NEWBORN

A. Immediate Care of the NB in DR

B. Immediate Care of the NB in
Nursery
C. Cephalocaudal Assessment
D. Physiologic Changes of the NB
E. Newborn Reflexes
F. Newborn Screening Test
G. Selected Newborn Condition
1
IMMEDIATE CARE OF THE NEWBORN: DELIVERY ROOM

1. ESTABLISH OF RESPIRATION
a. With head extension, clear the mouth and nose to prevent
meconium aspiration
b. After expulsion
* Place on SLIGHT TRENDEELENBURG position
(10-15 degrees angle ) to drain secretions.
* SUCTION briefly, gently from the mouth to the
nose using bulb syringe for shallow suctioning.
- Deep suctioning is contraindicated as this can cause
stimulation of the vagus nerve, laryngospasm and
bradycardia.

2
 * OXYGENATE in between suctioning using safe oxygen
concentration ( NOT MORE THAN 40% concentration )
- Excessive oxygen concentration can result to oxygen
toxicity leading to neonatal blindness:

RETROLENTAL FIBROPLASIA .

- CHOANAL ATRESIA is a congenital anomaly of

the nose where the posterior nares are not patent.
* check for patency of the nostrils by occluding
one nostril at a time.

3
2. KEEP WARM
a. DRY and WRAP newborn to prevent heat loss.
b. The newborn’s high temp. at birth 36.5 - 37.2 C- drops
quickly at birth because of losing heat by the PROCESSES of:
1. EVAPORATION 3. CONVECTION
2. CONDUCTION 4. RADIATION

3. APGAR SCORING
a. Done twice - 1 and 5 minutes after birth
* First APGAR SCORE is to detect the cardio-respiratory-
nervous functioning of the newborn
* Second APGAR score: used for planning nursing care

4
 APGAR SCORING

ADAPTATIONS 0 1 2
Heart rate Absent Below 100 Above 100
Respiratory Absent Weak cry Lusty cry
Effort respiration
Muscle Tone Limp, flaccid Some flexion Acute flexion
Reflex Irritability No response Grimace
Sneezing, crying
Color Blue, pallor Acrocyanosis Pink

Interpretation:
0-3 : POOR : severely depressed
needs resuscitation
5
 4-6 : FAIR : moderately depressed
needs suctioning and oxygenation

7-10 : GOOD : needs only routine

admission care

•Most important - HEART RATE

•Least important – COLOR
•But the first thing the nurse is able to evaluate-Respi
A score of 0 - means no HR
A score of 9 - means ACROCYANOSIS

6
4. PROPER IDENTIFICATION

a. Bracelets and foot tags can be used with

b. FOOTPRINTING - best way to identify

c. Identification is done BEFORE THE BABY IS
SEPARATED FROM THE MOTHER
5. CHECK FOR -
* Gestational Age
* Birth Injuries
* Congenital Defects
* Gross Anomalies

7
Immediate Care of
the Newborn in
Nursery
• Bathing
• Cord care
• Vit. K injection
• Credes Prophylaxis
• Vital Measurements
• Vital Signs
8
 IMMEDIATE CARE : NURSERY
1. Continue with measures to keep newborn warm
* Use droplight during admission care
2. CREDE’S PROPHYLAXIS or eye care
a. Done to prevent OPTHALMIA NEONATRUM
or gonorrheal conjunctivitis
b. Mandatory - done to all newborns
c. Drugs used - 1% Silver Nitrate 1-2 gtts into each
conjunctival sac and Terramycin ophthalmic 1 cm
from INNER TO OUTER CANTHUS
d. CREDE’S PROHYLAXIS is delayed for 1-2 hours
in order not to interfere with bonding process.
EYE-TO-EYE CONTACT is prerequisite to bonding.
9
3. SKIN CARE - done to prevent skin infection
a. OIL BATH : given to premature and high-risk newborns
and those with plenty of vernix caseosa
b. SOAP AND WATER bath : given to normal fullterm
4. CORD DRESSING
a. Strict asepsis prevents TETANUS NEONATORUM
b. CHECK for 1 umbilical vein and 2 umbilical arteries
* Report incomplete vessels
c. In the first 24 hours, check the cord for bleeding called
OMPHALANGHIA

10
5. VITAMIN K Injection

a. Mandatory, given to all newborns to prevent bleeding.

b. Reasons for bleeding tendency : gastrointestinal tract of
newborns INITIAL STERILE ------- no bacteria to synthesize
vitamin K ----- decrease clothing factor ----- bleeding tendency
c. Site for intramuscular injections in newborns :
Thigh muscles - VASTUS LATERALIS ( best site )
RECTUS FEMORIS ( alternate site )

11
6. Weighing and Taking of Other Antropometric
Measurement
Weight : 3000g - 3,400g (7-7.5 lbs.) - International Standard
: 6-6.5 lbs. - average birth weight of a Filipino newborn
* lower limit normal : 2,500 g
Height : 19 - 21 inches ( ave. 50 cm )
HC : 33 - 35 cm/13 -14 inches
CC : 31 - 33 cm/12 -13 inches
AC : 31 - 33 cm/12 -13 inches
7. Vital Signs
Checking when infants is asleep/quiet
8. Gentle, minimal handling and watchful eyes
12
C. CEPHALOCAUDAL
ASSESSMENT

13
 NEWBORN SKIN MARKS
1. LANUGO : fine, downy hair, more on preterms
2. VERNIX CASEOSA : whitish, cheesy, odorless usually on
folds of skin; more in full term
* protects skin and prevents heat loss
3. MILIA : white, pinpoint papules on the
nose/chin/cheeks
* disappears as early as 2 weeks or 3-4 weeks
4. MONONGOLIAN SPOT : grayish blue patch at the lower back
from accumulation of pigment cells melanocytes
* disappears school age
5. NEVI (STORK BITES) : red spots found at the back of the
neck and above eyelids
* disappears spontaneously before 1 year
14
6. ERYTHEMIA TOXICUM NEONATORUM : newborn rash
* pink papular rash appearing on the body within 24-28
hours after birth : harmless
* disappears within a few days

7. DESQUAMATION : dry peeling of the skin

particularly on the palm and soles, more in post terms

15
• Skin color: Acrocyanosis
Yellow –Erythroblastosis
Fetalis
Gray -- Infection
Blue -- Congenital
Heart Defects

16
2. Head

• Fontanelles – closure, shape , size

tense&bulging =ICP

sunken =DHN

CRANIOSYNOSTOSIS – premature
closure of the suture lines and
cranial bones.

