Physiologic Integrity

HEALTH MAINTENANCE CARE

USA a. History b. Physical Examination c. Screening Procedures d. Immunization e. Anticipatory Guidance & Health Education

GROWTH increase in size increase in mass QUANTITATIVE measured in : - cm - inches - kilograms (kg) - pounds

Growth & Development

DEVELOPMENT Maturation Function & skills QUALITATIVE DATA Developmental task - physical - psychologic - cognitive

GROWTH PARAMETERS
Screening Details weight : 3500 grams height : 35-50 cms HC : 33-35 cms CC : 33-35 cms **head > chest circumference

PHYSICAL DEVELOPMENT
1 2 3 4 5 6 : regards : smiles : turns head : holds head : rolls over : transfers object 7 : sits w/o support 8 : crawls 9 : pulls over 10 : cruises 11 : walk w/ support 12 : stands alone

Stack toys, blocks, pots Drums to bang Push & pull toys Make-believe play Toddler Parallel Rocking horse, swing Finger paints, puzzle Pre-Sch Associative Trucks, dollhouse Doctor & nurse kits Sandbox, outdoor gym Schooler Cooperative Games & sports Boardgames, book & TV

Infancy

Solitary

PLAY

First 0-4 months *Breast Feeding *Bottle Feeding Solid Foods *4-6 months Table Foods *8-12 months

Nutrition Breastmilk
Bottle Feeding more nutrients prone Sequence: to colic anti-infective properties Guidelines: STOOL: 1. rice cereals prevents hypersensitivity -no nuts -firm 2. fruitsfood with seeds STOOL: & vegetables -no -sticky -pasty, 3. meats soft -no popcorn -foul-smelling

4. egg yolks

-golden-yellow -sour in odor

Care of Neonate

Delivery Room Care

Prevent Heat Loss
Check Airway Initiate Breathing Appraise Clinically *APGAR SCORE

APGAR SCORE 0 1
Appearance Blue (Pale) Pulse Grimace Activity Respiration
(-) (-) Limp, flaccid (-) Acrocyanosis <100 Grimace Some flexion Slow irregular

2 Pink all over > 100 Cry, cough Full flexion Strong cry

Nursery Room Care

a. b. c. d. e. f. g. h. Anthropometric measurements Baby bath Vitamin K Injection Antibiotic Opthalmic Ointment Cord Care Detailed Physical Examination Vital Signs Monitoring Bonding with Mother

Genetic Disorders
(Principles of Inheritance)

Autosomal Dominant
DOMINANT 1 parent Counselling *There is 50% chance with each pregnancy that child will have disease Marfan Syndrome Hereditary Spherocytosis Huntingtons Disease Hyperlipidemia Neurofibromatosis Tuberous Sclerosis Von Willebrands

Marfan Syndrome (Arachnodactyly)

Autosomal Dominant USA Defective gene : Chromosome population 15 1:10,000 Pathology: defective cross linking Characterized by: Tallness & Thinness

Features
SKELETAL Tall stature Scoliosis Lordosis Dental crowding Flexion contractures OCULAR Ectopia lentis Flat cornea Severe myopia Retinal detachment

Marfan Syndrome

CARDIAC

mitral valve prolapse

Aortic dissection Mitral regurgitation

Autosomal Recessive
RECESSIVE both parents must pass disease Counseling 25% - DISEASE 25% - Normal 50% - Carrier
Cystic Fibrosis Sickle Cell Anemia Tay-Sachs Disease Galactosemia Phenylketonuria Wilsons Disease Congenital Adrenal Hyperplasia (CAH)

Tay-Sachs Disease
Autosomal Recessive Features: healthy for 2-6 mos Common: Eastern Europe & Jewish decreased in eye contact most devastating lipid storage disease Pathology: Absence of hexoaminidase A loss of vision (catabolism of hyperreflexia ganglioside for SEIZURE (2 years) normal cellular function) death @ 2-4 years

Hemophilia A&B Color Blindness females : carrier Lesch-Neehan males: diseased Syndrome no male to male Duchene Muscular transmission Dystrophy X chromosome
Agammaglobulinemi a

Sex-Linked Disorders

NeuroSensory Disorders

Spina Bifida (Myelodysplasia)

