NCM 109 Module Final Edited

Table of Contents
UNIT 1: Nursing Care Of A Family With A High-Risk Newborn.............................................. 11

Objective: ................................................................................................................................. 12
Nursing Diagnosis ................................................................................................................... 12
Classification Of High-Risk Newborns ................................................................................... 12
Overview Of The Newborn ..................................................................................................... 13
Assessing The Average Newborn ........................................................................................... 14
Initial Care Of The Newborn ................................................................................................... 16
Assessment .......................................................................................................................... 16
Implementation ................................................................................................................... 16
Common Birth Injuries ............................................................................................................... 21
Head Trauma ........................................................................................................................... 21
Fractures .................................................................................................................................. 22
Paralysis .................................................................................................................................... 22
Things To Remember .................................................................................................................. 23
Post Discussion Activities: .......................................................................................................... 23
References .................................................................................................................................... 23
UNIT 2: Nursing Care Of The High- Risk Newborn To Maturity.............................................. 24
Objective: ................................................................................................................................. 24
Nursing Diagnosis ................................................................................................................... 24
Prematurity .............................................................................................................................. 24
Pathophysiology And Etiology ........................................................................................... 24
Nursing Assessment And Interventions ............................................................................ 25
Post Term Infants .................................................................................................................... 30
Post-Term Infant Characteristics ....................................................................................... 30
Assessment .......................................................................................................................... 30
Nursing Implementation..................................................................................................... 30
Problems Related To Gestational Weight .................................................................................. 32
Small For Gestational Age ................................................................................................... 33
Causes Small For Gestational Age (Sga) ............................................................................ 33
ACUTE AND CHRONIC PEDIATRIC NURSING

GIRLIE DE LUNA TAYAO, MAN, RN 1
MARK DENVER V. MANUEL, MAN, RN 2635
UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

SCIENCE AND TECHONOLOGY
Diagnosis: ............................................................................................................................. 34
Treatment Of The Sga Baby May Include: ......................................................................... 34
Small For Gestational Age Characteristics ............................................................................ 34
Assessment .............................................................................................................................. 35
Symptoms And Signs ........................................................................................................... 35
Nursing Implementation......................................................................................................... 35
Complications ...................................................................................................................... 35
Large For Gestational Age ....................................................................................................... 36
Complications ...................................................................................................................... 37
Diagnosis .............................................................................................................................. 38
References .................................................................................................................................... 39
UNIT 3: Acute Conditions Of The Neonates .............................................................................. 40
Respiratory Distress Syndrome (Rds) ................................................................................... 40
Symptoms Of Respiratory Distress Syndrome ................................................................. 40
Etiology And Pathophysiology. .......................................................................................... 40
Clinical Manifestation ......................................................................................................... 41
Meconium Aspiration Syndrome ............................................................................................... 42
Causes Of Mas .......................................................................................................................... 42
Risk Factors For Mas ........................................................................................................... 42
Symptoms Include The Following: .................................................................................... 43
Pathophysiology ...................................................................................................................... 43
Mechanical Obstruction Of Airways ...................................................................................... 43
Diagnosis Of Mas ................................................................................................................. 44
Preventive Measures Of Mas .............................................................................................. 44
Management Of Mas Prenatal: ........................................................................................... 45
Delivery Room Management .............................................................................................. 45
Complications Of Mas .......................................................................................................... 46
Prognosis Of Mas ................................................................................................................. 46
Sepsis ............................................................................................................................................ 46
Etiology .................................................................................................................................... 46


Pathogenesis ............................................................................................................................ 47
Classification ........................................................................................................................ 47
Clinical Features ...................................................................................................................... 48
Diagnosis .................................................................................................................................. 48
Differential Diagnosis.............................................................................................................. 49
Treatment ............................................................................................................................ 49
Prevention ............................................................................................................................ 49
Hyperbilirubinemia ..................................................................................................................... 49
Pathophysiology ...................................................................................................................... 50
Assessment .............................................................................................................................. 50
Nursing Implementation......................................................................................................... 50
Erythroblastosis Fetalis .............................................................................................................. 51
Diagnosis .................................................................................................................................. 51
Assessment .............................................................................................................................. 51
Nursing Interventions ............................................................................................................. 51
Sudden Death Syndrome (Sds) .................................................................................................. 51
References .................................................................................................................................... 53
UNIT 4: Common Health Problems That Develop During Infancy .......................................... 55
Key Terms .................................................................................................................................... 55
Objectives: .................................................................................................................................... 55
Intussussception .......................................................................................................................... 56
Causes ....................................................................................................................................... 56
Clinical Manifestations ............................................................................................................ 56
Assessment And Diagnostic Findings .................................................................................... 56
Medical Management .............................................................................................................. 57
Nursing Management .............................................................................................................. 57
Signs And Symptoms ............................................................................................................... 58
Diagnostic Test ........................................................................................................................ 58
Treatment .................................................................................................................................... 58


Failure To Thrive ......................................................................................................................... 58
Colic .............................................................................................................................................. 59
Causes ....................................................................................................................................... 60
Clinical Features ...................................................................................................................... 60
Differential Diagnosis.............................................................................................................. 60
Diagnosis Of Exclusion If Symptoms Started Suddenly And Recently, Consider: .............. 60
Common Causes In A Normal Infant Discomfort. ................................................................. 60
Management Of Colic .............................................................................................................. 60
Medical Treatment .................................................................................................................. 61
Trisomy 21, Down Syndrome ..................................................................................................... 62
Etiology & Pathophysiology ................................................................................................... 62
Types Of Down Syndrome ...................................................................................................... 62
Risk Factors.............................................................................................................................. 62
Treatments ............................................................................................................................... 63
Nursing Diagnosis & Interventions ........................................................................................ 63
Prevention & Education .......................................................................................................... 64
Cleft Lip And Palate ..................................................................................................................... 64
Etiology .................................................................................................................................... 64
Diagnostic Evaluation ............................................................................................................. 65
Management ............................................................................................................................ 65
Surgical Repair Technique For Cleft Lip ................................................................................ 65
Postoperative Care .............................................................................................................. 65
Diagnostic Test ........................................................................................................................ 66
Treatment ................................................................................................................................ 66


Imperforate Anus ........................................................................................................................ 67
Assessment .............................................................................................................................. 67
Hirsprung Disease ....................................................................................................................... 67
Diagnostic Test ........................................................................................................................ 67
Treatment ................................................................................................................................ 68
Neural Tube Defect ...................................................................................................................... 68
Types ........................................................................................................................................ 68
Diagnostic Test ........................................................................................................................ 68
Treatment ................................................................................................................................ 68
Hydrocephalus ............................................................................................................................. 68
Types Of Hydrocephalus ......................................................................................................... 68
Signs/Symptoms ..................................................................................................................... 69
General Nursing Interventions ............................................................................................... 69
Otitis Media .................................................................................................................................. 69
Risk Factors.............................................................................................................................. 70
Treatment ................................................................................................................................ 70
Interventions ........................................................................................................................... 70
Pain Management .................................................................................................................... 70
Meningitis .................................................................................................................................... 70
Bacterial Meningitis .................................................................................................................... 70
Seizure Disorder .......................................................................................................................... 70
Classifications Of Seizure ........................................................................................................ 71
Therapeutic Management ....................................................................................................... 72
Nursing Care Management ..................................................................................................... 72
Fever ............................................................................................................................................. 72
References .................................................................................................................................... 74


UNIT 5: Health Problems Common In Toddlers ....................................................................... 75
Burns ............................................................................................................................................ 75
Nursing Care Of Children With Burns.................................................................................... 76
Poisoning...................................................................................................................................... 78
General Nursing Care Of Children With Poisoning ............................................................... 78
Kinds Of Poisoning ...................................................................................................................... 79
Acetaminophen Poisoning ...................................................................................................... 79
Salicylate Poisoning And Toxicity .......................................................................................... 80
Petroleum Distillate Poisoning............................................................................................... 80
Corrosive Chemical Poisoning................................................................................................ 81
Lead Poisoning ........................................................................................................................ 82
Nursing Care For Children With Lead Poisoning .............................................................. 83
Child Abuse .................................................................................................................................. 83
Types ........................................................................................................................................ 83
Nursing Care Of Children Who Are Abuse............................................................................. 84
Cerebral Palsy (Cp)...................................................................................................................... 85
Nursing Care Of Children With Cerebral Palsy ..................................................................... 86
UNIT 6: Health Problems Common In Pre-Schoolers ............................................................... 89
Leukemia ...................................................................................................................................... 89
Nursing Care Of Children With Leukemia ............................................................................. 90
Wilms Tumor (Nephroblastoma)............................................................................................... 90
Nursing Care Of Children With Wilms Tumor ...................................................................... 91
Asthma ......................................................................................................................................... 92
Nursing Care Of Children With Asthma ................................................................................. 93
Urinary Tract Infection (Uti) ...................................................................................................... 93
Nursing Care Of Children With Urinary Tract Infection ...................................................... 94
References .................................................................................................................................... 95
UNIT 7: Health Problems Common In School-Age Children .................................................... 96
Diabetes Mellitus ......................................................................................................................... 96


Nursing Care For Children With Diabetes Mellitus .............................................................. 97
Rheumatic Fever.......................................................................................................................... 98
Nursing Care Of Children With Rheumatic Fever ................................................................. 99
Juvenile Idiopathic Arthritis (Jia) ............................................................................................... 99
Nursing Care For Children With Juvenile Idiopathic Arthritis .......................................... 100
Scabies ........................................................................................................................................ 101
Pediculosis ................................................................................................................................. 101
Impetigo ..................................................................................................................................... 102
Assessment ............................................................................................................................ 102
Therapeutic Management ..................................................................................................... 102
UNIT 8: Health Problems Most Common In Adolescents ...................................................... 104
Scoliosis ...................................................................................................................................... 104
Nursing Care Of Adolescents With Scoliosis ....................................................................... 105
Bone Tumors ............................................................................................................................. 105
Nursing Care Of Adolescents With Bone Tumors ............................................................... 106
Anorexia Nervosa ...................................................................................................................... 107
Nursing Care Of Clients With Anorexia Nervosa ................................................................ 108
Substance Abuse ........................................................................................................................ 109
Obesity........................................................................................................................................ 110
Suicide ........................................................................................................................................ 110
Amenorrhea ............................................................................................................................... 112
Management: ......................................................................................................................... 112
Sexually Transmitted Disease .................................................................................................. 112
Kinds Of Sti’s .......................................................................................................................... 112
Candidiasis ............................................................................................................................. 112
Assessment ........................................................................................................................ 113
Diagnostic Procedure: ....................................................................................................... 113
Therapeutic Management Therapy ................................................................................. 113
Trichomoniasis ...................................................................................................................... 113
Assessment ........................................................................................................................ 113
Diagnostic Procedure: ....................................................................................................... 114


Bacterial Vaginosis .................................................................................................................... 114
Assessment: ........................................................................................................................... 114
Diagnostic Procedure: ........................................................................................................... 114
Therapeutic Management: .................................................................................................... 114
Chlamydia Trachomatis Infection ............................................................................................ 114
Assessment: ........................................................................................................................... 114
Human Papillomavirus ............................................................................................................. 114
Assessment: ........................................................................................................................... 115
Herpes Genitalis (Herpes Simplex Type 2) ............................................................................. 115
Assessment ............................................................................................................................ 115
Hepatitis B And Hepatitis C ...................................................................................................... 116
Gonorrhea .................................................................................................................................. 116
Assessment: ........................................................................................................................... 116
Nursing Diagnoses And Related Interventions ................................................................... 117
Syphilis ....................................................................................................................................... 117
Assessment: ........................................................................................................................... 117
Human Immunodeficiency Virus (Hiv).................................................................................... 118
Dysmenorrhea ........................................................................................................................... 119
Assessment............................................................................................................................. 119
Therapeutic Management. .................................................................................................... 120
Nursing Management And Related Interventions .............................................................. 120
Post Discussion Activities: ........................................................................................................ 121
References .................................................................................................................................. 121


This module designed for NEUST nursing students enrolled in PEDIATRIC
NURSING: CARE FOR CHILD AND ADOLESCENTS AT RISK OR WITH PROBLEMS
(ACUTE AND CHRONIC). For it provided a comprehensive, in-depth discussion
of the child health care in its normal perspective and promotes a sensitive,
holistic outlook on nursing practice, this module will be useful in expanding
the knowledge of the student nurse with concepts, principles, theories, and
techniques in the nursing care of at-risk/high-risk/sick clients during
childbearing and childrearing years toward health promotion, disease
prevention, restoration, and maintenance, and rehabilitation. The learners
expected to provide safe, appropriate, and holistic nursing care to clients
utilizing the nursing process.
Girlie de Luna Tayao, MAN, RN
Mark Denver V. Manuel, MAN, RN


NCM 109 CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC)
INTRODUCTION
The most profound physiologic change required of neonates is transition from fetal or
placental circulation to independent respiration. The loss of the placental connection means the loss
of complete metabolic support, especially the supply of oxygen and the removal of carbon dioxide.
The normal stresses of labor and delivery produce alterations of placental gas exchange patterns,
acid–base balance in the blood, and cardiovascular activity in the infant. Factors that interfere with
this normal transition or that interfere with fetal oxygenation (including conditions such as
hypoxemia, hypercapnia, and acidosis) affect the fetus’s adjustment to extrauterine life. ( Pilliteri,
2020)


UNIT 1: NURSING CARE OF A FAMILY WITH A HIGH-RISK NEWBORN
This unit discusses high-risk neonates and their nursing care. A high-risk neonate can be
defined as a newborn, regardless of gestational age or birth weight, who has a greater than average
chance of morbidity or mortality because of condition or circumstances associated with birth and
adjustment to extrauterine existence. High-risk period – from the period of viability (23 weeks of
gestation) to 28 days after delivery; thus, includes threats to life and health during the prenatal,
perinatal, and postnatal period. (Hockenberry and Wilson,2013)


Objective:
After this unit, the students will be able to:
1. Provide basic delivery room care for the newborn
2. Identify high risk newborn as early as possible and able to undertake basic neonatal
resuscitation
3. Provide proper nursing care for the normal neonate immediately after birth
4. Perform assessment of the newborn before discharge
5. Detect and manage the common neonatal problems
6. Refer neonates with serious problems as soon as possible to higher facilities
Nursing Diagnosis
To establish nursing diagnoses for high-risk infants, it is important to know newborns' standard
assessment parameters. Nursing diagnoses generally center on the nine priority areas of care for any
newborn:
1. The risk for imbalanced nutrition, less than body requirements related to lack of energy for
sucking
2. The risk for infection related to a lowered immune response in newborn
3. The risk for impaired parenting related to illness in the newborn at birth
4. Deficient diversional activity (lack of stimulation) related to illness at birth
5. Readiness for developmental care to decrease overstimulation easily caused by necessary
life-saving procedures
Classification of high-risk newborns
They are classified according to birth weight, gestational age, and predominant pathophysiologic
problems. Common problems related to physiologic status are closely associated with the maturity
of the infant and usually involve chemical disturbances (e.g., hypoglycemia, hypocalcemia), immature
organs and system (e.g., hyperbilirubinemia, respiratory distress, hypothermia)
Classification According to Size
Low-birthweight (LBW) infant—An infant whose birth weight is less than 2500 g (5.5 pounds)
regardless of gestational age
Very low–birth weight (VLBW) infant—An infant whose birth weight is less than 1500 g (3.3
pounds)
Extremely low–birth weight (ELBW) infant—An infant whose birth weight is less than 1000 g (2.2
pounds)
Appropriate-for-gestational-age (AGA) infant—An infant whose weight falls between the 10th
and 90th percentiles on intrauterine growth curves
Small-for-date (SFD) or small-for-gestational-age (SGA) infant— An infant whose rate of
intrauterine growth was slowed and whose birth weight falls below the 10th percentile on
intrauterine growth curves
Intrauterine growth restriction (IUGR)—Found in infants whose intrauterine growth is restricted
(sometimes used as a more descriptive term for SGA infants)


Symmetric IUGR—Growth restriction in which the weight, length, and head circumference are all
affected
Asymmetric IUGR—Growth restriction in which the head circumference remains within normal
parameters while the birth weight falls below the 10th percentile
Large-for-gestational-age (LGA) infant—An infant whose birth weight falls above the 90th
percentile on intrauterine growth charts
Classification According to Gestational Age
Preterm (premature) infant
An infant born before completion of 37 weeks of gestation regardless of birth weight
Full-term infant
An infant born beginning 38 weeks and the completion of the 42 weeks of gestation
regardless of birth weight
Late-preterm infant
An infant born between 34 0 7 and 36 6 7 weeks of gestation regardless of birth weight*
Post-term (postmature) infant
An infant born after 42 weeks of gestational age regardless of birth weight
Classification According to Mortality
Live birth
Birth in which the neonate manifests any heartbeat breathes or displays voluntary movement
regardless of gestational age.
Fetal death
Death fetus after 20 weeks of gestation and absence of any signs of life before delivery
Neonatal death
Death occurs in the first 27 days of life; early neonatal death occurs in the first week of life;
late neonatal death occurs at 7 to 27 days.
Perinatal mortality
Total number of fetal and early neonatal deaths per 1000 live births
OVERVIEW of the Newborn
The newborn body must initiate respirations and accommodate a circulatory system to
extrauterine environment oxygenation. Within 24 hours, neurologic, renal, endocrine, GI, and
metabolic functions must be operating competently to sustain life. Infants death occurs during the
neonatal period.


ASSESSING THE AVERAGE NEWBORN NEWBORN PRIORITIES IN FIRST DAYS OF
• Length – 46-54 cm LIFE
• HC -34-35cm
• 8 priority needs in the first few days of life
• Temp. – 97.6-98.6F
1. Initiation and maintenance of
• CC – 32-33 cm
respirations
• HR – 120-140/min 2. Establishment of extrauterine
• RR – 30-50/min circulation
• Temp. – 97.6-98.6F= 3. Control of body temperature
4. Intake and adequate nourishment
5. Establishment of waste elimination
6. Prevention of infection
7. Establishment of an infant-parent
relationship
8. Developmental care, or care that
balances physiologic needs and
stimulation for mental development
Predisposing factors for the respiratory Drugs Used in Resuscitation

difficulty in newborn
Drugs commonly used in newborn resuscitation
1. low birth weight include:
2. maternal history of diabetes
3. PROM Atropine: Reduces bronchial secretions, keeping the
4. Meconium staining airway clear during resuscitation. Reduces vagus nerve
5. Irregularities FHB detected during labor effects, relieving bradycardia.
6. Cord prolapses
Calcium chloride: Increases heart contractility.
7. Lowered APGAR score (under 7) at 1 or 5
minutes Dopamine: Increases systemic blood perfusion by
8. Postmaturity increasing blood pressure through beta-agonist action.
9. Small for gestational age
10. Breech presentation Epinephrine: Strengthens or initiates cardiac
11. Multiple births contractions; increases heart rate and blood pressure.
12. Chest, heart, respiratory tract anomalies Lidocaine: Counteracts ventricular arrhythmias by
decreasing the automaticity of ventricular cells.


Drugs Used in Resuscitation
Sodium bicarbonate (NaHCO3) or tromethamine: Corrects metabolic acidosis. Caution: Do not give these
agents unless ventilation is adequate, or acidosis can be increased by retained CO2.
Many preterm infants have such respiratory distress at birth that they need continued therapy, including:
Surfactant: All preterm infants weighing less than 1500 g receive surfactant administered by endotracheal tube
at birth. Some newborns need administration of additional surfactant to prevent symptoms of respiratory
distress syndrome.
Surfactant (Survanta)
Action: Surfactant restores naturally occurring lung surfactant to improve lung compliance.
Pregnancy risk category: X
Dosage: 4 mL/kg intratracheally; four doses in the first 48 hours of life
Possible adverse effects: Transient bradycardia, rales
Nursing Implications
a. Suction infant before administration.
b. Assess the infant's respiratory rate, rhythm, arterial blood gases, and color before
administration.
c. Ensure proper endotracheal tube placement before dosing.
d. Change the infant's position during administration to encourage the drug to flow to both lungs.
e. Assess the infant's respiratory rate, color, and arterial blood gases after administration.
f. Do not suction the endotracheal tube for 1 hour after administration to avoid removing the
drug.
Nitric oxide: Nitric oxide is a potent vascular dilator. Because it dilates the capillaries next to alveoli, reduces
the pulmonary resistance, and therefore increases oxygenation and lung function (Barrington & Finer, 2009).
Liquid ventilation: Liquid ventilation is the installation of liquid fluorocarbon (Perflubron) into the lungs. It fills
and clings to alveoli. The body does not absorb Perflubron but instead leaves the lungs by evaporation. Although
studies in young infants are few, liquid ventilation has the potential to reduce lung disease (Davies & Sargent,
2009). It acts as an anti-inflammatory and reduces oxygen toxicity and perhaps infection because bacteria
cannot live in the medium. Adverse effects may be pneumothorax and mucus plugging.
Naloxone (Narcan)
Classification: Naloxone is a pure narcotic antagonist.
Action: Administered parenterally to reverse the effects, such as respiratory depression, that may occur
with opioid narcotic agents (Karch, 2009).
Pregnancy risk category: B
Dosage: Initially, 0.01 mg/kg IV. Dosage may be repeated at 2- to 3-minute intervals.
Possible adverse effects: Hypertension, irritability, tachycardia
a. Assess respiratory status carefully, including rate, depth, and character of respirations.
b. Anticipate the need for repeat doses.
c. Maintain a patent airway at all times.
d. Have emergency resuscitation equipment readily available and prepare to resuscitate
if necessary