17
Cont… Assessment

4 NECK - Webbed neck, torticollis

5. CHEST - Witch Milk – 1st – 3rd wk of life
6. ABDOMEN
7. BACK - SPINA Bifida
8. UROGENITAL - Brick red dust vs. greenish
blotches
- Phimosis. Epispadias,
hypospadias,hydrocele,cryptorchidism
7. MUSCULOSKELETAL - CHD , Clubfoot
8. SENSORY

18
 PHYSIOLOGIC CHANGES IN THE NEWBORN
1. Weight Loss : 7-10 days
* 5% to 10% of BW
* After day 10, weight gain of 1 lb per
month from 1-6 months
*BW is doubled at 6 months and tripled
at 1 year ,quadruples by 2 yrs.
2. Jaundice : 2-7 days full terms and
3-10 days for preterm
* N.Value : 2 – 6 mg/dl
* Mgmt: early morning sun exposure
decrease breastfeeding to every 3hrs

19
 * Because of liver immaturity and fetal
increase in RBC’s (polycythemia)
* Expose to morning sunlight, decrease
breastfeeding
3. Fever : 2-4 days
4. Physiologic Anemia : 4-6 months

20
 SIGNIFICANT NEWBORN REFLEXES

A. FEEDING REFLEXES
1. Rooting - if the cheek or corner of the mouth is
touched,
he turns to that side; for food location
*May disappears at 3-4 months when he can
2. Sucking - anything that touches
follow moving objectsthe lips is sucked; present
even before birth
2. Swallowing Reflex – anything put in the posterior tongue
will be swallowed
3. Extrusion Reflex – anything put in the anterior tongue
will be extruded or spit out. A reflex that will protect the
21
infant from ingestion of inedible object.
 B. PROTECTIVE
REFLEXES

1. Sneezing and coughing - protect and clear the air passages

2. Yawning - protects cells from depleted oxygen
3. Blinking - protects eyes from objects coming near it

* Protective reflexes are the only permanent reflexes while

the rest will disappear.

22
 • NEUROLOGICAL REFLEXES
2. MORO or STARTLE - embracing motion in the arms or the
upper and lower extremities will flexed then gradually
relaxes in response to loud noise, jarring of the crib
and falling sensation
* Nsg. Implications:
Absence – Brain Damage
Assymetrical -- Paralysis
Non disapperance -- Brain Damage
* Disappears by the end of 4th or 5th month

23
2. DARWIN - dancing reflex: few quick alternating steps when
the new born is held upright and his feet touch a hard surface
* Disappears at 4 month
* Implication if absent & legs scissors - Cerebral Palsy
3. MAGNET - If pressure is appLied on the soles of the feet
while infant lies supine, he pushes back against the pressure
* A test of spinal cord integrity
4. CROSSED EXTENSION - if one leg of a newborn lying
supine is extended and the sole is irritated by rubbing it with a
sharp object, he will raise the other leg and extend it as if trying
to push away the hand irritating the first leg
* A test of spinal cord integrity

24
Cont…

5.TNR/FENCING/BOXING – newborn
lying supine position when the
head is turned to one side, the
upper & lower extremities of that
side will extend while the opposite
will flexed
6. BABINSKI – fanning of the toes
results when the soles of the feet
is stroked with inverted ”J”.
25
 INBORN ERRORS OF
METABOLISM
Inherited disorders caused by absence of a substance essential to
cellular metabolism

Characterized by abnormal fat, protein, or carbohydrate metabolism

Usually inherited as autosomal recessive trait

26
Phenylketonuria (PKU)
Data Base
• A. Lack of the enzyme phenylalanine
hydroxylase, which changes phenylalanine
(essential amino acid) into tyrosine

• B. Clinical findings
– 1. Mental retardation from damage to the nervous
system by buildup of phenylalanine if untreated
• a. Often noticed by 4 months of age
• b. IQ is usually below 50 and most frequently under 20
– 2. Strong musty odor in urine from phenylacetic acid
– 3. Absence of tyrosine reduces the production of
melanin and results in blond hair and blue eyes
– 4. Fair skin is susceptible to eczema

27
Phenylketonuria (PKU)
C. Therapeutic interventions
• 1. Guthrie blood test: testing should be done after
protein ingestion;if testing is done during initial 24
hours, it should be repeated by the third week of life

• 2. Early detection is essential

• 3. Dietary: low-phenylalanine: use Lofenalac or PKU-1 as

a milk substitute and restrict foods to those low in this
amino acid
– a. Use of phenylalanine-free formulas such as PKU-2 or
Phenyl-Free for children over 3
– b. Dietary restrictions of phenylalanine through
adolescence and possibly for life
– c. Individuals with phenylketonuria who become pregnant
mustconsume a low-phenylalanine diet
• 4. Treat eczema

28
Galactosemia
Data Base
• A. Missing enzyme that converts
galactose to glucose

• B. Clinical findings
– 1. Jaundice develops
– 2. Weight loss/vomiting
– 3. Hepatosplenomegaly
– 4. Cataracts

29
Galactosemia
C. Therapeutic interventions
• 1. Early detection: test for galactosemia
at birth; Beutler test(method similar to
Guthrie test for PKU) mandatory in
many states
• 2. Dietary reduction of lactose: use a
soy-based formula as a milk substitute
and restrict foods to those low in lactose
(usually continued until the child is 7 to
8 years of age), followed by a dietary
modification throughout life
30
Congenital Hypothyroidism
Data Base
• A. Failure of embryonic
development of the thyroid gland
or inborn enzyme defect in the
formation of thyroxine

31
Congenital Hypothyroidism
B. Clinical findings
• 1. Prolonged physiologic jaundice,
feeding difficulties, inactivity(excessive
sleeping, little crying), anemia,
problems resulting from hypotonic
abdominal muscles (constipation,
protruding abdomen, and umbilical
hernia)
• 2. Appears at 3 to 6 months of age in
formula-fed babies; may be delayed in
breastfed babies
32
Congenital Hypothyroidism
3. Impaired development of nervous system leads to
mental retardation; level depends on degree of
hypothyroidism and interval before therapy is begun

4. Decreased growth and decreased metabolic rate

resulting in increased weight

5. Characteristic infant facies: short forehead; wide, puffy

eyes;wrinkled eyelids; broad, short, upturned nose;
large, protruding tongue; hair is dry, brittle, and
lusterless with low hairline

6. Skin is mottled because of decreased heart rate and

circulation

7. Skin is yellowish from carotenemia resulting from

decreased conversion of carotene to vitamin A
33
Congenital Hypothyroidism
C. Therapeutic interventions
• 1. Detection: neonatal screening for
thyroxine (T4) and thyroid-stimulating
hormone (TSH)
– a. Test is routine and mandatory in many
areas
– b. Performed by heel-stick blood test at the
same time as other neonatal metabolic
tests
• 2. Treatment: replacement therapy with
thyroid hormone; if therapy begun
before 3 months of age, chances for 34

normal growth and normal IQ increased

I. IMPETIGO
A. Bacteria infection of the superficial layers of the skin
invaded by streptococci, staphylococci, or pneumococci;
commonly found on the face
B. Causes; poor skin care; overcrowding, malnutrition
C. Characteristics: vesicle like, papules. Pustules, crusts
D. Treatment: meticulous hygiene of skin;
hexachlorophene scrubbing of lesions, antibiotics for
widespread lesions to prevent nephritis and rheumatic fever.
II. BOILS/FURUNCLES
A. Bacterial infection of hair follicales common face
neck, axilla buttocks
B. Progresses from papules to postules than hard
tender, hot nodless which form a pus ‘point’
35
 Selected Newborn Condition

1. Hypoglycemia
2. Hypothermia
3. Hyperbilirubinemia
4. Erythroblastosis Fetalis
5. RDS or Hyaline Membrane
Disease
6. LBW
7. Premature vs. Postmature
36
 SELECTED NEWBORN CONDITIONS

