MATERNAL NURSING

PRENATAL CARE
Antenatal/antepartal care
The proper care and supervision of the pregnant woman that will enable her
to pass through the danger of pregnancy and labor with the least possible
risk
A systematic examination, observation and anticipatory guidance of a
pregnant woman
Purpose of Prenatal Care
Establish a baseline data of the present health
Determine gestational age of the fetus
Monitor fetal development
dentify the woman at risk for complication
Minimi!e the risk of possible complication by anticipating and preventing
problems before they occur
"rovide time for education about pregnancy and possible danger
Components of Prenatal Visit
A# $%T&'( ) it should b e obtained unhurriedly and in a private setting
a# "E'%&*A+ A*D %&,A+ $%T&'(
Ask the mother whether she is single or married
*umber of years married
-hether she is employed or not
-hether working outside the house
nature of her .ob
ask about the occupation of her husband
b# /AM+( $%T&'(
Diseases or events in which hereditary is a contributory factor
A history of contagious or communicable disease
f parents, brothers or sister is dead, the cause of death should be
ask for tactfully
c# "A%T D%EA%E% A*D &"E'AT&*
Ask about previous illnesses affecting the different body system
Allergies
"revious surgery or operation especially in the abdomen
d# ME*%T'0A+ $%T&'(
Menarche
,haracteristics of subse1uent periods paying special attention to the
regularity and cycle length
Ask for the date of the last menstrual cycle
e# ,&*T'A,E"T2E $%T&'(
f# "A%T &3%TET',A+ $%T&'(
T4 refers to the number of full term infants the patient has delivered
including livebirths and still birth
P4 refers to number of premature infants including livebirths and still births
A ) refers to the number of abortion
L ) refers to the number of children presently alive
Ask the client about the history of difficult or complicated labor
GRAVIDA4 the number of times a woman has been pregnant
PARITY ) refers to pregnancies that have continued to viability and have
been delivered
g# "'E%E*T "'E5*A*,(
The expected date of confinement and age of gestation are calculated
6# *agele7s rule
Take the date of the first day of the last menstrual period
%ubtract 8 months, add 9 days and 6 year : for the month of april )
december;
Add < months and 9 days : for .anuary ) march;
Age of gestation=
Take the date of the of the first day of the last menstrual period
Add the number of days from +M" to the date of prenatal check up
Add the total number of days then divide by 9 : to get the A&5 in
weeks;
B. PYSICAL E!AMINATI"N
This is done after the history is taken
t is best to ask the patient to empty her bladder before the examination
a. GENERAL SURVEY
The height, weight, vital sign, nutritional and developmental status are
noted and recorded
#. REGI"NAL SURVEY
t should be done systematically so that no point is omitted
Always begin at the head :head4to4toe;
$. EAD
*ote the color of the con.unctiva, lips and gums and note the
presence of pallor
*ote the presence of swelling of the eyelids or face
,heck the condition of the gums and note the presence of dental
caries
&bserve enlargement of the tonsils and redness of the throat
%. NEC&
,heck for the presence of the enlargement of the anterior aspect of
the neck : thyroid gland;
*ote the presence of enlarged lymph nodes
*ote for the engorgement of the neck veins
'. E!TREMITIES
*ote for the swelling of the fingers : tightness of the ring;, the
ankles and the dorsum of the feet
record the degree of swelling
note the presence of varicose veins, their location and degree
(. S&IN
*ote for the presence of skin eruptions or lesions
). CEST
The nipples are checked to find out if it is everted :normal;, flat, ,
inverted or retracted
*. ABD"MEN
+E&"&+D7% maneuver is then performed to determine fetal
position, presentation and the degree of descent of the presenting
part
LE"P"LD+S MANEUVER
$. ,IRST MANEUVER
To determine what fetal part occupies the fundus of the uterus
"rocedure=
"alpate the fundus of the uterus gently with the palm surface of
both hands to determine which pole of the fetus is there
The head is hard, round, smooth and ballottable
The breech is irregular, softer and not ballottable
%. SEC"ND MANEUVER
To determine which part of the fetus are on the either side of the
mother7s abdomen
To locate the back of the fetus
"rocedure=
"lace the palm surface of both hands on each side of the
abdomen, making gentle, deep pressure
&n one side, the hard resistant plane of the back will be felt, on the
other the softer small modulation of the fetal extremities will be
approached
'. TIRD MANEUVER
To determine what occupies the lower uterine segment
To determine whether it is engaged or not
"rocedure=
The examiner grasp the lower abdomen .ust above the symphysis
pubis , between the thumb and finger of the hand -PA.LI&+S
GRASP/
"alpation of this region will give the characteristics of the fetal part
and its motility
f the presenting part is not engaged, it will be very movable and
the fingers of the examiner may even be inserted between it and
the upper border of the symphysis pubis
(. ,"URT MANEUVER
To determine the location of the cephalic prominence
To ascertain the attitude of the head whether flexed or extended;
"rocedure=
/acing the patient7s feet, the examiner makes a deep pressure
with both hands, one on either side of the lower abdomen, along
the direction of the axis of the inlet, if the head presents, one of the
hands will be arrested sooner by a hard, smooth, rounded surface,
the cephalic prominence
The other hand will descends deeper into the pelvis before
reaching the less prominent portion of the fetal head
C. LAB"RAT"RY TEST
a. URINALYSIS
Test for sugar and albumin
This is re1uested during the first visit, and ideally at least twice in each
trimester or unless there is an indication for more fre1uent examination
#. BL""D E!AMINATI"N
Determination of the hemoglobin count, complete blood count,
hematocrit determination, , blood typing, 'h determination
%erologic test for syphilis
EALT PR"M"TI"N DURING PREGNANCY
BATING
%he needs a daily bath because during pregnancy the woman7s
sebaceous and sweat glands have become more active
CL"TING
,lothing should be non4constricting
As the breast enlarge, the bra si!e may need to increase, and the woman
may choose nursing bra before delivery
An abdominal support can be use such as light maternity girdle : for
support; not to compress and constrict the abdomen
%he should avoid garters, extremely firm girdles with panty legs and
knee4high stockings, because they may impede lower extremity
circulation
Advise to wear shoes with a moderate to low heel to minimi!e pelvic tilt
and possible head ache and also to feel comfortable
"RAL YGIENE
Daily oral hygiene and flossing is essential during pregnancy
A visit to the dentist early in pregnancy will detect any cavities that could
make the mother susceptible to infections
SE!UALITY
0nless contraindicated by a medical condition or complications of
pregnancy, continuing sexual activity is encourage
Early in pregnancy, a woman may experience a decreased desire in coitus
resulting from the increased estrogen level in her body
As the woman7s abdomen enlarges, she and her husband may need to
use new positions for intercourse
,EMININE YGIENE
2aginal douching is contraindicated during pregnancy because the force
of the irrigating fluid could possibly enter the cervix and can lead to
infection
SLEEP
Drinking a glass of warm milk before retiring at night can help those who
have troubles falling asleep
Do relaxation exercise : lying 1uietly, systematically relaxing the neck
muscle;
NUTRITI"N
The diet in pregnancy should provide for= the needs of the growing fetus> the
maintenance of maternal health> physical strength and vitality during labor>
and successful lactation
ncrease in food re1uirement is more on 1uality not on 1uantity
A normal, well balanced diet rich in proteins, vitamins and mineral is
recommended
a. PR"TEINS
This is the only substance used for building tissue
They are re1uired for growth of the fetus, placenta, uterus, breast and
increased blood volume
Attention should be given to the protein needs of the developing fetal
brain cell especially during the third trimester of pregnancy
Deprivation of essential proteins during this period will affect the
mental capacity of the offspring
'e1uired daily intake is= ?@46@@ g#
#. CARB"YDRATES
These supply heat and energy
The pregnant mother should be advised to avoid excessive intake of
foods such as cakes, ice cream, chocolates, sweets and other starchy
foods
'e1uired daily intake= 8@@4A@@ g
0. ,ATS
These supply heat and energy
'e1uired daily intake= <@ g
%ources= meat fat, all fried foods, coconut milk or oil, chocolate, bacon,
1. MINERALS
1.$. IR"N
This is needed by both mother and fetus for blood formation as it is
important component of hemoglobin
t is needed by the mother during lactation
Daily re1uirement= 6? g
%ources= liver, beef, egg, green vegetables, raisins/prunes, potatoes,
cereals
B the diet of the pregnant woman rarely suffices to meet the iron re1uirements
during pregnancy, therefore it has
become a practice to prescribe 8@ mgs of elemental iron as supplement
in the form of oral tablets or capsule throughout the latter half of
pregnancy and during lactation
1.%. CALCIUM
This is needed for ossification of the fetal bones and skeleton and for
teeth formation
t plays apart in blood clotting and macro4muscular action
The calcium need is greatest during the last twelve weeks of gestation
because of rapid ossification of the fetal skeleton which is taking
place during this time
Daily re1uirement= 6#C46#D g
1.'. P"SP"RUS
This is essential in fixed proportion with calcium for bone and teeth
formation
Daily re1uirement= 6#C46#D g
1.(. I"DINE
This is essential for normal thyroid function
Daily re1uirement= 6D@ mg
/ood sources= sea foods, iodi!ed salt
1.). VITAMINS
There is vitamin deficiency due to= insufficient intake> persistent
nausea and vomiting> poor absorption
1.).$. VITAMIN A
Essential for reproduction, growth, and lactation
Daily re1uirements= E@@@ #0#
%ources= green vegetables, animal fats such as in butter,
margarine, cod liver oil
1.).%.VITAMIN B$
Essential for proper metabolism of food and for proper nerve
function
Daily re1uirement= C4C#D mg
%ources= unpolished rice, whole wheat bread, yeast, beans,
spinach, meat liver, cheese
1.).'. VITAMIN C
Essential for growth of teeth, bones and blood vessels
*eeded for iron absorption and concerned with blood formation
Daily re1uirement= 6@@ mg
%ources= papaya, citrus fruits, fresh fruit .uices, green vegetables,
tomatoes, strawberries
1.).(. VITAMIN D
Essential in the absorption of calcium in the intestine
'egulates the metabolism of calcium and phosphorus
*eeded for growth of the skeleton
Daily re1uirements= A@@ #0#
%ources= it is produced by the body when exposed to sunlight,
milk, eggs, cheese and butter
Excessive intake may produce harmful effects on the off4spring like supraF
vulvar
pulmonic and aortic stenosis : supra4vulvar syndrome; and
physical and mental retardation
1.).). VITAMIN E
nvolved in proper implantation and embryonic growth
Daily re1uirements= A@ 0
%ources= milk, eggs, meat, green vegetables, whole wheat bread
1.).*. VITAMIN &
Essential for the formation of prothrombin which is necessary for
blood coagulation
Too much vitamin G given during the last weeks of pregnancy may
prove harmful to the liver of the fetus especially if the fetus is born
prematurely
%ources= cabbage, lettuce, cauliflower, carrots
1.).2. ,"LIC ACID
Essential for normal development of red blood cells from bone
marrow
daily re1uirements= @#D46 mg
sources= dark green vegetables, liver, kidney, salt
TE"RIES ", LAB"R "NSET
t is believed that it is influenced by the combination of factors from the mother
and fetus=
0terine muscle stretching :0terine %tretch Theory;
"ressure on the cervix :Mechanical rritation Theory;
&xytocin stimulation : &xytocin Theory;
,hange in ratio of estrogen and progesterone : "rogesterone Deprivation
Theory;
"lacental age
'ising fetal cortisol level
%easonal and time influences
"rostaglandin Theory
,ACT"RS A,,ECTING LAB"R AND DELIVERY
PASSAGE
t refers to the route the fetus must travel from the uterus through the
cervix and vagina to the external perineum
PASSENGER
t is the fetus
The body part of the fetus that has the widest diameter is the H$EADI
POWER
contraction
PSYCHE
refers to the psychological state or feeling s that woman bring into
labor
PREM"NIT"RY SIGNS ", LAB"R
$. LIGTENING
t refers to the descent of the uterus as a result of the sinking of the
fetal presenting part into the pelvic inlet which occurs C48 weeks
before term
%. ,ALSE LAB"R PAIN
These are merely an exaggeration of the relatively painless,
intermittent uterine contractions :3raxton $ick7s ; they may begin as
early as 84A weeks before the onset of true labor
'. PASSAGE ", S".
t refers to the small amount of usually blood tinged cervical mucus plug
(. RIPENING ", TE CERVI!