INITIAL CARE OF THE NEWBORN b. Begin with general observations;
▪ ASSESSMENT then perform assessments that are
a. observe/assist with the initiation of least disturbing to the NB first
respiration c. Initiate nursing interventions for
b. assess Apgar Score abnormal findings
c. note characteristic of cry d. Document all abnormal findings
d. monitor for nasal flaring, grunting, ➢ Vital signs:
retractions, abnormal respirations a. HR- 100-150/minute (apical), assess for a
e. obtain V/S full minute because of irregularities after
f. observe or signs of hypothermia or birth
hyperthermia b. RR- 30-50/minute
g. assess for gross abnormalities c. Temp- 96.8-99F
▪ IMPLEMENTATION d. BP- 70/50
1. suction mouth, nares, with a bulb HEAD
syringe
2. dry newborn and stimulate crying by a. 25% of the body length (cephalocaudal
rubbing development)
3. maintain temperature stability; wrap b. Bones of the skull are not fused
the newborn in warm blankets and c. Palpable sutures (the connective tissue
place a stockinette cap on the between the skull bones
newborn’s head d. Fontanels: unossified membranous
4. keep newborn with mother to tissue at the junction of the sutures
facilitate bonding 1. Anterior-soft, flat, diamond-
5. place the newborn at the mother's shaped 3-4 cm wide by 2-3cm
breast if breastfeeding is planned, or long-closes between 12-18 mos
place on the mother's abdomen 2. Triangular- 0.5-1cm wide,
6. position the newborn in a modified T- located between occipital and
burg position to facilitate drainage of parietal bones-closes between
mucus birth and 2-3 mos
7. ensure newborn’s proper 3. Head lag
identification e. Common when pulling NB to a sitting
8. footprint newborn and fingerprint of position
mother on identification sheet, per f. When prone, NB should be able to lift the
agency policies and procedures head slightly and turn the head from side
9. place matching identification bracelets to side
on mother and newborn Eyes
10. perform and record the APGAR a. Slate gray (light skin) or brown-gray
SCORING at 1 minute and 5 minutes (dark skin)
- 7-10 indicates a healthy b. Symmetrical and clear
newborn c. Pupils equal, round, react to light by
- 3-6, moderately depressed accommodation
- 0-2, severely depressed d. Blink reflex present
▪ INITIAL PHYSICAL EXAM e. Eyes cross because of weak extraocular
➢ General Guidelines: muscles
a. Keep NB warm during the f. Red reflex present
examination


g. Eyelids often edematous as a result of Skin
pressure during the birth process and
the effects of eye medication a. pinkish-red to pinkish-brown or pinkish
Ears yellow
b. vernix caseosa
a. Symmetrical c. lanugo
b. Firm cartilage with recoil d. milia
c. Pinna should be on or above line draw e. dry peeling skin
from canthus of the eye f. dark red color common in premature
d. Low-set ears associated with down’s NB’s
syndrome g. cyanosis common to hypothermia,
Nose infection, and hypoglycemia, and with
cardiac, respiratory, or neurological
a. Flat, broad, in center of the face abnormalities
b. Obligatory nose breathing h. acrocyanosis is a normal phenomenon
c. Occasional sneezing to remove and may be due to compromised
obstructions peripheral circulation
Mouth i. assess for ecchymosis and petechiae
a. Pink, moist gums resulting from the trauma of birth
b. Soft and hard palates intact j. assess skin turgor over the abdomen to
c. Epstein's pearls (small white cysts) may determine hydration status
be present on the hard palate k. harlequin sign
d. uvula in midline a. deep red color develops over one
e. tongue moves freely, symmetrical has a side of the NB’s body while the other
short frenulum side remains pale; due to vasomotor
f. sucking and crying movements disturbance
symmetrical b. skin resembles a clown’s suit
g. able to swallow l. Birthmarks
h. gag reflex present 1. Mongolian spots- bluish-black
Neck pigmentation on lumbar dorsal area
and buttocks, gradually fade during
a. Short and thick 1-2 years old, common in Asian and
b. Head held on the midline dark-skinned races
c. Trachea on midline Abdomen
d. Good ROM and able to flex and extend
Chest a. Umbilical cord- 3 vessels, 2 arteries, and
1 vein
a. It appears circular since anteroposterior b. Small thin cord may be associated with
and lateral diameters are about equal poor fetal growth
b. Respirations appear diaphragmatic c. Assess for an intact cord, ensure that
c. Bronchial sounds heard on auscultation clamp is secured, the cord should be
d. Nipples prominent and often edematous st
e. Milky secretions (witch’s milk) common clamped at least the 1 24h after birth-
f. Breast tissue present removed when the cord is dried and
g. Clavicles need to be palpated to assess occluded
for fractures d. Note any bleeding or drainage from the
h. cord


e. Apply 70% alcohol at least 3 x /day to b. CR for 1 full minute
promote drying c. Listen for murmurs
f. Moistness, oozing, discharge, and d. Palpate pulses
reddened base indicates infection- e. Assess for cyanosis
antibiotic treatment is prescribed f. Observe for cardiac distress when NB is
Gastro-Intestinal feeding
Respiratory system
a. Monitor cord for meconium staining
b. Assess for umbilical hernia a. Position NB
c. Assess for abdominal distention b. Suction as necessary- bulb syringe-upper
associated with diaphragmatic hernia airway suctioning; French catheter-
d. Assess for abdominal distention deeper suctioning
associated with obstruction, mass, or c. Observe for respiratory distress and
sepsis hypoxemia
e. Monitor bowel sounds-1-2 h after birth d. Nasal flaring
e. Severe retractions
Anus f. Grunting
g. Cyanosis
a. Patent h. Bradycardia and period of apnea lasting
b. First stool pass w/in 24h for 15 secs.
Genitals i. Administer O2 as prescribed
a. Female Hepatic system
1. Labia edematous, clitoris enlarged a. Physiologic jaundice appears 24h after
2. Smegma present- white thick mucus birth in FT neonates and 48 h in
discharge) th
3. Pseudomenstration possible – blood- premature neonates, peak-5 day of life
tinged mucus –indirect Bil levels- 6-7mg/dl)
4. Hymen tag may be visible b. Pathologic jaundice – occurs before
5. First voiding occurs w/in 24 h 24/48h- indicates early hemolysis of the
b. Male RBC
1. The prepuce (foreskin) covers the c. Monitor serum bilirubin level
glans penis d. Feed early to stimulate intestinal activity
2. Scrotum edematous and to keep the billow
3. Meatus at the tip of the penis e. IF BF temporarily d/c bf for 48h if
4. Testes descended but may retract bilirubin levels > 15-20mg/dl and as
with cold prescribed by the physician
5. Assess for hernia /hydrocele f. Prevent chilling, as hypothermia-cause
6. First voiding within 24 h acidosis that interferes with bilirubin
Extremities Conjugation and excretion
g. Neonate is at risk for hemorrhagic
• Slight tremors are common but could be a disorders; coagulation factors
sign of hypoglycemia or drug withdrawal synthesized in the liver-administer
vitamin K-is not synthesized until
BODY SYSTEM ASSESSMENT intestinal bacteria are present
h. Handle NB carefully and monitor for any
Cardiovascular system
bruising or bleeding episodes
a. Keep NB warm i. Assess NB Hgb and blood glucose level


Renal system i. Meconium stool- greenish-black with a
thick sticky, tar-like consistency-24h
a. Immature kidneys are unable to j. Transitional stool- greenish-brown and
concentrate urine of looser consistency than meconium
b. Wt loss of 5-15% during the first week of k. Soft yellow stool- noted in breastfed NB,
life occurs as a result of voiding and seedy, yellow stools in formula-fed NB
limited intake l. NB screening (insert lecture on NBS)
c. Weigh Newborn daily NEUROLOGICAL SYSTEM
d. Assess for signs of DHN (dry mucous
membranes, sunken eyeballs, poor skin a. the head is proportionally larger due to
turgor, sunken fontanels cephalocaudal development
Immune system b. fontanels are open to allow for brain
growth
a. Passive immunity via the placenta (IgG) c. assess for abnormal head size and a
b. Passive immunity from colostrum’s (IgA) bulging or depressed anterior fontanel
c. Use the aseptic technique in caring for (insert picture of the location of suture
NB lines of the skull on page 1648 MCN
d. Observe universal/standard precaution book-Pillitteri)
e. Handwashing d. assess NB’s movements, noting
f. Administer eye medication w/in 1 h after symmetry, posture, and abnormal
birth to prevent ophthalmia neonatorum movements
g. Erythromycin 0.5% and tetracycline 1%- e. observe jitteriness, marked tremors, and
prophylaxis against Neisseria seizures
gonorrhea/Chlamydia trachomatis f. test NB reflexes
h. Silver nitrate 1%-minimal use-can cause g. assess for lethargy
chemical conjunctivitis h. assess pitch of cry
i. Provide cord care THERMAL REGULATORY SYSTEM
METABOLIC SYSTEM AND
GASTROINTESTINAL SYSTEM a. NB’s do not shiver to produce heat
b. NB’s have brown fat deposits, which
a. Newborns can digest simple produce heat
carbohydrates but are unable to digest c. Heat is dissipated through vasodilation
fats because of the lack of lipase d. Prevent heat loss resulting from
b. Proteins are partially broken down, and evaporation by keeping NB dry and well-
they may serve as antigens and provoke wrapped with a blanket
an allergic reaction e. Prevent heat loss resulting from
c. NB has a small stomach capacity (90ml) radiation by keeping NB away from cold
with rapid intestinal peristalsis (bowel objects and outside walls
emptying time-2.5-3h) f. Prevent heat loss resulting from
d. BF can begin immediately after birth convection by shielding the NB from
e. Observe feeding reflexes, such as rooting, drafts
sucking, and swallowing g. Prevent heat loss resulting from
f. Burp NB after feeding conduction by performing all
g. Assess for regurgitation or vomiting instruments on a warm padded surface
h. Observe for normal stool and the passage h. Keep the temperature in the room warm
of meconium i. Take temp of the NB/axilla every hour
for the first 4 h and then every shift


REFLEXES shoulders momentarily falling
down, the head will lift for a few
1. Sucking and rooting- NB turns to head minutes.
toward the nipple, opens the mouth, - The response depends on the NB's
takes hold of the nipple, and sucks. general muscle tone and condition
Disappears after 3-4 mos. But persists for as well as the maturity levels.
up to 1 year 8. Babinski sign-plantar- beginning at the
2. Swallowing reflex – occurs heel of the foot, gently stroke upward
spontaneously after sucking and alo0ng the lateral aspect of the sole; then
obtaining fluids; in coordination with the examiner moves the finger along with
sucking w/o gagging, coughing, or the ball of the foot. The NB toes
vomiting hyperextend while the big toe
3. Tonic neck or fencing – while the NB is dorsiflexes. Disappears at 1 yr old;
falling asleep, gently and quickly turn the absence of this reflex indicates the need
head to one side; when the head is turned for a neurological exam.
to the right side, the right arm and leg 9. Stepping/Walking- hold the NB in a
extend outward while the left arm and vertical position, allowing 1 foot to touch
leg flex. Disappears within 3-4 mos a tale surface. NB stimulates walking,
4. Palmar-plantar gasp- NB finger’s curl alternately flexing and extending the
around the examiner’s fingers, the NB’s feet. Present for 3-4 mos
toes curl downward 10. Crawling – place the newborn on the
5. Palmar response lessens within 3-4 mos abdomen; NB begins making crawling
and plantar within eight mos movements with the arms and legs.
6. Moro reflex- hold the NB in a semi-sitting Disappears after 6 weeks
position; allow the head and trunk to fall PARENT TEACHING
backward to at least a 30-degree angle
- the NB symmetrically abducts and 1. Formula Feeding
extend the arms a. Each sterilization techniques
- fans the fingers out and form a C b. For bottle and water
with the thumb and the finger c. Remind the mother not to heat the
- adduct the arms to an embracing bottle of formula in a microwave
position and return to a relaxed d. Inform the mother that formula is a
flexion state sufficient diet for the first 4-6 mos.
- present at birth, a complete e. Assess the mother the ability to burp
response may occur at eight weeks, the NB
body jerks occur from 8 -18 weeks 2. Breastfeeding
- a persistent reply lasting > 6 mos. a. Assess the NB’s ability to attach to
may indicate the occurrence of brain the mother’s breast and suck
damage during pregnancy b. Teach the mother about
7. Startle reflex – the examiner makes a engorgement
loud noise or claps hands to elicit the4 c. Teach the mother how to pump
response-the newborn arms adduct breasts and hoe to store breast milk
while the elbows flex, the hand stays properly
clenched. Disappear w/in four months. d. Inform the mother that breast milk
- Pull to sit- the head will lag until the is a sufficient and superior diet for
NB is in an upright position; then the the first 4 -6 months
head will be level with the chest and


e. most neonates eat 6-8 times/day d. Proceed from the cleanest area to
with 2 – 4 h between feedings; the dirtiest
establish fairly regular feeding e. Clean the eyes from the inner
patterns in 2 weeks canthus outward
f. caloric requirements are high- 110- f. Special care should be taken to clean
130 cal/kg of body weight daily under the folds of the neck,
g. most digestive enzymes are present underarms, groin, and genitals
at birth g. Make bath time enjoyable for both
h. imperfect control of cardiac and the newborn and the mother
pyloric sphincters; immaturity 4. CLOTHING
results in regurgitation a. Assess diaper and clothing needs for
3. BATHING the newborn with the mother
a. Bathe the NB in a warm room before b. Instruct the mother the needs to
feeding cover the newborn's head in cold
b. Have all equipment for bathing weather to prevent heat loss
available c. Instruct the mother to layer the NB’s
c. Use a mild soap (not on the face) clothing in cooler weather
Common Birth Injuries

Head Trauma
1. Caput Succedaneum
The most commonly observed scalp lesion, a vaguely outlined area of edematous tissue situated over the scalp's
portion, presents a vertex delivery. The swelling consists of serum, blood, or both accumulated in the tissues above
the bone, which often extends beyond the bone margins. The swelling may be associated with overlying petechiae
or ecchymoses. No specific treatment is needed, and the swelling subsides within a few days.
2. Cephalhematoma
They are formed when blood vessels rupture during labor or delivery to produce bleeding into the area
between the bone and its periosteum. The injury occurs most often with primiparous delivery and is
often associated with forceps delivery and vacuum extraction.
3. Subgaleal Hemorrhage
Subgaleal hemorrhage is bleeding into the subgaleal compartment

(Fig. 9-1, C). The subgaleal compartment is a potential space
containing loosely arranged connective tissue; it is located beneath
the galea aponeurosis. The tendinous sheath that connects the
frontal and occipital muscles forms the inner surface of the scalp.
The injury occurs as a result of forces that compress and then drag
the head through the pelvic outlet (Verklan and Lopez, 2011).
Instrumented delivery, particularly vacuum extraction and forceps
delivery, increase
Nursing Care Management
Nursing care is directed toward assessing and observing the
common scalp injuries and vigilance in monitoring for possible


associated complications such as infection or, as in the case of subgaleal hemorrhage, acute blood loss, and
hypovolemia. Nursing care of a newborn with a subgaleal hemorrhage includes careful monitoring for signs of
hemodynamic instability and shock (Schierholz and Walker, 2010). Because caput succedaneum and
cephalhematoma usually resolve spontaneously, parents need the reassurance of their usual benign nature.
FRACTURES
The clavicle, or collarbone, is the bone most frequently fractured during the birth process. It is often associated with
shoulder dystocia or a difficult vertex or breech delivery of large infants for gestational age. Crepitus (the coarse
crackling sensation produced by the rubbing together of fractured bone fragments) may be felt or heard on
examination. A palpable, spongy mass representing localized edema and hematoma may also be a sign of a fractured
clavicle.
PARALYSIS
Facial Paralysis
Pressure on the facial nerve (cranial nerve VII) during delivery may injure that
nerve. The primary clinical manifestations are loss of movement on the affected
side, such as an inability to completely close the eye, drooping of the corner of the
mouth, and absence of wrinkling of the forehead and nasolabial fold (Fig. 9-2). The
paralysis is most noticeable when the infant cries. The mouth is drawn to the
unaffected side, the wrinkles are more in-depth on the normal side, and the eye on
the involved side remains open.
No medical intervention is necessary. The paralysis usually disappears

spontaneously in a few days but may take as long as several months.
Brachial Palsy
Plexus injury results from forces that alter the normal position and relationship of the arm, shoulder, and neck. Erb
palsy (Erb-Duchenne paralysis) is caused by damage to the upper plexus. Usually, it results from stretching or pulling
away from the shoulder from the head, as might occur with shoulder dystocia or a difficult vertex or breech delivery.
The less common lower plexus palsy, or Klumpke palsy, results from severe stretching of the upper extremity while
the trunk is relatively less mobile.
The clinical manifestations of Erb palsy are related to the paralysis of
the affected extremity and muscles.
The arm hangs limp alongside the body while the shoulder and arm
are adducted and internally rotated.
The elbow is extended, and the forearm is pronated, with the wrist
and fingers flexed; a grasp reflex may be present because finger and
wrist movement remain normal (Tappero, 2009)
In lower plexus palsy, the hand muscles are paralyzed, with
consequent wrist drop and relaxed fingers. In a third and more severe
form of brachial palsy, the entire arm is paralyzed and hangs limp and
motionless at the side. The Moro reflex is absent on the affected side for all forms of brachial palsy. Treatment of the
affected arm aims to prevent the paralyzed muscles' contractures and maintain the correct placement of the humeral
head within the scapula's glenoid fossa. Complete recovery from stretched nerves usually takes 3 to 6 months. Full
recovery is expected in 88% to 92% of infants (Verklan and Lopez, 2011).

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF SCIENCE AND

TECHONOLOGY
THINGS TO REMEMBER
1. Transition from fetal or placental circulation to independent respiration is the most important physiologic
change required of newborns.
2. Chemical and thermal factors help initiate a neonate’s first respiration.
3. Circulatory changes in neonates result from shifts in pressure in the heart and major vessels and from
functional closures of the fetal shunts.
4. Newborns’ large surface area, thin layer of subcutaneous fat, and unique mechanism for producing heat
predispose them to excessive heat loss.
5. Infants’ high rate of metabolism is closely correlated with the rate
of fluid exchange, which is much higher in infants than in adults.
6. The skin and mucous membranes, the macrophage system, and antibodies are the first, second, and third
lines, respectively, of defense against infection.
7. The Apgar score, the initial assessment of newborns, focuses on heart rate, respiratory effort, muscle tone,
reflex irritability, and color.
8. Physical assessment of newborns includes clinical assessment of gestational age, general measurements,
general appearance, head to-toe assessment, and parent–infant attachment or bonding.
9. Neurologic assessment focuses on localized reflexes and posture, muscle tone, head control, and movement
and is best accomplished during the general physical examination.
10. Behavioral assessment of newborns with the BNBAS examines responses to seven categories: habituation,
orientation, motor performance, range of state, regulation of state, autonomic stability, and reflexes.
11. Physical care for newborns includes maintaining a patent airway, maintaining a stable body temperature,
protecting from infection and injury, and providing optimal nutrition.
12. Although the attachment, or bonding, process primarily affects
infants and parents, siblings also play an important role.
13. An essential aspect of discharge teaching is ensuring newborns’ safe transportation home in federally
approved, backward-facing car safety seats
Post discussion activities:

1. Choose three diseases/cases from this chapter, make a diagram format illustrating the pathophysiologic
sequence of changes in your chosen diseases/cases. An outline format is acceptable as long as the cause-
and-effect sequence can be seen.
2. Make a narrative explanation of the pathophysiologic diagram of the disease.
3. Make one nursing care plan out of each pathophysiology you have made.
References
Marilyn J. Hockenberry and David Wilson (2013) WONG’S ESSENTIALS OF PEDIATRIC NURSING
ISBN: 978- 0-323-08343-0 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Pilliteri, A. (2020). Maternal and Child Health Nursing: Care of the Child Bearing and Child Rearing Family. 530
Walnut Street, Philadelphia: Wolters Kluwe/Lippincott Williams & Wilkins.


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UNIT 2: NURSING CARE OF THE HIGH- RISK NEWBORN TO MATURITY
Objective:
1. Define the following terms—small-for-gestational-age infant, term infant, large-for-gestational-age infant,
preterm infant, and post-term infant—and describe common illnesses that occur in these and other high-
risk newborns
2. Recognize physiologic factors that compromise the preterm infant’s health status.
3. Perform a systematic assessment of a high-risk newborn.
4. Formulate nursing diagnoses related to a high-risk newborn.
5. Identify expected outcomes for a high-risk newborn and family.
6. Plan nursing care focused on priorities to stabilize a high-risk
7. newborn’s body systems.
Nursing Diagnosis
To establish nursing diagnoses for high-risk infants, it is important to be aware of newborns' normal assessment
parameters. Nursing diagnoses generally center on the nine priority areas of care for any newborn:
1. Ineffective airway clearance related to the presence of mucus or amniotic fluid in the airway
2. Ineffective cardiovascular tissue perfusion related to breathing difficulty
3. Risk for deficient fluid volume related to insensible water loss
4. Ineffective thermoregulation related to newborn status and stress from birth weight variation
Prematurity
Most organ systems' immaturity places infants at risk for a variety of neonatal complications (e.g.,
hyperbilirubinemia, respiratory distress syndrome [RDS], intellectual and motor delays). Factors such as poverty,
maternal infections, previous preterm delivery, multiple pregnancies, pregnancy-induced hypertension, and
placental problems that interrupt the normal course of gestation before completion of fetal development are
responsible for a large number of preterm births.p.25
b. complications of pregnancy-associated with
PRETERM NEWBORN prematurity include:
a. a neonate born before 37 weeks of gestation 1. PIH
b. immaturity of all body systems 2. Bleeding
c. low birth weight neonate is < 2.5 kg 3. Placenta previa/abruptio placenta
regardless of gestational age 4. Incompetent cervix
d. very low birth weight neonate is below 1.5 kg 5. PROM
irrespective of gestational age 6. Polyhydramnios/oligohydramnios
1. Chorioamnionitis
PATHOPHYSIOLOGY AND ETIOLOGY c. fetal factors associated with prematurity
a. factors associated with prematurity include: include:
1. poor nutrition 1. chromosomal abnormalities
2. diabetes 2. anatomic abnormalities such as
3. drug abuse tracheoesophageal atresia or fistula
4. chronic disease and intestinal obstruction
5. being a multigravida mother younger 3. fetoplacental unit dysfunction
than age 18/primigravida mother older d. systems and situations that are most
than age 40 likely to cause problems in the
premature infant include:


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1. respiratory system b. Expiratory grunting, retractions,
2. digestive system chest lag, or nasal flaring should be
3. thermoregulation reported stat
4. immune system c. Watch for cyanosis (other than
5. neurologic system acrocyanosis-coldness and
cyanosis of hands and feet) and
NURSING ASSESSMENT AND other signs of respiratory distress
INTERVENTIONS d. Increased (> 180/min) or irregular
1. Notice the physical characteristics of the heart rate indicates cardiac and
premature neonate: circulatory difficulties
a. Hair – lanugo, fluffy e. Muscle tone and activity should be
b. Poor ear cartilage evaluated
c. Skin- thin, capillaries are visible f. Hypoglycemia may result from
(maybe red and wrinkled) inadequate glycogen stores,
d. Lack of subcutaneous fat respiratory distress, and cold
e. Sole of the foot is smooth. stress
f. Breast buds 5mm g. Hypotension may be caused by
g. Testes – undescended hypoglycemia
h. Labia majora- undeveloped 5. Institute cardiac monitoring and care for
i. Rugae of scrotum- fine the infant in an isolette, omit bath
j. Fingernails-soft 6. Observe for any signs of jaundice and
k. Abdomen- relatively large check maternal history for any blood
l. Thorax-relatively small incompatibilities. Be aware of maternal
m. Head-appears disproportionately factors that can lead to additional
large complications (drug use, diabetes, and
n. Muscle tone poor, possibly weak infection)
reflexes 7. NURSERY: 24-48 h is a critical time
2. Obtain accurate body measurements requiring constant observation and
a. HC intensive care management; observe the
b. AC following:
c. CC a. Note bleeding from the umbilical
d. Length cord-apply pressure
e. Shoulder to umbilicus- use to b. and notify AP
calculate the proper length of the c. Note first voiding- occur within
catheter for umbilical arterial 36h after birth; after first voiding
catheter placement. report any 4-6h period when
f. Wt. voiding does not occur
3. Assist with laboratory testing as d. Note stool- abdominal distention
indicated for blood gases, blood glucose, and lack of stool may indicate
CBC (hgb, Hct), electrolytes, calcium, intestinal obstruction or other
bilirubin intestinal tract anomalies.
4. Monitor closely for respiratory or cardiac Measure AC.
complications e. Note activity and behavior- look
a. RR above 60/min indicates a for sucking movement and hand-
respiratory difficulty to-hand maneuver-help to
determine oral feeding initiation.


f. Observe for a tense and bulging
fontanel-indicates intracranial
hemorrhage, be alert for
twitching and seizures
g. Monitor and record V/S



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POST TERM INFANTS be stained a deep yellow or green, which is
usually an indication of meconium in the
amniotic fluid.)
Infants born of gestation that extends beyond 42 C. Hair and nails long
weeks as calculated from the mother's last D. Dry peeling skin
menstrual period (or by gestational age E. Creases cover soles
assessment) are considered to be post-term or F. absence of lanugo,
postmature, regardless of birth weight. G. little if any vernix caseosa,
A fetus who remains in utero with a failing H. abundant scalp hair,
placenta may die or develop post-term syndrome I. The skin is often cracked, parchment-like,
and desquamating
Post-term Infant Assessment
a. Assess that vernix and lanugo
• Gestation > 42 weeks
b. Assess skin
• Must determine if EDC is truly posted c. Check fingernails and toenails
term d. Assess size
e. Observe for Hypoglycemia
• After 42 weeks placenta loses the ability f. Observe for signs of birth injury
to nourish the fetus
Nursing Implementation
Post-term Infant Characteristics a. Similar to care given to preterm infants, if
A. Newborn emaciated (a wasted physical premature characteristics are observed
appearance that reflects intrauterine b. Symptoms depend on conditions at birth.
deprivation. Depletion of subcutaneous fat c. Monitor for possible complication
gives them a thin, elongated appearance.) (Asphyxia, Polycythemia)
B. Meconium stained (The little vernix
caseosa that remains in the skinfolds may