I. HYPOGLYCEMIA

A. Etiologic Factors - babies born to diabetic mother,

prematurity, postmaturity, SGA, birth injuries,
congenital defects, low APGAR, inadequate intake,
stresses (cold stress, difficult birth, CS)
B. S/S-high pitch cry, poor sucking &feeding, irritability,
jitteriness, apnea, tachypnea, tremors, and convulsion
C. Nursing Implementation

37
C. Nursing Implementation
* Give oral glucose
* Administered ordered 10%-25% IV glucose; monitor
rate of flow strictly to prevent hyperglycemia
* Keep warm
* Prevent infection : handwashing - best measure
* Prevent convulsion : decrease environmental stimuli
* Monitor VS, behavior, serum glucose
* Handle gently
38
II. HYPOTHERMIA - low body temperature less than 36.5 C
A. Etiologic Factors - prematurity, postmaturity, SGA,
malnourished newborn ---- absence of inadequate brown
fat to burn and with increased body surface area
compared to decreased body weight
B. Danger signs - low body temperature, mottling,
cyanosis, crying, increased activity, tachypnea
C. Nursing Implementation
* Keep warm : maintain in incubator (best place for
maintaining body warmth)
* Prevent heat loss by evaporation, conduction,
convection and radiation. ( Most heat is lost by radiation.)
* Oxygenate PRN
* Monitor temperature per axilla
39
III. HYPERBILIRUBINEMIA-increase serum bilirubin more
than 12-13 mg%
* Normal serum bilirubin in newborns - 2-6 mg%
A. Etiologic Factors - Rh and ABO incompatibility, infection,
prematurity, drugs, breastfeeding (because of pregnanediol)
polycythemia
B. Assessment Findings -
* pathologic jaundice ( present in first 24 )
* dark, concentrated urine or tea colored urine
* lethargy, poor feeding
* Pallor due to hemolytic anemia
C. Treatment : phototherapy and exchange transfusion
D. Nursing Responsibility - Detect and report early
pathologic jaundice
40
 IV. HEMOLYTIC DISEASE OF THE
NEWBORN ERYTHROBLASTOSIS FETALIS

A. Blood incompatibility characterized by :

1. Hemolytic anemia 2. hyperbilirubinemia

B. Types : Rh incompatibility and ABO incompatibility

* Rh incompatibility is more severe: does not usually
affect the first child.
C. Danger Signs : severe paleness at birth and pathologic
jaundice ( appears in the first 24 )

41
D. Diagnosis : COOMBS’ TEST
* Direct Coombs’ test uses newborn blood mixed with
Coombs’ reagent whereas indirect Coombs’ test uses
maternal blood mixed with Rh (+) bllod.
* Positive result : with RBC agglutination; mother has
produced antibodies ( + isoimmunization )
* Negative result : without RBC agglutination ; mother
has not produced antibodies yet (- isoimmunization )
E. Prevention : RhoGAM
* RhoGAM is given to an RH (-) mother, with Rh (+)
fetus. Abortus or ectopic pregnancy, with negative
COOMBS’ Test, for every delivery of preterm or
fullterm, and stillbirth infant, and for every
amniocentesis
* Action - destroys fetal antigens ( fetal RBC’s ) before 42
mother produces antibodies.
 * Given intramuscularly in the first 72Hrs@ a dose of
300ug/kg
F. Treatment : phototherapy and exchange transfusion
PHOTOTHERAPY - decreases serum bilirubin
Nursing Responsibilities :
* Undress infant leaving diapers
* Cover eyes with eye shield
* Have light 16 inches away from infant
* Turn gently every 2 hours
* Give sterile water in between regular milk feedings
* Monitor temperature, I & O, serum bilirubin, jaundice
and side effects: rise in temperature & dehydration

43
 Retinal damage if eyes are not shielded, sterility if
genitalia is not covered, respiratory distress if shield is
not properly anchored.
EXCHANGE TRANSFUSION - decreases serum bilirubin
and maternal antibodies, and elevates hemoglobin
Nursing Responsibilities :
* Have appropriate blood ready : Rh (-) and type ( O ),
fresh, at room temperature with hematocrit 50% + and
pH 7.1 or as specified by the physician; heparinized.
* Check VS before and q 15 min. during especially CR.
* NPO 3-4 hours before or aspirate stomach to prevent
vomiting and aspiration
* Have resuscitative equipments ready
* Place infant on his back with arms and legs restrained
44
and under radiant warmer
* Albumin (1gm/kg) maybe given 1-2 hours before to
allow more binding sites for bilirubin making exchange
more effective.
* Note and record the time of exchange more effective.
* Note and record the time of exchange; monitor
exchanges - 10% calcium gluconate maybe given after
each 100 ml. of blood exchanged to prevent
hypocalcalcemia.
* Protamine sulfate maybe given after the exchange
transfusion to prevent bleeding.
* After transfusion: leave umbilical catheter with IV plug
for a repeat exchange or remove catheter, small pressure
dressing applied and site observed for bleeding.
45
V. RESPIRATORY DISTRESS SYNDROME/HYALINE
MEMRANE DISEASE

1. Pulmonary condition common in preterms and

characterized by hyaline membrane formed in the alveoli
causing atelectasis.
2. Etiologic Factors : prematurity, hypothemia, acidosis
hypoxia
3. Main pathologic finding : inadequate surfactant
4. Major Assessment Findings :
* Expiratory grunting * Tachypnea (more than
* Flaring 70/min.)
* See-saw breathing * Chest retractions: and
xiphoid process lower chest 46
 THE PREMATURE INFANT
A. Also called LOW-BIRTH-WEIGHT infant
B. Classification of newborn infants is now based on
GESTATIONAL, AGE AND BIRTH WEIGHT
* The better measure is gestational age
C. Low-birth-weight is one weighing 2,500g (5 1/2 lbs) or less
D. An infant born at term, 37 weeks or over, is a fullterm
whereas an infant born before completed 37 weeks is a
preterm
E. A full-term infant maybe of low-birth-weight
F. Prematurity is the leading cause of neonatal deaths because of -
1. Respiratory distress syndrome - leading cause of deaths
2. Intracranial hemorrhage
3. Infection/sepsis 4. Congenital defects 47
THE PREMATURE INFANT AND POSTMATURE INFANTS

THE PREMATURE INFANT POSTMATURE INFANTS

A. Born at 36 weeks or less A. Born at 43 weeks or over

B. Low-birth-weight, poorly B. Low-birth-weight: with
developed muscles and fatty placental insufficient from
tissues aging process
C. Weak, lethargic with poor C. Wide awake, mentally alert
muscle tone and reflexes
D. Skin : red, wrinkled, trans- D. Skin : greenish (meconium-
parent to translucent with visible stained) leatherly desquamating,
capillaries, less sub- cutaneous parchment-like, absent or slight
fats. MORE LANUGO, LESS lanugo and vernix caseosa
VERNIX CASEOSA
48
THE PREMATURE INFANT POSTMATURE INFANTS