2/1000 live births multifactorial 85% occurs in
- lower thoracic - lumbar - sacral TYPES: a. spina bifida occulta b. spina bifida cystica

Spina Bifida

Diagnosis
a. Prenatal Amniocentesis b. Post-partum 1. Ultrasound 2. CT Scan 3. Myelogram

Treatment
a. Sac Closure

Spina Bifida

Nursing Care
*a. Prevent trauma to the sac b. Provide adequate nutrition c. Provide sensory stimulation d. Emotional support e. Refer for rehabilitation

Hydrocephalus
Choroid plexus TYPES: a. communicating Lateral ventricle Foramen monroe b. non-communicating 3rd ventricle CAUSES: Aqueduct of Sylvius 1. injury 4th ventricle 2. infection Luscka Magendie 3. tumor Base of Brain 4. congenital

Diagnosis
a. CT Scan

Treatment
a. Extracranial shunts

Nursing Care
*a.maintain patency
b.monitor neuro status c.watch out for: -infection -increase ICP

Cerebral Palsy
neuromuscular disorder that affects motor neurons USA : 1.5-5/1000 live birth CAUSES: a. Prenatal b. Perinatal c. Postnatal

Cerebral Palsy

Assessment
-Spasticity -Tremors -Ataxia -Rigidity Associated Signs & Symptoms -mental retardation -hearing loss -defective speech -visual disturbances

Reyes Syndrome
acute encephalopathy with fatty liver

true pediatric emergency unknown etiology CLINICAL STAGING

I II III IV persistent vomiting, fatigue disorientation, confusion coma, decorticate posturing deeper coma, decerebrate posturing V seizures, absent DTR, flaccidity

Reyes Syndrome

Management
Supportive Treatment at PICU

Nursing Care
a. assess neurologic, respiratory, circulatory & hydration status b. support child & family c. maintain fluid & electrolyte balance d. seizure precaution

Cardiovascular Disorders

Fetal Circulation
Placenta Umbilical Vein Ductus Venosus Inferior Vena Cava Right atrium Foramen Ovale Left Atrium Left Ventricle Ascending Aorta

Fetal Circulation

Blood from upper extremities Superior Vena Cava

Right Atrium Right Ventricle

Pulmonary Artery
Ductus Arteriosus

Descending Aorta

Congenital Heart Disease

USA : 40,000 babies/year Cause : multifactorial Assessment a. failure to thrive b. poor feeding practices c. frequent respiratory infections d. activity intolerance e. pallor

CYANOTIC right to left shunt Tetralogy of Fallot Transposition of Great Arteries Truncus Arteriosus

Types of CHD

ACYANOTIC left to right shunt

Ventricular Septal Defect Atrial Septal Defect Patent Ductus Arteriosus Coarctation of Aorta

Ventricular Septal Defect

Most common CHD (30-40%) Assessment a. Small (<0.5 cm2) b. Large (>1 cm2) Treatment a. Surgical Repair for large defects b. Endocarditis prophylaxis

Tetralogy of Fallot
most common ACYANOTIC 4 Components (PROV) a. Pulmonary stenosis b. Right Ventricular Hypertrophy (RVH) c. Overriding Aorta d. Ventricular Septal Defect (VSD)

Assessment

Tetralogy of Fallot

a. cyanosis b. harsh holocystolic murmur c. squatting position d. exertional dyspnea Complication: Hypercyanotic Spells

Treatment:
a. Palliative : Blalock Tausig Procedure b. Definitive : Surgical Repair c. Endocarditis Prophylaxis

Rheumatic Fever
AUTOIMMUNE
Assessment : Jones Criteria MAJOR (SPECC) a. SQ Nodules b. Polyarthritis c. Erythema Marginatum d. Carditis e. Chorea

Rheumatic Fever

Minor Criteria: a. fever b. increase ESR, CR-P c. recent streptococcal infection d. (+) ASO e. prolonged PR interval in ECG Diagnosis: 2 Major 1 Major + 2 minor

Nursing Care
Polyarthritis - comfort measures - Aspirin Chorea - decrease stimulation - safe environment - small frequent meals Carditis - prophylactic treatment