t is the softening of the cervix that takes place in late pregnancy
DURATI"N ", LAB"R
"'M5'A2DA M0+T"A'A
6
st
%tage 6@46C hours E#D )9#D hours
C
nd
%tage 6#D hours 8@ minutes
8
rd
%tage D46@ minutes D46@ minutes
T&TA+ 6C46A hours E4? hours
STAGES ", LAB"R
A. STAGE OF DILATATION
6
st
stage of labor
begins with true labor contraction upto the full dilatation of the cevix
6# +ATE*T
3egins at the onset of regularly perceived uterine contraction and
ends with rapid cervical
,ontraction during this phase is mild and short , lasting C@ to A@
seconds
The cervix dilates from @ to 8 cm
*ullipara= E hours
Multipara= A#D hours
C# A,T2E
,ervical dilatation occurs more rapidly, going from A to 9 cm
,ontraction are stronger lasting A@ to E@ seconds and occuring
every 8 toD minutes
*ullipara= 8 hours
Multipara= C hours
%how and spontaneous rupture of the membrane may occur
8# T'A*%T&*
Maximum dilatation of ? to 6@ cm occurs
,ontraction occurs every 8 toC minutes with a duration of E@ to <@
seconds
The woman in labor experiences a feeling of loss of control,
anxiety, panic, and irritability
PYSI"L"GICAL CANGES DURING TE $
ST
STAGE ", LAB"R
,ontraction and retraction of the uterine muscle
/ormation of the upper and lower uterine segment
"olarity
Taking up of the cervix or cervical effacement
,ervical dilatation
"resence of show
/ormation of the bag of water
'upture of the membranes
CARE ", TE PATIENT DURING TE ,IRST STAGE ", LAB"R
6# "sychologic preparation of the patient
nstill to the patient confidence and trust
C# Maternal and fetal assessment
a# 5et the history
0terine contraction
"assage of show
%tatus of the membrane
/etal movement
%leep, rest, food
b# "hysical Examination
2ital signs
/undic height
c# 2aginal Examination
"urpose=
To know the degree of cervical effacement and dilatation
To verify the correctness of presentation and position as
gained during abdominal palpation
The determine the station of the presenting part
To determine if the forewater is intact, leaking or absent
To evaluate the capacity of the bony pelvis in relation to the
si!e of the baby
MANAGEMENT ", TE ,IRST STAGE ", LAB"R
a# "hysical preparation of the patient
2ulvar and perineal shaving and scrubbing
,leansing enema
3ath or shower
b# &bstetric nursing care
During early labor and in the presence of intact membranes,
the patient may be allowed or encourage to walk
f she is tired , she should relax and rest
+eft lateral recumbent position is recommended to prevent the
supine hypotensive syndrome and to facilitate kidney function
During the early stage of labor, the patient is allowed to take
li1uid diet like milk, soup or fruit .uices
The stomach should be empty preferably A4E hours before the
expected time of delivery to avoid vomiting and aspiration
Empty the bladder every C hours
5ive emotional support by giving encouragement and coaching
about the proper way to relax
n early labor, the parturient is excited, talkative and
apprehensive
c# ,omfort and %upportive/ "rotective Measures
'elief of backache or pain by rubbing back
'elief of leg cramps by extending the leg , putting pressure on
the knee and dorsiflexing the foot
Attention to the personal hygiene of the patient by washing or
wiping her face and hands, helping her fix her hair and keeping
her clothing clean
'elief of dryness of mouth cause by medications or mouth
breathing by giving ice chips or moistening the lips with
vaseline or lubricant to prevent cracked lips
$elping the patient to use breathing and relaxation techni1ue to
ease pain during contractions
3EA'*5 D&-* D0'*5 T$E /'%T %TA5E &/ +A3&'
%$&0+D 3E D%,&0'A5ED= because
6# it put great strain on the transverse cervical ligaments and
the paracervical tissue and predisposes to subse1uent
prolapse of the uterus
C# it causes the cervix to be compressed between the fetal
head and the symphysis pubis which may give rise to an
edematous anterior cervical lip
8# it might cause laceration to the cervix by forcing the
presenting part to pass through an incompletely dilated
cervix
A# the increased intrauterine pressure may cause premature
rupture of the membrane and fetal distress
D# it exhausts the patient unnecessarily and lowers her
resistance
monitor uterine contraction= fre1uency, interval, intensity
monitor fetal condition= fetal position, /$T,
monitor maternal condition
assess the progress of labor by vaginal examination
SIGNS TAT MAY RE3UIRE TE SERVICES ", A
D"CT"R4"SPITAL
a prolonged 6
st
stage of over 6C hours
rise in maternal blood pressure to level reaching 6A@ mm$g
systolic / <@ mm$g diastolic
rise in maternal temperature of 89#D and above
an increase in the rate of maternal pulse reaching 6@@
beats/minute and above
occurrence of convulsion
increase or decrease in fetal heart rate
passage of meconium or meconium stained fluid in a vertex
presentation
prolapse of the cord
unusual bleeding per vagina
B. EXPULSION OF THE FETUS
Cns stage of labor
period from full dilatation of the cervix to the birth of the infant
"'&3A3+E %5* &/ C
*D
%TA5E : signs usually but not always indicate
that the C
nd
stage has been reached;
strong uterine contraction coming every C48 minutes that lasts
E@ )<@ seconds
increase in bloody discharge
spontaneous rupture of the membrane
bearing down
sensation of defecation, this is brought about by the pressure of
the presenting part on the rectum
pressure signs appear like= bulging of the perineum> anus
dilates and pouts> gaping of the vulva
MATE'*A+ /EE+*5 / 'EA,T&*=
marked restlessness because of strong, fre1uent and painful uterine
contractions
presence of perspiration to the upper lip or forehead
shaking of the legs due to the pressure of the presenting part on the
perineal nerves
nausea and vomiting
PASES ", TE SEC"ND STAGE ", LAB"R
a. T5e Sta6e of Des0ent
This refers to the stage when after full dilatation of the cervix , the
head descent to the perineal floor
This may take only a few minutes or a single contraction in the
multipara but in primigravida , it may lasts for about 8@ minutes
#. T5e Perineal Sta6e
This refers to the stage beginning from the time the presenting part
reaches the pelvic floor and is seen at the vulva until its expulsion
n the multipara it takes only one to a few contractions while in the
primigravida, it may take as much as AD minutes
PYSI"L"GICAL CANGES DURING TE %
ND
STAGE ", LAB"R
,ontractions become stronger and more fre1uent occurring every C48
minutes
Displacement of the pelvic floor occurs
The fetus is expelled
Mechanism of labor play an important role in the second stage of labor
MANAGEMENT ", TE %
ND
STAGE ", LAB"R
a. Preparaton for !el"er#
%etting up of the delivery table
"reparation of the patient
6# transporting the patient to the delivery room
C# positioning the patient
lithotomy position on the hospital delivery table
patient lies either in the left or right side , buttocks at the edge
of the bed, and legs slightly flexed
8# perineal prep : vulvar scrubbing, painting with antiseptic solution;
A# drapping
"reparation of the nurse
6# scrubbing
C# sterile gowning
8# sterile gloving
$. O$ser"aton
,ontinue observing the contraction, maternal condition, fetal condition
AM*&T&M( can be done : if the bag of water has not ruptured
spontaneously at this time, it is punctured by means of an allis forcep
or amniotomy hook during contraction
%. General Care an! Assstan%e
3ladder should not be allowed to be distended, if unable to void, she
should be catheteri!ed aseptically
*o solid or li1uid food is given by mouth
'elief of leg cramps by changing the position of the legs or by a brief
massage
Teaching the patient the proper way to bear down : when and how to
bear down;
MET"DS "R MANUEVER .IC MAY BE EMPL"YED IN DELIVERING
TE EAD7
a. Mo1ifie1 Rit6en+s Man8e9er
This is a method of delivery of the head by lifting it upward through
the vulva between pain by pressing with the fingertips of one hand
over the perineum and with the fingers of the other hand over the
vertex or occiput exerting gentle downward pressure over it
#. &risteller+s Man8e9er
This is a method of expelling the fetus or the fetal head when it is
already at the vulva and the bearing down power is insufficient
-ith the abdomen sufficient relaxed the nurse grasps the uterine
fundus between the fingers behind the thumb in front and applies
pressure at the fundus along the axis of the birth canal during the
acme of the contraction
LACERATI"NS ", TE BIRT CANAL
,lassification=
a# 6
%T
Degree +aceration
one which involves the vaginal mucosa, the fourchette, the perineal
skin, but not the muscle
it is superficial and may re1uire a few stitches or none at all
bleeding is minimal
b# C
nd
Degree +aceration
one which involves in addition to the vaginal mucosa and perineal
skin, the fascia, and muscles of the perineal body but not the rectum
or anus
it re1uires repair similar to an episiotomy
c# 8
rd
Degree +aceration
also known as the complete tear
it extend completely thru the vaginal mucosa , the perineal skin, the
muscles of the perineal body and in addition the, involves the anal
sphincter
d# A
th
Degree +aceration
refers to the complete tears which extends through the anterior rectal
wall to expose the cavity of the rectum
it re1uires extensive repair
,A0%E%=
rapid and sudden expulsion of the fetal head
persistent occiput posterior position
excessive si!e of the infant
difficult forcep deliveries
pelvic outlet contraction forcing the head posteriorly
exaggerated lithotomy position
rigid perineum in primigravidas and in multiparas where scar tissue from a
previous laceration or episiotomy is present
MEANS ", LESSENING TE "CCURRENCE ", PERINEAL
LACERATI"N
obtaining the patient7s cooperation regarding bearing down or pushing
having control of the advancing head
preventing active extension before crowning
delivery of the head between contraction
taking care in delivering the shoulder and body
E"%&T&M( 4 incision of the perineum designed to substitute a clean
surgical incision for a ragged tear
"urposes=
to spare the fetal head from prolonged pounding against the perineum
which may cause brain in.ury
to shorten the C
nd
stage of labor
in mediolateral episiotomy, to reduce the likelyhood of a third degree
laceration
C. PLACENTAL STAGE
Third stage of labor
3egins with the birth of the infant and ends with the delivery of the
placenta
C"NDUCT ", TE TIRD STAGE
a. Re0o6nition of si6ns of pla0ental separation
Cal&n's s(n : refers to the change in the shape and consistency of
the uterus from a flattened, discoid body to a firmer globular mass/
this is the earliest sign of placental separation and results from an
emptied uterus contracting better;
The fundus of the uterus rises in the abdomen : this is brought about
by the descent of the placenta to the lower segment distending it and
pushing the uterus upward;
%udden gush of blood
The umbilical cord lengthens and feels limp
b. Me05anisms of Pla0ental E:p8lsion
6# %$0+TJE7% ME,$A*%M
The placenta appears like an inverted umbrella as it is forced out with the
smooth glistening fetal surface of the placenta coming out first
This is the more common type of placental expulsion
C#D0*,A* ME,$A*%M
t occurs when the placenta is attached to the lateral wall of the uterus
particularly if relatively low
%eparation occurs first at the periphery with the result that blood collects
between the membranes and the uterine wall
'ough maternal surface appears first at the vulva
c# Met5o1s of pla0ental e:p8lsion
Ask the patient to bear down
Modified ,rede7s Method : with one hand at the fundus, palm either
facing downward or behind the uterus with the thumb anterior to the
uterus, downward pressure along the axis of the birth canal is applied
to the contracted uterus using this as a piston or plunger while
simultaneously tracting on the cord with the other hand to bring out
easy delivery of the placenta;
3randt Andrews method : tension is applied to the umbilical cord with
the one hand, while on the other hand , palm facing either the
umbilicus or symphysis pubis is placed over the lower abdomen
approximately between the upper segment and the lower segment ,
and made to push the uterus upward in order to displace the placenta
from the lower segment into the vagina;
d# examine the membranes
Examine it for completeness
PYSI"L"GIC CANGES DURING TE '
RD
STAGE ", LAB"R
"lacental separation
"lacental expulsion
C"NDITI"NS TAT MAY RE3UIRE RE,ERRAL T" TE PYSICIAN
"rofuse bleeding before placental separation or expulsion
"rofuse bleeding from vaginal or perineal laceration
'etention of the placenta for 8@ minutes or more
Atony of the uterus
'etention of placental cotyledons or membrane
Multiple perineal or vaginal laceration
nversion of the uterus
ncrease in maternal pulse rate : 6C@ /minute or above;
+owering of maternal blood pressure : <@/D@ mm$g;
Difficulty of breathing
,onvulsions
MECANISMS ", LAB"R
t refers to the series of changes in the attitude and position of the fetus so
that it may successfully pass through the irregularly curved birth canal
$. En6a6ement
t is the descent of the biparietal plane of the fetal head to a level at or
below that of the pelvic brim or inlet
%. Des0ent
'efers to the downward movement of the fetus in the birth canal
'. ,le:ion
'efers to the movement where to chin is brought into more intimate
contact with the fetal thorax and the shorter suboccipito4 bragmatic
diameter
(. Internal rotation
This movement refers to the turning of the fetal head along its vertical
axis
). E:tension
*. E:ternal rotation4 restit8tion
2. E:p8lsion
DE/*T&* &/ TE'M%
,'A*0M 444 the upper most portion of the skull
%A5TTA+ %0T0'E 44 a membranous interspace , .oins the C parietal
bones of the skull
,&'&*A+ %0T0'E 444 it is the line of .unction of the frontal bone and C
parietal bones
+AM3D&D %0T0'E 444 it is the line of .unction of the occipital bone and
the C parietal bones
A*TE'&' /&*TA*E+ 444 lies in the .unction of the coronal and sagittal
suture
"&%TE'&' /&*TA*E+ 444 lies at the .unction of the lamboidal and
sagittal sututre/ triangular in shape
ATTT0DE 444 it is the term used to describe the degree of flexion the fetus
assumes or the relation of the fetal parts to each other
E*5A5EME*T 44
SPECI,IC C"NDITI"NS AND TEIR E,,ECT "N LAB"R
6# Parity# n the multipara, the cervix offer less resistance to dilatation as a
result of having been previously completely dilated in the past labors# Also
the perineal floor is generally more relax and less resistance# As a result,
labor in the multipara is faster or shorter in duration as compared to the
nullipara#
C# Age of the Mother. +abor in the young, teenage primigravida, 6C to 6E years
of age, is usually of average duration but the incidence of complications like
pregnancy induced hypertension , anemia and prematurity is greater# The
woman who undergoes her first pregnancy at or beyond the age of 8D is
termed as H E+DE'+( "'M5'A2DAI# The fre1uency of prolonged labor is
increased because of the greater incidence of uterine dysfunction and
cervical rigidity# There is also a greater incidence of hypertension and other
degenerative disorder
8# Interval between birth# -hen the interval between birth is ten years or more ,
labor is similar to that in the elderly primigravida
A# Size of the Baby. +abor tends to be prolonged in its 6
st
and C
nd
stages
C"MPLICATI"NS IN LAB"R AND DELIVERY
I. DYST"CIA
"rolonged, difficult labor
,essation of progress in labor as the result of abnormalities in
the mechanics involved
) *a+or Causes of D#sto%a
A# Abnormalities Due to 0terine ,ontractions
6# significant prolongation of any phase of labor, called uterine
dysfunction
a# %ubnormal or hypotonic patterns
nfre1uent
"oor intensity
,ontributes to minimal or lack of labor process
b# Abnormal or hypertonic pattern
*o relaxation between contraction
3# Abnormalities of "osition and "resentation
6# /aulty "resentation
a# persistent occiput posterior
b# breech
c# face
d# brow
e# shoulder
f# compound presentation
C# Abnormalities in fetal development
a# excessive fetal si!e
b# malformations
c# hydrocephalus
,# Abnormalities in the "elvis
6# ,ontractions of the pelvis whereby the diameter are
decreased and thus also the capacity of the pelvis
a# contraction of the pelvic inlet
b# contraction of the midpelvis
c# contraction of the pelvic outlet
C# "elvic deformities
a# dwarf pelvis
b# asymmetry due to childhood in.uries or other disease
II. UTERINE DYS,UNCTI"N
,auses=
ll ) timed and excessive administration of analgesia
Minor degree of pelvic contraction
%light extension of the fetal head as in occipital posterior
position
&verdistension of the uterus
mproper emotional approach to labor
,ervix is too rigid to dilate
Elderly primigravidas
,omplications=
/etal death and in.ury
Maternal exhaustion and dehydration
III. ABN"RMALITIES IN P"SITI"N4PRESENTATI"N
A. Peritent O!!i"#t Poterior Poition
-hen normal rotation does not occur
,auses=
More fre1uent in an anthropoid pelvis
More common in android and in cases of midpelvic contraction
f membranes have ruptures prematurely
$ead is poorly flexed
"resence of uterine dysfunction
Management=
/orceps delivery
Deep mediolateral episiotomy should be made
B. Bree!h Preentation
Types=
a# /rank 3reech
the legs are extended and lie against the abdomen and the
chest#
The feet are at the level of the shoulder#
The buttocks are the presenting part#
The most common type of breech presentation
b# ,omplete 3reech
The feet and the legs are flexed on the thighs
The thighs are flexed on the abdomen
The buttocks and the feet are the presenting part
c# /ootling
The legs are unflexed and extended
The feet are the presenting part
c#6# single footling
c#C# double footling
,auses=
,ommon in small babies
&bserved repeatedly in same woman :habitual breech
presentation;
5estation age under A@ weeks
Abnormalities in the fetus
,ontracted pelvis which allows the breech to enter the inlet but
not the larger head
"endulous abdomen
$ydramnios that allows for free fetal movement so that the
fetus does not have to make a H most comfortable choiceI
Diagnosis=
+eopold7s maneuver
K4ray pelvimetry
2aginal/rectal exam
/$3# 3ack of the child usually at the level of the umbilicus or
slightly above it
IV. PR"LAPSE UMBILICAL C"RD
t is a condition wherein a loop of cord protrudes through the
cervix into the vagina and exceptionally emerges from the vulva
,auses=
,ommon in shoulder or foot presentation
Early rupture of 3&- while head is still freely movable about
superior
Degree of "rolapse=
1 6# &ccult 4 the cord is near the pelvis but not within reach
of finger
1 C# /orelying ) cord is palpable but with intact 3&-
8# "rolapsed 4 the cord is outside with 3&- ruptures
Management=
t will depend mainly upon the degree to which the cervix is
dilated and upon presentation of the child
The head of the table is lowered to minimi!e pressure of the
presenting part upon the cord thus impair circulation
f the cervix is dilated, immediate delivery is necessary
-rap cord in sterile &% soaked in *%%
/etal heart beat should be checked regularly
V. PRECIPITATE LAB"R
+abor and delivery that is completed in less than 8 hours after
the onset of true labor pain
,auses=
Abnormally slight degree of resistance offered by the presenting
part
Abnormally strong uterine and abdominal contraction
Absence of painful sensation during labor
,onse1uences=
nfant mortality is high because of the following reasons=
a# the tumultuous uterine contractions often with negligible
interval between prevent proper oxygenation of the fetal
blood
b# the rapid transit of the baby through the bony pelvis
sometimes produces cerebral trauma
c# such babies are often born unattended and suffer from lack
of proper care during the first few minutes of life
VI. PR"L"NGED LAB"R
n primigravidas, labor more than 6? hours
n multi, more than 6C hours
Danger=
Maternal exhaustion
0terine atony
,aput succedaneum
VII. PREMATURE LAB"R AND DELIVERY
0terine contractions occur before the 8?