E. ASSOCIATED PROBLEMS E. Associated Problems

1. Respiratory Distress Syndrome 1. Meconium Aspiration
2. Hypothemia 2. Hypothemia
3. Hypoglycemia 3. Hypoglycemia
4. Hyperbilirubinemia 4. Polycythemia =
hyperbilirubinemia
5. Infection 5. Infection
6. Rickets and Anemia
7. Mental Retardation from
Kemicterus
8. Retrolental Fibroplasia
49
 GROWTH & DEVELOPMENT
• Definition
• Rates of G & D
• Factors Affecting G & D
• Principles
• Theories
• DDST / MMDST

50
 FACTORS IN INFLUENCING GROWTH
AND DEVELOPMENT

HEREDITY
* Sets the upper limits of growth

ENVIRONMENT - prenatal, natal, postnatal

* Most important especially post-natal’s
HEALTH & NUTRITION

SOCIOECONOMIC STATUS
RACE and CULTURE:
Tay Sachs Dse - Ashkenazi Jewish
Sickle Cell Anemia - Black Americans
Celiac Dse - Europeans
Thalassemia - Mediterrenean
51
 PRINCIPLES OF GROWTH AND DEVELOPMENT
1. Each child is INDIVIDUALLY UNIQUE.
2. Each child is COMPETENT, equipped with capacity for
growth and development
3. Upper limits of growth and development that can not be
surpassed exist. Heredity sets the upper limits.
4. Growth is a regular process occuring the in an ORDERLY,
PREDICTABLE sequence and directions.
DIRECTION AND GROWTH
Cephalo-caudal: from head to toes.
Proximo-distal: from the center to periphery
General to specific / grows to refined; simple to complex
52
5. Each individual grows AT HIS OWN RATE.
6. Different body parts grow at different rates.

7. There are critical period of growth and development

8. Development continous throughout life.
* Although physical growth may cease development occurs
throughout life with new skills and knowledge acquired if
basic potential is present.

9. There is an inherent urge for an individual to grow and

develop
10. Growth and development are influence by many factors.

53
 PHYCHOSOCIAL THEORY OF PERSONALITY
DEVELOPMENT (ERIC ERIKSONIAN THEORY)

The most commonly used by health professionals

INFANCY : trust vs mistrust
TODDLER : autonomy vs shame and doubt
PRESCHOOLER : initiative vs guilt
SCHOOLER : industry vs. inferiority
ADOLESCENCE : identity vs. role diffusion
YOUNG ADULT : intimacy vs isolation
LATER ADULT : generativity vs self-absorption
SENeSCENE : adapts to triumphs and
disappointments with a certain ego
integrity. 54
 PHYCHOSEXUAL THEORY OF PERSONALITY
DEVELOPMENT (SIGMUND FREUD’S THEORY)

INFANCY : ORAL phase stage of “ID”

TODDLER : ANAL phase stage of the “Ego”
PRESCHOOLER : PHALLIC stage
ELECTRA COMPLEX - the daughter is attached to
daddy and is jealous of mommy
OEDIPAL COMPLEX - the son is attached to mommy
and is jealous of daddy.
Stage of “Superego”
SCHOOLER : LATENCY stage
stage of “Strict superego”
ADOLESCENCE : genital stage
55
 DDST / MMDST
• Target age group
• Pre-requisite
• The first nsg. Procedure
• 4 sectors:
Personal – Social
Fine Motor
Language
Gross Motor

56
 SIGNIFICANT PERSONS
INFANCY : Mother, mother substitute
Primary Caregiver
TODDLER : Parents
PRESCHOOLER : Members of the Basic Family
SCHOOLER : Teacher
Peers of SAME SEX: neighbors and
classmates; Adults other than parents are
“HERO - WORSHIPPED”
ADOLESCENCE : Peers - greatest determined of his behavior
Models of leadership
Sexual models
* Adults other than parents are IDOLIZED Partners
of same and OPPOSITE SEX ( Establish close
relationship with opposite sex )
57
 FEARS OF CHILDREN

INFANCY : Stranger Anxiety

* Starts at 6 months; peaks at 7-8 months
TODDLER : -Separation Anxiety
* Phases : protest, despair, denial
PRESCHOOLER : -Castration fears; ghost, dark and
inanimate objects
SCHOOLER : Fear of Displacement or Replacement
Fear of death, disease and body injury
ADOLESCENCE : Fear of loss of identity: acne, obesity,
Homosexuality, body odor, Fear of
Unknown, Fear of Disease, death

58
 LEADING ACCIDENT/CAUSES OF INJURIES IN
CHILDREN
INFANCY : aspiration (leading)
Falls, suffocation, burns; poisoning - lead paint
TODDLER : falls (leading)
Burns, drowning; poisoning ( most common drug
that poisons)
* The natural curiosity of the toddler leads him to accidents.
PRESCHOOLER : Motor accident (leading) burns, drowning
SCHOOLER : Motor accident (leading) Sports accident
ADOLESCENCE : Motor vehicular
Sports accidents, burns, drowning
Drug, Alcohol, Suicide
59
 + DEATH & DYING +
• INFANCY - no concept of d/d
• TODDLER -
temporary,reversible
• PRE-SCHOOL -
temporary,punishment
• SCHOOL AGE - final,permanent, or
irreversible
• ADOLESCENCE- universal
60
 PLAY - THE LANGUAGE OF THE CHILD
TYPES OF PLAY
INFANCY : SOLITARY play
* He plays alone with his body or his toys
TODDLER : PARALLEL play
* He plays alone in the presence of the other
children; no sharing
PRESCHOOLER : ASSOCIATIVE / COOPERATIVE play
* He plays with the others; can be with large
group of boys and girls
SCHOOLER : COMPETITIVE play
* Plays with peers of same sex; games have rules
where winning is desired.
61
ADOLESCENCE : RECREATION/LEISURE activities
* Can be with friends of same and opposite sex
* Leisure activities are meant to get closer to
friends of opposite sex.

GAMES/TOYS FOR CHILDREN

INFANCY - Rattles, cribmobiles (best) teethers, pacifiers, musical
boxes, squeeze toys, large cuddly toys
“Peek-a-boo” game played at 10 months

TODDLER - push and pull toys (best) building blocks, ball play
telephone ( age of language training ) play hammer,
drum, ball pots and pans (outlets for aggressive
behavior) dolls (security blanket),riding rocking
horse.
62
PRESCHOOLER - tricycle (can ride it at 3 years) play house,
coloring books, clay cutting and pasting tools,
superheroes and costumes dress-up dolls, ball

SCHOOLER - bicycle (can ride it at 7 years) quiet games like

reading, painting, radio, T.V., family computer, sport
games, table games, like scrabble handicrafts (late
schooler)

ADOLESCENCE - parties, outings, picnics, movies, fantasy and

daydreaming (normal) telephone/conversations,
reading romance novels, sports games hobbies.

