications
1. Cholinergics
a. Betanicole (Urecholine) - to increase esophageal tone and peristaltic
activity
b. Metochlopromide (Reglan) – to decrease esophageal pressure by
relaxing pyloric and duodenal segments increasing peristalsis without
stimulating secretion
c. Histamine receptor antagonist (Ranitidine/Zantac) – to decrease
gastric acidity and pepsin secretion
d. Antacid (Maalox) – to neutralize gastric acid between feedings
Management
1. Administration of thickened feeding with cereal to prevent vomiting
2. Feed slowly
3. Burp often every 1 oz.
4. Position: below 9 months place in prone with head of mattress slightly elevated
on a 30O angle
5. Surgery: fundoplication
8. OBSTRUCTIVE DISORDERS
PYLORIC STENOSIS
- Hypertrophy of pylorus muscle causing narrowing and obstruction
Assessment
1. Projectile vomiting
Nursing Alerts:
- Vomiting is an initial symptom of upper GI obstruction
- Vomitus of upper GI can be blood tinged not bile streaked
- Vomitus of lower GI is bilous
- Projectile vomiting is either a sign of ICP or GI obstruction
- Abdominal distention is the major symptom of lower GIT obstruction
2. Failure to gain weight
3. Palpate olive shape mass
4. Peristaltic wave visible from left to right across epigastrium
1. ABG – metabolic alkalosis 1
2. Serum electrolyte: increase Na and K, decrease chloride
3. Ultrasound
4. X-ray of upper abdomen with barium swallow reveals string sign

- Surgery: pyloromyotomy
INTUSSUSCEPTION
- Telescoping of one portion of the bowel to another
- Complication of peritonitis
Signs and Symptoms
- Acute paroxysmal abdominal pain
- Vomiting
- Curant jelly stool
- Sausage shape mass
Diagnostic test
- X-ray with barium enema reveal staircase sign
Management
- Hypostatic reduction with barium enema
9. INBORN ERRORS OF METABOLISM

- Deficient liver enzyme
PHENYLKETONURIA
- Deficiency of liver PHT (Phenylalanine Hydroylase Transferase)
- No tyrosine, melanin, tyroxine – basal metabolism
Signs and Symptoms
- Fair skin
- Blonde hair
- Blue eyes
- Accumulation of phenyl pyrobic acid in the blood
- Musty or mousy odor urine
- Atopic dermatitis
- Seizure
- Mental retardation
Diagnostic Tests
a. Guthrie test
Management
- Low phenylalanine indefinitely
- No food rich in protein (chicken, eggs, meat, legumes, peanut)
- Lofenalac 1
CELIAC DISEASE
- Gluten Enteropathy

- Intolerance to foods containing barley, rye, oats, wheat (normally converted to
gluten)
- With celiac disease gluten is converted to gliadin (toxic to the epithelial cells of villi
leading to malabsorption of:
- Fats (steatorrhea), Protein and Carbohydrates (malnutrition), Calcium
(osteomalacia), Vitamin K (bleeding), Vitamin B12 (anemia)
Assessment
1. Early signs
a. Diarrhea; failure to regain weight ff diarrheal episodes
b. Constipation
c. Vomiting
d. Abdominal Pain
e. Steatorrhea
2. Late signs
a. Behavioral changes: irritability and apathy
b. Muscle wasting and loss of subconscious fats (protuberant abdomen)
3. Celiac Crisis
a. Exaggerated form of vomiting (emergency condition)
1. Laboratory Studies: Stool Analysis
2. Serum antigliadin and antireticulin antibodies – presence indicates disorder
3. Sweat test – to rule out cystic fibrosis
1. Vitamin supplements
2. Mineral supplements
3. Steroids
11. POISONING
- Common among toddlers
Principles
1. Determine the substance taken, assess LOC
2. Unless the poison was corrosive, caustic (strong alkali such as LYE) or a
hydrocarbon, vomiting is the most effective way to remove the poison from the body
3. Syrup of ipecac – oral emetic to cause vomiting after drug over dose or poisoning
a. 15 ml to adolescent, school age and pre school
b. 10 ml to infant
4. Universal antidote – charcoal, milk of magnesia, and burned toast
5. Never administer the charcoal before ipecac
6. Antidote for Acetaminophen poisoning. Acetylsysteine (Mucomyst)
7. For caustic poison
a. Prepare tracheostomy set
b. Kerosine (use mineral oil to coat the intestine to prevent absorption)
c. Give vinegar to neutralize acid (for muriatic acid ingestion)
LEAD POISONING
- Destroy RBC functioning
- Resulting to hypochromic mycrocytic anemia 1
- Leading to kidney destruction
- That leads to accumulation of amonia
- Then encephalitis