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PROBLEMS RELATED TO GESTATIONAL WEIGHT
SMALL FOR GESTATIONAL AGE
Refers to infants who are significantly undersized for gestational age—also called Intra-Uterine
Growth Retardation.
Small for gestational age (SGA) is a term used to describe a smaller baby than the usual amount for the number
of weeks of pregnancy. SGA babies usually have birthweights below the 10th percentile for babies of the same
gestational age. This means that they are smaller than 90 percent of all other babies of the same gestational
age. SGA babies may appear physically and neurologically mature but are smaller than other babies of the
same gestational age. SGA babies may be proportionately small (equally small all over), or they may be of
normal length and size but have lower weight and body mass. SGA babies may be premature (born before 37
weeks of pregnancy), full-term (37 to 41 weeks), or post-term (after 42 weeks of pregnancy).
a. SGA weightless than 5lb 8 oz and below the 10th% at term
b. IUGR- High-risk growth does not meet the norm and is pathologic
- Symmetric IUGR- a poor growth rate of the head, abdomen, and long bone
- Asymmetry IUGR- head long bones spared
Symmetric: Height, weight, and head circumference are about equally affected.
Asymmetric: Weight is most affected, with a relative sparing of growth of the brain, cranium, and long
bones.
Symmetric growth restriction usually results from a fetal problem early in gestation, often during the
1st trimester. When the cause begins relatively early in gestation, the entire body is affected, resulting
in fewer cells of all types.
Causes small for gestational age (SGA)
Although some babies are small because of genetics (their parents are small), most SGA babies are small
because of fetal growth problems that occur during pregnancy. Many babies with SGA have a condition called
intrauterine growth restriction (IUGR). IUGR occurs when the fetus does not properly receive the necessary
nutrients and oxygen needed to grow and develop organs and tissues. IUGR can begin at any time in
pregnancy. Early-onset IUGR is often due to chromosomal abnormalities, maternal disease, or severe
problems with the placenta. Late-onset growth restriction (after 32 weeks) is usually related to other
problems.
Some factors that may contribute to SGA and/or IUGR include the following:
1. Maternal factors:
a. high blood pressure
b. chronic kidney disease
c. advanced diabetes
d. heart or respiratory disease
e. malnutrition, anemia
f. infection
g. substance use (alcohol, drugs)
h. cigarette smoking
1.1 Factors involving the uterus and placenta:
a. decreased blood flow in the uterus and placenta
b. placental abruption (placenta detaches from the uterus)
c. placenta previa (placenta attaches low in the uterus)


TECHONOLOGY
d. infection in the tissues around the fetus
1.2 Factors related to the developing baby (fetus):
a. multiple gestations (twins, triplets, etc.)
b. infection
c. birth defects o chromosomal abnormality
Common problems at birth, including the following:

a. decreased oxygen levels
b. low Apgar scores (an assessment that helps identify babies with difficulty adapting after delivery)
c. meconium aspiration (inhalation of the first stools passed in utero) which can lead to difficulty
breathing
d. hypoglycemia (low blood sugar)
e. difficulty maintaining normal body temperature
f. polycythemia (too many red blood cells)
Diagnosis:
Other diagnostic procedures may include the following:
ULTRASOUND
Ultrasound (a test using sound waves to create a picture of internal structures) is a more accurate
estimating fetal size method. Measurements can be taken of the fetus' head and abdomen and
compared with a growth chart to estimate fetal weight. The fetal abdominal circumference is a
helpful indicator of fetal nutrition.
DOPPLER FLOW
Another way to interpret and diagnose IUGR during pregnancy is Doppler flow, which uses sound
waves to measure blood flow. The sound of moving blood produces waveforms that reflect the
blood's speed and amount as it moves through a blood vessel.
Blood vessels in the fetal brain and the umbilical cord blood flow can be checked with Doppler flow
studies.
MOTHER'S WEIGHT GAIN
A mother's weight gain can also indicate a baby's size. Small maternal weight gains in pregnancy may
correspond with a small baby.
GESTATIONAL ASSESSMENT
Babies are weighed within the first few hours after birth. The weight is compared with the baby's
gestational age and recorded in the medical record. The birthweight must be compared to the
gestational age. Some physicians use a formula for calculating a baby's body mass to diagnose SGA.
Treatment of the SGA baby may include:
a. temperature-controlled beds or incubators
b. tube feedings (if the baby does not have a strong suck)
Small for Gestational Age Characteristics

a. Decreased breast tissue


TECHONOLOGY
b. Scaphoid abdomen (sunken)
c. Wide sutures
d. Thin umbilical cord
e. Head larger than body
f. Wasted appearance to extremities
g. Reduced-fat stores
h. Little Subcutaneous tissue
i. Loose, dry, scaling skin
j. Appears thin and wasted; old for size
k. Maybe meconium staining of skin, nails
l. Sparse hair on the head
m. Active, alert, and seem hungry
n. Cord dries more rapidly
Assessment
a. Assess for Hypoglycemia or poor glucose control
b. Assess for Hypothermia
c. Assess for Asphyxia
d. Assess for Polycythemia
Symptoms and Signs
Despite their size, SGA infants have physical characteristics (e.g., skin appearance, ear cartilage, sole
creases) and behavior (e.g., alertness, spontaneous activity, zest for feeding) of normal-sized infants of like
gestational age. However, they may appear thin with decreased muscle mass and subcutaneous fat tissue.
Facial features may appear sunken, resembling those of an elderly person ("wizened facies"). The umbilical
cord can appear thin and small. (Robert L. Stavis, 2019)
a. provide care similar to Premature infants until stabilized.
b. Protect from cold stress; Keep warm; Usually in an isolette
c. Perform test for glucose
d. Weigh daily and maintain I&O
Complications
Full-term SGA infants do not have the complications related to organ system immaturity that premature
infants of similar size have. They are, however, at risk of
a. Perinatal asphyxia
b. Meconium aspiration
c. Hypoglycemia
d. Polycythemia
e. Hypothermia
Perinatal asphyxia during labor is the most serious potential complication. It is a risk of
intrauterine growth restriction. It is caused by placental insufficiency (with marginally adequate
placental perfusion) because each uterine contraction slows or stops maternal placental perfusion by
compressing the spiral arteries. Therefore, when placental insufficiency is suspected, the fetus
should be assessed before labor, and the fetal heart rate should be monitored during labor. If a fetal
compromise is detected, rapid delivery, often by cesarean delivery, is indicated.


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Meconium aspiration may occur during perinatal asphyxia. SGA infants, especially those who are
postmature, may pass meconium into the amniotic sac and begin deep gasping movements. The
consequent aspiration is likely to result in meconium aspiration syndrome. Meconium aspiration
syndrome is often most severe in growth-restricted or postmature infants because the meconium is
contained in a smaller volume of amniotic fluid and thus more concentrated.
Hypoglycemia often occurs in the early hours and days of life because of a lack of adequate glycogen
synthesis and decreased glycogen stores and must be treated quickly with IV glucose.
Polycythemia may occur when SGA fetuses experience chronic mild hypoxia caused by placental
insufficiency. Erythropoietin release is increased, leading to an increased rate of erythrocyte
production. The neonate with polycythemia at birth appears ruddy and may be tachypneic or
lethargic.
Hypothermia may occur because of impaired thermoregulation, which involves multiple factors,
including increased heat loss due to the decrease in subcutaneous fat, decreased heat production due
to intrauterine stress and depletion of nutrient stores, and increased surface to volume ratio due to
small size. SGA infants should be in a thermoneutral environment to minimize oxygen consumption.
Nursing Diagnosis:
Ineffective breathing pattern related to underdeveloped body systems at birth
Outcome Evaluation:
Newborn maintains respirations at a rate of 30 to 60 breaths per minute after resuscitation at birth. Birth
asphyxia is a common problem for SGA infants, both because they have underdeveloped chest muscles and
are at risk for developing meconium aspiration syndrome due to anoxia during labor. Fetal hypoxia causes a
reflex relaxation of the anal sphincter and increased intestinal movement. When gasping for breath in utero,
the fetus draws meconium that was discharged from the intestine into the amniotic fluid down into the
trachea and bronchi. Acting as a foreign substance, this blocks airflow into the alveoli, leading to hypoxemia,
acidosis, and hypercapnia.
For this reason, many SGA infants require resuscitation at birth. Closely observe both respiratory rate and
character in the first few hours of life. Underdeveloped chest muscles can make SGA infants unable to sustain
the rapid respiratory rate of a normal newborn.
Nursing Diagnosis:
Risk for ineffective thermoregulation related to lack of subcutaneous fat
Outcome Evaluation:
The infant's temperature is maintained at 36.5° C (97.8° F) axillary. SGA infants are less able to control body
temperature than other newborns because they lack subcutaneous fat. A carefully controlled environment is
essential to keep the infant’s body temperature in a neutral zone.
LARGE FOR GESTATIONAL AGE
Large gestational age means that a fetus or infant is larger or more developed than normal for the baby's
gestational age. Gestational age is the age of a fetus or baby that starts on the first day of the mother's last
menstrual period.


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Large for gestational age (LGA) refers to a fetus or infant larger than expected for their age and gender. It can
also include infants with a birth weight above the 90th percentile.
The LGA measurement is based on the estimated gestational age of the fetus or infant. Their actual
measurements are compared with normal height, weight, head size, and development of a fetus or infant of
the same age and sex.
a. LGA weight- Larger than 9 lbs and above the 90th%
b. Large body-plump full face
c. Body size is proportionate.
d. Poor motor skills
e. Difficulty in regulating behavioral state (arouse to quiet alert state)
Common causes of the condition are:
a. Gestational diabetes
b. Obese pregnant mother
c. Excessive weight gain during pregnancy
A baby that is LGA has a higher risk of birth injury. There is also a risk for complications of low blood sugar
after delivery if the mother has diabetes.
Large for Gestational Age Common Problems
a. Birth Trauma-
b. Hypoglycemia
c. Polycythemia
d. Hyperbilirubinemia
Symptoms of large-for-gestational-age newborns are mainly related to any complications that occur.
Kernicterus. Kernicterus is the destruction of brain cells by an indirect bilirubin invasion (Symons &
Mahoney, 2008).
Complications
Common complications, according to R. Stavis, in large-for-gestational-age newborns include the following:
Birth injuries: Common injuries include stretching of the shoulder's nerves (brachial plexus injuries) and
fractures.
Difficult delivery: Vaginal delivery, especially if the fetus is in a breech presentation, may be difficult when
the fetus's head is large compared to the mother's pelvis. Cesarean delivery (C-section) is commonly done for
LGA infants.
Low Apgar score: The Apgar score is a rating of the baby's condition in the first minutes of life. LGA infants
tend to have lower Apgar scores and are more likely to require assistance at birth.
Perinatal asphyxia: This complication decreases blood flow to the baby before, during, or just after delivery.
This complication may result from a problem with the placenta before or during delivery. (Robert L. Stavis,
2019)
Meconium aspiration: LGA babies may pass meconium (dark green fecal material produced in the fetus's
intestine before birth) in the amniotic fluid and take forceful gasps that cause the meconium-containing
amniotic fluid to be breathed (aspirated) into the lungs. (Robert L. Stavis, 2019)


TECHONOLOGY
Low blood sugar (glucose) levels (hypoglycemia): If the fetus has been exposed to high glucose levels
because the mother's diabetes was poorly controlled during pregnancy, the fetus has a high insulin level. At
the time of delivery, the placental supply of glucose is abruptly stopped, and the high level of insulin can
rapidly drop the baby's blood sugar level, resulting in hypoglycemia. Hypoglycemia may cause no symptoms,
but some babies are lethargic and limp, and some are jittery and very excitable. Despite their large size,
newborns of mothers with diabetes often do not feed well for the first few days. (Robert L. Stavis, 2019)
Lung problems: Lung development may be delayed in newborns whose mothers have diabetes, and the
babies are at increased risk of respiratory distress syndrome or transient tachypnea of the newborn, even
when they are not premature. (Robert L. Stavis, 2019)
Birth defects: Infants of mothers with diabetes have an increased risk of birth defects, including those
involving the brain, heart, kidneys, digestive tract, and lower part of the spine.
Excess red blood cells (polycythemia): LGA babies may have a higher blood count than usual. Too many red
blood cells may cause the blood to become too thick, which may slow blood flow. Newborns with polycythemia
have a reddish complexion and are sluggish. Polycythemia can contribute to hypoglycemia, respiratory
distress, and hyperbilirubinemia. (Robert L. Stavis, 2019)
Diagnosis
1. Before birth, measurement of the uterus and ultrasonography.
a. Ultrasonography can assess the fetus's size and estimate the fetal weight to confirm the LGA
diagnosis.
2. After birth, assessment of gestational age and size and weight of the baby
a. LGA newborns are assessed for any complications. Blood sugar is measured to detect
hypoglycemia, and doctors do a thorough examination to look for birth injuries and structural or
genetic abnormalities.
Treatment of complications
a. There is no specific treatment for large-for-gestational-age newborns, but underlying conditions
and complications are treated as needed.
b. Newborns with polycythemia are given intravenous fluids. If the polycythemia is severe, the
physician may remove some blood and replace it with plasma (partial exchange transfusion),
which dilutes the remaining red blood cells. (Robert L. Stavis, 2019)
c. Newborns with hypoglycemia are treated with frequent feedings or sometimes are given glucose
by vein.
d. Respiratory distress and meconium aspiration are treated with supplemental oxygen or other
supportive devices such as continuous positive airway pressure (CPAP—a technique that allows
newborns to breathe independently while being given slightly pressurized oxygen) or a
mechanical ventilator, depending on the severity of the problem.
3. During pregnancy, doctors measure the distance on the woman's abdomen from the top of the pubic
bone to the top of the uterus (fundus). This measurement, called a fundal height measurement,
corresponds roughly with the number of weeks of pregnancy. If the measurement is high for the number
of weeks, the fetus may be larger than expected. (Robert L. Stavis, 2019)
Nursing Diagnosis: Risk for imbalanced nutrition, less than body requirements, related to additional
nutrients needed to maintain weight and prevent hypoglycemia
Outcome Evaluation: Infant’s weight follows percentile growth curve; skin turgor is good; specific gravity
of urine is 1.003 to 1.030; serum glucose is above 45 mg/dL.


TECHONOLOGY
As a rule, an LGA infant needs to be breastfed immediately to prevent hypoglycemia. The infant may need
supplemental formula feedings after breastfeeding to supply enough fluid and glucose for the larger-than-
normal size for the first few days. Newborns who are offered bottles often have more difficulty than do
others learning to breastfeed. Offer both the mother and baby support to overcome this hurdle.

1. Choose three diseases/cases from this chapter, make a diagram format illustrating the
pathophysiologic sequence of changes in your chosen diseases/cases. An outline format is acceptable
as long as the cause-and-effect sequence can be seen.
References
ISBN: 978-0-323-08343-0 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Muhammad Waseem, M. M. (2020, June 08). Medscape. Retrieved from
emedicine.medscape.com:https://emedicine.medscape.com/article/1009987-overview
O’Malley, G. F. (2020, April). MSD MANUAL PROFESSIONAL VERSION. Retrieved from https://www.msdmanuals.com/:
https://www.msdmanuals.com/professional/injuries-poisoning/poisoning/hydrocarbon-poisoning
Patrici M. Nugent, RN, EdD, Judith S. Green, RN, MA, Phyllis K. Pelikan, RN, MA, Marry Ann Hellmer Saul, RNCS, Ph.D.
(2014). Mosby's Comprehensive Review of Nursing for the NCLEX-RN Examination 20th edition. Elsevier.
Pilliteri, A. (2020). Maternal and Child Health Nursing: Care of the Child Bearing and Child Rearing Family. 530 Walnut
Street, Philadelphia: Wolters Kluwe/Lippincott Williams & Wilkins.
Robert L. Stavis, Ph.D., MD, 2019; Small-for-Gestational-Age (SGA) Infant - Pediatrics ....
https://www.merckmanuals.com/professional/pediatrics/perinatal-problems/small-for-gestational-age-sga-infant
Robert L. Stavis, Ph.D., MD, 2019; Large-for-Gestational-Age (LGA) Newborn - Children's ....
https://www.merckmanuals.com/home/children-s-health-issues/general-problems-in-newborns/large-for-
gestational-age-lga-newborn


TECHONOLOGY
UNIT 3: ACUTE CONDITIONS OF THE NEONATES
This unit discusses the common acute conditions of neonates.
RESPIRATORY DISTRESS SYNDROME (RDS)
a. Hyaline membrane disease
b. Syndrome of premature neonates characterized by progressive and fatal respiratory failure
resulting from atelectasis and immaturity of the lungs
c. Common to premature neonates
d. RDS can be fatal
e. Those who survive are at risk for chronic respiratory and neurologic complications.
f. Respiratory distress is a name applied to respiratory dysfunction in neonates and is primarily a
disease related to developmental delay in lung maturation. The terms respiratory distress syndrome
(RDS) and hyaline membrane disease are most often applied to this severe lung disorder, which is
responsible for more infant deaths than any other disease and carries the highest risk in terms of
long-term respiratory and neurologic complications. It is seen almost exclusively in preterm infants.
The disorder is rare in drug-exposed infants and infants who have been subjected to chronic
intrauterine stress (e.g., maternal preeclampsia or hypertension). Respiratory distress of a non-
pulmonary origin in neonates may also be caused by sepsis, cardiac defects (structural or
functional), exposure to cold, airway obstruction (atresia), intraventricular hemorrhage,
hypoglycemia, metabolic acidosis, acute blood loss, and drugs. Pneumonia in the neonatal period
may result in respiratory distress caused by bacterial or viral agents and may occur alone or as a
complication of RDS.
Symptoms of Respiratory Distress Syndrome c. High surface tension makes it hard to

The symptoms of NRDS are often noticeable expand the alveoli. The adequate surface
immediately after birth and get worse over the area in air spaces to allow for gas exchange
following few days. d. The tendency of affected lungs to become
atelectatic at end-expiration when alveolar
They can include: pressures are too low to maintain alveoli in
a. blue-colored lips, fingers, and toes expansion.
b. rapid, shallow breathing e. Leads to failure to attain adequate lung
c. flaring nostrils inflation and therefore reduced gaseous
d. a grunting sound when breathing exchange
f. With advancing gestational age, increasing
ETIOLOGY AND PATHOPHYSIOLOGY. amounts of phospholipids are synthesized
a. Surfactant deficiency is the 1O cause of and stored in type II alveolar cells.
RDS. g. Wk 20: start of surfactant production and
b. Low levels of surfactant cause high surface storage. It does not reach the lung surface
tension, an adequate amount of surfactant until later.
lining the alveolar cells, which allows for h. Wk 28-32: maximal production of
alveolar stability and prevents alveolar surfactant and appears in amniotic fluid
collapse at the end of expiration i. Wk 34-35; mature levels of surfactant in
lungs


TECHONOLOGY
j. Quality: The amounts produced or released d. Grunting; closure of glottis during
may be insufficient to meet postnatal expiration.
demands because of immaturity. e. Cyanosis
k. Surfactant inactivating states, e.g., maternal Management of Respiratory Distress
DM, may lead to surfactant of lower
quality/ immature. 1. Monitoring
l. Rare genetic disorders may cause fatal 2. Supportive
respiratory distress syndrome e.g. a. IV fluid - Maintain vital signs.
m. Abnormalities in surfactant protein B and C b. Oxygen therapy
genes c. Respiratory support
3. Specific
n. the gene responsible for transporting Initial Care
surfactant across membranes (ABC a. Maintain warmth- cold stress will
transporter 3 [ABCA3]) are associated with mimic other causes of distress.
severe and often lethal familial respiratory b. Monitor blood glucose levels-
disease assure they are normal.
Clinical manifestation c. Provide enough oxygen to keep the
a. Tachypnea baby pink
b. Nasal flaring
c. Intercostal, sternal recession


TECHONOLOGY
MECONIUM ASPIRATION SYNDROME
The first intestinal discharge from newborns is meconium, a
viscous, dark-green substance composed of intestinal epithelial
cells, lanugo, mucus, and intestinal secretions (e.g., bile).
a. Meconium is typically passed for 2-3 days after birth.
b. Sometimes, the fetus passes the meconium while it is
still in the womb.
c. Intestinal secretions, mucosal cells, and solid elements
of swallowed amniotic fluid are the meconium's major solid
constituents.
MECONIUM
a. Aristotle coined the term from the Greek word
"meconium arion," meaning "opium-like."
b. It consists of gastrointestinal, hepatic, and pancreatic
secretions, cellular debris, swallowed amniotic fluid, lanugo, vernix caseosa, and blood.
c. Appear in the fetal intestines by the 10th week of life, gradually increasing in an amount to reach
200gms at birth. Meconium Aspiration Syndrome
Meconium Aspiration Syndrome

Meconium aspiration syndrome (MAS) is respiratory
distress in a newborn who has breathed( aspirated)
meconium into the lungs before or around the time of
birth.
Causes of MAS
a. Hypoxia in distressed baby
b. Meconium Stained Liquor
c. Uterine Infections
d. Difficulty during the labor process
e. The passage of meconium from the fetus
into amnion is prevented by lack of b. Post-dated pregnancy
peristalsis (low motilin level), tonic c. Maternal hypertension
contraction of the anal sphincter, terminal d. Pre-eclampsia
cap of viscous meconium. e. Oligohydramnios
f. Vagal Stimulation due to in utero hypoxia, f. Maternal drug abuse, especially of tobacco
acidosis, cord, or head compression cause and cocaine
increased peristalsis and a relaxed anal g. Maternal infection/ chorioamnionitis
sphincter. h. Fetal gasping secondary to hypoxia (fetal
g. Fetal maturation (post-term) causes a high distress)
motilin level i. Inadequate removal of meconium from the
1. increased peristalsis Meconium airway prior to the first breath.
Aspiration Syndrome
Risk factors for MAS
Factors that promote the passage of meconium in a. Post-term pregnancy
utero include the following: b. Primigravida
c. Maternal Anemia
a. Placental insufficiency


TECHONOLOGY
d. Chorioamnionitis b. End-expiratory grunting
e. Prolonged Labour c. Nasal flaring
f. Fetal Distress d. Breathing problems like( difficulty in
g. IUGR breathing, no breathing, and rapid
h. Maternal Age >30yrs breathing)
i. Maternal DM e. Intercostal retractions
j. Maternal heavy cigarette smoking f. Tachypnea
k. Pre-eclampsia / eclampsia g. Barrel chest in the presence of air trapping
l. Oligohydramnios h. Auscultated rales and rhonchi ( in some
m. Antepartum Hemorrhage cases).
Symptoms include the following: i. Yellow-green staining of fingernails,
a. Cyanosis umbilical cord, and skin may be observed.
Pathophysiology
1. Mechanical obstruction of airways
2. Chemical Pneumonitis
3. Surfactant Inactivation
Mechanical obstruction of airways
1. With the onset of respiration – meconium migrates from central to peripheral airways.
2. Thick particulate and viscous meconium lead to complete or partial airway obstruction.
3. Complete obstruction
3.1. Atelectasis
3.2. Ventilation-Perfusion (V-Q) mismatch
4. Partial obstruction


TECHONOLOGY
4.1. Ball-valve – air trapping
4.2. Obstructive Emphysema
4.3. Risk of pneumothorax (15 – 33%)
Chemical pneumonitis
1. Meconium in the airways initiates an inflammatory reaction
2. Meconium inhibits oxidative burst and phagocytosis by neutrophil
2.1. increased risk of infection
3. Meconium induces the production of inflammatory cytokines
3.1. Injury of parenchyma and vascular leakage
3.2. injury similar to ARDS
Surfactant inactivation
1. Bilirubin, fatty acid, triglycerides, cholesterol, and proteins present in meconium alter the
phospholipid structure of surfactant
1.1. reduced surfactant function
2. Bile has a cytotoxic effect on Type II Pneumocytes
2.1. Reduced surfactant production.
Diagnosis of MAS
1. High-risk infants may be identified by
1.1. fetal tachycardia
1.2. bradycardia or
1.3. absence of fetal accelerations (upon CTG ) in utero
2. At birth, the infant may look cachexic and show signs of yellowish meconium staining on the skin,
nails, and umbilical cord.
3. These infants usually progress onto Infant Respiratory distress syndrome within 4 hours.
4. Investigations that can confirm the diagnosis are :
5. A fetal chest x-ray will show hyperinflation, diaphragmatic flattening, cardiomegaly, patchy
atelectasis, and consolidation.
6. ABG samples, which pH, the partial pressure of oxygen( p02), the partial pressure of CO2 ( pCO2), and
continuous oxygenation measurement by pulse oximetry are necessary for management.
7. Complete blood count: hemoglobin & hematocrit level must be sufficient to ensure adequate oxygen-
carrying capacity.
8. Serum electrolytes: obtain sodium, potassium, and calcium concentration when the infants with MAS
aged 24 hrs because the syndrome of inappropriate secretion of antidiuretic hormone( SIADH) and
acute renal failure are frequent complications of perinatal stress.
Preventive measures of MAS
1. MAS is difficult to prevent
1.1. When there is meconium-stained liquor, careful suctioning of the posterior pharynx after
delivery of head decreases the potential for meconium aspiration.
1.2. When aspiration occurs, intubation and immediate suctioning of the airway can remove much of
the aspirated meconium.
1.3. Do not perform the following harmful techniques in an attempt to prevent aspiration of
meconium-stained liquor:
1.3.1. Squeezing of the chest of the baby
1.3.2. Inserting a finger into the mouth of the baby.