63
 CALORIE REQUIREMENTS OF CHILDREN

Newborn 400 (45-55 kcal/lb or 80-120cal/kg)

Infant 800 - 1200

Toddler 1300

Preschooler 1700

Schooler 2400

Adolescence 2200- 2700

Males have higher caloric requirements

64
 FEEDING PROBLEM IN CHILDREN

I. Infancy
Aspiration tendency Burping
Colic - more common Weaning
Supplementary food introduction
Diarrhea
Food allergies

II. Toddlers
Physiologic anorexia
Iron-deficiency anemia

65
III. Preschool
Food likes and dislikes

IV. School
Food junks
Zero-caloric foods (soft drinks)

V. Adolescence
Food fats
Obesity
False dieting
Anorexia Nervosa
Iron-deficiency anemia
66
 THE TODDLER
I. Behavioral traits :
A. Negativism ; “no” - “no” age
* an attempt to show autonomy
B. Temper tantrums ; crying and screaming when he does
not get what he wants
* an attempt to show autonomy and NOT a sign of poor
discipline
C. Ritualism ; doing thing over over and over again
RESPECT HIS RITUALS; if hospitalized, adhere to his
rituals to minimize separation anxiety
D. Dawdling : slowness in accomplishing tasks
* be patient ; allow to dawdle; do not give him tasks he
cannot accomplish
E. Egocentricity ; selfishness *normal 67
II. Developmental Tasks: Toilet Training, Dentition,
Language Training, & Discipline

I. Language Training Principles

A. Teach one language at a time
B. Talk to child in simple, clear words
C. Do not baby talk
D. Talk to child at eye level
E. Provide a good model of speech
F. Provide plenty of sensory stimulation
II. Schedule
9-10 mo : says 2 words “ma” and “pa”
11-12 mo : says 4-5 words with gesture language
18 mo : has 20 words
68
 TOILET TRAINING

A. Sphincter control - most important

B. Ability to understand and walk to the bathroom
C. Understands the act of elimination
D. Can express need to eliminate
E. Desire to please the mother

69
 DISCIPLINE IN CHILDREN

I. FORMS OF DISCIPLINE
Ignoring
Diverting attention
Time - out
Corporal punishment
Explaining, reasoning and reprimanding for
other children
Withdrawal of privileges

II. PRINCIPLES OF GOOD DISCIPLINE

A. Consistency

70
B. Discipline a toddler RIGHT WAY after wrongdoing
C. Explain the reason for discipline and allow child to
explain first
D. Disapprove of the behavior and NOT OF THE CHILD
E. Withdraw privileges and NOT BASIC NEEDS.
* You don’t send a child to bed without food for a
wrongdoing
F. Provide physical care after “ignoring” of temper tantrums
G. Methods of discipline should be SAFE.

71
 BREASTFEEDING REFLEXES

A. Milk secretion reflex - Prolactin reflex

* The best way to stimulate mild secretion reflex is to
TOTALLY EMPTY the breast with each feeding --
always start with the breast that was used last.

B. Milk ejection reflex - Letdown reflex

* Licking and sucking of the nipples plus POSITIVE /
RELAXED MATERNAL ATTITUDE stimulate the
letdown reflex
* Most important to success of breastfeeding

72
 “ESSENTIALS” OF BREASTFEEDING

A. START
* Right on the delivery table PRIMARILY to promote
bonding.
* 30 min. after birth in normal spontaneous delivery
* 4 hours after cesarean section

B. DURATION OF FEEDING

* 5 min. per breast after establishment of feeding :

- the first 10 min. for nourishment
- the 2nd 10 min. is for sucking pleasure
- total breastfeeding time: 20 min.
73
 MILK STOOLS

Breastfed Formula fed

1st 24 hrs of Meconium Blackish

life green
=
2nd – 3rd day Transition Brownish
of life green
al
3rd-5th day stools
Golden Pale yellow
onwards yellow formed 74
loose
 SUPPLEMENTARY FEEDING

A. REQUISITES/CUES TO START SOLID FOODS

1. Feeding reflexes are fading
2. Can sit with support
3. A Nutritional requirement for iron to be met
4. Developed salivary glands and presence of intestinal
enzymes needed for digestion
B. SCHEDULE : Earliest (4 mos) Best time(6 mos)
C. SIMPLE RULES TO FOLLOW
* Introduce one food at a time
* Small amount ( 1 tsp.) each time
75
 * Have an interval of 4-7days to 2 weeks between new foods
to detect what food he is allergic to
* Do not mix new food with formula

* Do not force, bribe, plead nor threaten

D. SEQUENCE OF INTRODUCING SOLIDS
1. Cereals
2. Vegetables (yellow, green, eggplant)
3. Fruits
4. Egg
5. meat
6. citrus fruits & ascorbic acid
76
 MARASMUS
I. Synonyms : infantile stropy, inanition, athrepsia
II. Marasmus is caloric malnutrition
III. Causes -
* insufficient diet
* improper feeding habits
* emotional cause - disturbed mother-child relationship
* metabolic disorders
* congenital malformations
IV. Signs -
* underweight, emaciated
* “old-man’s” facies
* all skin and bones look
77
 * pot belly (distended abdomen)
* skin wrinkled and loose with no subcutaneous fat
* muscle wasting
* hypotonia, hunger
* subnormal temperature, slow pulse
* usually constipated or with “starvation diarrhea -
frequent, small tools with mucus

V. Treatment :

FOOD - Increase calories in the diet

78
 KWASHIORKOR
I. This is PROTEIN MALNUTRITION
II. Cause -
* insufficient protein intake
* impaired protein absorption - diarrhea
* abnormal losses - proteinuria in nephrosis
* infection
* burns
III. Signs -
* lethargy, apathy, irritability
* edema
* loss of muscular tissue
* with hair sign - flag sign : thinning, straight with
alternate - dark light bands
79
 THE ILL AND HOSPITALIZED CHILD

I. Factors Affecting Responses To Illness And Hospitalization

A. Developmental stage in which child is in
B. Nature of illness or injury; seriousness of illness or injury
C. Level of anxiety of both child and parents
D. Type of relationship that exists between parents & the child
E. Past experiences with hospitalization, medical treatments
and surgical procedures
F. Support systems
G. Sociocultural status, race culture and education
II. Major Sources of Fears of Hospitalization
A. Separation D. Immobility
B. Pain E. Body Injury
C. Loss of control F. Punishment and rejection
80
 Preparation Of Child For Admission

1. Under 2 years : explanations are ineffective

: allow to take security blanket - the
favorite toy or objects

2. 2-7 years : tell child ahead in days equal to years of age

: c.g. 2 years old = tell the child 2 days ahead;
5 years = 5 days ahead

3. Over 7 years : determine what parents know

4. Adolescent : provide him with full explanations; answer

questions completely and honestly.

81
NEUROLOGIC AND COGNITIVE DYSFUNCTION

1. Hydrocephalus
2. NTDs or Neural Tube Defects
3. Epilepsy and Seizure disorder
4. Cerebral Palsy
5. Mental Retardation
6. Down’s Syndrome
7. Reye Syndrome
8. Lead Poisoning (Plumbism)

82
GASTROINTESTINAL DYSFUNCTION

1. Cleft lip and palate

2. Tracheoesophageal fistula
3. GER /Chalasia
4. Pyloric Stenosis
5. Intussusception
6. Celiac Disease
7. Hirschsprung Disease
8. Imperforate Anus

83
 CHALASIA/ GER

A. Abnormal relaxation of the cardiac sphincter of the

stomach resulting to self-limiting vomiting.