Assessment
a. Beginning symptoms of lethargy
b. Impulsive and
c. As lead increases, severe encephalophaty with seizures and permanent mental
retardation
Diagnostic Procedure
a. Blood Smear
b. Abdominal X-ray
c. Long bones
Management
- Remove from source
- If higher than 20 mg/dl last management is chelating agent (balance dimmer
parol, CAEDTA) less side effects
- Binds with lead and excreted slowly via kidney
- Side Effects: nephrotoxicity
ANOGENITAL
Alerts
Female
- Pseudo menstruation
- Slight bleeding related to hormonal changes
- Rape
- Tearing of forchet
- Concerned with child’s care
- Wound follow different stages of healing
- Identical wound
- Report to authorities within 48 hours (barangay captain, bantay bata)
- Shape of pubic hair is inverted triangle
Male
- Check testes (undescended)
- Cryptorchidism common in preterms and management is orchidopexy
- Warm room and hand
- Check for arch of urine
- Hydrocele: fluid filled scrotum (translumination reveal a glowing sign)
- Phimosis: tight foreskin (balanitis infection of glans penis)
- Varicocele: veins in scrotum is increased
EPISPADIAS – meatus is located dorsal (above glans penis)

HYPOSPADIAS – meatus is located ventral (below glans penis)
CHORDEE – fibrous band causing penis to curve downward
Renal Disorder Causes Assessment Treatment Nursing Care

Findings

1. Nephrotic - Infectious - Anasarca (general - Steroid - Monitor
Syndrome body edema) (Prednisone) hydration status
- Massive proteinuria - Diuretics (weight
- No hematuria (Lasix) everyday with
- Serum lipid same clothing)
increase - Decrease
- Fatigue sodium, normal
- Normal or low BP protein
- Increase
potassium intake
(beef broth)
2. AGN -
Autoimmune - Primary peripheral - Anti
Grp. A beta periorbital edema hypertensive - Monitor weight
hemolytic - Moderate hydralasine - Monitor BP
streptococcu proteinuria (appresoline) - Neurologic
s - Gross hematuria - Hypertensive status
(smoky urine) encephalopathy - Increase iron
- Serum potassium (complication - Decrease
increased anemia) potassium
- Fatigue - Iron infusion - Decrease
- Increase BP sodium
BACK
- Check for symmetry and flatness
Spina bifida Occulta
- Failure of posterior laminae of vertebrae to fuse
- Signs and Symptoms: dimpling at lower back
- Abnormal tuffs of hair
Spina bifida Cystica
- With sac
Types
1. Meningocele – protrusion of CSF and meninges
2. Myelomeningocele – protrusion of CSF, meninges and spinal cord
3. Encephalocele – cranial meningocele or myelomeningocele
Common Complication
- Common problem is rupture of sac (place wet sterile dressing and place in prone
position)
- Infection
- Urinary and fecal incontinence
- Paralysis of lower extremities
- Hydrocephalus (CNS complication)
- Always check for a wet diaper
Treatment
- Surgery to prevent infection
SCOLIOSIS
- Lateral curvature of spine common in school age and adolescent
- Uneven hemline
- S shape back
- When bending 1 hip is higher and 1 shoulder prominent
Management
1. Conservative
a. Exercise
b. Avoid obesity
2. Preventive
a. Milwaukee brace worn 23 hours a day
1
3. Corrective
a. Surgery – insertion of Harrington rod (post op do log rolling or move as 1
unit)