Respiratory Disorders

Tonsillitis
10-20% caused by GABS Nursing Care: a. medications as ordered b. diet: liquid to soft diet c. comfort measures for enlarged tonsils Surgical Management: TONSILLECTOMY a. recurrent tonsillitis b. peri-tonsillar abscess c. airway obstruction

 most common operation performed Nursing Care: a. age appropriate pre-op preparation Post-Op a. position: side lying or abdomen b. diet: clear, cool, non-citrus, non-red c. apply ice collar d. avoid trauma to the site e. watch out for hemorrhage

Tonsillectomy

LaryngoTracheoBronchitis
virus : Parainfluenza common : <5 years old Nursing Care: a. steamy bathroom then cool mist vaporizer b. increase fluid intake c. bed rest Hospitalization: a. dehydrated b. superimposed bacterial infection

Epiglottitis
H. Influenza type B common: 3-7 years Assessment: a. inspiratory stridor b. fever c. drooling of saliva d. respiratory distress e. wants to lean forward

Epiglottitis

Nursing Care
position of comfort no direct examination prepare tracheostomy or emergency set give medications mist tent with O2 reassure parents

Cystic Fibrosis
USA : 1:2,500

Autosomal Recessive most common life threatening trait Four Fundamental Physiologic Defects a. failure to clear mucus secretions b. paucity of water in mucus secretions c. chronic infection of respiratory tract d. maldigestion

Affected Organs a. respiratory tract (99.9%) b. pancreas (85%) c. reproductive system d. liver e. sweat glands Diagnosis a. Pilocarpine Iontophoresis Sweat Test b. fecal fat : elevated c. hyponatremia

Cystic Fibrosis

Nursing Care a. Respiratory Involvement -aerosolized treatment -percussion & postural drainage -deep breathing exercises b. Pancreatic Involvement -pancreatic enzymes with meals -diet: high calorie & protein, low fat c. Electrolyte Involvement -add salt to all meals

Cystic Fibrosis

GastroIntestinal Disorders

Cleft Lip/Palate
USA : 1:1000 births

Treatment CHEILOPLASTY PALATOPLASTY PreOperative PreOperative a. feed in high fowlers a. prepare parents b. use large-hole nipple b. teach on feeding or rubber-tipped syringe methods c. burp frequently PostOperative PostOperative a. position: side lying a. maintain patent airway b. prevent trauma or b. dont strain suture line injury to suture line c. prevent crying c. diet : liquid soft

Altered Connections

Treatment : End to End Anastomosis Nursing Care Pre-Operative a. NPO post midnight b. suction secretions PRN Post-Operative a. position: HOB elevated 30-45 b. suction secretions c. maintain gastrostomy for feeding

Pyloric Stenosis *unknown cause

Assessment a. olive shape mass under right rib cage b. vomiting c. visible peristalsis d. failure to thrive e. dehydration

Nursing Care a. prevent vomiting b. aspiration precautions c. maintain IVF d. monitor for fluid & electrolyte balance Surgical Management Fredet-Ramstedt Procedure aka. Pyloromyotomy

Pyloric Stenosis

Intussuception
common : 6 months & older associated with cystic fibrosis & celiac disease Assessment a. vomiting b. currant-jelly stool c. abdominal pain

Intussuception

Treatment: Medical : Hydrostatic Reduction Surgical : Resection with End to End Anastomosis Nursing Care a. maintain fluid & electrolyte balance b. prevent vomiting c. monitor for peritonitis

Hirschsprungs Disease
absence of ganglion cells in large colon Assessment a. delayed passage of meconium b.distended abdomen c. ribbon-like stools d. vomiting (fecaloid) e. diarrhea

Hirschsprungs Disease

Nursing Care a. digital rectal evacuation of feces b. diet : low-residue c. do not treat loose stools d. stool softeners e. isotonic enema Surgical Management: Abdomino-Perineal Pull

 Malabsorption Syndrome common : Caucasians Nursing Care a. diet : Gluten-Free b. fat-soluble vitamins in water form c. avoid infection Health Teaching *Stress importance of adhering to diet

Celiac Disease

GenitoUrinary

Disorders

 most common GUT problem in children

common : schooler girls Escherichia Coli Nursing Care a. administer medications b. increase oral fluid intake c. acidify urine d. proper hygiene e. avoid tub baths or bubble baths

Urinary Tract Infection (UTI)

Undescended Testis
aka Cryptorchidism common : unilateral premature infants 75% descend spontaneously in 1 year Treatment : Orchipexy