TECHONOLOGY
Management of MAS Prenatal:
1. Identification of high-risk pregnancies - recognition of predisposing maternal factors - post dates
pregnancy inductions as early as 41 weeks.
2. Monitoring - careful observation and fetal monitoring during labor - corrective measures should be
undertaken in identifies compromised fetus.
3. Amnioinfusion - relieved umbilical cord compression during labor -> reducing the occurrence of
variable fetal heart rate decelerations - efficiency not well demonstrated.
Delivery room management
1. Immediate Management
1.1. If the baby is not vigorous:
1.1.1. Suction the trachea immediately after delivery
1.1.2. Suction for no longer than 5 seconds
1.1.3. If no meconium is retrieved, do not repeat intubation and suction.
1.1.4. If meconium is retrieved and no bradycardia is present, reintubate and suction.
1.1.5. If the heart rate is low, administer positive pressure ventilation, and consider suctioning again
later.
1.2. If the baby is vigorous:
1.2.1. Do not electively intubate
1.2.2. Clear secretions and meconium from the mouth and nose with a bulb syringe or a large-bore
suction catheter.
1.2.3. Dry, stimulate, reposition, and administer oxygen as necessary.
1.2.4. Transfer ill newborns with respiratory distress to NICU
2. General management
2.1. Continued care in the neonatal ICU (NICU)
2.1.1. Maintain an optimal thermal environment
2.1.2. Minimal handling to reduce agitation thus pulmonary hypertension and right-to-left shunting
causing hypoxia and acidosis
2.1.3. Insert the umbilical artery to monitor blood pH and blood gases without agitating the infant.
2.1.4. Continue respiratory care: oxygen therapy via hood or positive pressure is crucial in
maintaining adequate arterial oxygenation. Oxygen saturation ( 90-95%) should be maintained.
2.1.5. Newborns are treated with antibiotics because of the risk of infection(e.g., Gentamycin)
3. Supportive treatment
3.1. IV Dextrose to prevent hypoglycemia.
3.2. Fluid restriction (60-70 mL/kg/d) to prevent cerebral and pulmonary edema
3.3. Electrolytes to correct metabolic acidosis
3.4. Protein, lipids, and vitamins to prevent deficiencies
To treat persistent pulmonary hypertension of the newborn( PPHN), inhaled nitric oxide is the
pulmonary vasodilator of choice.
1. Surfactant Therapy: Replace displaced or inactivated surfactant and as a detergent to remove
meconium, may reduce the severity of the disease, progression to extracorporeal membrane
oxygenation, and decrease the length of hospital stay.
2. May decrease respiratory failure with MAS within 6 hrs of 3 doses.
3. ECMO EXTRACORPOREAL MEMBRANE OXYGENATION: Extracorporeal membrane oxygenation is
the last option focused on the function of oxygenation and CO2 removal. Effective but associated with
a high incidence of poor neurologic outcomes.


TECHONOLOGY
4. ECMO is done using only cervical cannulation, which can be performed under local anesthesia used
for longer-term support ranging from 3-10 days. Allow time for intrinsic recovery of the lungs and
heart. Survival rate 93-100%
Complications of MAS
1. In mild cases, respiratory distress usually subsides in 2-4 days, although tachypnea can persist
longer.
2. Cerebral hypoxia may lead to long term neurological damage.
3. Aspiration pneumonia
4. Brain damage due to lack of oxygen
5. Collapsed lung
6. Persistent pulmonary hypertension of the newborn.
Prognosis of MAS
1. The mortality rate of meconium-stained infants is considerably higher than that of non-stained
infants.
2. Meconium aspiration accounts for a significant proportion of neonatal deaths.
3. Residual lung problems are rare but include symptomatic cough, wheezing, and persistent
hyperinflation for up to five to ten years.
4. The ultimate prognosis depends on the extent of CNS injury from asphyxia and the presence of
associated problems such as persistent pulmonary hypertension. — The mortality rate is approx 5%.
SEPSIS
Neonatal sepsis may be categorized as early-onset (day of life 0-3) or late-onset (day of life 4 or later). Of
newborns with early-onset sepsis, 85% present within 24 hours (median age of onset 6 hours), 5% present at
24-48 hours, and a smaller percentage present within 48-72 hours. Onset is most rapid in premature neonates.
Early-onset sepsis is associated with the acquisition of microorganisms from the mother. Infection can occur
via hematogenous, transplacental spread from an infected mother or, more commonly, via ascending infection
from the cervix.
Neonatal sepsis (NS) is defined as a clinical syndrome of bacteremia with systemic signs and symptoms of
infection in the first four weeks of life.
Sepsis, or septicemia, refers to a generalized bacterial infection in the bloodstream. Neonates are highly
susceptible to infection as a result of diminished nonspecific (inflammatory) and specific (humoral) immunity,
such as impaired phagocytosis, delayed chemotactic response, minimal or absent immunoglobulin A and
immunoglobulin M (Ig and IgM), and decreased complement levels. Because of infants’ poor
ETIOLOGY
Common organisms identified:
1. Escherichia coli.
2. Group B Streptococci.
3. Listeria monocytogenes.
4. Others:
a. Coagulase-negative staphylococci.
b. Streptococcus pneumoniae.
c. Klebsiella pneumoniae.
d. Acinetobacter species.


TECHONOLOGY
e. Pseudomonas aeruginosa.
f. Candida.
Pathogenesis
Neonatal infections are unique in several ways:
1. Infectious agents can be transmitted from the mother to the fetus or newborn infant by diverse modes.
2. Newborn infants are less capable of responding to infection because of 1 or more immunologic
deficiencies.
3. Coexisting conditions often complicate the diagnosis and management of neonatal infections.
4. The clinical manifestations of newborn infections vary and include subclinical infection, mild to severe
manifestations of focal or systemic infection, and, rarely, congenital syndromes resulting from in utero
infection. The timing of exposure, inoculum size, immune status, and virulence of the etiologic agent
influences disease expression.
5. Maternal infection that is the source of transplacental fetal infection is often undiagnosed during
pregnancy because the mother was either asymptomatic or had nonspecific signs and symptoms at the
time of acute infection.
6. A wide variety of etiologic agents infect the newborn, including bacteria, viruses, fungi, protozoa, and
mycoplasmas.
7. Immature, very low birth weight (VLBW) newborns have improved survival. Still, they remain in the
hospital for a long time in an environment that puts them at continuous risk for acquired infections.
Classification
Neonatal sepsis includes the following:
Congenital infection —a major risk factor is a maternal infection.
1. Early-onset sepsis (birth to 7 days)—transplacental, ascending, or intrapartum.


TECHONOLOGY
2. manifests as:
2.1. Pneumonia (Frequently)
2.2. Less commonly as • Septicemia. •
Meningitis.
3. Late-onset sepsis (8 to 28 days)—acquired in
a hospital, home, or community
4. manifests as:
4.1. Septicemia.
4.2. Hematogenous seeding may result in
focal infections, such as meningitis (in
75% of cases), osteomyelitis (group B
streptococci, S. aureus), arthritis
(gonococcus, S. aureus, Candida albicans,
gram-negative bacteria), and urinary
tract infection (gram-negative bacteria).
CLINICAL FEATURES
Manifestations of neonatal sepsis are usually
VAGUE and demand A HIGH INDEX OF
SUSPICION for early diagnosis.
The most common manifestations include:
1. Respiratory distress in early-onset NS.
2. Altered feeding behavior in a well-
established feeding newborn (aspiration,
vomiting, etc.).
3. Active baby suddenly or gradually becomes lethargic, inactive or unresponsive, and refuses to suckle.
4. Temperature instability: Hypo- or hyperthermia.
5. Skin: Poor peripheral perfusion, cyanosis, pallor, petechiae, rashes, or jaundice.
6. Metabolic: Hypo- or hyperglycemia or metabolic acidosis.
Diagnosis
A. Non-specific:
1. White blood cell count and differential:
a. Neutropenia can be a threatening sign (< 1,800/cm).
b. Immature to Total neutrophil (I:T) ratio ≥ 0.2 is predictive (Normal: ˂ 0.16).
2. Acute phase reactants:
a. C-Reactive Protein (CRP): rises early.
b. ESR rises > 15 mm 1 st hr.
3. Platelet count:
a. Decreases, a late sign, and non-specific.
4. Others: – Bilirubin, glucose, sodium.
B. Definitive, specific:
Cultures:
1. Blood: Confirms sepsis.
2. Urine:
3. CSF: May be useful in clinically ill newborns or those with positive blood cultures.
C. Radiology
1. Chest X-Ray: – For infants with respiratory symptoms.


TECHONOLOGY
2. Renal ultrasound: – For infants with accompanying UTI.
3. CT scan: – For infants with probable meningitis or seizures.
Differential Diagnosis
a. Respiratory distress syndrome (RDS).
b. Metabolic diseases.
c. Hematologic diseases.
d. CNS diseases.
e. Cardiac diseases.
f. Other infections (e.g., ToRCH infections).
TREATMENT
1. Antibiotics:
1.1. Should be based on culture & sensitivity
1.2. Antibiotics are used to suppress bacterial growth, allowing the infant's defense mechanisms
time to respond.
1.2.1. Antibiotics:
1.2.1.1. A combination of ampicillin and an aminoglycoside (usually gentamicin) for 10 to 14
days is an effective treatment against most organisms responsible for early-onset
sepsis.
1.2.1.2. The combination of ampicillin and cefotaxime also is proposed as an alternative
method of treatment.
1.2.1.3. If meningitis is present, the treatment should be extended to 21 days or 14 days after
a negative result from a CSF culture.
2. Supportive therapy
a. Also, support measures, such as assisted ventilation and cardiovascular support, are equally
important to the infant's management.
Supportive therapy
1. Respiratory: Oxygen and ventilation as necessary.
2. Cardiovascular: Support blood pressure with volume expanders.
3. Hematologic: Treat DIC.
4. CNS: Treat seizures with phenobarbital.
5. Metabolic: Correct hypo-/hyperglycemia and metabolic acidosis.
PREVENTION
1. Good antenatal care.
2. Maternal infections were diagnosed and treated early.
3. Babies should be breastfed early.
4. Infection control policies applied in the unit.
HYPERBILIRUBINEMIA
An abnormal elevation of bilirubin in the newborn (above 12.9 mg/100mL for formula feed infants
and above 15 mg/100 mL for breastfed infants and Premature)
Hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the blood and is characterized by
jaundice, or icterus, a yellowish discoloration of the skin, sclerae, and nails. Hyperbilirubinemia is a common
finding in newborns and, in most instances, is relatively benign. However, in extreme cases, it can indicate a
pathologic state.


TECHONOLOGY
Hyperbilirubinemia may result from increased unconjugated or conjugated bilirubin. The unconjugated form
of indirect hyperbilirubinemia is the type most commonly seen in newborns. The following discussion of
hyperbilirubinemia is limited to unconjugated hyperbilirubinemia.
Pathophysiology
Bilirubin is one of the breakdown products of the hemoglobin that results from RBC destruction. When RBCs
are destroyed, the breakdown products are released into the circulation, where the hemoglobin splits into two
fractions: heme and globin. The body uses the globin (protein) portion, and the heme portion is converted to
unconjugated bilirubin, an insoluble substance bound to albumin. In the liver, the bilirubin is detached from
the albumin molecule. In the presence of the enzyme glucuronyl transferase, it is conjugated with glucuronic
acid to produce a highly soluble substance, conjugated bilirubin, then excreted into the bile. In the intestine,
bacterial action reduces the conjugated bilirubin to urobilinogen, the pigment that gives stool its characteristic
color. Most of the reduced bilirubin is excreted through the feces; a small amount is eliminated
in the urine.
Normally, the body can balance the destruction of RBCs and the use or excretion of byproducts. However,
when developmental limitations or a pathologic process interferes with this balance, bilirubin accumulates
in the tissues to produce jaundice.
Possible causes of hyperbilirubinemia in newborns are:

1. Physiologic (developmental) factors (prematurity)
2. An association with breastfeeding or breast milk
3. Excess production of bilirubin (e.g., hemolytic disease, biochemical
4. defects, bruises)
5. The disturbed capacity of the liver to secrete conjugated bilirubin (e.g.,
6. enzyme deficiency, bile duct obstruction)
7. Combined overproduction and under secretion (e.g., sepsis)
8. Some disease states (e.g., hypothyroidism, galactosemia, infant of a
9. diabetic mother)
10. Genetic predisposition to increased production (American Indians, Asians)
The most common cause of hyperbilirubinemia is the relatively mild and self-limited physiologic jaundice or
icterus neonatorum. Unlike hemolytic disease of the newborn (HDN)
Hyperbilirubinemia in the first 24 hours of life is most often the result of HDN, an abnormally rapid RBC
destruction rate. Anemia caused by this destruction stimulates RBC production, which provides increasing
numbers of cells for hemolysis. Major causes of increased erythrocyte destruction are isoimmunization
(primarily Rh) and ABO incompatibility.
Assessment
a. Observe for Jaundice, which progresses from head to extremities.
b. Observe for Pallor
c. Evaluate Activity Level
d. Assess if urine is concentrated and stools are light in color.
e. Assess the progress of conditions
f. Evaluate Blood Tests.
a. Observe infant for signs of increased jaundice


TECHONOLOGY
b. Observe for and prevent acidosis
c. Maintain adequate hydration and offer fluids between feeding as ordered.
d. Using a skin temperature probe
e. Prevent Infections
f. Provide Phototherapy
g. Meet the infant's emotional needs
h. Reinforce Physician's teaching to parents and allow parents to express concerns and feelings
i. Monitor Exchange Transfusion.
j. Administer care after Transfusion
ERYTHROBLASTOSIS FETALIS
The destruction of Red Blood Cells that results from an Antigen-Antibody reaction and is characterized by
Hemolytic Anemia and or Hyperbilirubinemia
Diagnosis
1. Indirect Coombs' test
2. Directs Coombs' test
3. Spectrophotometric Analysis of Amniotic fluids
Assessment
1. Assess anemia
2. Assess for Jaundice
3. Evaluate edema
Nursing Interventions
1. Administer immunization against hemolytic disease with RhoGAM as ordered
2. Monitor exchange transfusion after birth or Intrauterine transfusion.
3. Follow interventions for Hyperbilirubinemia.
SUDDEN DEATH SYNDROME (SDS)
The sudden unexplained death of a child of less than one year of age is sudden infant death
syndrome (SIDS), also known as cot death or crib death.
SIDS usually occurs during sleep; typically, death occurs between the hours of 00:00 and 09:00. There is
usually no noise or evidence of a struggle.
The exact cause of SIDS is unknown.
Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant younger than 1 year of age
that remains unexplained after a complete postmortem examination, including an investigation of the death
scene and a review of the case history.
SIDS is sudden unexplained death in infancy. It tends to occur at a higher-than-usual rate in infants of
adolescent mothers, infants of closely spaced pregnancies, and underweight and preterm infants.
a. Factors that place infants at high risk for SIDS include prone sleeping position, soft bedding, sleeping
in a noninfant bed with an adult or older child, and environmental exposure to smoking.


TECHONOLOGY
b. Factors that are protective for SIDS include supine sleep position, breastfeeding, pacifier use at
bedtime and naptime, and updated immunization status.
c. The primary nursing responsibility in care associated with sudden infant death is educating the
family of newborns about the risks for SIDS, modeling appropriate behaviors in the hospital, such as
placing the infant in a supine sleep position and providing emotional support of the family who has
experienced a SIDS loss.
THINGS TO REMEMBER
1. Priorities for infants born with special needs, such as preterm or post-term infants, are the same as
for term infants: initiation and maintenance of respiration, the establishment of extrauterine
circulation, control of body temperature, intake of adequate nourishment, establishment of waste
elimination, the establishment of an infant-parent relationship, prevention of infection, and
provision of developmental care for mental and social development.
2. Many high-risk infants need resuscitation at birth. Prompt action with such measures as warmth,
oxygen, intubation, and suctioning is needed.
3. A small-for-gestational-age infant is one whose birth weight is below the 10th percentile on an
intrauterine growth curve for that age infant. An infant could be preterm, term, or postterm.
4. Small-for-gestational-age infants have difficulty maintaining body warmth because of low-fat stores
and may develop hypoglycemia from low glucose stores.
5. A large-for-gestational-age infant is one whose birth weight is above the 90th percentile on an
intrauterine growth chart for that gestational age. The infant could be born preterm, term, or
postterm.
6. Large-for-gestational-age infants tend to be infants of diabetic women; they are particularly prone to
hypoglycemia or birth trauma.
7. A preterm infant is one born before 37 weeks of gestation. Preterm infants have particular
respiratory function problems, anemia, jaundice, persistent patent ductus arteriosus, and
intracranial hemorrhage. Infants born weighing 1500 to 2500 g are also termed low-birthweight
infants; those born weighing 1000 to 1500 g are very-low-birth-weight infants; those born weighing
between 500 and 1000 g are extremely very-low-birthweight infants. All such infants need intensive
care from the moment of birth to give them their best chance of survival without neurologic
aftereffects caused by their being so close to the age of viability.


TECHONOLOGY
8. A postterm infant is one who has remained in utero past week 42 of pregnancy. Post-term infants
have particular problems with establishing respirations, meconium aspiration, hypoglycemia,
temperature regulation, and polycythemia.
9. Respiratory distress syndrome commonly occurs in preterm infants from a deficiency or lack of
surfactant in the alveoli. Without surfactant, the alveoli collapse on expiration and require extreme
force for reinflation. Primary therapy is synthetic surfactant replacement at birth by endotracheal
tube insufflation, followed by oxygen and ventilatory support.
10. Transient tachypnea of the newborn is a temporary condition caused by the slow absorption of lung
fluid at birth. Close observation of the infant is necessary until the fluid is absorbed and respirations
slow to a normal rate.
11. Meconium aspiration syndrome occurs when an infant aspirates meconium-stained amniotic fluid
before or during birth. Meconium is irritating to the airway and leads to both airway spasm and
pneumonia. Infants need oxygen, ventilatory support, and possibly an antibiotic until the effects of
the insult to the airway subside. Infants should be suctioned before oxygen administration under
pressure to prevent meconium from being forced further into their lungs.
12. Apnea is a pause in respirations longer than 20 seconds, with accompanying bradycardia. It tends to
occur in preterm infants with secondary stresses such as infection, hyperbilirubinemia,
hypoglycemia, or hypothermia. Apnea monitors are used to detecting this, and infants at high risk for
apnea may be discharged home on a home monitoring program.
13. Sudden infant death syndrome is the sudden, unexplained death of an infant. It is associated with
infants sleeping on their stomachs (prone) and preterm birth. An important preventive measure is
advising parents to position their infant on the back for sleeping.

pathophysiologic sequence of changes in your chosen diseases/cases. An outline format is acceptable
as long as the cause-and-effect sequence can be seen.
References
Muhammad Waseem, M. M. (2020, June 08). Medscape. Retrieved from emedicine.medscape.com:

https://emedicine.medscape.com/article/1009987-overview
O’Malley, G. F. (2020, April). MSD MANUAL PROFESSIONAL VERSION. Retrieved from
https://www.msdmanuals.com/: https://www.msdmanuals.com/professional/injuries-
poisoning/poisoning/hydrocarbon-poisoning
Patricia M. Nugent, RN, EdD, Judith S. Green, RN, MA, Phyllis K. Pelikan, RN, MA, Marry Ann Hellmer Saul,
RNCS, Ph.D. (2014). Mosby's Comprehensive Review of Nursing for the NCLEX-RN Examination 20th
edition. Elsevier.


TECHONOLOGY
Ranabhat, R.D & Niraula, H.(2017) A textbook of midwifery & reproductive health (1st ed.). Kathmandu,
Page no: 580- 582
Tuitui, R. (2016) Manual of midwifery III (11th ed.). Vidyarthi Pustak Bhandar, Kathmandu, Page no: 227-
231 — Dutta, D.C. (2011). A textbook of obstetrics, including perinatology and contraception (7th
ed.). A central book agency(P) Ltd., Hyderabad, Page no: 476


TECHONOLOGY
UNIT 4: COMMON HEALTH PROBLEMS THAT DEVELOP DURING INFANCY
This unit adds information about common health problems that develop during infancy.
KEY TERMS
1. Ankyloglossia (Tongue-Tie)
Ankyloglossia is an abnormal restriction of the tongue caused by an abnormally tight frenulum, the
membrane attached to the tongue's lower anterior tip (Kelley et al., 2008). Usually, in newborns, the
frenulum appears short and is positioned near the tip of the tongue. As the anterior portion of the infant's
tongue grows, the frenulum becomes located farther back. Therefore, in most instances, an infant
suspected of being tongue-tied has a normal tongue at birth; it just seems short to parents unaware of a
newborn's appearance. This condition rarely causes speech difficulty or destructive pressure on gingival
tissue. If it does, then surgical release can be performed, but this is rare.
2. Anencephaly. Anencephaly is the absence of the cerebral hemispheres. It occurs when the upper end of
the neural tube fails to close in early intrauterine life. It is revealed by an elevated AFP level in the
maternal serum or amniocentesis and confirmed by a prenatal sonogram.
3. Microcephaly. Microcephaly is a disorder in which brain growth is so slow that it falls more than three
standard deviations below normal on growth charts. The cause might be a disorder in brain development
associated with an intrauterine infection such as rubella, cytomegalovirus, or toxoplasmosis.
Microcephaly may also result from severe malnutrition or anoxia in early infancy.
4. Spina Bifida Occulta. Spina bifida occulta occurs when the posterior laminae of the vertebrae fail to
fuse. This occurs most commonly at the fifth lumbar or first sacral level but may occur at any point along
the spinal canal.
5. Meningocele. If the meninges covering the spinal cord herniate through unformed vertebrae, a
meningocele occurs. The anomaly appears as a protruding mass, usually approximately an orange's size,
at the back's center. It generally occurs in the lumbar region, although it might be present anywhere
along the spinal canal. The protrusion may be covered by a layer of skin or only the clear dura mater.
6. Myelomeningocele. In myelomeningocele, the spinal cord and the meninges protrude through the
vertebrae the same as with a meningocele. The difference is that the spinal cord ends at the point, so the
motor and sensory function is absent beyond this point. Because this results in lower motor neuron
damage, the child will have flaccidity and lack of sensation of the lower extremities, and loss of bowel
and bladder control. Infants' legs are lax, and they do not move them; urine and stools continually
dribble because of lack of sphincter control. Children often have accompanying talipes (clubfoot)
disorders and developmental hip dysplasia.
7. volvulus - (a twisting of the bowel causing obstruction),
8. Pierre Robin Syndrome
The Pierre Robin syndrome (also called Pierre Robin sequence) is a triad of micrognathia (small
mandible), cleft palate, and glossoptosis (a tongue malpositioned downward). It is an example of cleft
palate occurring as only one part of a syndrome (Hoffman, 2008). It is rare, occurring only once in every
8500 births (Lidsky, Lander, & Sidman, 2008).
OBJECTIVES:
At the end of the unit, the students will be able to:
1. Describe common physical and developmental birth disorders.
2. Use critical thinking to analyze the effect of a physically or developmentally challenged child on a
family and propose ways to make care more family centered.
3. Assess a child who is born with a physical or developmental problem.