EXTREMITIES
I. Digits
a. Syndactyly – webbing of digits (ginger like foot) congenital
b. Polydactyly – extra digit
c. Olidactyly – lacking digit
Amelia – total absence of extremities
Pocomelia – absence of distal part of extremities
 Both are caused by THALIDOMIDE
II. Erb-duchennes paralysis/Brachial Plexus injury/Brachial palsy

- Birth injury due to lateral and excessive traction during a breech delivery
Signs and Symptoms
- Inability to abduct arm from shoulder, rotate arm externally and supinate forearm
- Absence/asymmetrical moro reflex
Management
- Abduct from shoulder with elbow flexed
III. Congenital Hip Dislocation

- The head of femur is outside acetabulum
Types
1. Subluxated – most common type
2. Dislocated
Signs and Symptoms
1. Shortening of the affected leg
2. Asymmetrical gluteal fold
3. Limited movement (early sign)
4. (+) Ortolani’s sign – clicking sound during abduction
5. When able to walk the child limps (late sign)
Management
1. Triple the diaper
2. Carry a stride
3. Frejka Splint
4. Pavlik Harness
5. Hip Spica Cast
IV. Talipes
- Club foot
Types
a. Equinos – plantar flexion (horse foot)
b. Calcaneous or Dorsiflexion – the heel is held lower than the foot/the anterior
portion of foot is flexed towards the anterior leg
c. Varus – foot turns in
d. Valgus – foot turns out
 Common combination is TALIPES EQUINO VARUS and TALIPES CALCANEO

VALGUS
Assessment
- Make a habit of straightening legs and flexing to improve to midline position 1
Management
- Corrective shoes (Dennis brown SPLINT)
- Spica cast

CAST
Purpose:
- Maintain bone alignment
- Prevent muscle spasm
- Immobilization
- Use open palm
- Support with soft pillow and dry naturally
Nursing Care to Patient with Cast
- Circulation, motion, sensation (neurovascular check)
Signs of Circulatory Impairment
Blueness or coldness
Lack of peripheral pulse
Edema not corrected with elevation
Pain on the casted extremity
Tingling sensation (notify doctor because it is a sign of neurological impairment)
- Petaling: making the rough surface of cast smooth
- Mark cast with ballpen if there is bleeding
CRUTCHES
- To maintain balance, support weakened leg
- Place body on palm
- Do palm exercises (squeeze ball)
Different Crutch Gaits
1. Swing Through
Procedure:
1. Advance both crutches
2. Lift both feet/swing forward/land feet in front of crutches
4. Lift both feet/swing forward/land feet in front of crutches
2. Swing To
Procedure:
2. Lift both feet/ swing forward/land feet next to crutches
4. Lift both feet/ swing forward/land feet next to crutches
- 1 and 2 is indicated if weight bearing is not allowed in both lower
extremities
3. Three Point Gait

- Indicated if weight bearing is not allowed on lower extremities
Procedure:
1. Advance left foot and both crutches
2. Advance right foot
3. Advance left foot and both crutches 1
4. Four Point Gail

Procedure
1. Advance right crutch
2. Advance left foot
3. Advance left crutch
5. Two Point Gail

Procedure
1. Advance left foot and right crutch
2. Advance right foot and left crutch
3. Advance left foot and right crutch
4. Advance right foot and left crutch
- 4 and 5 is indicated if weight bearing is not allowed on both lower
extremities
Other Crutch-Maneuvering Techniques