Nephrotic Syndrome
caused by a lot of factors problem : increase glomerular basement membrane permeability Assessment a. protenuria (>2 gm/day) b. hypoprotenemia (<2.5 g/dl) c. hyperlipidemia (>200 mg/dl) d. edema e. anorexia, vomiting

Nephrotic Syndrome

Treatment a. corticosteroids b. diuretics c. antibiotics Nursing Care a. provide bed rest b. diet : high protein, low sodium c. avoid IM injections d. fluids maintained at 20 cc/kg/day e. protect from known sources of infection

Acute Glomerulonephritis
immune-complex disease self-limiting, resolves in 14 days caused by beta hemolytic streptococcus Assessment a. hematuria (100%) b. edema (98%) c. hypertension (82%) d. edema e. anorexia, lethargy

Hematologic Disorders

Iron Deficiency Anemia

most common anemia in children vulnerable : children on cows milk Nursing Care a. diet : iron rich foods b. add supplemental iron to formula c. administer iron -oral -intramuscular (IM)

Sickle Cell Anemia

USA : most common inherited disorder African-American Assessment a.asymptomatic initially b. colic (infancy) c. splenomegaly d. frequent infections e. leg ulcers f. pain

Nursing Care
well hydrated & oxygenated patient administer meds bed rest no tight clothing decrease stress avoid activities that interfere with oxygenation

Idiopathic Thrombocytopenic Purpura

cause : unknown platelet count : <100,000/mm3 muco-cutaneous bleeding Nursing Care a. control bleeding b. prevent bruising c. avoid intramuscular injections d. maintain safe environment e. no contact sports

Hemophilia
most common congenital coagulation d/o sex-linked disorder TYPES A - factor 8 deficient (75%) B - factor 9 deficient C - factor 11 deficient Assessment a. prolonged bleeding after minor injury b. hemarthrosis (hallmark) c. hematoma

Nursing Care
a. Control acute bleeding episodes b. Provide care for hemarthrosis c. Administer cryoprecipitate d. Prevent trauma e. Genetic counselling

MusculoSkeletal Disorders

 USA 1:1000 livebirth most common congenital malformation Causes a. genetic b. fetal position c. laxity of ligaments

Congenital Hip Dislocation

Assessment a. limitation on abduction b. apparent shortening of affected leg c. additional skin folds d. Ortolanis click Management Goal: Enlarge & deepen the socket by pressure

Scoliosis
common : adolescent girls 75% are idiopathic Assessment a. uneven hips & shoulders b. uneven bra strap marks c. back pain d. decrease in height e. cardiopulmonary failure

Treatment
Mild Scoliosis (<20 degrees) a. observation b. exercise & proper body mechanics Moderate Scoliosis (20-40 degrees) Goal : Prevent worsening of curve a. Milwakee brace b. Boston jacket Severe Scoliosis (>40 degrees) a. Spinal Fusion with Insertion of rod

Treatment
Mild Scoliosis (<20 degrees) a. observation b. exercise & proper body mechanics Moderate Scoliosis (20-40 degrees) Goal : Prevent worsening of curve a. Milwakee brace b. Boston jacket Severe Scoliosis (>40 degrees) a. Spinal Fusion with Insertion of rod

Pediatric poisoning

Which is Candy?

Sweet Tarts vs. Ecstacy

Physiologic Differences
Increased body surface area can lead to thermoregulatory issues.
Children reside lower to the ground. This puts them at higher risk for ingesting compounds heavier than air. Often adults will NOT have the same exposure. Inability to avoid hazards they do not read warning labels or Do Not Enter signs.

Definitions
A poison exposure is the ingestion of or contact with a substance that can produce toxic effects. A poisoning is a poison exposure that results in bodily harm. Poison exposures can occur by accident without intent, and these exposures are defined as unintentional poisonings. In some situations, poison exposures are the result of a conscious, willful decision; these cases are defined as intentional poisonings.