TECHONOLOGY
4. Formulate nursing diagnoses for children born with a physical or developmental difficulty.
5. Establish expected outcomes to meet the needs of a child with a physical or developmental difficulties.
6. Plan nursing care to meet the needs of a child born with physical or developmental difficulty, such as
encouraging mobility
INTUSSUSSCEPTION
A condition characterized by telescoping or invagination of small intestine or telescopes into the adjoining
intestinal lumen, causing bowel obstruction. It occurs most commonly at the juncture of the ileum and the
colon, although it can appear elsewhere in the intestinal tract. It is caused by abdominal polys, abdominal
mass, abdominal obstruction, and diverticula.
Intussusception usually appears in healthy babies without any demonstrable cause.
The invagination is from above downward, the upper portion slipping over the lower portion pulling the
mesentery along with it.
Causes
In most cases, however, no cause can be identified for intussusception.
Hyperperistalsis. The intestine's normal wave-like contractions grab this lead point and pull it and the
lining of the intestine into the bowel ahead of it.
Digestive system activities. The unusual mobility of the cecum and ileum usually present in early life
may also cause intussusception.
Clinical Manifestations
The classic triad and constellation of signs and symptoms of vomiting, abdominal pain, and blood passage
per rectum occur in only one-third of patients.
Abdominal pain. Abdominal pain within 10 days to 6 months prior to the current episode; pain in
intussusception is colicky, severe, and intermittent.
Vomiting. Initially, vomiting is nonbilious and reflexive, but when the intestinal obstruction occurs,
vomiting becomes bilious.
Currant jelly stool. This is a mixture of mucus, sloughed mucosa, and shed blood.
Lethargy. Lethargy is a relatively common presenting symptom with intussusception; the reason
lethargy occurs is unknown because lethargy has not been described with other intestinal obstruction
forms.
Assessment and Diagnostic Findings
Rectal examination.
Palpation. a sausage-shaped mass can often be felt through the abdominal wall.
Radiographs. Plain abdominal radiography reveals signs that suggest intussusception in only 60% of
cases; as the disease progresses, the earliest radiographic evidence includes an absence of air in the right
lower and upper quadrants and a right upper quadrant soft tissue density present in 25-60% of patients.


TECHONOLOGY
Ultrasonography. One study reported that ultrasonography's overall sensitivity and specificity for
detecting ileocolic intussusception were 97.9% and 97.8%, respectively; the authors concluded that
ultrasonography should be used for the first-line examination for the assessment of possible pediatric
intussusception.
CT scanning. Computed tomography (CT) scanning has also been proposed as a useful tool to diagnose
intussusception; however, CT scan findings are unreliable, and CT scanning carries risks associated with
intravenous contrast administration, radiation exposure, and sedation.
Contrast enema. The traditional and most reliable way to diagnose intussusception in children is to
obtain a contrast enema (either barium or air); contrast enema is quick and reliable and can potentially
be therapeutic.
Medical Management
Unlike pyloric stenosis, intussusception is an emergency in the sense that prolonged delay is dangerous.
Intravenous fluid. For all children, start intravenous fluid resuscitation and nasogastric decompression
as soon as possible.
Therapeutic enema. Therapeutic enemas can be hydrostatic, with either barium or water-soluble
contrast, or pneumatic, with air insufflation; therapeutic enemas can be performed under fluoroscopic or
ultrasonographic guidance; the technique chosen is not important as long as the radiologist performing
the enema is comfortable with the method.
Surgical reduction. If a nonoperative reduction is unsuccessful or if obvious perforation is present,
promptly refer the infant for surgical care; the risk of recurrence of the intussusception after operative
reduction is less than 5%.
Laparoscopy. Laparoscopy has been added to the surgical armamentarium in the treatment of
intussusception; laparoscopy can be performed in all intussusception; reduction of the intussusception,
confirmation of radiologic reduction, and detection of lead points have all been reported.
Pharmacologic Management
Drug therapy is not currently a component of the standard of care for intussusception. Medications are
limited to those used for pain control after surgery. In the immediate postoperative period, weight-
adjusted intravenous morphine is usually administered.
Nursing Management
Assessment of a child with intussusception includes:
Physical examination. The hallmark physical findings in intussusception are a right hypochondrium
sausage-shaped mass and emptiness in the right lower quadrant (Dance sign).
History. The patient with intussusception is usually an infant, often the one who has had an upper
respiratory infection, presents with vomiting, abdominal pain, the passage of blood and mucus, lethargy,
and palpable abdominal mass.
Nursing Diagnoses
Based on the assessment data, the major nursing diagnoses are:
Acute pain related to bowel invagination.


TECHONOLOGY
Deficient fluid volume related to vomiting, nausea, fever, and diaphoresis.
Ineffective breathing pattern related to abdominal distention and rigidity.
Anxiety-related to change in health status.
Nursing Intervention
Intravenous fluids. Administer IV fluids as ordered; if the patient is in shock, give blood or plasma.
Decompression. A nasogastric tube is inserted to decompress the bowel.
Monitor I&O. Replace volume lost as ordered and monitor the intake and output accordingly.
Education. Educate the family caregivers on what happens during intussusception and about the
surgery, and answer questions to reduce the anxiety.
SIGNS AND SYMPTOMS
a. Sausage shape mass
b. Bile tinged vomitus
c. colicky abdominal pain
d. elevation of legs
e. abdominal distention
f. currant jelly
g. perforation
h. peritonitis
DIAGNOSTIC TEST
a. Barium enema
b. x-ray
TREATMENT
a. pull through procedure
b. reduction of the invaginated intestine
________________________________________________________________________________________________________________
FAILURE TO THRIVE
Failure to thrive (FTT) is a chronic, potentially life-threatening disorder of infants and children who fail to
gain and may even lose weight. Children are considered failing to thrive when their growth rate does not meet
the expected growth rate for a child of their age. The term characterized those whose weight is below the 3rd
percentile on an appropriate growth chart.
The deviation from a normal growth channel is more descriptive of what is happening to an individual than a
decrease in weight. Any infant or child at the fifth percentile should alert the caregiver that a problem exists.
If the condition progresses, the undernourished child may become irritable and/or apathetic and may not
reach typical developmental markers such as sitting up, walking and talking at the usual ages.
FTT is a term used to describe inadequate growth or the inability to maintain growth in childhood.
a. Attained growth


TECHONOLOGY
i. Weight<3rd percentile on the standard growth chart.
ii. Weight for height<5th percentile on the standard growth chart.
iii. Weight 20% or more below the ideal weight for height.
b. Rate of growth
i. Less than 20g/day from birth to 3 months of age.
ii. Less than 15g/day from 3 months to 6 months of age.
iii. Fall off from previously established growth curve.
iv. The downward crossing of >2 major percentiles.
Causes may be organic or non-organic

a. Organic FTT - is the result of a physical cause in which the child cannot obtain or utilize the
adequate caloric intake necessary for growth.
b. Non-Organic FTT – is caused by psychosocial factors, such as disturbance in the parent-child
bonding.
____________________________________________________________________________________________________________________________
COLIC
COLIC is reported to occur in 15% to 40% of

all infants (Morin, 2009), yet it has no
particular affinity regarding gender, race, or
socioeconomic status (Ellett, 2003). An
organic cause may be identified in fewer than
5% of infants seen by physicians because of
excessive crying (Roberts, Ostapchuk, and
O’Brien, 2004). The condition is generally
described as abdominal pain or cramping
manifested by loud crying and drawing the
legs up to the abdomen. Other definitions
include variables such as duration of cry
greater than 3 hours a day occurring more
than 3 days per week and for more than 3
weeks, and parental dissatisfaction with the
child’s behavior. Some studies report an
increase in symptoms (fussiness and crying)
in the late afternoon or evening (Morin,
2009); however, the onset of symptoms
occurs simultaneously in some infants. Colic
is more common in infants younger than 3
months than in older infants, and infants
with difficult temperaments are more likely
to be colicky.
Colic repeated excessive and inconsolable

crying in an infant that otherwise appears healthy and thriving below six months of age.


TECHONOLOGY
Rule of 3: at least 3 hours, at least three days a week, for at least three consecutive weeks.
PREVALENCE: 10-30% infants below 4mo. Often occurs in the evening. Any identifiable cause does not
accompany it.
Signs and symptoms
a. Colic starts in the first weeks of life and resolves by around 4 months of age.
b. Peak crying occurs at 6 weeks.
c. Crying most often occurs in the late afternoon or evening.
CAUSES
a. The underlying cause is UNKNOWN.
b. Suggested underlying causes include:
i. Transient intolerance to the protein in cow's milk or lactose.
ii. Gastrointestinal causes. Delayed maturation of gut flora.
iii. Parenting factors. Inexperience, psych-social background
iv. Others have suggested that colic is just the end of normal crying or due to the baby's
temperament. Some suggest it's a migraine variant.
Clinical Features
a. The mother perceives a cry as more urgent, discomforting and arousing, and irritating.
b. The acoustic analysis shows a turbulent and dysphonic, high pitched.
c. The baby draws its knees up to its abdomen or arches its back when crying.
d. History of taking frequent feeds vigorously.
e. The baby shows excellent weight gain.
Differential Diagnosis
Diagnosis of exclusion If symptoms started suddenly and recently, consider:
a. Intussusception
b. volvulus
c. strangulated hernia
d. Torsion of the testis
e. Corneal abrasion
f. Non-accidental injury
g. Hair or thread wrapped around finger or toe
h. Common causes of crying in a normal baby
i. Acute infections
Common causes in a normal infant Discomfort.
a. Hunger or thirst (assess feeding technique: is the baby feeding often enough?).
b. It is too hot or too cold (assess the suitability of clothing and keep the room temperature around 18 ｰ
C if possible).
c. Too itchy (e.g., eczema or itchy clothes or clothes labels).
d. Nappy rash.
e. Women's diet if breastfeeding (e.g., too much coffee, tea, or soft drinks containing caffeine, or too
much alcohol or spicy food).
Management of Colic
GOALS
1. To provide strategies to help soothe a crying baby.


TECHONOLOGY
2. To reduce parental anxiety and stress, Reassure the parents that their baby is well, they are not
doing something wrong, the baby is not rejecting them, and that colic is common and is a phase that
will pass within a few months.
a. Holding the baby through the crying episode may be helpful.
b. However, if there are times when the crying feels intolerable to parents, it is best to put the baby
down somewhere safe (e.g., their cot) and take a few minutes' 'time out.'
Optional remedies
a. Gentle motion (e.g., pushing the pram, rocking the crib)
b. 'White noise' (e.g., vacuum cleaner, hairdryer, running water).
c. Bathing in a warm bath.
d. Lullaby
e. Hypertonic glucose solution
Supporting The Parents

a. Emphasize that this is not a rejection.
b. Don't let other relatives blame the mother for diet or other customs
c. See the child frequently
d. Let parent rest when a child is sleeping and be fresh when colic attacks
e. involve grandparents and friends to carry and cuddle and allow parents time out.
Medical Treatment
THERE IS NO CONCLUSIVE EVIDENCE FOR ANY OF THE TREATMENT OPTIONS FOR COLIC!
Simethicone
Although simethicone studies have not provided benefit in infantile colic, studies suggest that a 1-week trial
as a placebo may still be worth a try because simethicone is easily available, licensed for this indication, and
cheap. It has no reported adverse effects, and the simple act of giving their baby something may help parents
cope better with the crying.
Lactase drops
a. The available evidence suggests that lactase drops may help ease some babies' symptoms, providing
that the lactase is given some time to incubate in the feed before it is given.
b. Low-lactose formula not recommended
c. Add four drops of commercially available Lactase preparation to three spoons of foremilk expressed
in a sterile container. Give BF and then give expressed foremilk by spoon.
d. If the baby is top milk-fed, add four drops of lactase to the entire warmed feed.
Hypoallergenic diet
There is limited evidence that switching to a hypoallergenic formula for bottle-fed babies or a hypoallergenic
diet for breastfeeding mothers (free of milk, eggs, wheat, and nuts) may help ease the symptoms of colic.
[Evans et al., 1981; Hill et al., 1995; Lucassen et al., 2000].
Dicyclomine in Colic
a. Commonly misused
b. It is effective but has serious side effects in five percent of patients, so not licensed below six mo. age
c. Can cause apnea, respiratory difficulties, syncope, seizure, and sudden death.


TECHONOLOGY
d. Preparations are highly concentrated.
When to stop treatment
By four months, the infants are expected to outgrow colic; hence treatment may be tapered over a week.
___________________________________________________________________________________________________________________
TRISOMY 21, DOWN SYNDROME

e. In Trisomy 21, one cell has two 21st
chromosomes instead of one, so the resulting
DS, also called Trisomy 21, is a genetic condition fertilized egg has three 21st chromosomes.
that causes physical and intellectual
TYPES OF DOWN SYNDROME
developmental delays. There is extra genetic
1. Trisomy 21 (95%): The extra 21
material from chromosome 21, so individuals with
chromosome (three instead of the usual two)
DS have 47 chromosomes in total instead of the
produces a complement of 47 chromosomes.
usual 46. The most common cause of cognitive
2. Translocation (3-4%): A segment of a 21
impairment (moderate to severe)
chromosome is found attached to other pairs
a. 1 in 600 live births of chromosomes.
b. Risk factor- pregnancy in women over 35 3. Mosaicism (1-2%): Nondisjunction occurs at
yrs old a later stage of cell division; therefore, some
c. Cause - extra chromosome 21 (faulty cell cells have the normal complement of 46
division) chromosomes and other cells 47
d. Causes change in normal embryogenesis chromosomes (with an extra 21
process resulting in: chromosome).
e. Cardiac defects, GI conditions, Endocrine RISK FACTORS
disorders, Hematologic a. Women who are 35 years or older are at
abnormalities, Dermatologic changes the most significant risk for giving birth to
f. Physical features: small head, flat facial an infant with DS
profile, broad flat nose, small 1. 35 years: 1/400 live births
mouth, protruding tongue, low set ears, 2. > 40 years: 1/110 live births
transverse palmar creases, 3. According to the CDC, younger
hypotonia mothers (< 35 years) who smoke, use
oral contraceptives, and have a Meiotic
II error are at an increased risk as well.
* Feeding is often a problem in infancy *
b. Despite many years of research, advanced
ETIOLOGY & PATHOPHYSIOLOGY maternal age has been the only factor
a. DS is usually caused by an error in cell established with Down Syndrome.
division called nondisjunction: CLINICAL MANIFESTATIONS
b. During meiosis, one pair doesn’t divide & the a. Microcephaly
whole pair goes to one daughter cell. b. Flat face with upward slant to the eye,
c. In the resulting cells, one will have 24 short & wide neck, small, low-set ears, flat
chromosomes & the other will have 22. nasal bridge & a Thick and protruding
d. If sperm or egg with abnormal chromosomes tongue.
merges with a normal mate, the resulting c. Brush field spots (tiny white spots on the
fertilized egg will have an abnormal # of iris of the eye).
chromosomes. d. Short, broad hands & feet with a single
crease on the palm of their hands. (Simian
creases)


TECHONOLOGY
e. Small pinky fingers that sometimes curve NURSING DIAGNOSIS & INTERVENTIONS
towards the thumb. Delayed growth and development r/t impaired
f. Excessive space between large toe & ability to achieve developmental tasks
second toe.
g. Muscle hypotonia a. Provide environmental stimulation in a
h. Duplication of chromosome 21 supervised setting. Social interaction &
i. Epicanthal fold activities are essential for development in all
j. Recurrent URTI children, but cognitive impairment needs
k. Congenital heart disease much more environmental enrichment.
l. Mental retardation b. Provide resources to the child & family of
m. Potbelly therapeutic programs, exercises, and
n. Drooling activities designed to address developmental
delays early to reach their developmental
TREATMENTS
potential later in childhood.
a. DS is not a condition that can be cured.
c. Modify gross motor and sensory activities to
b. Treatment is directed at addressing a
accommodate the toddler’s limitations and
particular individual (e.g., certain heart
promote a sense of autonomy.
defects may require surgery).
Self-care deficit: Bathing & hygiene, dressing,
c. Timely surgeries for cardiac and GI
feeding, toileting r/t cognitive impairment
anomalies are necessary to prevent
serious complications. a. Consistent care by the same people in which
d. Because of the risk of vision problems, the child can be encouraged to have some
hearing loss, and infection is increased, control and perform age-appropriate tasks
screening and treatment may be within the limitations of the disability helps
necessary. to provide a sense of trust & routine.
Nursing Management b. Encourage independence & allow the child to
a. Nurses should obtain a hx of the mother's make as many choices as possible to ensure
pregnancy, birth hx, & genetic testing. the child a better feeling of control & self-
b. Observe physical characteristics of DS worth.
c. Assess the following: c. Give the child positive reinforcement for
d. Respiratory functioning due to poor demonstrating appropriate skills &
muscle tone behaviors to promote similar behavior in the
e. Heart sounds for the presence of a future.
murmur. Impaired Verbal Communication r/t impaired
f. Infant’s ability to eat due to protruding receptive or expressive skills.
tongue & mouth breathing
a. Enlist a speech/language therapist who can
g. Bowel functioning
help develop a program specific to the child's
h. In an older child, assess height & weight
needs.
and compare to an appropriate growth
b. Talk slowly & use pictures and articles when
chart.
communicating with the child. Doing so gives
i. Cognitive development
the child time to process what is being said &
j. Skin integrity due to the tendency toward
reinforces what is being communicated.
dry, rough, cracking skin
c. Use a positive approach with examples &
k. Determine family knowledge, coping, &
demonstrations since this method achieves
support
better results than using a constant stream of
l. Observe interaction & bonding between
"don't touch" or "stop that."
mother & infant
Risk for Infections r/t decreased muscle tone &
m. Parental feelings about having a child with
poor drainage of mucous.
Down Syndrome


TECHONOLOGY
a. Teach family good handwashing to prevent have babies. • screening test of AFP to
the spread of bacteria & communicable determine chances
diseases. d. Teach parents the importance of food & fluids
b. Rinse the child's mouth with water after to maintain adequate nutrition.
feeding & at other times of the day when dry. e. Emphasize the need to balance adequate
Mucous membranes are dry due to constant nutrition. Poor feeding can result in obesity
mouth breathing, increasing the risk for a later in life.
respiratory infection. f. Teach the family how to prevent physical
c. Teach parents to perform postural drainage & complications
percussion if needed to keep the lungs clear. g. Avoid infection by engaging in good
PREVENTION & EDUCATION handwashing.
a. No prevention for DS h. Increase fiber in the diet to avoid constipation
b. Absolutely nothing that anyone can do to i. Encourage physical activity
prevent a trisomy & there is nothing that j. Advise parents to seek regular checkups for
anyone can do to cause a trisomy. their child
c. Efforts of prevention are aimed at genetic k. Identify and refer to child/parents to support
counseling of couples who are preparing to groups.
____________________________________________________________________________________________________________________________
f. Maternal malnutrition
CLEFT LIP AND PALATE g. Maternal smoking – severity is depending
a. A condition characterized by maxillary upon the number of cigarettes smoked.
bone and palate inability to fuse, causing h. Ingestion of drugs, e. g. thalidomide,
physical deformity, speech problem, corticosteroids.
aspiration, and sucking problem. i. Exposure to radiation during pregnancy
b. A cleft lip is common in men. Clinical manifestations
c. Cleft palate is common in women. Cleft lip has the following manifestations.
d. Cleft lip refers to open space between lips, a. A notched vermilion borders
especially in vermilion line or failure b. Dental anomalies – supernumerary teeth,
infusion of the lip. It is also known as extra teeth, teeth may be absent.
"harelip”. . .…. WONGS textbook of c. Variably sized clefts that involve the
pediatric alveolar ridge
e. Cleft palate refers to failure in developing Clinical manifestations
parts that make the palatine bone Cleft palate includes,
(maxillary process), soft palate (uvula). . a. Opening in roof of the mouth felt with
.…. WONGS textbook of pediatric examiners finger on the palate.
b. Nasal distortion
Etiology c. Breathing difficulty
a. Genetic factors- It has been estimated that d. Exposed nasal cavities
the chances of having a cleft lip and cleft e. Recurrent ear and throat infection
palate are two percent when one of the f. Speech defects and psychological
parents has a cleft lip or cleft palate. problems.
b. Unfavorable maternal factors- g. Feeding problems
c. Illness, especially viral infections during h. Inability to coordinate breathing and
the fifth and twelfth weeks of gestation, e.g., feeding leads to inadequate nutrition.
rubella i. Difficulty in feeding leads to anemia,
d. Anemia malnutrition, and failure to thrive.
e. Hypoproteinemia


TECHONOLOGY
j. Mouth breathing. iii. Historically, the surgery for cleft lip
Diagnostic Evaluation and cleft palate is planned by
a. History collection – collect the history of “Kleiner's rule of ten."
parents with cleft lip and cleft palate, and a. For cleft lip – 10 weeks of age, 10-pound
antenatal check-up. weight, and 10 grams of hemoglobin.
b. Prenatal ultrasonography- enables many cleft b. For cleft palate – 10 months of age, 10 kg
lips and some cleft palates to be identified in weight, and 10 gm of hemoglobin was the
utero. norm.
c. Physical examination – cleft lip and palate are Surgical repair technique for cleft lip
diagnosed by inspection. Physical a. Cheiloplasty
examination reveals anemia, breathing b. Ralph Millard's Rotation advancement
difficulty, speech defects, and dental technique
anomalies. c. Logan bow
d. X-ray – it shows the deformity of the palatine Cleft palate repair technique
bone. a. Palatoplasty
e. MRI-to evaluates the extent of abnormality b. Von langenback procedure
before treatment. c. Veau wardil killers
f. Dental imprecision’s for expansion d. Three flap technique & Millards
prosthesis. e. Double revising ‘Z’ plasty
g. Genetic evaluation – to determine recurrence Nursing management
risk. Preoperative care:
Management a. Keep the infant NPO for 6 hours before
a. Management is based on the severity of the surgery.
defect. b. Administer premedication as per doctors
b. Management of cleft lip and cleft palate orders
requires a team effort involving c. Physical, physiological, psychological, and
i. a pediatrician, legal preparation should be done.
ii. a plastic surgeon, Postoperative care
iii. orthodontist a. Keep the airway clear from the accumulation
iv. ENT specialist and of mucus in the nose and mouth.
v. speech therapist, b. Mild sedation may be prescribed to prevent
vi. psychologist and the infant from crying.
vii. community health nurse. c. Careful positioning (never on the abdomen)
Children with Cleft Lip and Palate d. Restraining the arms if necessary.
a. Cleft lip repair: 3 to 6 months e. The mother and father should be encouraged
b. Cleft palate repair: 9 to 12 months to remain with their child as much as
i. Ear tubes at palate repair: 9 to 12 possible.
months f. The infant is fed with a medicine dropper.
ii. Lip/nare revision: 4 years g. Clear fluids offer initially; breast milk or
c. Phase I orthodontics: 7 years formula can be given when tolerated.
i. Alveolar bone graft: 6 to 10 years h. The mouth should be rinsed with water
d. Phase II orthodontics: 15 to 17 years before and after feeding.
i. Orthognathic surgery: 15 years for i. Do not brush the teeth 1-2 weeks after the
females; 18 years for males surgery.
ii. Definitive rhinoplasty: Teenage j. The suture line must be cleaned gently with
years cotton, gauze-tipped swab dipped in
hydrogen peroxide or saline solution, and


TECHONOLOGY
dried several times a day carefully to ensure discharge and prevention of upper
proper healing. respiratory tract infection. • •
k. The parents are taught the ways by which l. Speech therapy should be given.
injury to the palate can be prevented after m. Encourage the child to socialize with family
members and others.
The maxillary and median nasal processes normally fuse between weeks 5 and 8 of intrauterine life. In
infants with cleft lip, the fusion fails to occur in varying degrees, causing this disorder to range from a small
notch in the upper lip to total separation of the lip and facial structure up into the nose's floor, with even the
upper teeth and gingiva absent. The deviation may be unilateral or bilateral. The nose is generally flattened
because the upper lip's incomplete fusion has allowed it to expand in a horizontal dimension. A cleft lip is
more prevalent among boys than girls. It occurs at a rate of approximately 1 in every 750 live births. This
incidence is significantly higher in the Asian population, 1 in 300, and significantly lower in the black
population, 1 in 2000. About 46% of children have combined cleft lip and palate, 21% only a cleft lip, and 33%
only a cleft palate. Almost 30% of children with cleft lip and palate deformity have associated congenital
disabilities, or the cleft palate occurs as only a portion of a larger syndrome (Hoffman, 2008).
Cleft lip occurs as a familial tendency or most likely occurs from the transmission of multiple genes. The
formation may be aided by teratogenic factors present during weeks 5 to 8 of intrauterine life, such as a viral
infection or possibly a deficiency of folic acid (Novak, 2007). Parents of a child with a cleft lip should be
referred for genetic counseling to ensure they understand that they have a 4% chance of having another child
with a cleft lip or palate. Future children are at a greater risk than usual for this problem.
The palatal process closes at approximately weeks 9 to 12 of intrauterine life. A cleft palate, an opening of the
palate, is usually on the midline and may involve the hard anterior
palate, the posterior soft palate, or both. It may be a separate anomaly, but it occurs in conjunction with a cleft
lip as a rule. As a single entity, it tends to occur more frequently in girls than in boys. Like cleft lip, it appears
to be the result of polygenic inheritance or environmental influences.
In connection with cleft lip, the incidence is approximately 1 in every 1000 births. It occurs in approximately
1 in every 2000 births (Hoffman, 2008).
SIGNS AND SYMPTOMS 2. done at 6 months to 2years old to save

a. Facial deformity the speech
b. Speech problem
c. Poor sucking Nursing Diagnosis: Risk for imbalanced
d. Abdominal gas nutrition, less than body requirements, related to
e. aspiration feeding problem caused by cleft lip or palate
Nursing Diagnosis: Risk for ineffective airway
DIAGNOSTIC TEST clearance related to oral surgery
a. x-ray
NURSING MANAGEMENT
TREATMENT a. NPO
a. cheiloplasty b. Give pacifier
1. surgical repair of cleft lip c. Obtain consent
2. done at 4-month-old to save d. Prone position post-op for the repair of cleft
sucking reflex palate
b. uranoplasty e. Fowler's position post-op for repair cleft lip
1. surgical repair of cleft palate f. Lodan bay
g. Avoid the use of a toothbrush and spoon.