To Sit Down
1. Grasp the crutches at the hand pieces for control
2. Bend forward slightly while assuming a sitting position
3. Place the affected leg forward to prevent weight-bearing and flexion
To Stand Up
1. Move forward to the edge of the chair with the strong leg slightly under the sit
2. Place both crutches in the hand on the side of the affected extremity
3. Push down on the hand piece while raising the body to a standing position
To Go Down Stairs
1. Walk forward as far as possible on the step
2. Advance the crutches to the lower step. The weaker leg is advanced first and then
the stronger one. In this way the stronger extremity shares the work of raising and
lowering the body weight with the patient’s arms.
To Go Up Stairs
1. Advance the stronger leg first up to the next step
2. Then advance the crutches and the weaker extremity (Strong leg goes up first and
comes down last.) A memory device for the patients is “up with the good, down with
the bad.”
WALKER
- A walker provides more support than a cane or crutches
The patient is taught to ambulate with the walker as follows:
1. Patient must hold the walker on the hand grips for stability
2. Lift the walker, placing it in front of you while leaning your body slightly forward
3. Walk into the walker, support your body weight on your hands when advancing
your weaker leg permitting partial weight-bearing or non-weight-bearing leg as
prescribed
4. Balance yourself on your feet
5. Lift the walker and place it in front of you again. Continue this pattern of walking
CANE
- A cane is used to help the patient walk with greater balance and support and to
relieve pressure on weight-bearing joints by redistributing the weight. Quad canes 1
(four-footed canes.) The cane is held in the hand opposite to the affected extremity
Methods of transferring the patient from the bed to a wheelchair

a. Weight-bearing transfer from bed to chair. The patient stands up, pivots his
back is opposite to the new seat, and sits down
b. (Left) Non-weight-bearing transfer from bed to chair. (Right) With legs
braced
c. (Left) Non-weight-bearing transfer, combined method. (Right) Non-weight-
bearing transfer, pull-up method
Therapeutic Exercises
Exercise Description Purpose Action
Passive An exercise carried To retain as much Stabilize the proximal
out by the therapist joint range of motion joint and support the
or the nurse without as possible to distal part. Move the
assistance from the maintain circulation joint smoothly,
patient slowly, and gently
through its full range
of motion. Avoid
producing pain.
Active assistance To encourage normal
An exercise carried muscle function Support the distal
out by the patient part, and encourage
with the assistance of the patient to take
the therapist or the the joint actively
nurse through its range of
motion. Give no more
assistance than is
necessary to
accomplish the
action. Short periods
of activity should be
Active To increase muscle followed by adequate
strength. rest periods.
An exercise
accomplished by the When possible, active
patient without exercise should be
assistance, activities performed against
include turning from gravity. The joint is
side to side and from moved through full
back to abdomen and range of motion
moving up and down without assistance.
in bed. (Make sure that the
patient does not
Resistive To provide resistance substitute another
to increase muscle joint movement for
power. the one intended.)
An active exercise
carried out by the The patient moves
patient working the joint through its
against resistance range of motion while
produced by either the therapist resists
manual or slightly at first and
mechanical means. then with
progressively
increasing resistance.
Sandbags and
weights can be used
Isometric or and are applied at the
muscle setting To maintain strength distal point of the
when a joint is involved joint the
immobilized movement should be
Alternately performed smoothly.
contracting and
relaxing a muscle Contract or tighten
while keeping the the muscle as much
part in a fixed as possible without
position; this exercise moving the joint, hold
is performed by the for several seconds,
patient then let go and relax.
Breathe deeply.
TRACTION 1
- Use to reduce dislocation and immobilize fractures

Principles of Traction
1. The client should be in dorsal or supine position
2. For every traction there is always a counter traction
3. Line of pull should be in line with deformity
4. For traction to be effective it must continuous
Types
Straight Traction
- Weight of body serves as counter pull
Skin Traction
- Applied directly to skin
a. Bryant’s traction
- Use to immobilize ages below 3 years old
- 90O angle with buttoks off bed
b. Buck’s extension
- Immobilize fracture ages more than 3 years old
c. Skeletal
- Applied directly to bone
d. Halo traction
- Immobilize spine
Skeletal Traction
Nursing responsibility
1. Assess for circulatory and neurologic impairment
2. It can lead to hypertension
3. Be careful in carrying out nursing functions by not moving the weights
AUTOIMMUNE SYSTEM
Types of immunity
a. Passive Natural – maternal antibodies through placenta or breast milk
b. Active Natural – contract disease and produce memory cells
c. Passive Artificial – receive anti serum with anti bodies from another host
(Hepa B)
d. Active Artificial – receive vaccination and produce memory cell
Immunity from mother (last for 9 – 12 months)