Poisoning agents

Poisoning agents

Pediatric Poisoning
susceptible : toddlers & adolescents modes of exposure - ingestion (majority) - ocular - skin TYPES OF POISONING a. Acute b. Chronic

 Aspirin Analgesic cold medicines Toxic dose : 150-200 mg/kg Acute: severe toxicity occurs 300-500 mg/kg Peak Effect : 2-4 hours

Salicylate Poisoning

Nursing Care: a. syrup of ipecac or gastric lavage is performed b. activated charcoal to decerease absorption of salicylate c. Seizure precautions d. Emotional support to child & family

 analgesics anti-pyretic Toxic dose : 150-200 mg/kg Peak effects : 30 minutes-4 hours Major risk : SEVERE HEPATIC DAMAGE Nursing Care a. Assist in emergency management b. Administer Antidote *ACETYLCYSTEINE (Mucomyst) Dilute in juice or soda because of its offensive odor

Acetaminophen Poisoning

Lead Poisoning
-lead-based paints - newsprints -ceramics - automobile emisions -pencils - toothpaste tubes Health Hazard : > 15 ug/dl Symptoms Appear : >70 ug/dl Nursing Care a. Administer chelating agents *CALCIUM EDTA & DIMERCAPROL b. Provide nutritional counseling c. Eliminate conditions leading to lead ingestion

Management Considerations
Decontamination
Priority after stabilization Activated Charcoal is preferred method, and may be indicated even in the patient with equivocal exposure history
Adsorption of toxins to prevent their absorption Dependant on toxin
Heavy metals (lead, arsenic, mercury, iron), inorganic ions, boric acid, corrosives, hydrocarbons, alcohols, and essential oils are generally not well adsorbed by charcoal

Dependant on surface area of the charcoal preparation

Use 1g/kg prepared in slurry with a cathartic and chocolate milk, cola, fruit syrup. Can be repeated every 4-6 hours at the dose, and multiple doses can help interrupt enterohepatic circulation. Efficacy decreases over time; gastric lavage that follows or preceded and follows may be more effective than charcoal alone. Contraindications in child with depressed levels of consciousness and non-secure airway; caustics, hydrocarbons, ileus/perforation risk

Management Considerations
Decontamination
Priority after stabilization If ingestion has occurred within 1 hour, or a highly toxic substance is ingested that is usually not well bound to charcoal gastric lavage may be attempted; but no longer the routine Contraindicated if prior vomiting, hydrocarbon, unprotected airway, caustics, foreign body, at risk for hemorrhage Risk includes aspiration, trauma to anatomic structure.

Management Considerations
Whole bowel irrigation may be necessary in the ingestion of a sustained release product or toxin
Large volumes of balanced electrolyte solution used to decontaminate the GI tract Used in fewer than 1 percent, not well studied in pediatrics Can be useful in ingestion of enteric coated pills, illicit drug packets, large ingestions of substances that are poorly bound by activated charcoal Contraindicated in bowel obstruction, GI bleed, perforation, unprotected airway

Management Considerations
Ipecac syrup induces vomiting by stimulating central emetic centers.
No longer recommended for routine home use. Can be used only in the alert, conscious child over 6 mo who has ingested a potentially toxic amount of poison. (No longer routinely recommended to be used because of its questionable effect on outcome). Contraindicated in children less than 6mo, ingestion of a non-toxic substance, corrosive ingestion, hydrocarbon ingestion, altered mental status or airway compromise, GI bleed or coagulopathy,

Management Considerations
Ocular exposure requires copious irrigation with saline using a Morgan lens, measure pH and maintain at 7.5-8 Dermal cleansing with water or normal saline and subsequent identification:
Pay close attention to burns, pain, infection Water is absolutely contraindicated with reactive metals; use mineral oil instead Tar can be removed safely with vaseline

Management Considerations
Inhalation injuries need fresh humidified and oxygenated air
Treatment with B-agonists, corticosteroids Removal of offending environment

Hemodialysis and Hemoperfusion

Require anti-coagulation

Management Considerations
Prevention Strategies/Themes-primary
Store potentially toxic substances in higher places or out of reach/sight Store safe items within the childs reach; dont take medicine in front of kids Child-proof latches Avoid chemicals in the fridge, or insect traps that are accessible Remove toxic plants; avoid exposure to toxic animals Keep matches, combustibles out of reach Dispose of partially consumed alcohol Carbon monoxide detection system Read labels on products carefully Advocate for protective legislation

Store Products Safely

Keep all products locked up. Non-food products should be out of sight and reach of children and pets. Follow the directions for storage on the label. In general, storage areas should be cool, dry and away from living areas. Never store food and non-food items together.