TECHONOLOGY
h. Clean incision every day k. Use a brecker feeder or a syringe.
i. Monitor bleeding l. Upright position during feeding
j. Avoid crying m. Burp up
_____________________________________________________________________________________________________________________________
IMPERFORATE ANUS
Imperforate anus is the stricture of the anus (Vick et al.,2007). In week 7 of intrauterine life, the upper
bowel elongates to a pouch and combines with a pouch invaginating from the perineum. These two sections
of the bowel meet, the membranes between them are absorbed, and the bowel is then patent to the outside. If
this motion toward each other does not occur or the membrane between the two surfaces does not dissolve,
imperforate anus occurs. The disorder can be relatively minor, requiring just surgical incision of the persistent
membrane, or much more severe, involving sections of the bowel that are many inches apart with no anus.
There may be an accompanying fistula to the bladder in boys and the vagina in girls, further complicating a
surgical repair. The problem occurs in approximately 1 in 5000 live births, more commonly in boys than in
girls. The imperforate anus may occur as an additional complication of spinal cord disorders because both the
external anal canal and the spinal cord arise from the same germ tissue layer.
Assessment
A prenatal sonogram may detect the condition. It is discovered at birth when inspection of a newborn's
anal region reveals that no anus is present. However, this observation may not be helpful because the anus
can appear normal, and the condition can still exist far inside, so it is missed on simple inspection. Occasionally,
the condition may be revealed because a membrane filled with black meconium can be seen protruding from
the anus. A “wink” reflex (touching the skin near the rectum should make it contract) will not be present if
sensory nerve endings in the rectum are not intact. If these methods fail to detect the condition, a newborn
can discover it by the inability to insert a rubber catheter into the rectum. No stool will be passed, and
abdominal distention will become evident. A radiograph or sonogram will reveal the disorder if the infant is
held in a head-down position to allow swallowed air to rise to the end of the blind pouch of the bowel. This
method helps estimate the distance the intestine is separated from the perineum or the extent of the
correction that will be necessary.
It takes 3 to 4 days after birth to notice imperforate anus and when infants failed to pass stools after the first
24 hours.
____________________________________________________________________________________________________________________
HIRSPRUNG DISEASE c. Pigs tail

a. Congenital aganglionic megacolon. d. No fecal impaction
b. A condition characterized by the e. The clear return flow of the enema
absence of ganglion on the colon f. Abdominal distention
making the area paralyzed g. Spillage of liquid stool
c. The affected portion is constricted, h. abdominal pain
while the portion before the affected i. abdominal mass
area is dilated DIAGNOSTIC TEST
SIGNS AND SYMPTOMS a. barium enema
a. Fecaloid vomitus b. x-ray
b. Failure to pass meconium c. biopsy


TECHONOLOGY
TREATMENT a. Sac formation
a. RESECTION AND ANASTOMOSIS OF b. Sac contain CSF and meninges only
COLON DIAGNOSTIC TEST
b. COLOSTOMY a. X-ray
b. Ultrasound
NEURAL TUBE DEFECT TREATMENT
a. A condition characterized by failure of the a. surgery
neural tube and vertebral column to fuse. b. urology
b. Caused by folic acid deficiency c. protect sac
SIGNS AND SYMPTOMS d. TO cover sac with wet gauze
a. Dimpling e. avoid infection
b. Congenital club foot f. prone or lying position
g. avoid puncture of a sac
c. Hair growth on a sac
h. wear soft clothing
d. Bowel and bladder dysfunction
i. credes maneuver
e. Paralysis
f. Tingling sensation
g. Congenital pelvic disproportion
TYPES
1. SPINA BIFIDA OCCULTA
a. No sac formation
b. Dimpling on the area
c. Hair growth in the area
2. MYELOMENINGOCELE
a. Sac formation
b. Sac contains CSF, meninges, and spinal
cord
c. Most fatal form
d. Bowel and bladder dysfunction
e. Congenital hip disproportion and club
foot
3. MENINGOCELE
HYDROCEPHALUS a. The fluid passes between the

a. is caused by an imbalance in the production ventricles and the spinal cord.
and absorption of cerebral spinal fluid (CSF) b. Decreased absorption is caused by
in the ventricular system. post meningitis or intraventricular
b. As CSF accumulates, it causes signs and hemorrhage.
symptoms of increased intracranial pressure c. A tumor may cause increased
(ICP). production.
c. It may be congenital or acquired. 2. Non-communicating (obstruction)
d. Develops as a result of an imbalance of a. There is a block to such passage of
production and absorption of CSF. The fluid.
increase of CSF causes increased ventricular b. Tumors may cause it, Dandy-
pressure, leading to dilation of the ventricles, Walker syndrome, Arnold Chiari
pressing on the skull. syndrome (elongation of the lower
brain stem and displacement of the
Types of Hydrocephalus
4th ventricle unto the upper
1. Communicating (non-obstructive)


TECHONOLOGY
cervical canal), and severe a. Determine baseline
infection. b. Assess LOC
Signs/Symptoms of Increased ICP: c. Assess motor sensory
a. Poor feeding and vomiting d. Pupil checks
b. Bulging fontanel, head enlargement, e. Vital signs, Head circumference
separation of sutures 2. Provide Patient Safety
c. Lethargy, irritability, restlessness, not a. Seizure precautions
responsive to parents b. Fall precautions
d. CHILD - Headache, vomiting, diplopia, c. Possible restraints
ataxia, papilledema d. Determine LOC ac
e. Seizures 3. Decrease ICP
a. Cluster care/
A child’s head with an open fontanel (under 2 years b. decrease stress
old) can expand and better compensate for the c. Quiet environment
increased intracranial pressure. d. Increase HOB 30-45 degrees
e. Appropriate position (head
midline, no hip flexion, no prone)
Ventriculoperitoneal f. Medications (pain meds,
(VP) Shunts corticosteroids, diuretics, stool
softeners, anti-infectives,
a. Relief of anticonvulsants)
hydrocephalus 4. Maintain Adequate Cerebral Perfusion
a. Maintain airway
b. Monitor oxygenation and apply O2
PRN
c. Monitor temperature and
administer antipyretics PRN
d. Maintain normovolemia
e. Monitor I/O
b. Prevention/treatment of complications f. Assess perfusion
c. Management of problems related to 5. Maintain Nutritional & Fluid Needs
psychomotor development a. Determine swallow ability prior to
d. Surgical intervention: ventriculoperitoneal PO’s
(VP) shunt b. NGT feedings may be necessary
e. One-way pressure valve releasing CSF into c. Dietary consult PRN
the peritoneal cavity where it is reabsorbed d. Daily weight
e. Monitor lab results
General Nursing Interventions 6. Psychosocial Support
1. Monitor Neuro Status a. Child Life consult
b. Teaching
____________________________________________________________________________________________________________________________
OTITIS MEDIA c. Impaired eustachian tube causes decreased

a. Most common childhood illness ventilation and drainage.
b. Inflammation of the middle ear d. Acute otitis media (AOM)
e. The infectious process by the pathogen
f. Infection can spread, leading to meningitis.


TECHONOLOGY
g. S/S: pain, pulling on ears, fever, irritability, c. Daycare
vomiting, diarrhea, ear drainage, d. Pacifier > 6 mo old
full/bulging tympanic membrane TREATMENT
h. Otitis media with effusion (OME) a. Antibiotics (for AOM)
i. Inflammation of middle ear with fluid b. Myringotomy with Pressure Equalizing
behind the tympanic membrane-no (PE) tubes
infection INTERVENTIONS
j. Peaks spring and fall (allergies) a. Teaching
k. Chronic otitis media b. No bottle propping
l. Inflammation of middle ear > 3 mo c. Feeding techniques
m. Can lead to hearing loss/delayed speech d. Medication regimen
RISK FACTORS PAIN MANAGEMENT
a. Secondary smoke a. Fever management
b. Formula feeding (positioning) b. Surgery prep if needed
MENINGITIS It can occur at any age, but often between 1 month-

Inflammation of the meninges by bacteria, virus, or 5 years.
other organisms typically travel to the cerebral Most common sequel: hearing and/or visual
spinal fluid via the bloodstream. impairments, seizures, cognitive changes
Infants under 3 months are most susceptible. Diagnostic confirmation is done by lumbar
puncture, and CSF is cloudy with increased WBCs,
Bacterial Meningitis increased protein, and low glucose.
Infectious process of CNS, causing inflammation of
meninges and spinal cord. Nursing Interventions include appropriate IV
antibiotics and meds for increased ICP as well as
ISOLATION IS MANDATORY interventions to decrease ICP.
Signs and symptoms include increased ICP plus
photophobia, nuchal rigidity, joint pain, malaise,
purpura rash, Kernig's, and Brudinski’s signs.
SEIZURE DISORDER The focus of care is on patient safety, the cause of

fever, and parents' education for home care.
Seizures are sudden transient alterations Remember basic CPR during seizures – airway
in brain function as a result of abnormal neuronal before oxygen.
discharge. Seizure precautions: Suction, oxygen, padded rails
Febrile seizures are the most common in children, Infants often have subtle seizures with only ocular
caused by a RAPID elevation in temperature, movements or some extremity movements.
usually above 102°.
Various insults can cause seizure disorders to the
Most children do not have a second febrile seizure brain that can result from congenital anomalies
episode, and only about 3% develop epilepsy. and acquired.


TECHONOLOGY
Seizures in the neonatal period are usually the be distinguished from seizures by several
clinical manifestation of a serious underlying characteristics:
disease. The most common cause of seizures for
term and preterm neonates is hypoxic-ischemic • Jitteriness is not accompanied by ocular
encephalopathy secondary to perinatal asphyxia. movement, as are seizures.
Classifications of Seizure • Whereas the dominant movement in jitteriness is

1. Febrile seizure tremor, seizure movement is clonic jerking that
a. Caused by elevation of temp (> 40 C) cannot be stopped by flexion of the affected limb.
b. Usually occur in children between 6 • Jitteriness is highly sensitive to stimulation, but
months to 3 years. seizures are not. Jitteriness may be a sign of
c. Are most typically brief generalized hypoglycemia, and infants with jitteriness should
seizures. have a blood glucose level evaluated. Tremor is
2. Petit mal or absence seizure – defined as repetitive movements of both hands
a. Brief loss of consciousness without aura or (with or without movement of legs or jaws) at a
post-ictal lethargy. frequency of two to five per second and lasting
b. It may occur many times throughout the more than 10 minutes. It is common in newborn
day or may cluster. infants and has a variety of causes, including
c. Responds well to anticonvulsant therapy. neurologic damage, hypoglycemia, and
3. Infantile spasm hypocalcemia. In most instances, tremors are of no
a. Presentation peaks at age 4-6 months, pathologic significance.
b. With flexion of the trunk, it is often
triggered by drowsiness or awakening. Neonatal seizures can be divided into four major
c. Treated with Adrenocorticotropic types. These classifications are outlined in order of
hormone. frequency in Table 9-11 and consist of clonic, tonic,
d. The outcome is often poor. subtle, and myoclonic seizures (Volpe, 2008).
The features of neonatal seizures are different Clonic, multifocal clonic
from those observed in older infants and children.
For example, the well-organized, generalized tonic-
clonic seizures seen in older children are rare in
infants, especially preterm infants. With its
immature anatomic and physiologic status and less
cortical organization, the newborn brain cannot
allow ready development and maintenance of a
generalized seizure.
Signs of seizures in newborns, especially preterm
neonates, are subtle and include findings such as
lip-smacking, tongue thrusting, eye-rolling, and
arching (Volpe, 2008).
In newborns, jitteriness or tremulousness is a
repetitive shaking of an extremity or extremities
that may be observed with crying, occur with
sleeping state changes, or is elicited with
stimulation. Jitteriness is relatively common in
newborns and, to a mild degree, may be considered
normal during the first 4 days of life. Jitteriness can


TECHONOLOGY
Therapeutic Management Recent research has shown that therapeutic
Treatment is directed toward preventing hypothermia provided by cooling either the
neurologic damage and involves correction of infant's head or the whole body reduces the
metabolic derangements, respiratory and severity of the neurologic damage in hypoxic-
cardiovascular support, and seizure activity ischemic encephalopathy when it is applied in the
suppression. The underlying cause is treated (e.g., early stages of injury (first 6 hours after delivery)
glucose infusion for hypoglycemia, calcium for in infants with a gestational age of 35 to 36 weeks
hypocalcemia, antibiotics for infection). If needed, or more (Azzopardi, Strohm, Edwards, and others,
respiratory support is provided for hypoxia, and 2009; Edwards, Brocklehurst, Gunn, and others,
anticonvulsants may be administered, especially 2010; Jacobs, Hunt, Tarnow-Mordi, and others,
when the other measures fail to control the 2007; Laptook, 2009).
seizures.
Nursing Care Management
Phenobarbital, given intravenously or orally, has The major nursing responsibilities in infants with
been the drug of choice and is used if seizures are seizures are recognizing when the infant is having
severe and persistent. Other drugs that may be a seizure so therapy can be instituted, carrying out
used are phenytoin (Dilantin) and lorazepam. the therapeutic regimen, and observing the
response to the therapy and any further evidence
Fosphenytoin sodium is a water-soluble prodrug of seizures or other symptomatology. Assessment
and may also be used for seizures. Fosphenytoin and other aspects of care are the same as for all
metabolizes to form phenytoin in the body yet can high-risk infants. Parents need to be informed of
easily be diluted or mixed in dextrose and normal their infant's status, and the nurse should reinforce
saline and may be given via IV or intramuscular and clarify the practitioner's explanations. The
routes. Also, fosphenytoin does not cause pain infant's behaviors need to be interpreted by the
during IV administration. parents, and the infant's responses to the
treatment must be anticipate
Fever
a. Causes – Often unknown, maybe due to dehydration, most often viral-induced.
b. The danger in infants is febrile seizures – most common between 3 months to five years. The seizure is
a result of how quickly the temperature rises. Hydration (20mls/kg is a formula for bolus)
c. Antipyretics – acetaminophen or ibuprofen
d. Cooling measures – avoid shivering.
e. Tepid bath
f. Remove excess clothing and blankets.
g. Cooling blankets/mattresses
h. NO ICE PACKS!


TECHONOLOGY
THINGS TO REMEMBER
1. Cleft lip and palate result from the failure of the maxillary process to fuse in intrauterine life. Surgical
repair is possible early in life, with a good prognosis for both these conditions.
2. Tracheoesophageal atresia and fistula occur from failure of the trachea and esophagus to divide
appropriately in intrauterine life. Surgical intervention often needs to be performed in several stages.
3. Omphalocele is the protrusion of abdominal contents through the abdominal wall at birth, protected
only by a peritoneal membrane. When the membrane is not present, this is called gastroschisis.
Although several stages of repair are often necessary, the surgical correction has a good outcome.
4. Intestinal obstruction can result from atresia (complete closure) or stenosis (narrowing) of a part of
the bowel. Correction is the surgical removal of the narrowed bowel portion.
5. A meconium plug occurs when an extremely hard portion of meconium blocks the lumen of the
intestine. Infants with meconium plug syndrome need to be observed for continuing bowel function
and need to be assessed for cystic fibrosis because a meconium plug is often a symptom of this.
6. A diaphragmatic hernia occurs when the abdominal organs protrude through a diaphragm defect into
the chest cavity. This prevents the lungs from fully expanding at birth. These infants are critically ill at
birth and need extensive surgical correction.
7. Imperforate anus is stricture of the anus, resulting in an inability to pass stool. The infant may have a
temporary colostomy created before a final surgical correction can be completed.
8. The nervous system's physical developmental disorders include hydrocephalus (excess cerebrospinal
fluid in the ventricles) and spina bifida (incomplete closure of the spinal cord). Infants with
hydrocephalus need surgery to relieve a ventricular obstruction or have a shunt implanted from their
ventricles to the peritoneal cavity to remove the excess cerebrospinal fluid. Children with
myelomeningocele, the most severe form of neural cord disorder, face permanent loss of lower neuron
function and require continued rehabilitation.
9. Absent or malformed extremities may range from the absence of a finger to the absence of an entire
limb. Children may need physical therapy and teaching to use a prosthesis to gain full mobility and
function.
10. Developmental hip dysplasia is the hip socket's improper formation and function; talipes deformities
are foot and ankle deformities. Children may need extensive bracing and casting to correct these
disorders.


TECHONOLOGY
pathophysiologic sequence of changes in your chosen diseases/cases. An outline format is
acceptable as long as the cause-and-effect sequence can be seen.
References

https://www.msdmanuals.com/professional/injuries-poisoning/poisoning/hydrocarbon-poisoning
Patrici M. Nugent, RN, EdD, Judith S. Green, RN, MA, Phyllis K. Pelikan, RN, MA, Marry Ann Hellmer Saul,
RNCS, Ph.D. (2014). Mosby's Comprehensive Review of Nursing for the NCLEX-RN Examination 20th
edition. Elsevier.
U-M Crohn's and Colitis Program. http://www.med.umich.edu/ibd/education/basics.html
Anencephaly: Causes, Symptoms and Diagnosis Example .... https://graduateway.com/anencephaly/
Intussusception Nursing Care Plan & Management - RNpedia. https://www.rnpedia.com/nursing-
notes/maternal-and-child-nursing-notes/intussusception-nursing-care-plan-management/
Intussusception Nursing Care Management Study Guide. https://nurseslabs.com/intussusception/
Failure to thrive by ulfat aimin. https://www.slideshare.net/ulfatamin/failure-to-thrive-by-ulfat-aimin
Failure to thrive - SlideShare. https://www.slideshare.net/ulfatamin/failure-to-thrive-80455907
PPT – INFANTILE COLIC PowerPoint presentation | free to .... https://www.powershow.com/viewfl/4356ca-
YjFkM/INFANTILE_COLIC_powerpoint_ppt_presentation
Down syndrome in child - SlideShare. https://www.slideshare.net/precilla2013/down-syndrome-in-child
Cleft lip and cleft palate - SlideShare. https://www.slideshare.net/pinkyantony/cleft-lip-and-cleft-palate-
132828152
Infantile colic milind - SlideShare. https://www.slideshare.net/milindbapat1/infantile-colic-milind


TECHONOLOGY
Unit 5: HEALTH PROBLEMS COMMON IN TODDLERS
(Reference: (Patrici M. Nugent, RN, EdD, Judith S. Green, RN, MA, Phyllis K. Pelikan, RN, MA, Marry Ann
Hellmer Saul, RNCS, PhD., 2014))
BURNS
Burns are injuries to body tissue caused by excessive heat (heat greater than 104° F [40° C]) (Pilliteri, 2010).
A. Incidence: the third leading cause of unintentional injury and related death among children 14 years
of age and younger
B. Risk factors: younger than 5 years of age, limited control of the environment, minimal ability to act
promptly and appropriately
C. Causative Agents:
a. Thermal (e.g., flame, hot water)
b. young children: scald burns by hot liquids and steam
c. older children: direct contact with fire
d. Chemical, electrical radiation
D. Classification
1. Depth of Injury
2. Extent of Injury
a. Described as a percentage of total body surface area (TBSA) injured
b. Standard adult rule of nines cannot be used in children younger than 15 years of age;
modifications of newborns, infants, 5-year-old, 10-year-old, 15-year-old. (figure 31-1: A & B,
Estimation of Distribution of burns in children.
A. B.
Figure 31-1 Estimation of the distribution of burns in children. A. Children from birth to age 5 years. B, older
children to adult


TECHONOLOGY
E. Clinical Findings:
1. Local response
a. Edema
b. Fluid loss from nonprotected skin
c. Circulatory stasis usually restored within 24 to 48 hours in partial-thickness burns
2. Systemic response
a. "Burn Shock" causes a precipitous drop in cardiac output; restored in 24 to 36 hours
b. Increased metabolic rate
c. physiologic stress response
d. paralytic ileus may develop
e. Anemia: initially, elevated hematocrit because fluid shifts from intravascular space; later,
increased red cell fragility contributes to decreased RBC life span.
f. metabolic acidosis
g. Post-burn growth retardation: severe growth delays in height and weight if the burn is greater
than 40% TBSA; growth lag may last for up to 3 years.
F. Therapeutic interventions
1. The burning process is stopped
a. Source of danger removed
b. Smoldering clothes removed
c. Superficial burns: immersed in cool water
2. First aid administered promptly
a. Patent airway maintained
b. Superficial burns: cleansed, sterile dressing soaked in sterile saline applied, if possible, avoidance
of creams, butter, or household remedies
c. Severe Burns (more than 10% of body): oral fluids withheld
3. Transportation to an appropriate health care facility as quickly as possible.
a. Large body surface area in proportion to weight results in greater potential for fluid loss
b. Shocks: the primary cause of death in the first 21 to 48 hours
c. Infection: the primary cause of death after the initial period
4. Treatment of fluid and electrolyte loss
a. Greatest in first 24 to 48 hours because of tissue damage
b. Immediate replacements of fluids and electrolytes
c. Monitoring of hematocrit, hemoglobin, and blood chemistry levels provide a guide for fluid
replacement
5. Tetanus Prophylaxis as needed
6. Management of pain
a. Opioids (e.g., morphine sulfate, fentanyl [Sublimaze])
b. Anesthetic agents during procedures (e.g., nitrous oxide, propofol [diprivan])
NURSING CARE OF CHILDREN WITH BURNS