th
week of gestation
6# f there is no bleeding and cervical dilatation and fetal heart
sounds are good, premature uterine contractions can be
stopped by=
a# Ethyl alcohol :Ethanol; 2
%ide Effects= nausea and vomiting, mental confusion : same
side effect when alcohol is taken orally in excessive amount;
b# 2asodilan 2
%ide effect= hypotension, tachycardia
c# 'itodrine &rally
d# 3ricanyl
C# f premature uterine contraction are accompanied by
progressive fetal descent and cervical dilatation, premature
delivery is inevitable
VIII. UTERINE RUPTURE
The term is usually employed to denote rupture after the period
of viability of the fetus
t occurs when the uterus undergoes more strain that it is
capable of sustaining
,auses=
%car from a previous classic ceasarian section
0nwise use of oxytocin
&verdistension
/aulty presentation or prolonged labor
Trauma
%igns and %ymptoms=
%udden, severe pain
$emorrhage and clinical sign of shock
,hange in abdominal contour
Management=
$ysterectomy
"ossible blood transfusion
I!. UTERINE INVERSI"N
The fundus is forced through the cervix so that the uterus is
turned inside out
Types=
6# ncomplete
-hen the fundus of the uterus becomes inverted and
comes into close contact with the external os
C# ,omplete inversion
-hen the fundus of the uterus becomes inverted and
protrude thru the external os
8# "rolapsed of the nverted 0terus
The entire organ appears outside of the vulva
,auses=
Marked laxity or thinness of the uterine walls particularly at the
placental site
nvertion of the placenta at the fundus, so that the fetus is
rapidly delivered, especially if unsupported , the fundus is pulled
down
%trong and vigorous fundal push when mother fails to bear
down properly
Attempts to deliver the placenta before signs of placental
separation appear
"ressure caused by too strong traction of the cord of the
placenta
%igns and %ymptoms=
Evidence of shock
Di!!iness
%evere uterine pain
"rofuse bleeding
%trangulation on cervical area resulting to gangrene
Management=
'epositioning ) in mild cases
2aginal hysterectomy ) in prolapsed
,olpohysterectomy
!. AMNI"TIC ,LUID EMB"LISM
At anytime after the membrane have ruptures there is a
possibility that the amniotic fluid may enter the venous sinuses
of the palcental site as well as the endocervical veins, be drawn
in the general circulation and in this way reach the pulmonary
capillaries
%igns and %ymptoms=
-oman in labor suddenly sits up and grasps her chest
Turns pale and then the typical bluish4gray color
%hock
0terine relaxation with hemorrhage
/ailure of blood to coagulate
Management=
Emergency measures to maintain life such as 2, oxygen
"rovide intensive care in the ,0
Geep family informed and provide emotional support
"rognosis=
Almost 6@@L fatal
Ne;#orn Care
Imme1iate Care of t5e Ne;#orn I
Directly after birth there should be attention to the condition of the
newborn# The -orld $ealth &rgani!ation :-$&; states that such attention is an
integral part of care in normal birth# mmediate care involves=
Drying the baby with warm towels or cloths, while being placed on the
motherMs abdomen or in her arms# This mother4child skin4to4skin
contact is important to maintain the babyMs temperature, encourage
bonding and expose the baby to the motherMs skin bacteria#
Ensuring that the airway is clear, removing mucus and other material
from the mouth, nose and throat with a suction pump#
Taking measures to maintain body temperature, to ensure no
metabolic problems associated with exposure to the cold arise#
,lamping and cutting the umbilical cord with sterile instruments,
thoroughly decontaminated by sterili!ation# This is of utmost
importance for the prevention of infections#
A few drops of silver nitrate solution or an antibiotic is usually placed
into the eyes to prevent infection from any harmful organisms that the
baby may have had contact with during delivery :e#g# maternal %TDs ;#
2itamin G is also administered to prevent hemorrhagic disease of the
newborn#
The babyMs overall condition is recorded at 6 minute and at D minutes
after birth using the Apgar %cale #
"utting the baby to the breast as early as possible# Early
suckling/breast4feeding should be encouraged, within the first hour
after birth and of nipple stimulation by the baby may influence uterine
contractions and postpartum blood loss but according to the -$&, this
should be investigated#
About E hours or so after birth, the baby is bathed, but the vernix
caseosa :whitish greasy material that covers most of the newbornMs
skin; is tried to be preserved, as it helps protect against infection#
,ord ,are= Diaper the baby below the cord stump# (ou can choose to
apply or not apply alcohol, to the babyMs cord stump#
Eyes= f eyes are goopy, clean them twice a day with boiled water and
sterile cotton balls# ,logged tear ducts are normal and usually start in
with one eye# Massaging the duct at the corner of the inner, lower lid
can help# 3reast milk dripped directly into your babyMs eyes can help
heal minor inflammation and irritation#
"ositioning= "lace baby on his/her back to sleep# Geep baby warm, but
not too hot in the summer# *ewborn temperature should be between
<9#D and << degrees#
%tools= :3M; At first they will be dark and gummy :tarry meconium;#
2egetable oil is good for cleaning it off# %tools should progress to
golden yellow, soft, somewhat like scrambled eggs in appearance#
3reastfed babiesM stools should not smell bad# The baby should void
and defecate within CA hours of birth#
3athing= 3athing a baby immediately after birth depends upon the
agency7s policy# Avoid soap on the babyMs skin> clean creases of skin
carefully# Avoid talc and mineral oil :petroleum; products# (ou can use
a natural vegetable oil to massage into baby after the bath#
Care of t5e Ne;#orn II
-rap the baby in a receiving blanket and move to a separate table,
preferably one with warming lights over it :even regular light bulbs will
work, .ust make sure they aren7t shining directly in the baby7s eyes;#
Dry the baby completely with a dry towel starting with the head and
working downward#
Assessment should be made A"5A' :Appearance, "ulse, 5rimace,
Activity, and 'espiratory effort; to help you determine how well the infant
is doing#
o A""earan!e4 This is looking at the baby7s skin color# Most
newborns will appear pink :red;, blue, or a combination of the two#
f the baby7s entire body is blue at the first scoring, resuscitation
may be necessary and it receives a score of !ero for this category#
f the torso is pink and the extremities are blue, the baby will
receive a score of one# f the entire body is pink or red, the score is
a two#
o P#le$ To take a newborn7s pulse rate a stethoscope is necessary#
"lace the stethoscope bell over the baby7s heart and count the
beats for a full minute# t should be very rapid and sound similar to
a horse galloping# The infant should have a pulse rate of AT
+EA%T 6@@ beats per minute# t may be as high as 6?@ beats per
minuteN f the pulse is 6@@ beats per minute or higher the score will
be a two# f it is ?@46@@ beats per minute the score will be a one
and resuscitation e1uipment should be available# 0sually more
stimulation by drying the baby off more or flicking the soles of the
feet will raise the heart rate# f the pulse is below ?@ the score will
be !ero and resuscitation should begin# /or a newborn, a pulse
rate below ?@ is fatal because the heart is not pumping enough
blood to sustain the body# ,"' should be started and
compressions should be done to make the heart rate at least 6@@
beats per minute#
o %ri&a!e4 This is the baby7s response to stimuli# The stimuli can be
anything that makes him cry# f the baby is crying spontaneously
without being stimulated, the score is a two# /lick the sole of the
baby7s foot and if the cry is loud and the baby draws up into a ball,
the score is still a two# f after flicking the foot the baby only gives
weak cry and doesn7t withdraw from the stimuli, the score is a one#
f there is no response to the flicking, the score is a !ero#
o A!tivity4 The baby should have some movement in its extremities#
The arms should be flailing and the legs kicking# f this is the case,
the score is a two# f there is slight flexion of the extremities, the
score is a one# f the extremities are flaccid, the score is !ero#
o Re"iratory effort4 This is observing how well the baby is breathing#
f there is a lusty cry, this indicates good air movement and the
score is a two# f the baby is whimpering, and you can see good
chest expansion, the score is a one# f there is no crying, slow
respirations, less than 8@ per minute, the score is a !ero#
'epeat the A"5A' test again five minutes after the baby is born# The
score should be higher this time, and the baby should be alert#
Allow the parents to hold and cuddle their new baby for awhile
3athe the newborn using tepid water# t should feel warm when you
submerge your elbow in it# -ash the baby hair and body, removing the
rest of the vernix, then be sure to dry him off completely#
f scales are available, get his weight#
*ext using a measuring tape, measure his length, chest circumference,
and head circumference#
f supplies for foot printing are available, footprint him#
'eplace the cap on his head, and bundle him in a receiving blanket#
f the mother is ready, return the baby to her and allow her to begin
nursing# $e will receive nutrients and antibodies to protect him against
common diseases#
Ap6ar S0orin6
Apgar scoring is a systematic tool used to assess and document the
clinical status of the newborn at birth, or more precisely at 6 and D minutes of life#
'he newborn i e(a&ine) for five ign*
3reathing
heart rate
muscle tone
reflex irritability
color
'he !ore )e"en) on the following*
severity of birth asphyxia
drugs given to the mother
anesthetics
fetal infection
fetal anomalies
pre4maturity
'able +* A"gar !oring
Si6n
S0ore
< $ %
$eart rate Absent %low :O6@@
beats/min;
PQ6@@ beats/min
,olor 3lue or pale "ink body with
blue extremities
,ompletely pink
3reathing Absent %low, irregular 5ood, crying
Muscle tone +imp %ome flexion Active motion
'eflex irritability *o response 5rimace ,ough, snee!e
Ne;#orn Care Prin0iples
6# -hen a baby is born to a mother being treated for complications, the
management of the newborn will depend on=
whether the baby has a condition or problem re1uiring rapid treatment>
whether the mother7s condition permits her to care for her newborn
completely, partially or not at all#
C# f the newborn has an acute problem that re1uires treatment within 6 hour of
delivery, health care providers in the labor ward will be re1uired to give the
care# "roblems or conditions of the newborn re1uiring urgent interventions
include=
not breathing>
breathing with difficulty>
central cyanosis :blueness of skin;>
low birth weight :less than C D@@ g;>
lethargy>
hypothermia/cold stress :axillary temperature less than 8E#DR,;>
convulsions#
8# The following conditions re1uire early treatment=
possible bacterial infection in an apparently normal baby whose mother
had pre4labor or prolonged rupture of membranes>
possible syphilis :mother has positive serologic test or is symptomatic;#
A# f the newborn has a malformation or other problem that does not re1uire
urgent care=
"rovide routine initial newborn care>
Transfer the baby to the appropriate service to care for sick newborns
as 1uickly as possible#
D# *ewborn without problems
f the newborn has no apparent problems, provide routine initial
newborn care, including skin4to4skin contact with the mother and early
breastfeeding#
f the mother7s condition permits, keep the baby in skin4to4skin contact
with the mother at all times>
f the mother7s condition does not permit her to maintain skin4to4skin
contact with the baby after the delivery :e#g# caesarean section;=
-rap the baby in a soft, dry cloth, cover with a blanket and ensure the
head is covered to prevent heat loss>
&bserve fre1uently#
f the mother7s condition re1uires prolonged separation from the baby,
transfer the baby to the appropriate service to care for newborns
Transferrin6 Ba#ies
Explain the baby7s problem to the mother#
Geep the baby warm# -rap the baby in a soft, dry cloth, cover with a
blanket and ensure the head is covered to prevent heat loss#
Transfer the baby in the arms of a health care provider if possible# f
the baby re1uires special treatment such as oxygen, transfer in an
incubator or bassinet#
nitiate breastfeeding as soon as the baby is ready to suckle or as
soon as the mother7s condition permits#
f breastfeeding has to be delayed due to maternal or newborn
problems, teach the mother to express breast milk as soon as possible
and ensure that this milk is given to the newborn#
Ensure that the service caring for the newborn receives the record of
the labor and delivery and of any treatments given to the newborn#
Profile of a ne;#orn
A# 2ital signs
6# Temperature ) range is 8E#D to 89#D , axillary
%tabili!es within ? to 6@ hours after delivery
,rying may elevate temperature
*ot a reliable indicator of infection
A temperature less than 8E#D , may indicate potential
distress
C# $eart 'ate 4 range is 6C@ to 6E@ beats per minute
$eart rate range to 6@@ when sleeping and 6?@ when crying
,olor pink with acrocynaosis
$eart rate maybe irregular when crying
"ersistent cyanosis
Murmurs should be referred for medical evaluation
Deviation from range and faint sound may indicate potential
distress
8# 3lood "ressure ) not done routinely
2aries with change in activity level
Appropriate cup si!e is important for accurate reading
A# 'espiration ) range is 8@ to E@ breaths per minute
%igns of potential distress= apnea for more6D seconds>
asymmetrical chest movements> diminished breath sound>
nasal flaring> deep sighing> tachypnea, persistent irregular
breathing and excessive mucus
3# 5eneral Measurements
6# $ead ,ircumference ) 88 to 8D cm
$ead should be C to 8 cm larger than the chest
Molding of head may result in a lower head circumference
measurement
C# ,hest ,ircumference ) 8@#D to 86 cm
$ead and chest circumference maybe e1ual for the first CA
to A? hours of life
8# -eight ) CD@@ ) A@@ grams :D lbs#? o! ) ? lbs# 68 o!;
A# +ength 4 A? to D8 cm :6< ) C6 inches;
,# *ewborn ,haracteristics
6# %kin ,olor ) depends upon the baby7s age, race or ethnicity,
temperature S whether or not the baby is crying
,hanges to red as the baby begins to breath
$ands and feet may stay bluish in color for several days
%ome may develop a yellow coloring called .aundice )
normal from C
nd
to 9
th
day and abnormal during the 6
st

day or beyond 9 days
Acrocyanosis is normal within the first week only
C# Molding ) elongation of the shape of a baby7s head which turns to
normal by the end of the 6st week> occurs when the movable
bones of the baby7s head overlap to
help the baby pass through the mother7s birth canal
8# 2ernix ) a white, greasy, cheese4like substance that covers the skin of
many babies at
birth> formed by secretions from the oil glands> protects the
baby7s skin
during pregnancy

A# +anugo ) soft, downy hair on a baby7s body especially on the
shoulders, back,
forehead and cheek
D# Milia ) tiny, white, hard spots that looks like pimples on a newborn7s
nose which
may also appear on the forehead and chin
E# %tork 3ites or %almon patches ) small pink or red patches found on a
baby7s eyelids,
and back or neck> caused by a concentration of immature
blood vessels
most of these fade and disappear completely
9# Mongolian %pots ) blue or purple4colored splotches on the baby7s
lower back S
?# buttocks> caused by a concentration of pigmented cells and usually
disappear
in the 6st four years of life
<# Erythema Toxicum ) a red rash on newborns that is often described as
Hflea 3ites
,ommon on the chest and back, but may be found all over
+ess common in premature babies> cause is unknown and
disappears by itself in a few days
6@# Acne *eonatorum ) usually appear on the cheeks S forehead caused
by maternal
hormones> disappears by itself
66# %trawberry $emangioma ) bright or dark red, raised or swollen, bumpy
area that
looks like a strawberry
mostly occurs on the head, formed by a concentration of
tiny,
immature blood vessels
may not appear at birth but often develop in the first C
months
often grows in si!e for several months then gradually fades
6C# "ortwine %tain ) a flat, pink or purple colored birthmark which usually
occur on the
head or neck> maybe small or may cove large areas of the
body
does not disappear overtime and may become darker and
bleed
when the child is older
presence on the face may indicate a more serious problemsT
treatment is with special type of laser or plastic surgery
68# *orma 3reast %welling ) palpable breast tissue is present in normal
newborns
Hwitch milkI may leak from the baby7s nipples and goes away
within a few days to weeks
6A# %wollen 5enitals ) depends on the gestational age> prominent clitoris
on premature
girls and larger outer labia for closer to full ) term girls
premature boys may have a flat smooth scrotum with
undescended
testicles and term baby boys may have ridges in the scrotum
with descended testicles
D# *ewborn 'eflexes
6# 'ooting reflex ) begins when the corner of the baby7s mouth is
stroked or touched the baby will turn his/her mouth to follow and
HrootI in the direction of the stroking
C# %ucking reflex ) occurs when the roof of the baby7s mouth is
touched and the baby begins to suck# May also suck on fingers or
hands
8# Moro reflex ) often called startle reflex because a baby is startled
by a loud noise or movement which last about D to E months# The
baby throws back his/her head, extends out the arms and legs,
cries then pulls the arms and legs back in
A# Tonic neck reflex ) occurs when the baby7s head is turned to one
side, the arm on that side stretches out S the opposite arms bend
up at the elbow :fencing position;> lasts about E to 9 months
D# "almar 5rasp reflex ) stroking the palm of a baby7s hand causes
the baby to close his/her finger in a grasp> lasts only a couple of
months
E# 3abinski reflex ) occurs when the sole of the baby7s foot is firmly
stroked, the big toe bends back toward the top of the foot and other
toes fan out> lasts up to about C years of age
9# %tep reflex ) also called waling or dance reflex because a baby
appears to take steps or dance when held upright with his/her feet
touching a solid surface
?# 3link reflex ) elicited by shining a strong light such as flashlight and
can rarely be elicited by a sudden movement toward the eye
<# %wallowing reflex ) food that reaches the posterior potion of the
tongue is automatically swallowed
6@# Extrusion reflex ) protective reflex prevents the swallowing of
inedible substances and disappears at about A months of age
66# "lantar 5rasp reflex ) when an ob.ect touches the sole of a
newborn7s foot at the base of the toes, the toes grasp in the same
manner as the fingers do
6C# Magnet reflex ) occurs when pressure is applied to the soles of the
feet to a newborn lying in a supine position, she pushes back
against the pressure
68# ,rossed Extension reflex ) occurs when one leg of the newborn
lying supine is irritated by being rubbed by a sharp ob.ect, the
newborn raises the other leg and extend it as if trying to push away
the hand irritating the first leg
6A# +andau reflex ) inability to lift their head or arch their back or
sagging into an inverted H0I position when held in a prone position
with support
E. Ne;#orn Senses
6# $earing ) present as soon as amniotic fluid drains or absorbed
form the middle ear by way of eustachean tube, but having difficulty
locating sound> responds with a generali!ed activity to as sound,
stop crying and seen to attend, calms in response to a soothing
sound and startle at loud noises
C# 2ision ) present as soon as newborns are born> demonstrated by
blinking at a strong light but cannot follow past the midline of vision>
focuses best on black and white ob.ects at a distance of < to 6C
inches
8# Touch ) well developed at birth> demonstrated by 1uieting at a
soothing touch an by positive sucking and rooting reflex> reacts to
painful stimuli
A# Taste ) taste buds are developed and functioning before birth> will
swallow amniotic fluid more rapidly than usual if glucose is added to
sweeten its taste and decreases if a bitter flavor is added> turns
away from bitter taste but readily accepts sweet taste
D# %mell ) present as soon as the nose is clear of mucus and amniotic