- Diptheria
- Polio
- Pertusis
- Tetanus
- Measles
NEUROMUSCULAR SYSTEM:
Reflexes
a. Blink reflex – rapid eyelid closure when strong light is shown 1
b. Palmar grasp reflex – solid object is placed on palm and baby grasp
object

- Purpose: cling to mother for safety (disappear by 6 weeks – 2 months)
c. Step in/Walk-in Place Reflex – neonate placed on a vertical position with

their face touching a hard surface will take few quick, alternating steps.
- Placing Reflex: almost the same with step in place reflex only that you are
touching anterior surface of a newborn’s leg.
d. Plantar grasp reflex – when an object touches the sole of a newborn’s
foot at the base of toes, the toes grasp in the same manner as fingers do
(disappear by 8 – 9 months in preparation for walking)
e. Tonic-neck-reflex – when newborns lie on their backs, their heads usually

turn to one side or the other. The arm and the leg on the side to which the
head turns extend, and the opposite arm and leg contract.
f. Moro reflex – test for neurological integrity (jarring crib, loud voice)
assume a letter C position (disappear by 4 – 5 months)
g. Magnet reflex – when there is pressure at the sole of the foot he pushes
back against the pressure.
h. Crossed extension reflex – when the sole of foot is stimulated by a sharp

object, it causes the foot to rise and the other foot extend (test for spinal
cord integrity)
i. Truck Incurvation reflex – while in prone position and the paravertical

area is stimulated, it causes flexion of the trunk and swing his pelvis toward
the touch.
j. Landau reflex – while prone position and the trunk is being supported, the
baby exhibit some muscle tone (test for muscle tone and present by 6 –
9 months)
k. Parachute reaction – while on ventral suspension with the sudden change

of equilibrium, it causes extension of the hands and legs (present by 6 – 9
months)
l. Babinski reflex – when the sole of foot is stimulated by an inverted “J”, it

causes fanning of toes (disappear by 2 months but may persist up to 2
years)

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PEDIATRIC NURSING

I. A. GROWTH AND DEVELOPMENT

Development – increase in the skills or capacity to function qualitative change

How to Measure Development?

Maturation – synonymous with development (readiness)

Cognitive Development – is the ability to learn and understand from experience, to

I. B. BASIC DIVISION OF LIFE

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

1. Growth and Development is a continuous process that begins from

3. Each child is unique

2 Primary factors affecting Growth and Development

4. Growth and Development occurs in a regular direction reflecting a

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

C. Secular – refers to the worldwide trend of maturing earlier and growing

Development Tasks is a skill or growth responsibility arising at a particular time in

PHASE OF PSYCHOSEXUAL THEORY

b. Anal Phase (18 months – 3 years)

c. Phallic Phase (4 – 6 years)

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

e. Genital Phase (12 – 18 years)

Ego Integrity vs. Despair (65 and above)

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

STAGES OF COGNITIVE DEVELOPMENT

SCHEMA AGE BEHAVIOR

C. Concrete Operational (7 – 12 years)

D. Formal Operational (12 and above)

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

Conventional (Level II)

Postconventional (Level III)

6 Universal ethical Principle orientation.

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

E.4. SCHOOL AGE (7 YEARS)

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

E.5. ADOLESCENT PERIOD

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

IMMEDIATE CARE OF THE NEWBORN

B. Proper Suctioning of catheter 1

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

2. Establishing extrauterine circulation

THE FETO-PLACENTAL CIRCULATION

A. 2 Way to facilitate Closure-of Foramen-ovale

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

B. Best position immediately after birth:

Signs of increase ICP

C. Effects of Hypothermia (Cold Stress)

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

D. Prevention of Cold Stress

4. Establish Adequate Nutritional Intake

A. Physiology of Breast milk Production

2. Transitional – covering 4 – 14 days

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

3. Mature milk – 14 days and above

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

PROBLEMS EXPERIENCED IN BREASTFEEDING

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010

5. With supplementary foods added

B. Indication of Stool Changes

ASSESSMENT FOR WELL-BEING

Compilation of Pediatric Nursing Notes | Karl Gerald C. Manalili, UASN 2010