Assessment/Analysis
1. Wound assessment/classification
2. Vital signs, respiratory status
3. Fluid balance, nutritional needs
4. The severity of the pain-on-pain rating scale
Planning/ Implementation


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1. Maintain fluids and electrolytes
a. Administer prescribed fluids meticulously, both in time and volume
b. Monitor fluid status (e.g., daily weights, I & O, weigh diapers)
2. Maintain NPO if paralytic ileus occurs
3. Help limit pain
a. Distinguish pain from fear of being left alone or being in strange surroundings
b. Use a pain rating scale a medicate appropriately
4. Maintain standard precautions; use personal protective equipment
5. Meet the psychological needs of a child who is isolated from others
a. Recognize that isolation may provoke feelings of guilt and punishment
b. Recognize that children younger than 5 years of age are frightened by isolation and personal
protective equipment
c. Recognize that touch needed for comfort and security may now be painful; reestablish
pleasurable touch (e.g., apply lotion to unaffected areas); maximize the use of other senses to
promote security and comfort
d. Encourage the child to express feelings verbally or through play, if possible
6. Provide for adequate nutrition
a. Consider that the initial hypometabolic state is followed by hypermetabolic state (begins about
fifth-day post-injury), causing decreased lean body mass, muscle weakness, immunodepression,
inadequate wound healing.
b. Offer diet high in protein, vitamins, calories; should b started immediately after paralytic ileus
resolved.
c. Encourage eating, maybe anorectic because of discomfort, isolation, depression, fear
d. Take advantage of food preferences when feasible; avoid forcing to eat or using food as a
weapon; encourage parent participation
e. After diet as needs change, especially when high-calorie foods are no longer needed.
f. provide care related to tube feeding in unable to (e.g., assess for gastric return and residual
before feeding, ensure the tube is cleared after feeding with a predetermined amount of water)
7. Prevent contractures
a. Make moving a game; initiate play that uses the affected part (e.g., throwing the ball for arm
movement)
b. Maintain functional body alignment
c. Perform passive exercises during bath or whirlpool treatments
d. Administer prescribed analgesics before exercise
8. Meet emotional needs
a. Encourage to play with gown, mask, gloves, bandages
b. Prepare for baths and whirlpool treatments, which can be frightening and painful
c. Encourage to reenact treatments and care to work through feelings
d. Help to cope with changes in body
1. Younger child: support parents whose reactions are communicated
2. An older child, especially during adolescence when body appearance is of great concern: devise
ways to conceal affected areas, especially when peers visit; emphasize how to improve looks
(e.g., wigs, cosmetics, clothing, eventual plastic surgery)
9. Teach prevention of burn Injuries
a. Educate children regarding fire safety
1. Teach to leave the house as soon as smoke is smelled, or flames are seen, without stopping
to retrieve pet or toy
2. Involve all family members in fire drills


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3. Demonstrate and practice "stop, drop, and roll" rather than running if clothes are on fire
b. Educate parents concerning their child's growth and development, about specific dangers at each
age level
c. Educate parents on how to prevent burns in the home
1. Avoid leaving children unattended
2. Cautiously use heaters, barbecue grills, and fireplace; place the shield in front of the heating
unit
3. Maintain the integrity of the electrical system
4. regulate household water heater to no higher than 120F *mandated in several states)
5. Use and maintain smoke and carbon monoxide detectors
Evaluation/Outcomes
1. Remains comfortable
2. Maintain fluid and nutritional balance
3. Heals with minimal scarring
4. Remains free from infection
5. Regains flexibility and functional capacity of joints
6. Child and family members verbalize feelings and concerns about the appearance
POISONING
Ingestion of/ exposure to toxic substance; ingestion of excessive amount of nontoxic substance
A. Incidence: more than 90% occur in a home
B. Risk factors: younger than 4 years of age; inadequate storage of toxic or potentially toxic substances
C. Most commonly ingested substances
1. Cosmetics and personal care products (e.g., perfume, aftershave)
2. Cleaning products (e.g., household bleach, disinfectants)
3. Plants (e.g., nontoxic gastrointestinal irritants, oxalates)
4. Medications: prescribed, over-the-counter (OTC) ( e.g., acetaminophen, ibuprofen), for pets
5. Foreign bodies, toys, miscellaneous (e.g., thermometer, bubble blowing solution)
GENERAL NURSING CARE OF CHILDREN WITH POISONING

Assessment/ Analysis
1. General response after ingestion/ exposure
2. Vital Signs
3. Need for respiratory or cardia support
4. See clinical findings for specific types of poisoning
Planning/Implementation
1. Terminate exposure
a. The empty mouth of pills, plant parts, other materials
b. Flush eyes with tap water if necessary
c. Flush skin, wash with soap and a soft cloth
d. Remove clothing, especially if exposed to pesticide, acid, alkali, or hydrocarbon
2. Report poisoning
a. Call poison control center, emergency facility, clinic, or health care provider for immediate advice
regarding treatment
b. Save all evidence of poison (e.g., container, vomitus, urine)
3. Do not induce vomiting


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a. Aspiration of low-viscosity hydrocarbon (e.g., gasoline, lighter fluid, mineral seal oil, [found in
furniture polishes]): vomiting can cause severe chemical pneumonitis
b. Ingestion of strong corrosive (e.g., acid or alkali, such as drain cleaners, bleach, electric
dishwasher detergents, batteries): emesis of corrosive reinjuries mucosa of esophagus and
pharynx
4. Remove poison
a. Administer activated charcoal (1g/kg of body weight), if possible, within 1 hour of ingestion; can
be effective within 4 hours of ingestion of an injurious substance
b. Prepare equipment for gastric lavage if within 1 hour of ingestion
5. Prevent aspiration when vomiting
a. Keep head lower than chest
b. When alert, place head between legs
c. When unconscious, position on the side
6. Provide care for latent manifestations of poisoning
a. Monitor vital signs
b. Treat appropriately (e.g., institute seizure precautions, keep warm, position for shock;
temperature if hyperpyretic)
7. Support child and parent
a. Keep calm and quiet
b. Do not admonish or accuse child or parent of wrongdoing
8. Teach parents prevention of poisoning
a. Institute anticipatory guidance based on the child's age and developmental level
b. Refer to the appropriate agency for the evaluation of the home environment and need for safety
measures
c. Assist with environmental manipulation when needed
d. Emphasize the importance of safe storage of all substances
e. Teach children about the hazards of ingesting nonfood items
f. Caution against keeping large amounts of medicines on hand
g. Discourage transferring medications to containers without safety caps
Evaluation/Outcome
1. Recuperates free from compilations
2. Parents and child demonstrate knowledge concerning the prevention of future poisoning
KINDS OF POISONING
ACETAMINOPHEN POISONING
Acetaminophen (Tylenol) is the drug most frequently involved in childhood poisoning today because
parents use acetaminophen to treat childhood fevers. Told that acetaminophen is safer than aspirin, parents
may not be as careful about putting this drug away as they were with aspirin (Pilliteri, 2010).
A. Most common
1. Therapeutic dose: 50 to 75 mg/kg/day
2. Toxic dose: 150 mg/kg/day
B. Clinical findings: overdose
1. First 2 to 4 hours: nausea, vomiting, profuse diaphoresis, pallor
2. Latent period (24 to 36 hours): symptoms subside; slow, weak pulse
3. Hepatic involvement (may last up to 7 days or be permanent): pain in right upper quadrant,
jaundice, confusion, stupor, coagulation abnormality


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4. Gradual recovery if death does not occur during hepatic come
C. Therapeutic interventions
1. IV fluids
2. Administration of oral antidote: acetylcysteine (Acetadote)
Nursing care for children with Acetaminophen Poisoning
A. Determine amount ingested
B. Monitor electrocardiograph
C. Measure I & O
D. Monitor vital signs
E. Obtain blood for hepatic and renal function tests
F. Support child and family
G. See General Nursing Care of Children with Poisoning
SALICYLATE POISONING AND TOXICITY

Salicylates are used as analgesic agents for the treatment of mild to moderate pain. Aspirin is used as
an antipyretic and as an anti-inflammatory agent for the treatment of soft tissue and joint inflammation and
vasculitides such as acute rheumatic fever and Kawasaki disease (Muhammad Waseem, 2020)
A. Toxic Dose: 300 to 500 mg/kg body weight or 7 adult aspirin (28 baby/aspirin) for 9 kg (20 lb) child
B. Clinical finding
1. Acute Findings
a. Dehydration caused by nausea and vomiting, diaphoresis, fever, hyperpnea; results in oliguria,
other signs of dehydration
b. Metabolic acidosis
c. Tinnitus, dizziness, disturbances of hearing and vision
d. Disorientation, delirium, confusion, coma
2. Chronic poisoning
a. Ingestion of more than 100mg/kg/day for 2 or more days
b. Subtle onset, dehydration, coma, seizures
c. Bleeding
1. Emesis, gastric lavage, activated charcoal, saline cathartics if life-threatening
2. IV fluids with sodium bicarbonate for correction of acidosis
3. Vitamin K if bleeding
4. Peritoneal dialysis if a severe complication
5. Hypothermia blanket for hyperthermia
Nursing care of Children with Salicylate Poisoning

A. Identify the amount of salicylate overdose
B. Assess blood gases and serum electrolyte concentration
C. Administer sodium bicarbonate, electrolytes, and vitamin K as prescribed
D. Use a hypothermia blanket for hyperthermia
E. See General Nursing Care of Children with Poisoning
PETROLEUM DISTILLATE POISONING

Hydrocarbon poisoning may result from ingestion or inhalation. Ingestion, most common among
children < 5 years, can result in aspiration pneumonitis. (O’Malley, 2020)


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A. Distillates: kerosene, turpentine, gasoline, lighter fluid, furniture polish, metal polish, benzene,
naphthalene, some insecticides, cleaning fluid
B. Clinical Finding
1. Gagging, choking, coughing
2. Nausea, vomiting
3. Weakness, alterations in sensorium(lethargy)
4. Pulmonary involvement: tachypnea, cyanosis, substernal retractions, grunting
1. Vomiting not induced because aspiration may result in chemical pneumonia
2. Gastric decontamination and emptying are questionable; if gastric lavage must be performed, a
cuffed endotracheal tube is inserted to prevent aspiration
3. Symptomatic treatment (e.g., oxygen, humidity, antibiotics for chemical pneumonia)
Nursing Care of Children with Petroleum Distillate Poisoning
A. Identify distillate ingested and amount
B. Prevent further irritation
1. Avoid causing emesis
2. Implement gastric lavage if ordered
C. See General Nursing Care of Children with Poisoning
CORROSIVE CHEMICAL POISONING

Ingestion of strong alkali, such as lye, often contained in toilet bowl cleaners or hair care products,
may cause burns and tissue necrosis in the mouth, esophagus, and stomach. The parents mustn't try to make
a child vomit after ingesting these substances because they can cause additional burning as they are vomited
(ATSDR, 2008) (Pilliteri, 2010).
A. Corrosive chemicals (e.g., oven and drain cleaners, electric dishwasher granules, strong detergents.
B. Clinical Findings
1. Severe burning pain in mouth, throat, and stomach
2. Respiratory obstruction (e.g., white, edematous mucous membranes; edema of lips, tongue, and
pharynx)
3. Strong chemical odor
4. Violent vomiting, hemoptysis, hematemesis
5. signs of shock
6. Anxiety and Agitation
C. Therapeutic intervention
1. Vomiting is never induced because regurgitation of substance will further damage mucous
membranes
2. Esophageal stricture: repeated dilations, surgery
Nursing Care of Children with Corrosive Chemical Poisoning
A. Identify Ingested substance and amount
B. Maintain patent airway
1. Examine pharynx for burns, monitor for respiratory difficulty
2. Have emergency equipment available; insert airway if necessary
3. Administer steroids if prescribed
C. Prevent further irritation
1. Avoid causing emesis
2. Give NPO except as ordered and tolerated, dilute with water or milk (no more than 120ml)


TECHONOLOGY
3. Do not neutralize substance because neutralization can cause an exothermic reaction, which
produces heat and causes more injury (e.g., thermal burn in addition to chemical burn)
D. Provide comfort and support to child and family
1. Use a pain rating scale and medicate appropriately
2. Remain with Child
3. Keep parents informed of their child’s progress
E. See General Nursing Care of Children with Poisoning
LEAD POISONING
When a lead enters the body, it interferes with red blood cell function by blocking the incorporation
of iron into the protoporphyrin compound that makes up the heme portion of hemoglobin in red blood cells
(Morgan & Borys, 2008) (Pilliteri, 2010).
A. A prevalent, significant preventable health problem that causes neurologic, intellectual, and
developmental problems based on the level of exposure
B. Incidence
1. Decreased since the screening of children at risk and banning of lead-based paint and leaded
gasoline in the United States
2. Peak blood levels at about 2 years of age
3. About 25% living in or near houses with deteriorating lead-based paint
4. High in Hispanic related to the cultural use of lead in/on toys and other articles.
C. Risk factors
1. Younger than 6 years of age *hand-to-mouth behavior)
2. Poverty
3. Living in urban areas and housing with peeling lead-based paint
4. Pica Practice
5. Exposure to or ingestion of soil, dust, drinking water, with lead, parental occupations, toys,
trinkets, hobbies involving lead
D. Clinical Findings
1. Subclinical effects on the central nervous system (CNS)
a. Alterations in hearing, balance
b. The lead line on teeth and long bones, joint pain
c. Behavioral changes: impulsivity, inattentiveness, hyperactivity, disorganization, difficulty
following directions, aggression, delinquency
d. Decreased mental ability; increased number of high school dropouts
2. Clinical effects of high blood levels
a. Anemia: pallor, listlessness, fatigue
b. Proximal tubular damage: proteinuria, glycosuria, ketonuria, decreased vitamin D
c. CNS effects: lead encephalopathy, mental retardation, paralysis, blindness, convulsion, death
E. Therapeutic interventions
1. Cooperation with the state health department in investigating and decreasing source
2. Instituting professional cleaning, paint stabilization, removal, and replacement of lead-based
building components.
3. Screening: universal at 1 to 2 years of age; 3 to 6 years if not previously screened; more than
once if at risk
4. Reduction of lead concentration in blood and soft tissue.


TECHONOLOGY
a. Chelation therapy: removes lead from circulating blood and some lead from organs; does not
reverse CNS damage
b. Succimer (Chemet)
(1) The oral chelating agent used if the blood lead level is greater than 45 mcg/dL
(2) Adverse effects: nausea, vomiting, diarrhea, loss of appetite, rash, liver damage,
neutropenia
(3) Adequate hydration to facilitate the clearance of chelates through kidneys
c. Edetate calcium disodium: used when succimer is ineffective; given IM or IV; rarely used
5. Prevention of further ingestion
Nursing Care for Children with Lead Poisoning
A. Provide anticipatory guidance to parents of infants and toddlers about the prevention of lead
poisoning
B. Assess lead hazards in home and childcare settings
C. Determine environmental exposure and oral ingestion
D. Screen Children at risk by recognizing clinical findings, especially behavioral changes
E. Monitor urinary output; keep well hydrated.
F. Monitor for side effects of succimer
CHILD ABUSE
Abuse may be physical (the child is beaten or burned), or it may be neglect (the child is not fed, clothed,
supervised properly, or offered medical care or educational opportunities). Abuse may also be psychological
or emotional (a child is made to feel unintelligent or inadequate). In some instances, women who threatened
their fetus's health by drug abuse have been viewed by the courts as child abusers (Sun, Freese, & Fitzgerald,
2007) (Pilliteri, 2010).
A. Types
1. Physical abuse: minor physical abuse responsible for more reported cases than significant physical
abuse, resulting in increased mortality
2. Neglect: most common form of maltreatment (e.g., emotional, physical)
3. Sexual abuse: incest, molestation, exhibitionism, pedophilia, child pornography, prostitution; directed
at females four times more than males.
4. Emotional abuse: acts or omissions that have caused, or could cause, serious behavioral, cognitive,
emotional, or mental disorders
B. Significant social problem that precipitated the Child Abuse Prevention and Treatment Act
(CAPTA)
1. Child Abuse and neglect: any recent act or failure to act that results in imminent risk of death, serious
physical or emotional harm, sexual abuse, or exploitation of a child by a parent or caretaker
responsible for the child’s welfare.
2. Sexual abuse: employment, use, persuasion, inducement, enticement, or coercion of any child to
engage in, or assist any other person to engage in, any sexually explicit conduct or any simulation of
such conduct for the purpose of producing any visual depiction of such conduct; includes rape,
statutory, molestation, prostitution, or other forms of sexual exploitation of children or incest with
children.
C. Characteristics of an abuser
1. History of abuse or neglect as a child


TECHONOLOGY
2. low self-esteem
3. Substance/alcohol abuse
4. Young maternal or paternal age
5. Difficulty controlling aggressive impulses; use of violence to resolve conflicts
6. Depression or other mental illness
7. Unwanted, unplanned pregnancy
8. Ignorance and negative perception of typical childhood behavior (e.g., awakening at night,
separation anxiety, exploration, ritualism, negativism, physiologic anorexia, difficult toilet
training, enuresis): unrealistic expectations of a child
D. Characteristics of child
1. Emotional and behavioral difficulties
2. Chronic illness
3. Physical or developmental disability, preterm birth
E. Environmental characteristics
1. Social isolation from the support system and community
2. Poverty, crowded living conditions
3. 3.Unemployment
4. Unpredictable, unstable surroundings
5. Frequent change of location
6. Inadequate parental education
7. 7.Single-parent home
8. non-biologically related male living in a home
9. Family or intimate partner violence
F. Clinical Findings
1. Physical evidence of abuse/previous injuries
2. Conflicting stories about the injury; injury blamed on a sibling or another party
3. Inappropriate parental response (e.g., exaggerated or absent; rarely looks at our touches child;
failure to sign consent for additional tests; delay in seeking treatment)
4. Inappropriate response of child (e.g., little or no reaction to pain; fear of being touched; excessive
or lack of separation anxiety; indiscriminate friendliness to strangers)
G. Therapeutic interventions
1. Treatment of injury
2. Protection of a child from further abuse
3. Suspected abuse reported to local authorities; all states and provinces in North America have laws
for mandatory reporting
Nursing Care of Children who are Abuse
Assessment/Analysis
1. History of Injury: objective data from examination does not match the story told by parents (e.g.,
"Toddler fell off chair" while examination reveals spiral fracture of the femur, which would not result
from this type of fall)
2. 2.Physical status: evidence of past injuries (e.g., skeletal, soft tissue); failure to thrive
3. 3.Parent-child interaction
4. Developmental level
1. Monitor for clues that indicate neglect or abuse
a. Child
1) Unexplained injuries, scars, bruises


TECHONOLOGY
2) Physical sign of neglect (e.g., malnourished, dehydrated, unkempt)
3) Cringes, when physically approached, seems unduly afraid
4) Responses indicate avoidance of punishment rather than gaining reward
5) Has an excessive interest in sexual matters; has sexually transmitted infection
b. Parental Behavior
1) Offer inconsistent stories explaining injuries
2) Emotional response is inconsistent with the degree of injury
3) May resist or fail to be present for questioning
2. Protect from further abuse
3. Know child laws; report suspected abuse/neglect to a designated authority
4. Provide consistent caregiver
5. Monitor when parents or others visit
6. Help parents to
a. Address their dependency needs
b. Learn to control frustration through other outlets
c. Learn about childhood growth and development, expected behavioral characteristics, realistic
expectations
d. Appropriate modes of limit-setting and discipline
7. Use therapeutic play with a child to help express feelings
8. Provide emotional support and therapy; abused children may grow to be abusive parents
9. Refer family for group therapy, home visits, foster grandparent visits
Evaluation/Outcomes
1. Child remains free from injury or neglect
2. Parents demonstrate effective parenting activities
CEREBRAL PALSY (CP)
Cerebral palsy (CP) is a group of nonprogressive disorders of upper motor neuron impairment that result
in motor dysfunction (Pilliteri, 2010). Impairment in the brain controls voluntary movement and muscle tone;
type and extent of disability vary from mild to profound (clumsiness to quadriplegia); associated with sensory,
intellectual, emotional, seizure disorder.
A. Risk Factors
1. Prenatal brain abnormalities: estimated to be the most common cause
2. Prematurity: increased prevalence in infants born before 36 weeks’ gestation weighing less than 2000
g (4.4lb)
3. Anoxia of the brain: a variety of insults at or near the time of birth
4. Trauma: brain attack (cerebral vascular accident)
B. Classification
1. Spastic (pyramidal): persistent primitive reflexes increased muscle tone (hypertonia)
a. Hemiplegia: weakness and poor motor control of one arm and one leg on the same side of body
b. Diplegia: paralysis of upper or lower extremities
c. Monoplegia: Paralysis of one limb
d. Triplegia: paralysis of 3 limbs
e. Quadriplegia: paralysis of all extremities
2. Dyskinetic: (nonspastic, extrapyramidal)
a. Artheroid (Chroea): involuntary, writhing movements
b. Dystonic: twisting movements


TECHONOLOGY
3. Ataxic (nonspastic, extrapyramidal): wide-based gait, difficulty reaching for objects
4. Mixed type: combined spastic dyskinetic
5. Hypotonic: limp
C. Characteristics
1. Evident before 3 years of age
2. Nonprogressive, but persists throughout life
3. Inability to achieve or delayed developmental milestones
4. May or may not have an intellectual disability
5. Problem with intellectual functioning (e.g., thinking, problem-solving): affect more than 50%
a. Average intellectual ability with learning disorders
b. Mental retardation
6. Seizures: affect 33%
7. Visual difficulties: more than 75% have strabismus, eye muscle incoordination
8. Difficulty speaking; language deficit
9. Contractures: common with spasticity
10. Oral disease: inadequate oral hygiene; enamel defects, side effects of medications
D. Clinical findings
1. Difficulty feeding, especially sucking and swallowing gastroesophageal reflux
2. Delayed motor development; abnormal motor performance; asymmetry of motion or contour of the
body
3. Muscular abnormalities: alteration in muscle tone
4. Abnormal posture
5. Delayed speech development
6. Reflex abnormalities (e.g., hyperreflexia)
E. Therapeutic interventions
1. Early treatment; multidisciplinary approach
2. Mobility devices (e.g., braces, cast)
3. Surgery to correct spastic muscle imbalance
4. Medications
a. Skeletal muscle relaxants, anticonvulsants, intrathecal baclofen (Lioresal) administration using an
implanted pump
b. Analgesics for muscle spasm pain
5. Physical, occupational, and speech therapy
Nursing Care of Children with Cerebral Palsy
Assessment/Analysis
1. Prenatal/perinatal risk factors
2. Ineffective feeding
3. Muscle of rigidity, tenseness, hypotonia
4. Delayed developmental milestones
1. Promote nutrition and facilitate feeding
a. Expect drooling from swallowing difficulty
b. Encourage self-feeding ( e.g., offer spoon and blunt forks, attach the plate to the table)
c. Offer a high-calorie diet for excessive energy expenditure (especially B6) for amino acid
metabolism
2. Promote relaxation
a. Provide rest periods in a quiet environment
b. Limit energy expenditure with quiet activities


TECHONOLOGY
3. Maintain safety
a. Protect from accidents resulting from altered sensations, impaired balance, lack of muscle
control
b. Provide a helmet, if necessary, for protection against head injuries
c. Provide physical supports/ restraint as necessary
4. Promote play
a. Ensure educational value appropriate to developmental level and ability
b. Avoid overstimulation
5. Promote elimination
a. Teach parents that toilet training difficulties are associated with impaired muscle control
b. Provide special bowel and bladder training
6. Facilitate speech development
a. Teach parents that word mispronunciation is associated with incoordination of lips, tongue,
cheeks, larynx, and impaired control of the diaphragm
b. Refer to speech therapy
7. Promote respiratory status
a. Teach parents that respiratory tract infections are associated with impaired control of
intercostal muscles and diaphragm; protect a child from people with infections, crowds
b. Monitor for manifestations of aspiration pneumonia
8. Promote healthy dentition
a. Teach parents: inability to control muscle affect development and alignment of teeth; brush
child’s teeth if muscular dysfunction impairs self-care.
b. Encourage continued dental supervisions; prone to dental caries
9. Promote visual acuity
a. Teach parents that strabismus and refractive errors may be related to impaired muscular
control
b. Monitor for and report visual disorders to prevent further problems ( e.g., amblyopia)
c. Encourage routine visits to the health care provider for diagnosis and treatment
10. Promote optimum hearing
a. Teach parents that hearing problems depend on the area of brain damage
b. Encourage parents to have a child's hearing checked periodically
11. Promote mobility
a. Perform passive and encourage active range-of-motion exercises to prevent contractures,
stretch ligaments and muscles
b. Encourage wearing of leg braces, if prescribed, to maintain functional alignment and prevent
deformities
c. Encourage use of assistive devices (e.g., forearm crutches, wheeled walker) to promote
stability
12. Provide emotional support to parents
a. Help to cope with lifelong disability and loss of an idealized child
b. Explain the need to avoid overprotection; be consistent with disciplining
c. Explain the importance of allowing time for healthy siblings
Evaluation/ Outcomes
1. Remains safe from injury
2. Consumes adequate nutrient for growth
3. Communicates needs to caregivers
4. Performs self-care activities within capabilities
5. Exhibits behavior indicative of positive self-image


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6. Parents and Siblings verbalize the effect of a child's disability on family
1. Choose three diseases/cases from this chapter and, in diagram format, illustrate the
pathophysiologic sequence of changes that occur in your chosen diseases/cases. An outline format
is acceptable as long as the cause-and-effect sequence can be seen.