fluid> turns towards their mother7s breast partly out of recognition of
the smell of breast milk and partly as a manifestation of the rooting
reflex
Ne;#orn I1entifi0ation an1 Re6istration
I)entifi!ation ) a plastic bracelet or bead necklace with permanent locks
that re1uire cutting to be removed with a number that corresponds to the
mother7s hospital number, the mother7s full name> the newborn7s sex,
date, and time of birth is attached to his/her arm or leg#
Regitration ) a birth registration must be filed with the 3ureau of 2ital
%tatistics of the state in which the infant was born#
,o!#&ent Birth Re!or) $ must list the following=
o Time of birth
o Time the infant breathed
o -hether respirations were spontaneous or aided
o Apgar score at 6 and D minutes
o -hether eye prophylaxis was given
o -hether 2itamin G was administered
o 5eneral condition of the infant
o *umber of vessels in the umbilical cord
o -hether cultures were taken :taken if at some point sterile delivery
techni1ue was broken or if the mother has a history of vaginal or
uterine infection;
o -hether the infant voided and passed a stool :the latter items are
helpful if, later on, the diagnosis of bowel obstruction or absence of
a kidney is considered;#
N8tritional Nee1s of t5e Ne;#orn
Sign of h#nger in a newborn*
'estlessness
Tense body posture
%macking lips or tongue thrusting
,rying
-#tritional Allowan!e for the -ewborn*
,alories ) re1uirement depends on the infant7s individual activity level and
growth rate# A newborn until C months of age re1uire 66@ to 6C@ calories/kg of
body weight#
"rotein ) necessary for the formation or new cells, especially with
the formation of new cells, especially with the very rapid growth
during infancy, and the maintenance of existing cells# "rotein
re1uirement is C#C gram/kg of body weight and can be provided by
both human and cow7s milk
/at ) +inoleic acid is necessary for growth and skin integrity and is
found in both human and cow7s milk
,arbohydrates ) +actose improves calcium absorption and aids in
nitrogen retention and decreases the possibility of gastrointestinal
illness# Ade1uate carbohydrates in formula allow protein use for
building new cells, encouraging normal water balance and
preventing abnormal metabolism# $uman milk contains more
carbohydrates than cow7s milk
/luid ) $igh rate of metabolism in infants re1uires a large amount
of water# /luid re1uirement is 6D@ to C@@ ml/kg of body weight per
CA hours
Minerals 4 A number of minerals are particularly important to early growth=
,alcium ) contributes to bone growth, more calcium is available in
human milk than in cow7s milk
ron ) supplement should be included in formula for formula4fed infant
especially if the mother7s diet was not iron4rich during pregnancy
/luoride ) for building sound teeth and for resistance to tooth decay#
/luoridated water should be taken by mothers who are breastfeeding
and formulas should be prepared with fluoridated water or a fluoride
supplement of @#CD mg daily should be given to the infant
2itamins ) %upplemental multivitamins :2it# A, ,, and D; are recommended for
the entire first year of life# These are incorporated into commercially prepared
formulas and naturally included in breast milk# A@@ 0 of 2itamin D daily may be
prescribed for the mother to increase this level in breast milk or given to the
infant if he is not exposed to sunlight for some reason
3reastfeeding ) provides numerous health benefits to both the mother and infant
and generally considered to be the ideal nutritional source for infants through the
first year of life
A)vantage of breatfee)ing*
/or the Mother=
%erves as a protective function in preventing breast cancer
Aids uterine involution thru the release of oxytocin from the posterior
pituitary gland
Empowers women because it is a skill only women can master
'educes the cost of feeding and preparation time
Enhances the formation of a true symbiosis bond between the mother
and child
/or the 3aby=
3reastmilk contains anti4infective properties that interferes with the
growth of pathogenic bacteria> an ideal electrolyte and mineral
composition for human infant growth> more linoleic acid for skin
integrity> and low ) level of phosphorous that prevents the fall in
calcium levels in the newborn
,ia)vantage*
May carry microorganisms such as hepatitis and $2 and both illicit
and prescription drugs
Contrain)i!ation*
An infant with galactosemia
$erpes lesions on mother7s nipples
Mother on a restricted )nutrient diet
Mother receiving medications that are inappropriate for breastfeeding
such as lithium or methotrexate
Maternal exposure to radioactive compounds such as could happened
during thyroid testing
3reast cancer
Too ill infant or mother
"revious breast reduction surgery in the mother especially if the
nipples were detached during surgery
Mother or infant being treated for tuberculosis
/ormula /eeding
,ommercial formula must be chosen as they closely mimic breast milk
/ormula must be ade1uate in terms of fluid and calories re1uired per
day
nformation must be provided regarding formula preparation and
feeding techni1ues
Carin6 for t5e ne;#orn at 5ome
.ee)ing
Decide whether to breastfeed or bottle4feed the baby
/eeding is given every C to 8 hours in the first month and given less
fre1uently as the baby grows older#
Each feeding should last no more than 6@ to C@ minutes#
Bathing
%hould be given C or 8 times a week during the 6
st
year#
%ponge baths should be given during the 6
st
two weeks or until the
umbilical cord falls off#
Slee"
The baby should be placed on his/her back while asleep to reduce the
risk of %udden nfant Death %yndrome :%D%;#
Make sure the crib mattress is firm and free from pillows or blankets
that could block the baby7s mouth or nose#
I&&#nization
%hould be given most of the immuni!ations before his/her second
birthday#
-ork with the baby7s doctor on the recommended immuni!ation
schedule#
B#r"ing
%hould be done fre1uently even if there is no discomfort#
3urp the baby after every C ) 8 ounces if the baby is bottle ) fed and
when he/she switches breasts when she7s nursing#
Hi!!#"
,hange the position and try to get her to burp or relax during feeding
and wait until the hiccups are gone before resuming feeding#
5ive a few sucks of water if they don7t disappear on their own after D )
6@ mins#
/eed the baby when he/she is relaxed or calm and before he/she is
extremely hungry#
S"itting
*o cause for concern and only means the baby has eaten more than
his/her stomach can hold#
Make each feeding calm and leisurely#
Avoid interruptions, sudden noises, bright lights and other distractions
during feeding#
3urp your baby at least every 8 ) D mins during feeding#
Avoid feeding when the baby is lying down#
"lace the baby in an upright position after feeding#
Do not play with the baby vigorously immediately after feeding#
Try to feed him/her before she gets frantically hungry#
f bottle4feeding, make sure that the hole of the nipples is neither too
big nor too small#
Elevate the head of the entire crib and put her to sleep on her back to
prevent choking in case the baby spits up while sleeping#
Bowel Move&ent
/irst bowel movement ) meconium, thick, dark green or black which
must be eliminated before normal digestion takes place#
5ive enough fluid to prevent constipation#
/rination
Every 6 to 8 hours or as fre1uently as A ) E times a day#
*otify physician for any sign of distress during urination at it maybe a
sign of infection or other urinary problems#
/&bili!al !or) !are
Geep the area around the umbilical cord clean and dry#
0se a cotton swab to apply alcohol to the base of the umbilical cord#
Expose the cord to air and allow it to dry at its base, which will hasten
its separation from the abdomen#
When to ee a )o!tor
Excessive crying
Abnormal sleep
nfection of the umbilical cord
Dehydration
'hing to )o
5ive the baby lots of love and attention#
"lace the baby in safety seat installed correctly in the back seat of the
car whenever you travel#
,reate a safe environment for the newborn#
Take the baby on the recommended check )ups and vaccinations#
Don7t allow smoking around the baby#
Geep your baby in the sun every morning#
Ne;#orn at ris= #e0a8se of Altere1 Gestational A6e or Birt5 .ei65t
%mall4for45estational )Age nfant
Chara!teriti!*
3irth weight is below the 6@
th
percentile on an intrauterine curve for
that age
%mall for their age because they have experienced intrauterine growth
restriction:05'; or failed to grow at the expected rate in utero
Ca#e*
Mother7s nutrition
"lacental anomaly ) either the placenta is unable to obtain sufficient
nutrients from the uterine arteries or it is insufficient at transporting
nutrients to the fetus
"lacental damage ) partial placental separation with bleeding
Developmental defect in the placenta
%ystemic diseases such as severe diabetes mellitus or pregnancy4
induced hypertension
%moking and narcotics
Prenatal Ae&ent*
/undal height becomes progressively less than what is expected
%onogram demonstrates the decreased si!e
3iophysical profile including a non4stress test, placental grading and
ultrasound
A""earan!e*
3elow average in weight, length, and head circumference
3elow average in weight
&verall wasted appearance
%mall liver which may cause difficulty regulating glucose, protein, and
bilirubin level,
"oor skin turgor
+arge heads because the rest of the body is too small
%kull sutures may be widely separated from lack of normal bone
growth
$air is dull and lusterless
%unken abdomen
,ord often appears dry and yellow
May have better developed neurologic responses, sole creases and
ear cartilage
%kull maybe firmer
nfant may seem unusually alert and active
0aboratory fin)ing*
$igh hematocrit level
ncrease in the total number of '3,
$ypoglycemia
Effe!t*
mpaired mental development due to lack of oxygen and nourishment
in utero
nability to reach normal level of growth and development
nterference in the development of self4esteem
+arge4for45estational )Age nfant
Chara!teriti!*
3irth weight above the <@
th
percentile on an intrauterine growth chart
for that gestational age
mmature development
Ca#e*
Diabetes Mellitus which causes overproduction of growth hormones
Multiparity
Transposition of growth vessels
3eckwith7s syndrome,
,ongenital anomalies
Prenatal Ae&ent*
%i!e of the uterus measures unusually large for the date of pregnancy
%onogram demonstrates the si!e of the infant
A non4stress test to asses the ability of the placenta to sustain the
large fetus
Amniocentesis to asses lung maturity
A""earan!e*
mmature reflexes and low scores on gestational age examinations in
relation to their si!e
Extensive bruising or birth in.ury such as a broken clavicle or paralysis
from trauma to the cervical nerves if the infant was delivered vaginally
"rominent caput succedaneum, cephalohematoma or molding
Effe!t*
,ardiovascular Dysfunction ) cyanosis, heart anomaly, polycythemia,
hyperbilirunimia
$ypoglycemia
"reterm nfant
Chara!teriti!*
+ive4born infant before the end of week 89 of gestation
-eight less than CD@@ g :D lb, ? o!;
mmature and small but well4proportioned for age
In!i)en!e*
&ccurs in approximately 9L of live births of ,aucasian infants
&ccurs in 6AL in African4American infants
nfant mortality rate is ?@ to <@ L in the first year of life
Ae&ent*
"hysical findings such as sole creases, skull firmness, ear cartilage
*eurologic findings
Mother7s report of her last menstrual period
Ca#e*
Exact cause is not known
$igh correlation between low socio4economic level and early
termination of pregnancy :6@4C@L;
nade1uate nutrition before and during pregnancy
A""earan!e
%mall and undeveloped
$ead is disproportionately large
0nusually ruddy skin with veins easily noticeable
,overed with vernix caseosa
+anugo is usually extensive
.a!tor ao!iate) with "reter& birth
+ow socio4economic level> "oor nutritional status
+ack of prenatal care> Multiple pregnancy
$istory> 'ace
,igarette smoking> Age
&rder of birth> ,losely spaced pregnancies
Abnormalities of the reproductive system> nfections
&bstetric complications
Early induction of labor> Elective caesarian birth
Potential Co&"li!ation
Anemia of prematurity 4 immaturity of the hematopoietic system
combined with destruction of red blood cells due to lower levels of
2itamin E which normally protects '3, from destruction
Gernicterus ) destruction of brain cells by invasion of direct billirubin
"ersistent Ductus Atreriosus ) non4compliance of lungs makes it more
difficult to move blood from the pulmonary artery to the lungs leading to
pulmonary hypertension that interferes with the closure of the ductus
arteriosus
"eriventricular/ntraventricular $emorrhage ) fragility of capillaries and
immature cerebral vascular development
&ther potential complications ) respiratory distress syndrome, etcU
Intervention for "reter& newborn
5iving the mother oxygen by mask during birth
Geeping maternal analgesia and anaesthesia to a minimum
'esuscitation within C mins after birth and keeping the baby warm
ntravenous infusion must be given to fulfill fluid and electrolyte
re1uirements :up to 6E@ to C@@ ml of fluid per kg of 3-
Monitoring of baby7s weight, serum electrolytes and glucose level
Measuring urine output by weighing diapers
/eedings by breast, gavage or bottle are begun as soon as the infant is
able to tolerate them and they must be closely observed for signs of
respiratory distress#
5avage feeding may be given every few hours or a drip feeding at about
6 ml/hr# %tomach secretions are aspirated, measured and replaced
before the feeding#
/eedings should be cut back if the stomach content is more than C ml
before the feeding# This will ensure better digestion and decrease the
possibility of regurgitation and aspiration#
5iving of formula with caloric concentration of CA cal/o! and mineral
supplement based pon blood studies
5iving of 2itamin k in.ection
3reast milk maybe manually expressed for the newborn7s gavage
feeding#
0nless there are obvious abnormalities noted when the child is born,
physical assessment of the infant should be delayed until the infant is
placed in the warmth of an solette of under a radiant warmer
f the infant is going to be transported to a department or hospital, keep
the baby warm during transport#
+inen and e1uipment used with the preterm infant must be clean and
staff members must be free of infection#
,onserve the baby7s strength by reducing sensory stimulation as much
as possible and provide maximum rest#
&bserve measures to help the infant develop a sense of trust in people
and hold him/her gently#
Encourage the parents to begin interaction with the infant in as normal a
manner as possible#
,are must be geared toward making the environment of the infant as
untraumatic as possible while helping the infant ad.ust to new
experiences with his limited ability#
T5e postterm Infant 4 one born after the ACnd week of pregnancy
Ca#e*
Miscalculation of gestational age
+abor is not induced until A8 weeks of pregnancy or after
Chara!teriti!*
Dry, cracked, almost leather4like skin from lack of fluid and absence of
vernix
Maybe lightweight from a recent weight loss
+ess amount of and meconium4stained amniotic fluid
/ingernails have grown well beyond the fingertips
May demonstrate alertness much more like a C week old baby than a
newborn
Co&"li!ation7
"ossible difficulty in establishing respirations
$ypoglycemia and low subcutaneous fat levels
"olycythemia and elevated hematocrit level
"ossible neurologic symptoms
Ae&ent7
%onogram to mesure the biparietal diameter of the fetus
*onstress test to establish whether the placenta is still functioning
ade1uately
Intervention for "otter& infant
,ontrol of hypoglycemia and meconium aspiration
Mother should be encouraged to spend time with the baby
/ollow4up care until at least school4age
Illnesses In T5e Ne;#orn
'espiratory Distress %yndrome :'D%; formerly termed $yaline Membrane
Disease ) most often occurring in preterm infants, infants of diabetic mothers,
those born by caesarian section or those who have decreased blood perfusion of
the lungs
Ca#e*
+ow ) level or absence of surfactant that normally lines the alveoli and
resists surface tension on expiration to keep alveoli from collapsing on
expiration
Ae&ent7
,linical signs of grunting, cyanosis in room air, tachypnea, nasal
flaring, retraction and shock
,hest x4ray will reveal a diffuse pattern of ground glass like areas
3lood gas will reveal acidosis
'hera"e#ti! Manage&ent*
%urfactant and 'eplacement 'escue
&xygen Administration
2entilation
Muscle relaxants and *itric &xide
Extracorporeal Membrane &xygenation :E,M&;
S#""ortive Care*
Geep the infant warm
"rovide hydration and nutrition with intravenous fluids, glucose or
gavage feeding
Monitor respiratory status closely and note any signs of changes and
distress
Minimi!e physical activity, anticipate needs and handle the newborn
gently
%uction the endotracheal tube as necessary
Transient Tachypnea of the *ewborn :TT*; 4 respiratory rate at a high level
between ?@ and 6C@ beats per minute
Ca#e=
%low absorption of lung fluid
%light decrease in the production of mature surfactant
Mange&ent*
&xyen administration
Monitoring of respirations
Meconium Aspiration %yndrome 4 Aspiration of meconium when it is expelled
into the amniotic fluid> May cause respiratory distress in three ways=
,an bring about inflammation of the bronchioles
,an block small bronhcioles
Decrease in surfactant production through lung cell trauma
Aee&ent
Apgar score is low, elevated respiratory rate
,oarse bronchial sound by auscultation
Enlargement of the anteroposterior diameter of the chest is observed
,hest x ) ray will show bilateral course infiltrates in the lung,
diaphragm is pushed downward
'hera"e#ti! Manage&ent*
Amniotransfusion to dilute the amount of meconium in amniotic fluid
%uctioning with a bulb syringe or catheter while at the perineum before
the delivery of the shoulders
&xygen administration and assisted ventilation after tracheal suction
Antibiotic therapy to forestall development of pneumonia
&bserve for signs of heart failure
Maintain a thermal neutral environment
%ome will be maintained on E,M&
,hest physiotherapy
Apnea ) a pause in respirations longer than C@ seconds with accompanying
bradycardia and beginning cyanosis
Ca#e*
"reterm birth
%econdary stresses such as infection, hyperbilirubinemia,
hypoglycemia or hypothermia
'hera"e#ti! Manage&ent*
5ently shaking an infant or flicking the sole of the foot to stimulate
respirations
'esuscitation maybe needed
,losely observe all newborns for episodes of apnea
0sing an apnea monitor
Maintain a neutral thermal environment and always hold the baby
gently
%uction the baby gently
&bserve the baby after feeding and burp carefully
'espiratory stimulants
%udden nfant Death %yndrome ) sudden unexplained death in infancy
Contrib#ting fa!tor
"rolonged but unexplained apnea
2iral respiratory or botulism infection
Distorted familial breathing patterns
"ossible lack of surfactant in the alveoli
%leeping prone instead than on the side or back
Apparent +ife ) Threatening Event :A+TE; 4 an episode of cyanosis and being
limp in beds but survives after mouth ) to ) mouth resuscitation
$emolytic Disease of the newborn ) the mother builds antibodies against the
infant7s '3,s
'h incompatibility 'h negative and 'h positive
A3& incompatibility ) maternal blood type H&I> infant7s blood type HAI
$emorrhagic disease of the newborn ) results from a deficiency of 2itamin G
essential for the formation of prothrombin by the liver
Twin4to4Twin Transfusion 4 occurs if the twins are mono!ygotic resulting in
anemia to one and polycytehmia to another#
'etinopathy of "rematurity ) an ac1uired ocular disease that leads to partial or
total blindness in children due to vasoconstriction of immature retinal blood
vessels
Maternal infe0tion4illness t5at poses ris= to t5e ne;#orn
%treptococcal nfection ) may cause pneumonia within CA hours of birth or
meningitis at C to A weeks of age
,ongenital rubella ) viral infection causing extensive congenital
malformations> the greatest risk to an embryo is during C to E weeks of
intrauterine life
&pthalmia *eonatorum ) eye infection at birth or during the first month
caused by n# 5onorrhea or ,hlamydia Trachomatis
$epatitis 3 2irus nfection :$32; ) can be transmitted to the newborn
infant through contact with vaginal blood at birth when the mother is
positive for the virus
5enerali!ed $erpesvirus nfection ) can be contacted by a fetus across