B. Etiology : unknown; common in babies of tense mothers

C. Signs and symptoms

a. Self-limiting, non-projectile, non-bile vomiting
b. Regurgitation after feeding
c. Dehydration
d. Increased hunger
e. Weight loss
D. Effect of frequent vomiting : METABOLIC ALKALOSIS

84
E. Nursing Care :
1. Correct feeding techniques
- Feed slowly in upright position
- Burp/bubble frequently
- Do not overfeed ( overfeeding is the most common
cause of vomiting )
- Maintain upright for 30 minutes more after feeding
- Put on right side after
- Refeed with thicker formula ( more difficult to vomit )
- Allow play before feeding time to relax mother
2. Provide psychological support
1. Encourage verbalization of concerns and feelings
about feeding/breastfeeding
3. Observe for signs dehydration.
85
 PYLORIC STENOSIS
A. Congenital hyperthrophy / hyperplasia of the muscle of the
pylorus causing obstruction of the pyloric sphincter
B. Etiology : unknown
C. Signs and Symptoms
1. Non-bile,projectile vomiting
2. Increasing hunger, dehydration in children
3. Visible gastric peritalsis
4. Olive shaped mass @ the RUQ
5. Abdominal distention
6. S/S of Fluid&electrolyte imbal as well as DHN

86
 b. As the child cries, gas in colon rises to reveal pouch in
relation to anal membrane
c. X-ray pictures taken ) no need for dye=danger of
aspiration
D. Treatment : Surgery
a. Anoplasty for the simple type
b. Pull-through operation with or without temporary
colostomy
E. Nursing Care
1. Provide preop care :
- Npo - NGT to decompress stomach - Warmth supervision
- VS monitoring - Prepare parents for surgical procedure
& for temporary colostomy if necessary
87
2. Provide postop care a. Prevent infection
* meticulous skin care : provide perirectal care with anoplasty
or pull through procedure observing strict aseptic techniques

b. Administer and maintain IV fluids

* Monitor rate of flow ( single most important in caring for a
child with IV therapy )
* Maintain strict I & O * Check weight daily
c. Provide oral feedings
* With pull-through, begin oral feedings slowly when peristalsis
returns
* With colostomy, begin oral feedings slowly tools are passed
d. Provide parental teaching : colostomy care if appropriate
88
 * empty pouch as needed * change pouch as necessary
* skin care
- clean peristomal area with mild soap and water, dry
thoroughly, apply clean pouch
- use skin barrier as ordered to protect skin from irritation

HIRSCHSPRUNG’S DISEASE / CONGENITAL MEGACOLON

A. A mechanical obstruction of the bowels due to the absence of

autonomic parasympathetic nerve ganglion cells in the distal
bowel = inadequate motility
B. Etiology :
a. Real cause is Unknown
89
C. Signs and Symptoms
1. Newborn - No meconium stools in 24-48 hours
- Bile-stained vomitus
- Feeding difficulties
2. Infants - Chronic constipation
- Explosive diarrhea
- Abdominal distention
3. Older Children
- Chronic constipation - hallmark
- Ribbon-like stools like pellets
- Palpable fecal masses
- Fecal odor of the breath
- Abdominal distention
- Abdominal pain :
irritability, crying
- Hallmark of megacolon
- Bile-stained vomiting
- Failure to thrive /
malnutrition
- Abdominal distention
- Visible peristalsis
- Anemia - Malnutrition
90
D. Diagnosis
Barium Enema Abdominal X-ray
Rectal biopsy : confirms megacolon
E. Treatment Surgery
a. Bowel resection with temporary colostomy
b. Abdomino-perineal pull-through by about 1 year
F. Nursing Care
a. NPO - pacifier (newborn) b. NGT c. I & O
d. Provide emotional need-touch, pacifier, consistent parental care
f. Administer : - low resudue, high-protein, high calorie diet if
appropriate (childhood) - parental nutrition as ordered
g. Bowel cleansing - Liquid diet - Stool softeners as ordered
-digital removal - daily isotonic saline enemas/colonic irrigation
91
c.) Keep incision site clean and dry
d.) Assess for correct colostomy functioning/provide colostomy
care : emphasize meticulous skin care
e.) Provide pain relief - analgesics PRN
f.) Monitor for signs of complications
+ Skin infection
+ Respiratory infection; coughing; deep-breathing, turning
every two hours
g.) Maintain NG tube to low suction; maintain patency
h.) Provide psychological support
+ stroke, hold, cuddle infant
+ explain to parents diagnostic and treatment procedure
92
Intussusception
Data Base
• A. Telescoping of one portion of
the intestine into another; occurs
most frequently at the ileocecal
valve
• B. Males affected two times more
frequently than females
• C. Usually occurs between 3 to 12
months of age
93
Intussusception
E. Clinical findings
• 1. Healthy, well-nourished infant or child
who wakes up with severe paroxysmal
abdominal pain, evidenced by kicking
and drawing legs up to the abdomen
• 2. One or two normal stools, then
bloody mucus stool ("currant jelly-like“
stool)
• 3. Palpation of sausage-shaped mass
• 4. Other signs of intestinal obstruction
usually present
94
Intussusception
F. Therapeutic interventions
• 1. Medical reduction by hydrostatic
pressure (barium enema)
• 2. Surgical reduction; sometimes
with intestinal resection

95
Intussusception
Nursing Care of Infants and Children
with Intussusception

A. Assessment
• 1. Sudden, acute, intermittent
abdominal pain
• 2. Vomiting
• 3. Red "currant jelly-like" stools
• 4. Tender, distended abdomen

96
Intussusception
B. Analysis/Nursing Diagnoses
• 1. Pain related to invaginating bowel
• 2. Altered family processes related to having a child
with life-threatening illness
• 3. Altered nutrition: less than body requirements related
to:
– a. Decreased intake
– b. Increased peristalsis
• 4. Risk for fluid volume deficit related to:
– a. Vomiting
– b. Diarrhea
• 5. Refer to General Nursing Diagnoses for the Family of
a Child with Special Needs and General Nursing
Diagnoses for Infants with Health Problems

97
 IMPERFORATE ANUS
A. Congenital anorectal malformation where the rectum ends in a
blind pouch or with a fistula connecting to the vagina
(rectovaginal fistula) or to the urethra (rectourethral fistula)
B. Signs and Symptoms
a. No anal opening on inspection
b. Non-insertion of the rectal thermometer
c. Progressive abdominal destention
d. Difficult defecation, inability to defecate
e. No meconium stool in the first 24
f. Meconium from inappropriate opening ( fistula )
C. Diagnosis : Wangesteen - Rice Method
a. infant held upside down
98
Respiratory Tract Infections
D. Classification
• Tonsillitis
• Acute laryngotracheobronchitis
• Cystic Fibrosis

99
Respiratory Tract Infections
Nursing Care of Infants and Children with
Respiratory Tract Infections

A. Assessment
• 1. Respirations: rate, depth, ease, and rhythm
• 2. Color: cyanosis
• 3. Lungs: adventitious sounds
• 4. Nasal discharge
• 5. Presence of sputum, cough
• 6. Occurrence of laryngeal spasms