 Keep products in their original containers. If the label is gone - dispose of properly. Never use milk, soft drink or other food containers for storage. Store medicine properly - keep them locked up and use child-resistant containers. Always replace caps tightly. Store alcoholic beverages safely - liquor cabinets should be locked or have safety latches.

 Return products to safe storage as soon as you finish using them. Clean out storage areas regularly. Check expiration dates and get rid of outdated products, especially medicines. Keep your purse out of reach of children and pets. Avoid storing medicine, vitamins, cigarettes and perfume in your purse.

 Dispose of products safely. Read directions for disposal on the label or contact Board of Health. Keep trash in covered receptacles, out of the reach of children and pets. Ask your pharmacist how to properly dispose of unused or outdated medicines.

 1. Teach children about the dangers of tasting unknown substances. Putting things in their mouths is one way for kids to discover the world around them. So its important to teach them early on that tasting may not be the best nor the safest way for them to satisfy their curiosity.

 2. Never store toxic substances in food and beverage containers. The most common cause of poisoning in Filipino children is accidental ingestion of kerosene. In a misguided effort to recycle, households often put paint thinner in juice bottles, formaldehyde in mineral water bottles, fertilizer in milk cans, and multivitamins in candy jars. Even if children are taught not to taste nonfood items, they will likely be confused if the dangerous substances are stored in food jars. A preschooler wont be able to read the label gasoline on a cola bottle.

 3. Store medicines and toxic chemicals properly. Keep medicine out of childrens reach, in a high compartment, or in a locked box. Also remember that the active ingredients of drugs are often sensitive to high temperatures, so it's important to store the drugs as indicated on the packaging. Some drugs become less efficacious, but there are some that become more toxic when heated.

 4. Do not transfer medications from one child to the other.

Consult your doctor about doses. In particular, do not use pediatric drops for older children. Pediatric drops are usually strongerthere are more milligrams of the drug in each unit of fluid. Giving a double or triple dose to an older child might lead to a fatal overdose.

 5. Dont mix cleaning chemicals. A cocktail of cleaning agents wont make a more effective toilet bowl cleaner. Remember those chemistry experiments with acids and bases? Mixing common cleaners might produce toxic gases.

 6. Know the dangers of personal care products. Because we use them for our bodies, we often forget that these products can be toxic when ingested in large amounts by children. These include nail polish remover, oils, lotions, and cosmetics. Some aromatic products are particularly attractive to kids.

 7. Choose the plants in your house and garden.

Remove all poisonous flora. Teach children not to eat wild roots, berries, or mushrooms unless under adult supervision.

 8. Check hobby materials. Many crafts require the use of toxic chemicalspaints and thinners, liquid glue, solders and flux, varnish, and photo developers. Be sure their containers dont leak. Open windows or turn on the fan when using them.

Child Abuse

CHILD ABUSE

Emotional
Neglect

Physical
Neglect

Sexual

Abuse

Abuse

Physical Abuse
Legal Definition Physical injury includes but not limited to lacerations, fractured bones, internal injuries, severe injuries or severe bodily harm suffered by the child Triptage of Information
History Given Presenting Injuries
Biomechanics

RED Flags
PARENTAL discrepancy between history & injuries incompatible history with development changing or varying story unreasonable delay in seeking care denial of injury hostility towards child BURNS dorsum of hands, feet & anogenitals repeated burns symmetric or patterned burns uniform thickness with clear borders delay in seeking care

Fractures months 80% abusive in children <18

Highly suggestive of Abusive Fractures - multiple, bilateral, symmetric - repetitive at different stages - complex, branched, > 3mm fractures - with intracrnial & visceral injury SHAKEN BABY SYNDROME *no fractures outside *baby with change in sensorium & in shocking state

Sexual Abuse
complete absence of hymenal tissue recent, partial or complete transection or laceration of hymen or anus presence of sperm presence of STD

Implications of Encountered STD

STD SEXUAL ABUSE ACTION

Gonorrhea
Syphilis Chlamydia

Certain
Certain Probable

Report
Report Report

C. Accuminatum
T. Vaginalis Herpes 1 Herpes 2 (oral) Bacterial vaginosis Candidiasis

Probable
Probable Probable Probable Uncertain Unlikely

Report
Report Report Report Follow-up Follow-up

Oncologic Disorders