the placenta if the mother has a primary infection during pregnancy> or
from the vaginal secretions from the mother who has active vulvovaginitis
at the time of birth
nfant of a Diabetic Mother ) typically longer and weighs more than other
babies> with greater chance of having congenital anomaly such as cardiac
defect> ,audal regression syndrome or hypoplasia of the lower
extremities> cushingoid appearance
nfant of a Drug4Dependent Mother ) small for gestational age> withdrawal
symptoms such as= irritability, disturbed sleep patterns, constant
movements, tremors, fre1uent snee!ing, shrill, high4pitched cry,
neuromuscular irritability, convulsions, tachypnea, diarrhea and vomiting
nfant with /etal Alcohol %yndrome ) causes pre and post natal growth
restriction, ,*% involvement, facial features :thin upper lip;> tremors,
irritability, weak sucking reflex and sleep disturbances depending on the
mother7s alcohol level at birth
C.T5e To11ler 4 Toddler is designated as the period from 6 year to 8 years#
Gro;t5 an1 1e9elopment of to11ler
A. P5>si0al Gro;t5
Weight
-eight gain= D to E lbs per month during the toddler period
Height
D inches increase in height during the toddler period
Hea) !ir!#&feren!e
ncreases only about 6C cm during the first year and C com during the
second year
Bo)y "ro"ortion
,hest circumference is greater than that of the head
Abdomen is prominent
Development of forward curvature of he spine and sacral area
-alks with a wide stance
Bo)y yte&
$eart rate ) slows down from 66@ ) <@ bpm by the end of the first
year
3lood "ressure ) about <</EA mm $g
'espiratory rate ) slows slightly but continue to be abdominal> the
lumens of the vessels increase progressively
5astrointestinal Tract ) stomach capacity increases to the point that
the child can eat three meals a day> stomach secretions become more
acid> therefore, gastrointestinal infections also becomes less common
*ervous system ) the brain develops about <@ L of its adult si!e
mmune system ) antibody production becomes mature at C years of
age> the passive immunity from intrauterine life are no longer
operative
0rinary and spinal sphincter become in control
3ody fluids ) extracellular fluid ) 8D L of the infant7s body weight and
intracellular fluid is A@ L by the end of the first year
Teeth ) eight new teeth :the canines and first molars; erupt during the
second year# All deciduous teeth are generally by C V to 8 years of
age
S8mmar> of Gro;t5 an1 1e9elopment of to11ler
Mont
h
Motor
)evelo"&ent
.ine &otor
)evelo"&ent
So!ialization
an) lang#age
Play
6D -alks alone
well> can seat
self in chair,
can creep
upstairs
"uts small pellets
into small bottles#
%cribbles
voluntarily with a
pencil or crayon#
$olds a spoon well
but may still turn it
upside down on the
way to mouth
A ) E words>
they become
resistant to
sitting in laps
and being
cuddled> still
enthusiastic
about
interacting with
people>
providing those
people are
willing to follow
them wherever
they want to go
,an stock C
blocks > en.oys
being read to>
drops toys for
adult to
recover
:exploring a
sense of
permanence;
6? ,an run and
.ump in place#
,an walk up
and down stairs
holding into a
person7s hand
or railing#
Typically places
both feet on
one step before
advancing#
*o longer rotates a
spoon to bring it to
mouth
9 ) C@ words>
uses .argoning>
names body
parts
mitates
household
chores,
dusting, etc#>
begins parallel
play
CA -alks up stairs
alone still using
both feet on
same step at
same time
,an open doors by
turning doorknobs>
unscrew lids
D@ words, C
word
sentences
:noun4pronoun
and verb;
"arallel play
evident
8@ ,an .ump down
from chairs
Makes simple lines
or strokes for
crosses with a
pencil
2erbal
language
increasing
steadily#
Gnows full
name> can
%pends time
playing house,
imitating
parents7
actions
name 6 color
and holds up
fingers to show
age
N8tritional Nee1s of To11ler
Re!o&&en)e) )aily )ietary allowan!e $ ,alorie allowances is recommended at
68@@ kcal daily#
Diets high in sugar should be avoided#
,hildren over C years should consume no more than 8@ L of total daily
intake of calories from fat#
Ade1uate intake of calcium and phosphorous bone minerali!ation#
Care of t5e To11ler
6# "rovide care to toddlers that will help them develop a sense of
autonomy#
C# 5ive up perfection while children learn to dress up#
8# "rovide toys that make welcoming sounds and read to the child daily
until the school age years#
A# $andle infants with assurance and gentleness#
D# Make mealtime for fostering trust as well as supplying nutrition by
being certain that feedings are at the infant7s pace and the amount
offered fits the child7s needs#
E# 3ath should be given depending on the parents7 and child7s wishes
and schedule# The schedule should not be too rigid# Avoid accidents
while giving bath#
9# "rovide activities that the toddler en.oys even at bedtime and shorten
afternoon naps if the child has difficulty sleeping at night#
?# Teeth should be brushed better thoroughly once a day before bedtime
than brushed poorly several times# "rovide a toothbrush the toddler
can identify his own#
<# 0nderstand that appropriate response to attempts at independences
is crucial to the healthy development of a child##
6@# 3e aware of the potential accidents such as aspiration, falls, vehicular,
suffocation, drowning, animal bites, poisoning, burns, and the ways to
prevent them#
Parental 0on0erns asso0iate1 ;it5 t5e to11ler perio1
66# 'oilet 'raining ) and individuali!ed task for each child and should
begin and be completed according to a child7s ability to accomplish it,
not according to a set schedule#
6# They must have control of rectal and urethral sphincters#
C# They must have cognitive understanding for what it means to hold
urine and stools until they can release them at a certain place and
time#
8# They must have a desire to delay immediate gratification for a more
socially acceptable action#
6C# Rit#aliti! Behavior ) give more guidelines and more rules> they may
not want so much independence
68# -egativi& ) +imit the number of 1uestions asked of the child and
provide opportunity to make choices :secondary;
6A# ,i!i"line ) some sense must be instilled early in life because it
involves setting limits and protecting others or property# 0se HtimeoutI
effectively by being certain that the child understand the rules
6D# Se"aration An(iety ) say goodbye firmly and avoid prolonged
goodbyes#
6E# 'e&"er tantr#& $ tell the child simply that their behavior is
disapproved and then ignore it
Care of t5e 1isa#le1 or 05roni0all> ill To11ler -to 5elp 1e9elop a sense of
a8tonom>/
Category A!tion
*utrition A special diet may limit typical finger foods# 0se imagination to offer
other foods not usually eaten this way as finger foods# Allow child to
help pour li1uid diet for a tube feeding# ,heck for possibility of
nausea
Dressing The child can hold pieces of tape or put tape in place to maintain
sense of control> can remove old bandages that are not
contaminated# Allow the child to view his incision and watch
dressing changes, explaining each step of a procedure as you
perform it> restrain only those body parts necessary during a
procedure#
Medication Allow children no choice as to whether a medicine will be taken> do
not ask the toddler to indicate his choice for in.ection site> Allow the
child to choose a HchaserI after oral medicine#
'est ,reate a ritual for bedtime# Allow a choice of toy or cover but not a
choice of bedtime or naptime#
$ygiene Allow the child a choice of bathtub toy or clothing# Allow the child to
wash face and hands to gain control of the situation> to put
toothpaste on a brush but Htouch upI teeth to ensure that all pla1ues
are removed#
"ain Encourage child to express and rate pain# $elp channel the child7s
expression to what is acceptable#
%timulatio
n
"rovide a toy that the toddler can manipulate,
Elimination Encourage the child to use a potty chair or toilet during an illness>
$elp the child with ureter or bowel stomas to help with changing
bags so they are independent in bowel function as possible#
D. T5e Pres05ooler ) preschool period includes 8, A and D years#
Gro;t5 an1 1e9elopment of a pres5ooler
P5>si0al Gro;t5
Weight
-eight gain= A#D lb :C kg; a year during the preschool period
Height
C ) 8#D inches : E ) ? cm; increase in height during the preschool
period
Bo)y "ro"ortion
definite contour changes> ectomorphic and endomorphic body built
more childlike proportions
Bo)y yte&
$eart rate ) slows to about ?D b/m> innocent heart murmurs maybe
heard due to the change in the si!e of the heart in reference to the
thorax
3lood "ressure ) about 6@@/E@ mm $g
+ymphatic tissue begins to grow
3ladder is easily palpable, voiding is < to 6@ times a day
mmune system ) antibody production increases
Teeth ) all C@of deciduous teeth are present by 8 years of age
S8mmar> of Gro;t5 an1 1e9elopment of a pres05ooler
Age .ine Motor
)evelo"&ent
%ro Motor
)evelo"&ent
So!ialization
an) lang#age
Play
8 0ndresses self>
stacks tower of
blocks> draws a
cross
'uns, alternates
feet on stairs> rides
tricycles> stands on
one foot
2ocabulary of
<@@ words
Able to take
turns> very
imaginative
A ,an do simple
buttons
,onstantly in
motion
2ocabulary of
6D@@ words
"retending is
a ma.or
activity
D Draws a E4part
man> can lace
shoes
Throws overhand 2ocabulary of
C6@@ words
+ikes games
with numbers
or letters
N8tritional Nee1s of t5e pres05ooler
Re!o&&en)e) )aily )ietary allowan!e 1 select food based on the food pyramid
Additional vitamins are not necessary if the child is eating well from the
basic food groups
Care of t5e pres05ooler
"rovide preschoolers the experience of choosing their own clothes#
3ath should be supervised as well as hair washing and care of nails
and ears#
Maintain en.oyable activities and continue bedtime routines to reduce
stress at bedtime#
Teeth should be brushed better thoroughly once a day before
bedtime with help in flossing than brushed poorly several times#
,heck that all teeth surfaces are cleaned#
5uide a child through struggles in opinions, food, place to go and
clothes to wear without discouraging the child to have an opinion#
Parental 0on0erns asso0iate1 ;it5 t5e pres05ool perio1
Health "roble& ) mortality of children at this stage is low but the
number of minor illness is exceptionally high> accept the fact that
minor illnesses are common during this stage and not a cause for
overprotection
Co&&on fear*
6# fear of the dark= exposure to stimuli should be monitored especially
around bedtime> sit on their bed until they fall back to sleep again
after a nightmare
C# fear of mutilation> fear of castration for boys
8# fear of separation or abandonment= relating time and space to
something the child knows such as meals is an effective way to
avoid this fear> prepare the preschooler thoroughly for experiences
that involves separation from home and significant figures
Behavior variation*
A# Telling tall tales= discourage storytelling that are exaggerated and
instead help the child separate fact from fiction
D# maginary friends= 'espond in a way that the child understand what
is real and what is made up, yet does not restrict his imagination
and creativity
E# Difficulty sharing= "rovide experience in learning property rights>
define limits and expose the child to the three categories :mine,
yours, and ours; so that he becomes aware of the ob.ects that
belong to him and those that belong to others
9# 'egression= caused by stresses such as= a new baby in the family,
a new school experience, marital difficulties of the parents,
separation caused by hospitali!ation> manifested by thumb sucking,
negativism, loss of bladder control, and inability to separate from
parents ) 'eassure the preschoolers that they are being loved
despite of the changing situations and ignore regressive behavior
?# %ibling 'ivalry= give the preschoolers security and help promote
their self4esteem by supplying them with a private drawer or box for
their things that nobody can touch
Pre"aring for a new ibling*
6# "repare the child for a new baby before the time when he begins to
feel the difference the new baby will make#
C# Move the preschooler to a bed about 8 months in advance before
birth of a new baby
8# The child should start school before the baby is born or C or 8
months afterward
A# f the mother is to be hospitali!ed for delivery, prepare the child in
advance for the separation#
Se( E)#!ation*
6# $elp the preschoolers learn rules to help them avoid sexual abuse#
C# $elp them understand that certain things are not done in some
places
8# ntroduce the topic of the origin of babies by visiting a new baby in
the neighborhood or point out a woman who is pregnant
Pre"aring a !hil) for !hool
6# ,hange the child7s daily routine a few months in advance of
beginning school to accustom him to waking earlier and going to
bed earlier#
C# Educate the child on the safe way of walking to school and
introduce to the form of transportation the child will take#
8# ntroduce the new experience of bringing lunch to school by
preparing a school lunch at home some noon or play HcafeteriaI at
home
A# nstill in the child the concept that learning in school is fun and that
they will not always be able to do all the things that other children
can do, but to try to do his best#
D# Encourage the children to spend time in a chair
Bro2en .l#en!y an) Swearing*
6# Do not discuss in the child7s presence the difficulty he is having with
speech and do not label him a Hstutter#I
C# +isten with patience to what the child is saying# Do not interrupt or
fill in a word for him and do not tell him to speak more slowly or to
start over#
8# Talk to him in a calm, simple way so he sees no need to rush and
to speak more clearly#
A# "rotect space for him to talk if there are other children in the family#
D# Do not force the child to speak if he does not want to# Do not ask
him to recite or sing for strangers
E# Do not reward him for fluent speech or punish him for nonfluent
speech# 3roken fluency is developmental stage in language
formation, not an indication of regression or a chronic speech
pattern#
Care of t5e 1isa#le1 or 05roni0all> ill pres05ooler -to en0o8ra6e a sense of
initiati9e/
Category A!tion
*utrition %erving toast or sandwiches cut into animal shapes, cereal in the
form of alphabet characters or food arranged on a plate to make a
face appeals to the imagination and may make a preschooler more
interested in food#
Dressing Allow preschooler to measure or cut tape or draw face on it and to
see the incision site> explain steps of dressing change as you work
to reduce unknowns and areas of fear> "rovide extra bandages to
put on a doll so child can see the bandages themselves are not to
be feared#
Medication Do not ask the toddler to indicate his choice for in.ection site> Allow
the child to choose a HchaserI after oral medicine#
'est "rovide light in the room or bring child7s bed into hallway so fear of
the dark is reduced and she can deal with only reality problems#
dentify sounds the child might hear in the hospital#
$ygiene Allow the child a choice of bathtub toy or clothing# Allow the child to
wash face and hands# Allow child to splash in water as a play
activity as well as for cleanliness#
"ain Encourage child to express pain> Allow child to handle syringe or
suction catheter and give HshotsI or suction to a doll to alleviate
anger and fear> encourage child to ask for analgesic if necessary#
%timulatio
n
5uessing games encourage a sense of initiative# "rovide
manipulative toys and encourage use of playrooms for sociali!ation>
allow preschooler to accompany you to other departments in the
hospital to encourage learning about it# 0se %imon sys games and
encourage child to interact with the family by drawing pictures for
the siblings or telephoning homes#
Common Safet> Meas8res to pre9ent a00i1ents 18rin6 pres05ool >ears
Poible A!!i)ent Prevention Mea#re
Motor 2ehicles Maintain child in a car seat> do not be distracted by the
child while driving> do not allow child to play outside
unsupervised> and do not allow to operate electronic
garage door> teach safety measures while walking in
streets and in parking space> provide helmets when riding
bicycles
/alls %upervise preschoolers at playgrounds> help child to
.udge safe distances for .umping or safe heights for
climbing
Drowning Do not leave child alone in bathtub or near water> teach
beginning swimming#
Animal bites Do not allow child to approach strange dogs> supervise
child7s play with family peers
"oisoning *ever present medication as a candy> never take
medication in front of a child> never store food or
substances in containers other than their own> post
telephone no# of local poison control center by telephone>
and keep antidote with proper instruction for
administering in a first aid box
3urns 3uy flame4retardant clothing> turn handles of saucepans
toward back of stove> store matches in closed containers>
do not allow preschoolers to help light candles, fireplaces>
keep screen in front of fireplace or heater#
,ommunity safety Teach preschoolers that not all people are friends> define
a stranger as someone a child does not know> not
someone odd looking> teach child to say HnoI to people
whose touching he or she does not en.oy including family
members#
5eneral Gnow whereabouts of preschooler at all times> be aware
that fre1uency of accidents is increased when parents are
under stress> special precautions must be observed
during those times> some children are more active,
curious and impulsive and therefore more vulnerable to
accidents than others
E. T5e S05ool A6e C5il1 ) school age refers to children between the ages of E
and 6C
Gro;t5 an1 1e9elopment of t5e S05ool ? A6e 05il1
P5>si0al Gro;t5
Weight
-eight gain= 8 to D lb :6#8 kg; a year during the preschool period
Height
6 to C inches : C#D ) D cm; increase in height during the preschool
period
Bo)y "ro"ortion
posture becomes more erect
Bo)y yte&
$eart rate ) decreases to 9@ ) ?@ bpm> left ventricles of the heart
enlarges to be strong enough t pump blood to eh growing body>
innocent heart murmurs may become apparent due to the extra blood
crossing heart valves
3lood "ressure ) about 66C/E@ mm $g
+ymphatic tissue continues to grow in si!e> lines the appendix
mmune system ) antibody production reach adult levels
Teeth ) if the eruption of permanent teeth and the growth of .aw do
not correlate with final head growth, malocclusion with teeth
malalignment will result
3rain growth is complete by 6@ years of age> adult vision level is
achieved
/rontal sinuses develop at about E years
Maturation of the respiratory system leads to increased oxygen4
carbon dioxide exchange which increases ability and stamina
Emotional 1e9elopment
Developmental task= ndustry vs nferiority
%chool age children need reassurance that they are doing things
correctly#
%chool age children feel a sense of accomplishment when they finish
a task given to them completely#
%chool age children en.oy hobbies and pro.ects if they are small and
can be finished within as short time#
Adults must take a step forward in the development along with the
child#
A step of independence away from parents and into the larger world is
a developmental task that will help them become emotionally mature#
Ade1uate encouragement and preparation by health care personnel
will help parent maintain the responsibility of educating their children
about sex, safety, avoidance of abusive substances and preparation
for family living more than the school can do#
,ompetitive sports must be evaluated carefully and a child must be
able to compete successfully or lost without feeling bad> the child7s
maturity and risk of athletic in.uries must be considered#
"roblem4solving is an important part of sense of industry and can be
developed through practice and instilling optimism rather than
pessimism#
%chool age is a good time for children to learn compassion and
thoughtfulness toward others#
Co6niti9e De9elopment
,oncrete operational thought
,e!entering ) the ability to pro.ect the self into other people7s
situations and see the world from their own point of view rather than
focus only on their view
A!!o&&o)ation ) the ability to adapt thought processes to fit what is
perceived
Conervation ) the ability to appreciate that a change in shape does
not mean a change in si!e
Cla in!l#ion ) the ability to understand that ob.ects can belong to
more than one classification
Moral an1 spirit8al 1e9elopment
"reconventional morality