100
Respiratory Tract Infections
B. Analysis/Nursing Diagnoses
• 1. Ineffective airway clearance
related to:
a. Mechanical obstruction
b. Inflammation
c. Increased secretions
d. Pain

101
Respiratory Tract Infections
• 2. Ineffective breathing pattern related to:
a. Inflammatory process
b. Pain

• 3. Risk for injury related to presence of

infective organisms

• 4. Pain related to:

a. Inflammatory process
b. Excessive coughing

102
Respiratory Tract Infections
C. Planning/Implementation
• 1. Increase fluid intake
a. Prevents dehydration from fever and
perspiration
b. Loosens thickened secretions

• 2. Increase humidity and coolness

a. Liquifies secretions
b. Decreases the febrile state and
inflammation of the mucous
membrane
• c. Causes vasoconstriction and bronchiolar
dilation
103
Respiratory Tract Infections

• 3. Promote nasal and pulmonary drainage

a. Clean the nares with a bulb syringe
b. Suction the oronasal pharynx
c. Perform postural drainage, clapping, and vibrating

• 4. Provide rest by decreasing stimulation

• 5. Increase oxygen

• 6. Never use tongue blade to visualize posterior pharynx in

children
with epiglottitis

• 7. Keep a tracheostomy set at bedside; if a tracheostomy is

necessary

104
SKELETAL
MALFORMATIONS

105
Clubfoot
Data Base
• A. Foot has been twisted out of normal
shape or position
• B. Most common type: talipes
equinovarus: foot is fixed in plantar
flexion (downward) and deviated
medially (inward)
• C. Clinical findings
– 1. Deformity is readily apparent at birth
– 2. Deformity may be rigid or flexible
106
Clubfoot
D. Therapeutic interventions
• 1. Treatment is most successful when started
early in infancy because delay causes muscles
and bones of legs to develop abnormally, with
shortening of tendons
• 2. Nonsurgical treatment: gentle, repeated
manipulation of the foot with casting; done
every few days for 1 to 2 weeks then at 1- to
2-week intervals
• 3. Surgical treatment: done if nonsurgical
treatment not effective
– a. Tight ligaments released
– b. Tendons lengthened or transplanted

107
Clubfoot
Nursing Care of Infants and Children with Clubfoot

A. Assessment
• 1. Parental understanding of treatment regimen
• 2. Skin and circulation of affected limb

B. Analysis/Nursing Diagnoses
• 1. Risk for injury related to knowledge deficit and use of
corrective devices
• 2. Risk for impaired skin integrity related to use of
corrective devices
• 3. Refer to General Nursing Diagnoses for the Family of
a Child with Special Needs and General Nursing
Diagnoses for Infants with Health Problems

108
Clubfoot
C. Planning/Implementation
• 1. Observe toes for signs of circulatory
impairment; make sure toes are visible at the
end of the cast
• 2. Watch for signs of weakness and wear of
the cast, especially if the child is allowed to
walk on it
• 3. Teach parents all the necessary care and
emphasize the need for follow-up, which may
be prolonged
• 4. For other areas of cast care, see Congenital
Hip Dysplasia
• 5. See Meeting the Needs of the Family of an
Infant or Child with Special Needs 109
Congenital Hip Dysplasia
Data Base
• A. Imperfect development of hip -
can affect femoral head,
acetabulum, or both
• B. Head of the femur does not lie
deep enough within the
acetabulum and slips out on
movement
• C. Occurs in females seven times
more often than in males 110
Congenital Hip Dysplasia
D. Classification
• 1. Acetabular dysplasia
– a. Mildest form
– b. Femoral head remains in acetabulum

• 2. Subluxation
– a. Most common form
– b. Femoral head partially displaced

• 3. Dislocation
– a. Femoral head not in contact with acetabulum
– b. Displaced posteriorly and superiorly

111
Congenital Hip Dysplasia
E. Clinical findings
• 1. Limitation in abduction of leg on the
affected side
• 2. Asymmetry of gluteal, popliteal, and thigh
folds
• 3. Audible click when abducting and externally
rotating the hip on the affected side: Ortolani's
sign
• 4. Apparent shortening of the femur:
Galeazzi's sign
• 5. Waddling gait and lordosis when the child
begins to walk

112
Congenital Hip Dysplasia
F. Therapeutic interventions
• 1. Directed toward enlarging and deepening the
acetabulum by placing the head of the femur within the
acetabulum and applying constant pressure

• 2. Proper positioning: legs slightly flexed and abducted

a. Pavlik harness
b. Frejka pillow: a pillow splint that maintains
abduction of the legs
c. Bryant's traction
d. Spica cast: from the waist to below the knees
e. Brace

• 3. Surgical intervention such as open reduction with

casting

113
Congenital Hip Dysplasia
B. Analysis/Nursing Diagnoses
• 1. Altered family processes related to having a
child with a physical defect
• 2. Altered growth and development related to
immobilization
• 3. Impaired physical mobility related to
immobilizing device
• 4. Risk for injury related to:
– a. Corrective device
– b. Immobility
• 5. Refer to General Nursing Diagnoses for the
Family of a Child with Special Needs and
General Nursing Diagnoses for Infants with
Health Problems
114
Congenital Hip Dysplasia
C. Planning/Implementation
• 1. Respiratory problems: hypostatic
pneumonia
– a. Change position frequently from back to
stomach; raise head of mattress rather
than head to prevent flexion of neck
– b. Teach parents postural drainage and
exercises for child, such as blowing bubbles
to increase lung expansion
– c. Encourage parents to seek immediate
medical care if the child develops
congestion or cough
115
Congenital Hip Dysplasia
2. Infection and excoriation of skin
• a. Observe for circulation to toes, pedal pulses,
and blanching
• b. Do not let the child put small toys or food
inside cast
• c. Use gauze strips inside cast as a scratcher
• d. Alert parents to signs of infection, such as
odor
• e. Protect cast edges with adhesive tape or
waterproof material, especially around
perineum
• f. Use diapers and plastic lining to minimize
soiling of cast by feces and urine
116
Congenital Hip Dysplasia
3. Constipation from immobility
• a. Teach parents to observe for straining on
defecation and constipation
• b. Increase fluids and fiber to prevent
constipation

4. Nutrition
• a. Provide small, frequent meals because of
inflexibility of cast around waist (a window
may be made over the abdominal area to
allow for expansion with meals)
• b. Adjust calorie intake, because less energy
expenditure can lead to obesity
117
 SPECIAL TOPICS
• SIDS
• AOI
• OTITIS MEDIA
• DOWN SYNDROME
• MENTAL RETARDATION
• CHILD ABUSE

118
Sudden Infant Death Syndrome
(SIDS; Infant Crib Death)
Data Base
• A. A definite syndrome with
unknown cause
• B. The number one cause of death
in infants between 1 week and 1
year of age; incidence of 1.4 in
every 1000 live births
• C. Peak age of occurrence: healthy
infants 2 to 4 months of age - 90%
occur by 6 months
119
Sudden Infant Death Syndrome
(SIDS; Infant Crib Death)
D. Higher incidence in:
• 1. Males
• 2. Premature infants
• 3. Multiple births
• 4. Newborns with low Apgar scores
• 5. Infants with CNS disturbances
• 6. Infants with respiratory disorders such as
bronchopulmonary dysplasia
• 7. Infants sleeping on abdomen
• 8. Infants using soft, moldable pillows and/or
mattresses