%chool age children concentrate on HfairnessI and do not yet possess
the highest level of reasoning
%chool age children begins to learn about the rituals and meaning
behind their religious practice, so that distinction between right and
wrong becomes more important to them
%chool age children may interpret something is being right because it
is good for them not because it is right for humanity#
S8mmar> of S05ool ? A6e De9elopment
Age3yr
4
Phyi!al ,evelo"&ent Py!hoo!ial 5 Cognitive ,evelo"&ent
E A year of constant motion, /irst4grade teacher becomes authority
skipping is a new skill, first
molars appear
figure> ad.ustment to all4day school may
be difficult and leads nervous
manifestations of fingernail biting, etc#
Defines words by their use
9 ,entral incisors erupt>
difference between sexes
becomes apparent in play>
spends time in 1uiet play
A 1uiet year> striving for perfection
leads to this year being called an eraser
year> conservation is learned> can tell
time, can make simple change
? ,oordination definitely
improved> playing with gang
becomes important> eyes
become fully developed
H3est friendsI develop> whispering and
giggling begin> can write as well as
print> understands concepts of past,
present and future
< All activities done with gang 5ang age= a <4year4old is formed to
spite someone, has secret codes, is all
boy or all girl> gangs disband and
reform 1uickly
6@ ,oordination improves 'eady for camp away from home>
collection age> like rules> ready for
competitive games#
66 Active, but awkward and
ungainly
nsecure with members of opposite sex>
repeats off4color .okes
6C ,oordination improves A sense of humor is present> is social
and cooperative
C5ronolo6i0 De9elopment of se0on1ar> se: 05ara0teristi0s
Age3yr
4
Boy %irl
< ) 66 "repubertal weight occurs 3reasts= elevation of papilla with breast
bud formation> areolar diameter
enlarges
66 )
6C
%parse growth of straight,
downy, slightly pigmented
hair at the base of the penis
%crotum becoming textured>
growth of penis and testes
begins
%ebaceous gland secretion
increases
"erspiration increases
%traight hair along the labia# 2aginal
epithelium becomes cornified
p$ of vaginal secretions acid> slight
mucous vaginal discharge present
%ebaceous gland secretion increases
"erspiration increases
Dramatic growth spurt
6C )
68
"ubic hair present across
pubis
"enis lengthens
Dramatic linear growth spurt
3reast enlargement occurs
"ubic hair grows darker> spreads over
entire pubis
3reasts enlarge> still no protrusion of
nipples
Axillary hair present
Menarche occurs
Promotin6 N8tritional ealt5 of t5e s05ool@a6e 05il17
%chool age children need breakfast to provide enough energy to get
them through active mornings at school#
%chool age children must be allowed to suggest the type of lunch they
will be bring to school or choose a meal in school as long as they
know some facts about nutrition#
%chool age children must be given nutritious snacks that will not dull
their appetite#
Make every attempt to make mealtime a happy and en.oyable part of
the day for everyone#
As part of fostering industry, school4age children can help plan or
prepare meals#
Table manners improve dramatically as the children become more
aware of the impression they make on others#
3oth girls and boys re1uire more iron in prepuberty as well as
ade1uate calcium and fluoride#
3oys re1uire more calories and nutrients than girls during school age#
Promotin6 De9elopment of t5e s05ool@a6e 05il1 in 1ail> a0ti9ities7
Teach children the importance of caring for their own belongings#
"rovide the children with 1uiet time after school and a 1uiet talk or reading
time at bedtime#
They should be stimulated to participate in some daily exercise#
"rovide information on the importance and safety of good hygiene#
Ensure that they visit a dentist at least twice yearly for a check4up cleaning
and possibly a fluoride treatment to strengthen and harden the tooth
enamel#
"rovide them lots of love and guidance#
Teach them simple tasks that can influence their opinions of themselves
and their ability to continue learning new tasks#
Common ealt5 pro#lems7
Dental caries ) progressive, destructive lesions or decalcification of the
tooth enamel
Malocclusion ) a deviation from the normal, maybe congenital and related
to conditions such as cleft palate, a small lower .aw or familial traits> may
result from constant mouth breathing or tongue thrusting
Common ,ears4An:iet> an1 pro#lems of t5e S05ool@a6e 05il1
Anxiety4related to beginning school ) many first grade children are
capable of mature action at school but appear less mature when they
return home showing signs of wrinkling the forehead, shrugging the
shoulder, twisting the mouth, coughing,, fre1uently blinking or rolling the
eyes, thumb sucking, nail biting or baby talking
%chool phobia 4 ,hildren who resist going to school may develop physical
signs of illness such as diarrhea, headache, vomiting or abdominal pain
during school days
+atchkey children ) school children who are without adult supervision for a
part of each weekday> these children can feel lonely and have an
increased tendency to have accidents, delin1uent behavior, and
decreased school performance and become more prone to alcohol and
beginning drug use
%ex education ) school ) age children should be educated about
prepubertal changes and responsible sexual practices
%tealing ) adults must set good example for honesty> property right should
be reviewed
'ecreational drug use ) children should be counseled against this and
adults should be role models
&besity ) intake of about 6C@@ calorie low in fat and designed to reduce
weight, active exercise and counseling program to discuss aspects such
as self4image and motivation to reduce weight should be encouraged
Care of t5e 1isa#le1 or 05roni0all> ill S05ool@a6e 05il1 -to en0o8ra6e sense
of in18str>/
Category A!tion
*utrition Allow choices of food and respect food preferences#
"rovide small food servings that child can finish, encouraging sense
of accomplishment
Dressing Allow child to make out re1uisitions for supplies
Ask for suggestions as to how bulky the child wants dressing, where
to apply tape#
Medicine Teach child name and action of medicine#
Encourage child to keep track of medication times by clock or
record#
,hild may feel more in control of in.ections or intravenous insertions
if allowed to choose the site from among options offered#
Allow child to choose oral medicine form :capsules or li1uids;#
'est Establish clear rules for rest periods
$ygiene 'espect modesty of school4age child at an adult level#
Allow as much choice as possible
"ain Encourage child to express and rate pain#
Encourage child to use distraction techni1ues, such as counting
backward or imagery, during episodes of pain
Explain source and cause of pain to give child sense of mastery#
%timulatio
n
Encourage school work#
Encourage activity that ends in a product
Encourage paper4and4pencil games, such as connect the dots,
"rovide social interaction and also encourage simple additions skills
: card games;
Do not suggest competition games for children less than age 6@ yr#
Encourage using playroom for sociali!ation#
Encourage child to keep in contact with school friends by
telephoning or writing notes to them#
Common Safet> Meas8res to pre9ent a00i1ents 18rin6 s05ool >ears
Poible A!!i)ent Prevention Mea#re
Motor 2ehicles Encourage children to use seat belts> teach safety
measures while street4crossing and that streets are no
place for pushing or shoving> teach bicycle safety, and
advise to use helmet> teach parking lot and school bus
safety
/alls Teach not to climb electric poles, skateboard safety and
the ha!ard of roughhousing on fences, climbing on roofs
Drowning ,hildren should learn how to swim> dares and
roughhousing on swimming is not appropriate> and teach
not to swim beyond capabilities
%ports in.uries -earing appropriate e1uipment for sports> is not babyish
but smart
%ex Teach rules of safer sex
3urns Teach safety with candles, matches, campfires,
beginning cooking skills, sun exposure
,ommunity safety Teach to avoid areas specifically unsafe, such as train
yards, back alleys> teach not to go with strangers> teach
to say HnoI to anyone who touches them whom they do
not wish to do so including family members
Drugs Teach to avoid all recreational drugs and to take
prescription medicine only as directed
/irearms Teach safe firearm use# Geep firearms in locked cabinets
with bullets separate form gun
5eneral Gnow whereabouts of preschooler at all times> be aware
that fre1uency of accidents is increased when parents are
under stress> special precautions must be observed
during those times> some children are more active,
curious and impulsive and therefore more vulnerable to
accidents than others
,. T5e a1oles0en0e ) Adolescent refers to children between the ages of 68 and
6? to C@ years which serves as the transition period between childhood and
adulthood> the physiologic period between the beginning of puberty and the
cessation of bodily growth
Gro;t5 an1 1e9elopment of t5e a1oles0ent
P5>si0al Gro;t5
Weight
-eight gain= boys ) 6D to ED lb :9 to 8@ kg; during adolescence
5irls ) 6D to DD lb : 9 to CD kg; during adolescence
Height gain* boys ) A to 6C inches :6@ to 8@ cm;
girls ) C to ? inches : D ) C@ cm;
Bo)y "ro"ortion
increase in body si!e does not occur in all organ systems at the same
rate, causing lack of coordination and possibly poor posture
Bo)y yte&
$eart rate ) decreases to 9@ b/m> increase in si!e of heart and lungs
more slowly
3lood "ressure ) about 66C/9@ mm $g, reaching adult level by late
adolescence
Androgen stimulates glands to extreme activity> formation of apocrine
sweat glands
Teeth ) C
nd
molars at about 68> 8
rd
molars between 6? and C6 years of
age> the .aw reaches adult si!e toward the end of adolescence
3rain growth is complete by 6@ years of age> adult vision level is
achieved
"uberty ) stage at which the individual first becomes capable of
sexual reproduction> girl starts to menstruate> boy begins to produce
spermato!oa
Emotional 1e9elopment
Developmental task= dentity vs 'ole ,onfusion
The developmental task of youngsters in early and mid adolescence is
to form a sense of identity, that is, to decide who they are and what
kind of person they will be
The developmental task in late adulthood is to form sense of intimacy
or form close relationships with persons of the opposite as well as the
same sex#
The four main areas in which adolescents must make gins to a
achieve a sense of identity are= accepting their changed body image>
establishing a value system or what kind of person they want to be>
making a career decision> becoming emaciated from parents
Adolescents must be educated about their bodies and to accept the
changes that mark maturity> children with low self4esteem may need
parental or health care provider support to understand that a person7s
worth is based on more than physical appearance> compassionate
understanding is a better communication#
%elf ) esteem can be challenged by all the changes that occur during
adolescence including= changes in one7s body and physiologic
functioning, changes in feeling and emotional focus, changes in social
relationship, and changes in family and school expectations
5irls re more at risk for conflicting feelings than boys throughout the
adolescence#
Adolescents need to be able to talk to peers to develop values and an
attentive adult ear who will listen to their fears, hopes, dreams and the
pressure they feel to somebody, the pressure of wanting to do
something and yet not knowing what or how> knowing who they are
not is one step in discovering who they are#
As adolescents show increased interest in learning as they select a
.ob field at the high school level they come to see education as
relevant to their future#
Adolescents must be given more freedom at the same time some
restrictions must be placed on their behavior
3y the time the adolescents are 6? years of age, some of them are
already en.oying their new independence that they find it difficult to
understand that adulthood can be challenging> a little more maturity
will help them reali!e that beginning adult maybe far easier than the
years ahead#
Adolescents maybe full of self ) doubt during the early stage, search
for role models, fall in and out of love fre1uently
Co6niti9e De9elopment
/ormal operations stage
This step involves the ability to think in abstract terms and use
scientific method to arrive at conclusions#
"roblem solving in any situation depends on the ability to think
abstractly and logically#
Thinking abstractly is what allows adolescents to pro.ect themselves
into the minds of others and imagine how others view them or their
actions#
Moral an1 spirit8al 1e9elopment
Almost all adolescents 1uestion the existence of 5od and any
religious practices they have been taught> this 1uestioning is a part of
forming a sense of identity and establishing a value system at a time
in life when they draw away from their families#
Se:8al mat8ration in A1oles0ents
Age3yr
4
Male .e&ale
68 )
6D
5rowth spurs continuing>
pubic hair abundant and
curly> testes, scrotum and
penis enlarging further>
axillary hair present> facial
hair fine and downy> voice
changes happening with
annoying fre1uency
"ubic hair thick and curly> triangular in
distribution, breast areola and papilla
from secondary mound> menstruation is
ovulatory, making pregnancy possible
6D )
6E
5enitalia adult> pubic hair
abundant and curly> scrotum
dark and heavily rugated>
facial and body hair present>
sperm production mature
"ubic hair curly and abundant :adult;>
may extend onto medical aspect of
thighs> breast tissue adult and nipples
protrude> areolas no longer pro.ect as
separate ridges from breasts> may have
some degree of facial acne
6E 469 "ubic hair curly and
abundant :adult;, may
extend along medial aspect
of thighs, testes, scrotum
and penis adult in si!e, may
some degree of facial acne>
gynecomastia if present
fades
End of skeletal growth
69 46? End of skeletal growth
Promotin6 N8tritional ealt5 for t5e A1oles0ents7
Adolescents must be given some responsibility for food planning or
meals to help them learn important lessons about nutrition without
conflict#
A weight loss diet which maybe appropriate during adolescence must
be supervised to ensure that it has sufficient calories and nutrients for
growth#
Adolescents need an increase number of calories to maintain a rapid
period of growth#
+arge amounts of iron are necessary to meet expanding blood volume
re1uirements#
/emales re1uire a high iron intake due to iron loss during
menstruation#
ncreased calcium is necessary for rapid skeletal growth and to Hstock
pileI calcium to prevent osteoporosis later in life#
Promotin6 De9elopment of t5e A1oles0ent in 1ail> a0ti9ities7
"rovide adolescents time for self4care#
Adolescents should continue to use fluoride toothpastes and be
conscientious in brushing their teeth especially when they are wearing
braces#
Adolescents need more sleep to support their growth spurt#
Adolescents need exercise everyday to maintain muscle tone#
Bo)y "ier!ing an) tattoo ) acts that are becoming a way for adolescents
make a statement
.atig#e ) caused by inade1uate sleep, diet, unreasonable activity
schedule and of emotional origin
Mentr#al Irreg#laritie ) may be pain or heavy blood flow
A!ne 1 a self ) limiting inflammatory disease that involves the sebaceous
glands that empty into the hair shafts mainly of the face and shoulders#
Obeity ) due to excessive food intake and familial history
Con0erns4pro#lems of a1oles0ents
Se(#ality an) e(#al a!tivity ) Adolescents are concerned with exposure
to %exually Transmitted Diseases and pregnancy
S#btan!e ab#e ) occurs in adolescence form a desire to expand
consciousness or to feel more confident and mature> it can also be a
response to peer pressure or a form of adolescent rebellion
S#i!i)e ) ranks 8
rd
as the cause of death in 6D to 6< year group> may be
caused by= incest, abuse, increased chemical dependency, marital
instability in the family, and poor problem ) solving ability, loss of self )
esteem, depression and stress
R#naway ) defined as an adolescent between the ages of 6@ and 69
years who has been absent from home at least overnight without
permission of parent or guardian> most likely from low income families with
history of unemployment, alcoholism, sexual abuse, and poverty
Common 1iseases in 05il1ren7
,onstipation ) difficulty passing hardened stools
Ca#e*
+ack of fluids and fibers in the diet
Emotional reasons, family stress
+ittle privacy in the bathroom
Manage&ent*
Thorough assessment
%oftening stool so that it will pass painlessly, 5lycerine suppository
Enema for severe constipation
"atience to avoid tension, $elp children to form bowel habits
Diarrhea
Ca#e*
2iral or bacterial invasion of the gastrointestinal tract :%almonella,
%higellosis, %taphylococcal food poisoning
Malabsorption or inflammatory cause
'y"e*
6# Mild diarrhea
Sy&"to&*
- 0nlimited, greenish stool
- Effortless passing> maybe explosive
- Acidic, %weet or foul4smelling
- "ositive blood occult
- /ever of 8?#A, to 8<,
Manage&ent*
- 'esting the 5T
- &'% :&ral 'ehydration %olution;, +owering down the
temperature
- ,aution in the use of over the counter drugs
- +actose4free to replace usual formula or breast milk
C# %evere Diarrhea
Sy&"to&*
- 'esult from progressive mild diarrhea
- /ever of 8<#D, to A@#@,
- -eak pulse and respiration, ,ool and pale skin
- Apprehension, listlessness, lethargy
- %igns of dehydration= depressed fontanelles, sunken eyeballs,
poor skin turgor
- Episode of bowel movement every few minutes
- %tool is li1uid green, with mucus and blood and passed with
explosive force
- %canty and concentrated urine output
- Elevated hemoglobin, hematocrit and serum levels due to
dehydration
- Acidosis
Manage&ent*
- 'egulation of fluid and electrolyte balance
- nitiating rest for the 5T
- %tool culture and blood exam :,3, and blood chemistry;
- Antibiotic therapy
8# ,roup 1 :+aryngotracheobronchitis;$ inflammation of larynx, trachea, and
ma.or bronchi
Ca#e*
2iral infection
$# nfluen!a
Sy&"to&=
- 3arking cough, nspiratory stridor
- Marked retractions
- 'estlessness and trashing
- ncreased heart and respiratory rate
Manage&ent*
- Geep the child in a warm, moist environment
- 3ring the patient to a hospital for severe attack
- %teroids and ntravenous therapy
- 2ital signs every 6D minutes
- ,lose observation, "rovide comfort
A# /ebrile convulsions
Ca#e*
- $igh fever :8?#<, to A@#@,;
- %ei!ures lasting from 6D to C@ minutes
- EE5 tracing normal
- /amily history
Manage&ent*
- Tepid sponge bath, cool washcloth on the child7s forhead, axilla and
groin
- Medical consultation
- Antipyretic and antibiotic therapy
- /urther evaluation
D# Measles ) brown or black, regular, 9 ) day measles, caused by Measles
virus
Sy&"to&*
- Enlargement of lymphnodes, high fever for D4E days, body malaise
- 'hinitis and sore throat, cough, nasal congestion
- ,on.unctivitis and photophobia
- Goplick7s spots :small7 irregular, bright red spots with a blue4white
center point on the buccal membrane
- 'ashes on the fourth day on the different parts of the body
Manage&ent*
- ,omfort measures for the rashes
- Antipyretics for fever
- +ubricating .elly on the area below the nose
- ,ough suppressant
- Drawn curtains or blinds
- "revention and treatment of complications
Co&"li!ation*
- &titis media, "neumonia
- Airway obstruction, Acute encephalitis
C5il1 a#8se
3attered child syndrome is one of the leading causes of childhood death and
disability affecting 6@L of all children seen in hospital emergency department for
traumatic in.uries
Effe!t of !hil) ab#e*
"hysically abused children are more angry, non4compliant and
hyperactive than others#
Emotionally abused children are more withdrawn and have a flatter affect
than others#
%exually abused children have long4term effects of depression, guilt and
difficulty en.oying sexual relations at the same level as others#
Abused children often have undiagnosed medical problems such as
anemia, otitis media, lead poisoning and sexually transmitted disease#
Abused children may rear their children in the same way they were
reared when they are already parenting
,hild abuse places a child in immediate risk#
'heorie of !hil) ab#e*
A parent has the potential to abuse a child = less than 6@ L have a history
of mental illness> many of them were abused as children> excessive use
of alcohol
A child is seen as HdifferentI in some way in the parent eye = maybe more
or less intelligent than other children in the family> have been unplannedI
have birth defect and attention span deficit> have been born prematurely
or had an illness at birth
A special event or circumstance brings about the abuse = parents unable
to deal with stress may not show the usual degree of compassion for
children7s degree of pain or offer to comfort#
Re"orting #"e!te) !hil) ab#e
$ealth care providers must report child abuse when they identify it#
The health care record of the child can be subpoenaed and displayed in
court#
"rotection from having a lawsuit brought against a health care provider
for reporting child abuse that is then proven false is provided in most
states#
'y"e of !hil) Ab#e*
"hysical abuse ) the action of caregiver that causes in.ury to the child commonly
revealed by burns or head and hand in.uries
Sign of "hyi!al ab#e=
"eculiar circular and liner lesions if beaten with electrical cords, belts or
clotheslines
Additional curved lacerations if beaten with a belt buckle
Abrasions or ecchymotic areas on the wrists or ankles if tied to a bed or
against a wall
3urns or scald on the dorsal surface of the hand> the feet and the skin up
to the knees are scalded when a child is lowered into scalding water as
punishment
,igarette burns
$uman bites or chunks of hair pulled off the scalp
$ead in.ury
%haken baby syndrome ) repetitive, violent shaking of a small infant by
the arms or shoulders causes in.ury to the neck, edema to the brain
stem, retinal hemorrhages and a potential halt to respirations
3roken bones include multiple fractures in different stages of healing, a
single fracture with multiple bruises, rib or occipital fractures
Intervention for vi!ti& of !hil) ab#e*
Approach the child in a calm manner and provide consistent caregivers
to the child#
Demonstrate acceptance of the child# &ffer praise for positive behavior#
Explain all procedures and treatments in language the child can
understand#
Encourage the child to talk about what happened and incorporate the
use of therapeutic play#
'eassure the child that he was not the cause of the abuse#
Make appropriate child abuse referral to keep child separated from
abusing adult#
Wo&en at high ri2 for "otential !hil) ab#e or negle!t that !an be i)entifie) in
the "regnant or "ot "art#& "erio)*
Mother has had fre1uent change of address in the year before delivery#
Mother has had past or present psychiatric illness#
+ikely incompetence of mother as a parent is seen because of apparent
emotional problems
Mother who lacks intellectual ability
Mother is having unrealistic expectations of the unborn child
Mother refused or dropped out of prenatal classes
Mother changed her decision regarding adoption of child#
A previous child was abused or neglected
Mother suffered parental violence or neglect as a child
"hysical neglect ) more subtle form of child abuse but can be as damaging to a
child7s welfare
Chara!teriti! of a negle!te) !hil)*
Appears unwashed, thin, and malnourished or inappropriately dressed
*ot brought for immuni!ations or not seeking early medical care for an
infection
*ot re1uired to attend school, deliberately kept from school or allowed to
go unsupervised after school
"sychological abuse ) includes belittling or threatening, re.ecting, isolating, or
exploiting the child> absence of positive parenting> children have difficulty
becoming emotionally confident as an adult
Munchausen %yndrome by proxy ) refers to a parent who repeatedly brings a
child to healthcare facility reporting symptoms or illness when in fact, the child is
well> the parent might report a history such as sei!ures, excessive sleepiness or
abdominal pain
Clai! fin)ing of the yn)ro&e*
The symptoms are not easily detected by physical examination, only by
history
%ymptoms are present only when the abuser is providing care and
disappear when care is provided by another person
/ailure to Thrive :'eactive Attachment Disorder; ) a uni1ue syndrome in which
an infant is falling in percentiles on a growth chart
Ca#e*
The parent feels little emotional attachment to the child
The parent is not offering enough food to the child
%ome children are offered sufficient food but they sense emotional
deprivation that makes them lethargic and not eat enough
The child may have neurologic dysfunction from birth in.ury and may not
respond as a normal child#
Care of !hil) with fail#re to thrive )ior)er*
%exual abuse ) any sexual contact between a child and an adult> adolescents
and older children may also be perpetrators> involves coercion of dependent,
developmentally immature children and adolescents in sexual activities they do
not comprehend, to which they are unable to give consent or that violate social
taboos of family roles
Effe!t*
t leaves children unable to trust others
They have a sense of ambivalence to intimacy and an overall sense of
worthlessness
'y"e*
Molestation ) includes Hindecent libertiesI such as oral4genital contact,
genital fondling and viewing, or masturbation
ncest ) sexual activity between family members that often involves an
older man and a young girl, although it may involve an older woman and
a younger boy, brother or sister, or same sex partners> may also involve
foster, adopted, and stepchildren
"ornography and prostitution ) photographing by any media of sexual
acts involving children or the distribution of such materials> child
prostitution is arranging or participating in sexual acts with children
Sign of e(#al ab#e*
A child verbally reports sexual activity with an adult
A child has awareness of sex and sexual vocabulary that is beyond age
expectations#
A child engages in sexual expressions with dolls#
A child younger than 6D years is pregnant
A child has perineal, vaginal or oral inflammation
A child has vaginal tears or anal fissures
A child has a sexually transmitted disease
%ymptoms of increased anxiety, such as sleep disturbance, development
of tics, nail biting, or stuttering are present
A child has a change in school performance, develops a school phobia,
or a truant
A child expresses fear of being left alone with a certain adult
A child develops vague abdominal pain or acting out behavior
'hera"e#ti! Manage&ent*
'eporting of sexual abuse
"sychological counseling of the both the child and the adult involved in
sexual abuse relationship
The adult should admit that the fault is hers or his to improve the self4
esteem of the child
All children should be taught some simple rules to help them avoid
sexual abuse
Care of t5e 05il1 ;it5 Ne8rolo6i0 1isor1er
Cere#ral Pals>
,efinition
,erebral palsy :,"; is a group of non4progressive disorders of upper motor
neuron impairment that result in motor dysfunction, speech or ocular difficulty,
sei!ures, cognitive impairment or hyperactivity#
.a!tor that !ontrib#te to the )evelo"&ent of !erebral "aly*
3rain anoxia before, during or shortly after birth that leads to cell
destruction
*utritional deficiency
Drugs
Maternal infections
2ery low4birth4weight or small for gestational age infant
%hort interpregnancy interval
Gernciterus from neonatal hyperbilirubinemia
Meningitis or encephalitis in the newborn
$ead in.ury such as from child abuse or shaken baby syndrome
%evere dehydration
'y"e of !erebral "aly=
"yramidal or spastic type :approximately D@L of affected children; Excessive
tone in the voluntary muscles
Sy&"to&*
Exaggeration of deep tendon reflex, abnormal reflexes such as a
positive babinski reflex past the age at which it usually disappears
S"ati! involve&ent
$emiplegia 4 involvement of both extremities on one side> arm is
usually more involved than the leg> involved arm may be shorter with
smaller arm circumference> difficulty identifying ob.ects placed in their
involved hand when their eyes are closed :astereognosis;
Wuadriplegia ) involvement of all four extremities> impaired speech
:pseudobulbar palsy;> continuous drooling an difficulty swallowing>
cognitive impairment
"araplegia ) involvement of the lower extremities> upper extremity
involvement may be limited to an abnormal, awkward arm movement
Dyskenetic or Athetoid type ) involves abnormal involuntary movement
Sy&"to&*
,hild is limp and flaccid early in life
%low, writhing motions
May involve all four extremities> the face, neck and tongue
Drooling, and speech that is difficult to understand
rregular and .erky movements :choreoid; during emotional stress with
dyskinesia
S#bty"e*
Ataxic type ) awkward, wide based gait, inability to perform the finger to
nose test or perform rapid repetitive movements
Mixed type ) show symptoms of both spasticity and athetoid movements
which results in a severe degree of impairment
Ae&ent*
$istory of possible anoxia during prenatal life or at birth
%ensory alterations such as strabismus, refractive disorders, visual
perception disorders, speech and hearing disorder c
,ognitive impairment
x4ray or sonogram may show cerebral asymmetry
EE5 is abnormal but pattern is highly variable
Care of t5e 05il1 ;it5 5eart 1isor1er
Con6enital 5eart 1efe0t
.etal !ir!#lation
6# Exchange of oxygen and carbon dioxide takes place in the placenta not in the
fetal lung
C# +ittle blood goes to the fetal lung causes less pressure in the left side of the
fetal heart than pressure in the right side
8# "resence of fetal accessory structures=
/oramen ovale ) bypasses pulmonary circulation, opening between right
and left area of the heart
Ductus arteriosus ) communication between pulmonary artery and aorta
Ductus venosus ) communication which bypasses the lungs
0mbilical vein ) carries oxygenated blood
0mbilical arteries ) carries deoxygenated blood
Ca#e of !ongenital heart )ieae*
/ailure of congenital heart disease is failure of heart structure to
progress beyond an early stage of embryonic development
Maternal rubella
Maternal history of defect
Claifi!ation 3ol) yte&4
Acyanotic heart defects ) heart or circulatory anomalies that involve
either a stricture to the flow of blood or a shunt that moves blood from
the arterial to the venous system :oxygenated to unoxygenated; causing
the heart to function as an ineffective pump and make the children prone
to heart failure
,yanotic heart defects ) occur when blood is shunted from the venous to
the arterial system as a result of abnormal communication between the
two :deoxygenated to oxygenated blood;
Claifi!ation 3new yte&4
Defects with increased pulmonary blood flow
,efinition
,ongenital heart disease associated with increased pulmonary blood flow from
the left side of the heart :under greater pressure;, to the right side of the heart
:lesser pressure;
'y"e*
6# 2entricular %eptal Defect :2%D;
Most common of all congenital heart defects> account for about
CDL of all congenital heart defects
An opening is present in the septum between the two ventricles
May not be evident at birth
A loud, harsh systolic murmur becomes evident
Diagnosis is based on examination by echocardiography by
Doppler or M' which reveals right ventricular hypertrophy and
possible pulmonary artery dilatation from increased blood flow
Management is closure by interventional cardiac catheteri!ation or
open heart surgery
Assess for arrhythmia postoperatively
C# Atrial %eptal Defect :A%D;
Abnormal communication between the two atria more fre1uent in
boys than in girls
%tronger contraction of the left side of the heart increases the
volume in the right side of the heart resulting in ventricular
hypertrophy and increased pulmonary blood flow
Echocardiography with Doppler will generally reveal the enlarged
side of the heart and the increased pulmonary circulation
Management is open heart surgery or interventional cardiac
catheteri!ation> if the defect is large, a %ilastic or Dacron patch
may be sutured in place to occlude the space
Asses for arrhythmia after operation
8# Atrioventricular ,anal :A2,; Defect
'esults form incomplete fusion of the endocardial cushion or in the
septum of the heart at the .unction of the atria and the ventricles
3lood may flow in all four chambers
About one in nine children with Down syndrome are affected
Distortion of the mitral and tricuspid valve
%urgery may involve a valve repair and septal repair
,hildren need to be closely observed for .aundice resulting from
red blood cell destruction from the newly constructed valve
A# "atent Ductus Arteriosus :"DA;
/ailure of the ductus arteriosus to close at birth :or at 8 months;
blood will be shunted from the aorta :oxygenated blood; to the
pulmonary artery :deoxygenated blood;
%ymptom of wide pulse pressure, low diastolic pressure because
of the shunt, typical continuous HmachineryI murmur is heard
Administration of drugs or surgical procedure
&bstructive Defects
,efinition*
,ongenital anomalies that cause the blood flow to be obstructed because of
narrowing of vessel or a valve
'y"e*
6# "ulmonic %tenosis
*arrowing of the pulmonary valve or the pulmonary artery .ust
distal to the valve
Accounts for CD L to 8D L of congenital heart inabilities
,hild is asymptomatic or may show signs of mild heart failure or
cyanosis if the narrowing is severe
Management is by balloon angioplasty
C# Aortic %tenosis
%tenosis or strictur of the aortic valve prevents blood form passing
freely from the left ventricle of the heart into the aorta
%ymptoms are murmur, decreased cardiac output
Management by balloon angioplasty, surgical repair
8# ,oarctation of the Aorta
*arrowing of the lumen aorta due to a constricting band occurring
between the subclavian artery and the ductus arteriosus> and
second constriction is distal to the ductus arteriosus
$igh 3" in the upper part of the body may occur
Epistaxis and ,2A may also occur
Mixed defects
,efinition
Mixed defects are cardiac anomalies involving the mixing of blood from the right
pulmonary and systemic circulation in the heart chambers which results in a
relative deoxygenation of systemic blood flow
'y"e*
6# Transposition of the 5reat Arteries ) the aorta arises from the right
ventricle instead of the left and the pulmonary artery arises from the left
ventricle instead of the right
C# Total Anomalous "ulmonary 2enous 'eturn ) the pulmonary veins return
to the right atrium of the superior cava instead of to the left atrium as they
normally would
8# $ypoplastic $eart %yndrome ) the left ventricle of the heart is
nonfunctional# $eart transplant is a possible answer> infants rarely live
longer than one month
Defects with Decreased "ulmonary 3lood /low
,efinition
Defects with decreased blood flow involve some type of obstruction of pulmonary
blood flow
'y"e*
6# Tricuspid Atresia ) an extremely serious disorder, the tricuspid valve is
completely closed, allowing no bleed to flow from the right atrium to the
left ventricle> the bloodcrosse through the patent foramen ovale into the
left atrium, bypassing the lungs and step of oxygenation
C# Tetralogy of /allot ) four anomalies are present= pulmomic stenosis,
ventricular septal defect, overriding of aorta and hypertrophy of the right
ventricle
A0A8ire1 eart Disease
6# $eart /ailure ) results when the myocardium of the heart cannot circulate
and pump enough blood to supply oxygen and nutrients to body cells
Ca#e*
'esult of congenital defect that lessens the effectiveness of heart
pumping
May occur after cardiac surgery or rheumatic fever
%evere anemia, hypocalcemia and myocarditis
Sy&"to&=
ncreased heart rate
2entricular hypertrophy
Decreased renal blood flow resulting in both fluid and sodium retention
Excessive sweating and pallor
Ae&ent*
/irst signs= tachycardia, tachypnea, hepatomaegaly,> irritability and
restlessness forn abdominal pain
+eft sided heart failure ) dyspnea and rales in supine positon>
cyanosis
'ight sided heart failure ) breathlessness, rapid respirations, fatigue,
generali!ed edema, difficulty feeding, hepatomegaly and enlarged
heart
Manage&ent*
Evacuating the accumulated fluid through the use of diuretics,
%trengthening cardiac function though the use of intertropic drug
'educing afterload with the use of vasodilators
-#ring intervention*
"rovide for rest periods
"lace the child in a semifowler7s position
%edation
&rgani!e nursing care to allow periods of sustained rest but do not
attempt to perform too many procedures at once
"rovide &xygen as necessary
Monitor oxygen saturation
Assess the nostrils of the child receiving oxygen with nasal prongs to
prevent possible pressure and irritation
Talk about oxygen e1uipment before it is brought to the bedside
Administer drugs as necessary
Assess the child7s pulse rate before administering medication such as
digitalis
Monitor serum electrolytes level if diuretics are given
"romote and maintain proper nutrition
5ive small fre1uent meals to minimi!e energy and prevent the
stomach from becoming full
Maintain ade1uate fluid intake in infants by using soft HpreemiI nipples
to make sucking easier#
Minimi!e anxiety and fear
&ffer reassurance that the treatment they are receiving will help to
improve their condition
&bserve them closely in between as well as during the procedure
Allow them time to talk and use play to express their fears
3e certain that the child is brought to the doctor for follow ) up
C# 'heumatic /ever ) an autoimmune disease that occurs as a reaction to a
group A beta hemolytic streptococcus infection involving the .oints> course
is E ) ? weeks
Ca#e*
&ften follows an attack of pharyngitis, tonsillitis, scarlet fever, Hstrep
throatI or impetigo
&ccurs most often in children E to 6D years with a peak at ? years
Sign an) y&"to&=
$eart involvement
,horea :sudden involuntary movement of the limbs;
+oss of voluntary muscle control
Dysfunctional speech
$and grasp may be weak or may consist of spasmodic reaction
$yperextension of arms, wrist and fingers
Macular rash on the trunk
%ubcutaneous nodules
"ainless lumps on tendon sheaths by the .oints
%welling and tenderness of large .oints
Manage&ent*
3edrest during the acute phase of illness based on the degree of
carditis present and range form C weeks as long as heart failure is
present
Monitor the vital signs especially the pulse rate :apical;
A course of penicillin therapy erythromycin for penicillin4sensitive
children
&ral salycilates to help in reducing inflammation> steroids for
unresponsive cases
&bservation for symptoms of aspirin toxicity
"ossible mitral valve replacement if there is mitral valve deficiency
-#ring Intervention*
"revention of nitial attacks
'eduction of incidence by eliminating streptococci from the respiratory
tract through proper administration of medication
"revention of 'ecurrent attacks
Maintaining the child who have had rheumatic fever in prophylactic
antibiotic therapy for at least D years after the initial attack or until they
are 6? years old
Additional prophylactic measures should be done when dental or
otnsillar surgery is planned
mprovement of self esteem
Emphasi!e the transitory nature of the chorea, that lack of
coordination will pass without permanent effects
"rovide toys and games that do not re1uire fine coordination
The bedrails should be padded to avoid in.ury from trashing
movement
8# Endocarditis ) inflammation and infection of the endocardium or valves of
the heart
Ca#e*
As a complication of congenital heart disease
%treptocci, fungal or staphylococcal microorganism invasion
nvading process destroys the endocardial lining of the heart,
Ae&ent*
"allor with anorexia and weight loss is observed
Malaise, period of sweating, may occur
%ignificant murmurs and signs of heart failure will appear
"etechiae of the con.unctiva or oral mucosa, hemorrhage of the
fingernails
Echocardiogram shows vegetative growth on heart vessels
+eukocytosis and increased E%'
Manage&ent*
+arge doses of penicillin through a large vessel over a period of A to E
weeks
"rophylactic antibiotic therapy in case of surgery of the mouth, ear,
nose, throat
Common C5romosomal 1isor1ers t5at res8lt in p5>si0al or 0o6niti9e
1e9elopmental 1isor1ers
Trisomy 68 syndrome 4 :"atau7s syndrome> A9xx68X or A9xy68X; is a condition
in which children have an extra chromosome 68 which cause severe cognitive
impairment#
Chara!teriti!*
ncidence s#AD per 6@@ live births
Midline body disorders
Microcephaly with abnormalities of the forebrain and forehead
Micropthalmia or absence of eyes
,lept lip and palate
+ow set ears
$eart defects, particularly ventricular septal defects
Abnormal genitalia
Most of these children don7t survive past childhood
Trisomy 6? syndrome ) :A9xx6?X or A9xy6?X; have three number 6?