120
Sudden Infant Death Syndrome
(SIDS; Infant Crib Death)
E. Feeding habits not significant; breastfeeding does not
prevent SIDS

F. May be a greater incidence in siblings of children with

SIDS

G. Pulmonary edema and intrathoracic hemorrhages found

on autopsy

H. Clinical findings
• 1. Sudden, unexplained death of an infant under 1 year
of age
• 2. Frothy, blood-tinged fluid fills mouth and nose

I. Therapeutic interventions
• 1. Avoid implying wrongdoing, abuse, or neglect
• 2. Support parents
121
• 3. Be nonjudgmental about parents' attempts at
resuscitation
Sudden Infant Death Syndrome
(SIDS; Infant Crib Death)
Nursing Care of Families of
Infants with Sudden Infant
Death Syndrome
A. Assessment
• 1. Parental knowledge of SIDS
• 2. Parental support system

122
Sudden Infant Death Syndrome
(SIDS; Infant Crib Death)
B. Analysis/Nursing Diagnoses
• 1. Family coping: potential for growth
related to successfully coping with loss
• 2. Ineffective family coping: disabling
related to situational crisis
• 3. Altered family processes related to
disruption of life-style
• 4. Dysfunctional grieving related to loss
of child
• 5. Risk for altered parenting of other
children related to grief
123
Sudden Infant Death Syndrome
(SIDS; Infant Crib Death)
C. Planning/Implementation
• 1. Know signs of SIDS to distinguish it from
child neglect or abuse; do or say nothing that
instills guilt in the parents
• 2. Reassure the parents that they could not
have prevented the death or predicted its
occurrence
• 3. Reinforce that an autopsy should be done
on every child to confirm diagnosis
• 4. Visit the parents at home to discuss the
cause of death and help them with their guilt
and grief
• 5. Refer the parents to a national SIDS parent
group 124
Sudden Infant Death Syndrome
(SIDS; Infant Crib Death)
D. Evaluation/Outcomes
• 1. Family exhibits positive coping
behavior
• 2. Family members avail
themselves of support services
• 3. Family exhibits positive
bereavement behavior
• 4. Parents maintain supportive
relationship with other children
125
Apnea of Infancy (AOI)
Data Base
• A. Apnea of 15 seconds or less is
normal at any age
• B. Pathologic apnea lasts at least
20 seconds
• C. May be symptomatic of sepsis,
seizures, upper airway
abnormalities, gastroesophageal
reflux, hypoglycemia, or impaired
regulation of sleep or feeding
126
Apnea of Infancy (AOI)
• D. No cause identified in 50% of
cases
• E. Less than 7% of SIDS cases
• F. Clinical findings
– 1. Usually presents as an apparent
life-threatening event
– 2. Is associated with cyanosis,
marked pallor, hypotonia, or
bradycardia
127
Apnea of Infancy (AOI)
G. Therapeutic interventions
• 1. Continuous home monitoring of
cardiorespiratory rhythm
• 2. Use of respiratory stimulant
medication such as
theophylline
• 3. Treatment discontinued when
child has gone 2 to 3 months
without a significant number of
alarms or with apneic episodes
that did not require intervention 128
Apnea of Infancy (AOI)
Nursing Care of Infants with
Apnea

A. Assessment
• 1. Parental fears and concerns
• 2. Knowledge about
cardiopulmonary resuscitation
(CPR) and home monitoring
• 3. Description of apparent life-
129
threatening event
Apnea of Infancy (AOI)
B. Analysis/Nursing Diagnoses
• 1. Ineffective breathing pattern related to
periods of apnea
• 2. Caregiver role strain related to constant
monitoring
• 3. Ineffective family coping: compromised;
related to prolonged need for monitoring that
exhausts supportive capacity of parents
• 4. Altered family processes related to constant
monitoring
• 5. Fear related to possible loss of child
• 6. Anticipatory grieving related to loss of
perfect child
• 7. Knowledge deficit related to home
monitoring, CPR
130
Apnea of Infancy (AOI)
C. Planning/Implementation
• 1. Monitor type and quality of
apneic episodes
• 2. Teach parents about home
monitoring
• 3. Teach parents how to
stimulate/resuscitate infant
• 4. Assist parents to identify
support system
131
Apnea of Infancy (AOI)
D. Evaluation/Outcomes
• 1. Parents can demonstrate proper
use of equipment for home
monitoring
• 2. Parents demonstrate CPR
• 3. Parents verbalize fears
• 4. Family identifies support system

132
Respiratory Tract Infections
Data Base
• A. Frequent cause of morbidity
• B. Young children have four to five
infections per year
• C. Children between 6 months and
3 years react more severely

133
Otitis Media

Data Base
• A. Acute infection of the middle ear;
causative organism usually Streptococcus
pneumoniae, Haemophilus influenzae, or
Staphylococcus aureus

• B. One of most common diseases of early

childhood

• C. Highest incidence between ages 6

months to 2 years
134
Otitis Media
D. Classification
• 1. Otitis media: inflammation of middle ear without
reference to cause or pathogenesis

• 2. Acute otitis media: rapid, short onset of signs and

symptoms lasting about 3 weeks

• 3. Otitis media with effusion: middle ear inflammation with

fluid present

• 4. Subacute otitis media: lasts more than 3 weeks

• 5. Chronic otitis media with effusion: lasts more than 3

months

135
Otitis Media

E. Clinical findings
• 1. Acute otitis media
a. Pain: infant frets and rubs ear or rolls
head from side to side
b. Drum bulging, red, may rupture; no
light reflex
• 2. Otitis media with effusion
a. No pain or fever, but "fullness" in the
ear
b. Drum appears gray, bulging
c. Possible loss of hearing from scarring
of the drum
136
Otitis Media
F. Therapeutic interventions
• 1. Antibiotic therapy
• 2. Surgery including myringotomy
or insertion of tympanotomy tubes

137
Otitis Media
Nursing Care of Infants and
Children with Otitis Media

A. Assessment
• 1. Pain
• 2. Signs and symptoms of infection
• 3. Allergies

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B. Analysis/Nursing Diagnoses
• 1. Altered family processes related to
having child with an infection
• 2. Risk for infection related to:
a. Inadequate treatment
b. Infectious organism
• 3. Risk for injury related to:
a. Inadequate treatment
b. Infectious organism
• 4. Pain related to pressure caused by
inflammatory process
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C. Planning/Implementation
• 1. Teach parents proper administration of
antibiotics; stress importance of full course of
therapy
• 2. Teach parent proper instillation of ear drops
a. If the child is under 3 years of age, pull the
auricle down and back
b. For an older child, pull the auricle up and
back
• 3. Minimize recurrence
a. Eliminate environmental allergens
b. Feed in upright position
• 4. Encourage medical follow-up to check for
complications such as chronic hearing loss,
mastoiditis, or possible meningitis 140
Otitis Media

D. Evaluation/Outcomes
• 1. Child sleeps and rests without
signs of discomfort
• 2. Child remains free from infection
• 3. Family verbalizes importance of
antibiotic therapy

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