chromosomes that causes severe cognitive impairment
Chara!teriti!*
ncidence is approximately @#CD per 6@@@ live births
%mall for gestational age at birth
Markedly low4set ears, small .aw
,ongenital heart defects
Misshapen fingers and toes : the index finger crosses over other
fingers;
'ounded soles of the feet :rocker4bottom feet;
,hildren do not survive beyond infancy
,ri du ,hat syndrome ) :AExxD1; the result of a short arm on chromosome D#
Chara!teriti!*
Abnormal cry much more like the sound of a cat7s than a human
infant7s
%mall head, wide4set eyes
-ith severe cognitive impairment
Turner7s syndrome ) :gonadal dysgenesis> ADK&; has only one functional K
chromosome
Chara!teriti!*
ncidence is 6 per 6@@@ live births
%hortness in stature
$airline at the nape of the neck is low4set and the neck appear to be
webbed and short
*ewborn may have appreciable edema of ht hand and feet and
congenital anomalies of the heart and kidney disorders
%treak :small and nonfunctional; gonads> secondary sex
characteristics do not develop at puberty
+ack of ovarian function results sterility
Maybe cognitively challenged but more commonly intelligence is
normal
'reat&ent*
Estrogen treatment started at approximately 68 years, secondary
characteristics will appear, and if taken continuously for 8 out of every
A weeks, withdrawal bleeding may occur that results in menstrual flow#
5rowth hormone can be helpful to achieve additional height
Glinefelter7s syndrome ) affects males with an KK( chromosome pattern :A9xxy;
Chara!teriti!*
ncidence is about 6 in 6@@ live births
,haracteristics may not be noticeable at birth
"oorly developed secondary sex characteristics and small testes that
produce ineffective sperm at puberty
Development of gynecomastia
Associated with an increased risk of developing cancer especially
male breast cancer
/ragile K syndrome ) and x linked pattern of inheritance in which long arm of an
x chromosome is weakened
Chara!teriti!*
ncidence is about 6 in 6@@ live births
,ommonest cause of cognitive impairment in boys
Maladaptive behavior such as hyperactivity and autism before puberty
'educed intellectual functioning with marked deficit in mathematics
and arithmetic
+arge head, long face with a high forehead, prominent lower .aw and
large protruding ears
$yperextensive .oints and cardiac disorders maybe present
Enlarged testicles maybe present after puberty> affected individuals
are fertile and can produce
,arrier females may show some evidence of physical and cognitive
characteristics
'reat&ent*
/olic acid and phenothia!ide administration may improve
concentration
Down syndrome :Trisomy C6; ) :A9xxC6X or A9xyC6X; the most fre1uent
chromosomal abnormality
In!i)en!e* 6 in ?@@ live births
Contrib#ting fa!tor*
"regnancies of women above 8D years of age :6 in 6@@ live births;
"aternal age :over DD; may also contribute
,hara!teriti!*
3road and flat nose
Extra fold of tissue at the inner canthus :epicanthal fold;
"alpebral fissure tend to slant upward
3rushfield7s spot :white specks on the iris;
Tongue protrusion> oral cavity is smaller
3ack of head is flat,> neck is short, extra pad of fat at the base of the
head
+ow4set ears> "oor muscle tone
%hort and thick fingers and the little finger is curved inward
-ide space between the first and second toes and the first and
second fingers
0sually have some degree of cognitive impairment but can range from
that of educable :W of D@ to 9@; to one re1uiring institutionali!ation :W
less than C@;> extent is not evident at birth
3rain is not developed well shown by smaller head si!e
Altered immune function> prone to infection, congenital heart disease,
stenosis or atresia of the duodenum, strabismus and cataract
disorders
+eukemia occurs more fre1uently than in healthy children :C@ x more;
Aging seems to occur faster than normal :lifespan generally A@ to D@
years;
Intervention for a !hil) with !ognitive i&"air&ent*
/or self4care deficits related to impaired cognitive fuction
Assess the child7s daily routine
Modify care activities as much as possible to stimulate the child7s daily
routine
-ith each activity or procedure, offer simple, single explanations and
instructions# nclude the child7s doll in each explanation
Encourage the mother to bring in personal care items from home if the
child is hospitali!ed
3reak down each aspect of self4care into simple steps# Allow the child
ample time to complete each step# "raise the child for
accomplishments and provide help as necessary#
nstruct the child to use the call bell when necessary and assist as
necessary#
/or risk for in.ury related to impaired cognitive function
nstitute developmentally appropriate safety measures such as raised
side rails for the child
nstruct the child to use call bell and keep the call bell within easy
reach
Make fre1uent visit to the child and check on the child
'ea!hing g#i)eline for the !ognitively !hallenge) !hil)*
Teach one step at a time
ntroduce motivators for learning such as generous praise#
'educe the number of extra stimuli present#
Demonstrate the skill to be learned#
Geep things simple> 5ive praise accordingly#
C5il15oo1 Mental Disor1ers
De"elop,ental Dsor!ers-
Mental 'etardation )
A developmental disorder characteri!ed by delay in one or more areas of
development including attention, cognition, language, affect, and social
and moral behavior
3orderline normal functioning 4 neighborhood of I6 between 78 an) 79.
"eople in this range of W may or may not be diagnosed with mental
retardation, depending on how well they can carry on the business of
everyday life like deficits in at least two of the following areas=
communication, self care, home living, social skills, use of community
resources, self direction, functional academic skills, work, leisure, health,
and safety# "eople with I6 below 78 usually will show deficits in several
of these areas#
Ca#e of &ental retar)ation*
genetic flaws through problems in
embryonic development
birth or medical conditions
brain in.uries
'y"e of &ental retar)ation*
Mild retardation with W of D@4DD to about 9@> about ?@ to <@ L belong to
this group> given optimum opportunities, they are likely to be able to live
in the community> some can live independently> others in places where
they can be supervised
Moderate retardaton with W of 8D4A@ to D@4DD> people with moderate
retardation comprise about 6@L of those with mental retardation> they can
benefit from education, but are unlikely to be able to function without
supervision> they may be able to perform unskilled or semiskilled labor
after vocational training#
%evere retardation with C@4CD to 8D4A@> 8 to AL of people with severe
mental retardation can sometimes learn to do simple tasks under close
supervision> their communication skills, however, will be very slow to
develop> they may adapt reasonably well to family life or group homes#
"rofound retardation below with W of C@4CD> 6 or CL of the group> may be
able to develop some self4care skills under close supervision and with
optimal training> they, too, may learn to perform simple tasks> their
communication skills will be severely limited or absent, but they may learn
some words or to use other means of communication, given sufficient
training
Ae&ent*
Done by history taking and W testing
%hould be done as soon as parents become aware that their child is
experiencing problems with development
ntelligence is routinely measured with standardi!ed tests :-echsler
ntelligence scale for ,hildren;
Adaptive behavior functioning is .udged according to standardi!ed
instruments for assessing social maturity and adaptive skills#
'hera"e#ti! Manage&ent*
$elp children achieve their full potential by having realistic expectations
based on the best .udgment possible#
Intervention*
$ealth seeking behaviors related to increasing knowledge of care needs of the
cognitively challenged child
Geeping children at home and maintaining a home and school
environment for them as normal as possible increases stimulation and
their desire to achieve#
f it is not possible for the child to be taken care of at home, a foster home
placement is suitable for the advantage of family setting#
$ealth maintenance needs
,hildren must be treated according to their intellectual age, not their
chronological age#
,hildren must be observed closely for symptoms that will help them
locali!e discomfort#
A simple, ade1uate explanation on the procedures that will be done to
them must be geared according to intellectual age
Education
,hoose a school for the child depending on the degree of intellectual
delay and on the school situations#
,hildren should be included in regular classes as much as possible for
stimulation and to help them reach their best potential#
3us and pedestrian safety should be taught#
%elf4care activities
,hildren with cognitive impairment need to learn the maximum amount of
self4care possible to provide them with a sense of control and
accomplishment#
Assess carefully whether they need special aids to achieve self4care skills#
A continuous reminder for self4care is needed because they are unaware
of the importance of self4care#
"lay
Toys should be chosen according to the child7s cognitive development#
%ocial 'elationships
%peech therapy maybe necessary
Talking picture boards can help communication#
Teaching early social behavior is important to help children relate to other
children and adults#
They must be enrolled in pre4school programs to help them learn to be
comfortable with other children as early as possible#
"reparation for adulthood
Adolescents who are cognitively challenged benefit from orientation to
sexual responsibility like the other children#
$elp them understand socially acceptable sexual activities
$elp them understand the changes that take place in their bodies during
adolescents#
Per"as"e De"elop,ental Dsor!er
nfantile Autism
,efinition*
A category of pervasive developmental disorders that is marked by
serious distortions in psychological functioning
In!i)en!e
A rare condition, occurring only in C ) 6@ children out of 6@,@@@
&ccurs more often in boys than in girls
D@ L are also cognitively impaired
Ca#e*
Exact cause is unknown
3elieve to be a result of multiple factors such as= genetics> perinatal
complications> problems with biochemical substances in the body
Sy&"to& 1 all occurring within 8@ months of age
%ocial isolation and abnormal interactions
%tereotyped behaviors
'esistance to any change in routine
Abnormal responses to sensory stimuli
nsensitivity to pain
nappropriate emotional expressions
Disturbance of movement
"oor development of speech and impaired communication
%pecific, limited intellectual problems
+ability of mood
Ae&ent*
ntelligence testing maybe difficult because they do not respond well to
test situations and they score poorly on verbal aspect of these tests
'hera"e#ti! Manage&ent*
3ehavior modification therapy may be effective in controlling some of the
bi!arre mannerisms
A day care program can help promote social awareness#
Paro.#s,al Dsor!ers
'ecurrent ,onvulsions
,efinition*
A !onv#lion is an involuntary contraction of muscle caused by abnormal
electrical brain discharges
E"ile"y comes from a 5reek word Hto take hold of7 and refers to a person with
chronic convulsions
The preferred terms now are !onv#lion or eiz#re.
Claifi!ation of eiz#re*
"artial :/ocal; %ei!ures ) originate from a specific brain area
%imple partial sei!ures :no altered level of consciousness; includes i&"le
"artial eiz#re with &otor ign and i&"le "artial eiz#re with enory
ign
,omplex partial sei!ures :psychomotor; sei!ures :some alteration in level
of consciousness; ) most difficult to control
5enerali!ed sei!ures
Tonic4clonic sei!ures :formerly grand mal; may either be tonic or clonic )
are generali!ed sei!ures occurring in four stages= "rodromal consisting of
drowsiness, malaise, lack of coordination or tension> Aura consisting of
smelling unpleasant odors, seeing flashlights, repeated hallucinations,
numbness of an extremity and a H,heshire ,atI grin> Tonic stage
consisting of contraction of all muscles of the body, falling to the ground,
stiffening of the extremities and distortion of the face, hypoxia and
cyanosis, collection of saliva in the mouth> clonic stage in which the
muscles of the body rapidly contracts and relaxes producing 1uick, .erky
movements> postictal period during which the person sleeps soundly for 6
to A hours and will rouse only to painful stimuli
Absence sei!ures :formerly petit mal; ) consist of a staring spell that lasts
for a few seconds which may be accompanied by rhythmic blinking and
twitching of the mouth or an extremity> can occur up to 6@@ times a day>
can be outgrown in adulthood
Atonic sei!ures :formerly Hdrop attacksI;
Myolonic sei!ures
nfantile spasms
%ei!ures in the newborn period
Sy&"to&*
twitching of the head, arms or eyes
%light cyanosis
'espiratory difficulty or apnea
Ca#e*
trauma and anoxia :head trauma with the birth processes;
metabolic disorders :hypoglycemia;
neonatal infection :,*% nfection or prolonged rupture of membranes
before delivery;
Gernicterus
Manage&ent*
high dosage of anticonvulsant medication to control convulsions
%ei!ures in infants and toddler periods=
Seiz#re in this age group are infantile "a& or infantile &yo!loni! eiz#re.
Chara!teriti! of eiz#re*
2ery rapid movements of the trunk with sudden strong contractions of
most of the body
/lexion and adduction of the limbs
%lumping forward form a sitting position of falls from a standing position
Episodes may appear singly or in clusters as fre1uently as 6@@ times a
day
Most common in the first E months of life
Ca#e*
Exact cause is unknown
%pasms apparently results from a failure of normal organi!ed electrical
activity in the brain#
%ometimes accompany a preexisting neurologic damage> approximately
<D L are cognitively impaired
Trauma or a metabolic disease in D@ L of those affected
May follow invasion by viruses such as herpes
Effe!t*
ntellectual development appears to halt or even regress#
The phenomenon disappears by C years of age but the associated
cognitive or developmental lag remains
%ei!ure in children older than 8 years of age
Ca#e*
Exact cause cannot be discovered
May result form focal or diffuse brain in.ury that has left residual damage
5rowing brain tumor maybe possible
/ebrile ,onsvulsions
Chara!teriti!*
Associated with high fever :6@C to 6@A /;
Most common in preschooler children
Tonic4clonic pattern lasts for 6D to C@ seconds
$istory of other family members having sei!ures
%ei!ures subside 1uickly once the fever is lowered
Prevention*
Geep fever below 6@6 / or 8?#A ,
"henobarbital is given if the child has had two or more febrile convulsions
'hera"e#ti! Manage&ent*
+owering the fever by T%3
Do not give oral medications during sei!ures
,old compress must be applied on the forehead, axilla, and groin
Transport the child in light clothing to a health care facility
Antibiotics maybe given to treat the underlying cause of the fever
Safety )#ring eiz#re*
'emain calm
Move away furniture or sharp ob.ects
Turn the head gently on his side or abdomen with the head to prevent
aspiration
Don7t restrain him other than to keep is head turned to the side
Do not attempt to place a stick or padded tongue blade
Try to keep crowd off the area
/ollow4up should be made after the sei!ures
f there is another convulsion rapidly following the other, oxygen
administration maybe necessary and also a muscle relaxant