TECHONOLOGY
UNIT 6: HEALTH PROBLEMS COMMON IN PRE-SCHOOLERS
(Reference: (Patrici M. Nugent, RN, EdD, Judith S. Green, RN, MA, Phyllis K. Pelikan, RN, MA, Marry Ann
Hellmer Saul, RNCS, PhD., 2014)
LEUKEMIA
Leukemia is the distorted and uncontrolled proliferation of WBCs (leukocytes) and is the most frequently
occurring type of cancer in children (Pilliteri, 2010). cancer of blood-forming organs; overproduction of
immature, non-functioning leukocytes
A. Incidence: most common type of childhood cancer; prognosis is improving

1. Peaks between 2 to 6 years of age
2. More common in males after 1 year of age
B. Classification
1. Acute lymphoblastic leukemia (ALL) affects lymphocytes
a. Divided into subtypes based on morphological, cytochemical, and immunologic
characteristics (T, B, null, and pre-B subtypes)
b. Five-year disease-free survival: 91% when diagnosed at younger than 5 years of age
2. Acute myelogenous leukemia (AML): acute non-lymphoblastic leukemia
a. Prognosis less favorable than ALL
b. Five-year survival: 61% when younger than 15 years of age at diagnosis
C. Clinical Findings
1. Decreased erythrocytes: anemia (e.g., pallor, weakness, irritability)
2. Decreased neutrophils: increased risk for infection (e.g., fever)
3. Decreased platelets: bleeding tendencies (e.g., ecchymosis, petechiae, bleeding gums, and other
mucous membranes)
4. Invasion of bone by leukemic cells: bone pain, fracture
5. Enlarged spleen, liver, and lymph glands
6. 6.Intestinal Inflammation: anorexia, vague abdominal pain
7. Later signs: Central Nervous System (CNS) involvement and frank hemorrhage
D. Therapeutic Interventions
1. Chemotherapy: protocols for AML and ALL are different; each protocol is based on child and disease
factors
a. Induction therapy for 4 to 6 weeks
1.1.1. Corticosteroids: prednisone or dexamethasone
1.1.2. Chemotherapeutic agents: based on subtypes
b. Intensification (consolidation) therapy for ALL: further decreases numbers of leukemic cells;
a combination of two or more drugs given in routine periodic stretches of administration
(pulse) during the first 6 months
c. CNS prophylactic therapy: irradiation and triple intrathecal medications (e.g., methotrexate,
cytarabine, hydrocortisone) because leukemia drugs do not pass the blood-brain barrier
d. Maintenance therapy: preserves remission and further reduces the number of leukemic cells
2. Hematopoietic stem cell transplantation (HSCT); not performed during the first remission
3. Transfusions to replace and provide needed blood factors (e.g., RBCs, platelets, WBCs)


TECHONOLOGY
Nursing Care of Children with Leukemia
Assessment/Analysis
1. Hematologic status: Anemia (e.g., pallor, fatigue); thrombocytopenia (e.g., hematuria, bleeding
gums); neutropenia (e.g., signs of infection)
2. Activity level
3. Complications of therapy/disease process
4. Family/child knowledge of disease process
5. Family support systems and coping strategies
1. Encourage adjustment to chronic illness; stress need for maintaining a lifestyle
2. Identify the perception of illness and death based on a level of understanding
a. Preschooler: concept that death is reversible; greatest fear is separation
b. Young school age (6 to 9 years old): death is personified as an individual who comes to remove a
child
c. Older school age (over 9 years old): the adult concept of death as irreversible and inevitable
3. Support while experiencing side effects of medications; administer prescribed antiemetics (e.g.,
ondansetron) before chemotherapy
4. Encourage adequate nutrition despite anorexia; provide preferred foods, even hot dogs
5. Teach infection prevention: hand washing; avoiding contact with those with active infections;
avoiding crowded places
6. Handle gently to reduce pain, the risk for hemorrhage
7. Use a pain rating scale and medicate appropriately
8. Provide gentle oral hygiene: use soft-tipped applicator; saline mouthwash rinses; offer soft, bland
foods; cool liquids/food rather than cold or hot
9. Provide for frequent rest periods, quiet play
Evaluation/Outcomes
1. 1.Participates in developmental, age-appropriate activities
2. Remains comfortable
3. Consumes adequate calories for growth
4. Remains free from complications (e.g., infection, bleeding, anemia, impaired skin integrity)
5. Family and child discuss fears, concerns, and needs
WILMS TUMOR (NEPHROBLASTOMA)
Nephroblastomas distort the kidney anteriorly so that the tumor is felt as a firm, non-tender abdominal
mass. Parents sometimes are aware that their infant has a mass in the abdomen but bring the infant to their
health care provider, thinking that it is a hard stool from chronic constipation (Pilliteri, 2010). Most common
malignant kidney neoplasm in children.
A. Incidence: estimated frequency is 9 per 1 million

1. More common in Caucasian children younger than 15 years old
2. Peak age at diagnosis between 3 and 4 years of age; 80% diagnosed by 5 years of age
B. Risk Factors:
1. Mode of familial inheritance (less than 2%): autosomal dominant; more common among siblings
2. May be associated with congenital anomalies


TECHONOLOGY
C. Factors favoring positive prognosis
1. Stage I and II with a localized tumor: 90% cured with multimodal therapy
2. Favorable histology of the tumor
3. More than 12 months elapsed since the first remission
1. Swelling or nontender abdominal mass; confined to one of midline
2. 2.Weight loss; fever; fatigue; malaise (with compression of abdominal organs)
3. Hematuria, caused by intrarenal hemorrhage; occurs in less than 25% of children
4. Hypertension occasionally occurs
5. Other findings associated with compression of neighboring organs or metastasis (e.g., lungs: cough,
dyspnea, shortness of breath)
E. Therapeutic Interventions
1. Abdominal palpation and renal biopsy contraindicated to prevent rupture of the encapsulated tumor
2. Surgery: scheduled soon after confirmation of mass
a. Tumor, kidney, and associated adrenal gland removed
b. Partial nephrectomy of the contralateral kidney is affected
c. regional lymph nodes and organs removed when indicated
3. Chemotherapy: indicated for all stages; continued for 6 to 15 months based on staging
4. Radiation therapy: to shrink large tumors before surgery; metastasis; residual disease after surgery;
unfavorable cell type
Nursing Care of Children with Wilms Tumor
1. Observation of abdomen for mass or swelling
2. Laboratory results of RBCs for anemia
3. Weight loss
4. Signs and symptoms of compression of abdominal organs
5. Signs of metastasis to lung (e.g., dyspnea, cough, shortness of breath)
1. Preoperative
a. Handle and bathe carefully to prevent abdominal trauma (may cause rupture of tumor capsule);
place "Do not palpate abdomen" sign inappropriate place for professional staff while maintaining
the confidentiality
b. Monitor blood pressure, I & O
c. Prepare parents and child for postoperative expectations (e.g., large dressing, drainage tube)
d. Begin teaching family about chemotherapy/radiation therapy
2. Postoperative
a. Monitor blood pressure, I&O
b. use a pain rating scale and medicate appropriately
c. Encourage to turn, cough, and deep breathe to prevent pulmonary complications
d. Teach parents to identify untoward reactions to chemotherapy and radiation therapy
3. See Leukemia, Nursing Care
Evaluation/ Outcomes
1. Remains free from complications (e.g., infection)
2. Maintains blood pressure within an acceptable range
3. Consume adequate calories for growth
4. Child and family members discuss feeling and concerns


TECHONOLOGY
ASTHMA
Asthma tends to occur in children with atopy or those who tend to be hypersensitive to allergens. Mast
cells release histamine and leukotrienes that result in diffuse obstructive and restrictive airway disease
because of a triad of inflammation, bronchoconstriction, and increased mucus production (Pilliteri, 2010).
A. Chronic inflammatory disorder or airways

1. Reversible airflow limitation
2. Spasms of bronchi and bronchioles
3. 3.Edema of mucous membranes
4. Increased secretions
5. Respiratory acidosis from the accumulation of carbon dioxide
B. Incidence: increasing rate of occurrence, severity, and mortality; most common chronic disease of
childhood
C. Risk factors
1. Immunologic exposure to an antigen that is deposited on the respiratory mucosa
2. Nonimmunologic stimuli (e.g., viral infections, physical and chemical substances)
D. Primary cause of school absences; leading cause of pediatric hospitalizations
E. Classification
1. Mild intermittent: symptoms two or fewer times each week; brief exacerbations; nighttime
symptoms two or fewer times each month
2. Mild persistent: symptoms more than two times per week but less than once a day; exacerbations
affect activity; nighttime symptoms more than twice per month
3. Moderate persistent: daily symptoms; frequent nighttime symptoms; limited physical activity
4. Severe persistent: continual symptoms; frequent exacerbations; frequent nighttime symptoms;
limited physical activity
F. Status asthmaticus: continued respiratory distress despite usual interventions; considered a medical
emergency
G. Clinical Findings
1. Wheezing, especially on the expiration
2. Labored breathing, flaring nares
3. Cough, increased secretions
4. Tachycardia
5. Restlessness, apprehension
6. Upright sitting position with shoulders forward
7. Diminished peak expiratory flow (PEF)
H. Therapeutic Interventions
1. Long-term control medications (preventive medicines): achieve and maintain control of
inflammation (e.g., inhaled corticosteroids, long-acting beta-adrenergic, methylxanthines,
leukotriene modifiers, mast cell stabilizers)
2. Quick-relief medications (rescue medications): treat symptoms and exacerbations (e.g., short-acting
beta-adrenergic, anticholinergics, systemic corticosteroids)
3. Medications for both quick relief and long-term control: beta-adrenergic, methylxanthines,
anticholinergics
4. Commonly used medications


TECHONOLOGY
a. Corticosteroids
1. Action: anti-inflammatory effect diminishes inflammatory component of asthma and
reduces airway obstruction; preferred controller medicine for all ages; safe for most
children in the recommended dosage
2. Inhaled: few side effects
b. Leukotriene modifiers: zafirlukast (Accolate), montelukast (Singulair)
1. Action: prevents the release of medication of type I allergic reactions (e.g., histamine);
lessens bronchoconstriction
2. Adverse effects: nausea, vomiting, headache, dizziness, infection angioedema
c. Beta-adrenergic agonists: albuterol (Proventil), levalbuterol (Xopenex), terbutaline
1. Action: act on beta-adrenergic receptors in bronchi to relax smooth muscle and increase
respiratory volume; used for quick relief in rescue situations
2. Adverse effects: tachycardia, hyperactivity, insomnia, tremors; overuse of inhalants may
cause "congestive rebound."
Nursing Care of Children with Asthma

1. Respiratory status
2. History of current and previous attacks
3. 3.Precipitating events/Environmental factors
4. Knowledge of drug therapy
1. Administer parenteral drugs per protocol
2. Improve ventilating capacity
a. Position in a high-fowler or orthopneic positions
b. Teach breathing exercises and controlled breathing
c. Observe return demonstration on using peak expiratory flow meter (PEFM) to monitor airflow
3. Teach parents
a. How to give control and rescue medications; explain why control medications are necessary even if
the child is asymptomatic
b. To encourage rinsing the mouth after inhalation to reduce the risk for oral candidiasis (thrush)
c. How to minimize exposure to environmental triggers in-home (e.g., dust, dust mites, mold,
secondhand cigarette smoke, animal dander)
d. That controlled environment can limit attacks
1. Allergy-proof home (e.g., damp dust, no carpets, vacuum daily
2. Manage exertion, limit exposure to cold air, avoid people with infections
Evaluation/Outcomes
1. Continues medication protocol
2. Breathes without dyspnea when at rest or engaging in activities
3. Manages respiratory secretions
4. 4.Obtain sufficient sleep
5. Maintains family and peer-group relationships
6. Child and family members cope with the impact of chronic illness.
URINARY TRACT INFECTION (UTI)
UTI occurs more often in females than in males at a rate of about 8% to 2% (Lum, 2008). Pathogens
appear to enter the urinary tract most often as an ascending infection from the perineum. Most urinary


TECHONOLOGY
pathogens are gram-negative rods. E. coli is a frequent offender (Pilliteri, 2010). Microorganisms in the
urethra/ bladder causing inflammation and infections; may progress to kidneys and/or blood (septicemia)
A. Incidence: peaks at 2 to 6 years of age; after the neonatal period, females have a 10 to 30 times
greater likelihood of UTI
B. Risk Factor: lower urinary tract anatomy of females (short urethra, the proximity of meatus to anus)
C. Classification
1. Bacteriuria: asymptomatic or symptomatic
2. Recurrent UTI
3. Persistent UTI
4. 4.Febrile UTI
5. Cystitis: bladder infection
6. Urethritis: urethral infection
7. Pyelonephritis: renal pelvis infection
8. Urosepsis: bacterial infection of blood in the urinary tract
1. Younger than 2 years of age: mimic GI disorders, failure to thrive, feeding problems, vomiting,
diarrhea
2. Older than 2 years of age: dysuria, urgency, frequency, daytime incontinence, enuresis
E. Therapeutic Interventions
1. Antibiotics to eliminate the infection
2. Identification and correction of structural anomalies if present
3. Prevention of recurrence: preservation of renal function
Nursing Care of Children with Urinary Tract Infection
Assessment/Analysis
1. Discomfort on urination (dysuria)
2. Pattern of urinary elimination
3. Pattern of bowel elimination
4. Amount of fluid intake
5. Result of urinalysis/ urine culture and sensitivity
1. Develop a voiding schedule to limit urinary stasis; encourage the empty bladder when voiding
2. Increase fluids to enhance urine production/voiding
3. Encourage girls to wear loose cotton underpants; avoid tight, outer pants
4. Encourage routine health care supervision
5. Encourage an increase in dietary fiber to minimize constipation, which contributes to UTI
Evaluation/Outcomes
1. Resolve infection
2. Implements measures to prevent a recurrence


TECHONOLOGY
References

RNCS, Ph.D. (2014). Mosby's Comprehensive Review of Nursing for the NCLEX-RN Examination 20th edition.
Elsevier.


TECHONOLOGY
UNIT 7: HEALTH PROBLEMS COMMON IN SCHOOL-AGE CHILDREN
Reference:(Patricia M. Nugent, RN, EdD, Judith S. Green, R.N., MA, Phyllis K. Pelikan, RN, MA, Marry Ann
Hellmer Saul, RNCS, PhD., 2014)
Diabetes Mellitus
Type 1 diabetes is a disorder that involves an absolute or relative deficiency of insulin in contrast to type
2, where insulin production is reduced. Type 1 diabetes (formerly referred to as juvenile diabetes or insulin-
dependent diabetes) occurs almost exclusively in childhood (Pilliteri, 2010).
A. Incidence
1. 11 to 20 per 100,000
2. Peaks at 10 to 15 years of age; can occur at any age
B. Risk Factors
1. Genetic
a. Based on the ethnic origin (e.g., type 1 more frequent among Caucasians, less frequent among
African Americans)
b. Gene mutation (maturity-onset diabetes of the young)
c. Inheritance: 100% concordance in identical twins
2. Immunologic
3. Environmental (e.g., Obesity for type 2)
C. Classification: Characteristics of type 1 and Type 2 Diabetes Mellitus)
1. Type1: lack of insulin production
2. Type 2: resistance to insulin action; defective glucose-mediated insulin secretion.
3. Other types: pancreatic defects (e.g., cystic fibrosis-related)
D. Differences between children and obese children/ adults
1. Children
a. Usually, type 1; rapid onset.
b. Prone to hypoglycemia and Ketoacidosis
c. Medication: insulin
d. Degenerative vascular changes develop after adolescence.
2. Obese children/ adults
a. Usually type w, insidious onset.
b. Hypoglycemia and Ketoacidosis less common
c. Dietary treatment: can effective with weight loss, exercise
d. Degenerative vascular changes: child-usually develop after adolescence; adult-usually
present at the time of diagnosis.
E. Clinical findings, Type 1
1. Onset: rapid, obvious
2. Usually thin, underweight
3. Three P’s: Polydipsia; Polyphagia; Polyuria
4. Hyperglycemia, Ketoacidosis, diabetic coma
a. Causes
i. Inadequate exogenous insulin
ii. Emotional Stress
iii. Physical Stress (e.g., fever, infection)
iv. Increases food intake
v.


TECHONOLOGY
b. Characteristics:
Characteristics of type 1 and 2 Diabetes Mellitus
Characteristic Type 1 Type 2
Age at onset <20 yrs Increasingly occurring in younger
children
Type of onset Abrupt Gradual
Sex ratio It affects males slightly more than Females outnumber males
females
Percentage of diabetic population 5% to 8% 85% to 90%
Heredity:
Family history Sometimes Frequently
Human leukocyte Associations No association
Twin concordance 25% to 50% 85% to 90%
Ethnic distribution Primarily Caucasians Increased incidence in Native
Americans, Hispanics, African-
Americans
Presenting symptoms 3Ps common: polyuria, Maybe related to long term
polydipsia, polyphagia complications
Nutritional status underweight overweight
Therapy:
Insulin Always 20%-30
Oral agents Ineffective 20%-30%
Diet only Ineffective Often effective
Chronic Complications >80% 5%
Ketoacidosis Common Infrequent
5. Hypoglycemia related to insulin therapy

a. Causes
i. Inadequate exogenous insulin
ii. Emotional Stress
iii. Physical Stress
iv. Increased food intake
F. Therapeutic Intervention
1. Dietary: calories, carbohydrate, fat, protein intake, balanced with physical activity and metabolic
needs
2. Insulin
3. Exercise: Increased physical activity to reduce the need for insulin
4. Hyperglycemia: hospitalization with the administration of fluids, electrolytes, insulin.
5. Hypoglycemia: immediate supply of readily available glucose followed by complex carbohydrates
and protein.
Nursing care for children with Diabetes Mellitus
1. Knowledge and attitudes about the disease and its management
2. Blood glucose levels: expected values for child, 50 to 85 mg/dl; for adolescent 60 to 110 mg/dl
3. Glycosylated hemoglobin (hemoglobin A1c)


TECHONOLOGY
4. Insulin types, dosages, response (e.g., the onset of action; peak action)
5. Signs of hypoglycemia/ hyperglycemia.
6. Complications.
Planning/ implementation
1. Discuss disorder based on parent’s and child’s knowledge
2. Teach factors that affect insulin requirements (e.g., physical growth, activity, food intake, presence
of infection)
3. Teach signs and symptoms of hyperglycemia and hypoglycemia; provide a written list for
reinforcement
4. Teach appropriate intervention for complications
a. suspected insulin reaction: give glucose and skim milk
b. suspected Ketoacidosis: notify health care provider; do not increase insulin dose.
5. Explain prescription for insulin is adjusted as indicated
6. Teach about prevention of infection (e.g., skincare; correctly fitted shoes; prompt treatment of
small cuts, protection from exposure to communicable illness)
7. Encourage a well-balanced diet.
a. Equal quantities of food to be eaten at regular intervals if possible, rather than three large
meals.
b. Regularly scheduled snacks, particularly before bedtime, if taking intermediate-acting
insulin.
c. Usually unrestricted within reason.
8. Help plan exercise and adjust food intake and insulin dosage to meet requirements; food intake
and insulin dosage to meet requirements; food intake and insulin dosage to meet requirements,
food intake should increase before exercising.
9. Teach self-care skills when the motor and mental abilities allow, usually by 7-9 years of age
a. Give simple explanations
b. How to perform blood glucose testing
c. How to administer insulin (by injection or pump); use diagrams for administration sites'
location.
10. Encourage periodic adult observation of self-care techniques.
11. Provide emotional support; offer choices when possible for a sense of control.
12. Encourage continued health care supervision.
Evaluation/Outcomes
1. Maintains blood glucose level within the identified range
2. Consumes adequate calories for growth and development
3. Remains free from complications (e.g., insulin coma, Ketoacidosis)
4. Demonstrates behaviors reflective of a positive self-image
5. The child and parents demonstrate the ability to follow a health care regimen.
RHEUMATIC FEVER
Inflammatory disease is affecting the heart, joints, central nervous system, subcutaneous system. It
follows infection with group B-hemolytic streptococcus pharyngitis in 2 – 6 weeks if untreated. Rheumatic
heart disease with damage and scarring of the mitral valve is a complication of R.F.
a. Risk factors are inadequate health care and limited access to antibiotics (most frequently in
developing countries.)


TECHONOLOGY
b. Clinical findings:
i. Heart: endocarditis, mitral and aortic valve stenosis
ii. Joints: edema, inflammation, and effusion in knees, elbows, hips, shoulders, wrists.
iii. Skin: erythematous macules with clear center, wavy demarche border on the trunk, and
proximal extremities
iv. Neurologic: chorea
v. Other manifestations: low-grade fever, epistaxis, abdominal pain, arthralgia, weakness,
fatigue, pallor, anorexia, weight loss
c. Therapeutic interventions
i. Antibiotic therapy to eradicate organism and prevent recurrence, prophylactic therapy
before dental work or invasive procedures.
ii. Prevention of permanent cardiac problem
iii. Palliation of other manifestation
iv. Salicylates to control the inflammatory process
v. Prevention of recurrences
Nursing care of children with rheumatic fever
1. Typical clinical manifestation
2. Activity level
3. Pain
4. Medication protocol
1. Encourage bed rest to reduce the heart's workload during the acute phase; gradually increase
activity during recovery.
2. Handle painful joints gently; maintain functional alignment to prevent deformities.
3. Use the pain scale and medicate appropriately.
4. Offer small frequent meals; encourage intake of nutritious food and fluids.
5. Emphasize abilities rather than limitations; promote the development of quiet hobbies and
collections.
6. Provide emotional support
a. Keep communication channels open at home and with the school.
b. Refer for a tutor as necessary
c. Encourage to do homework.
Evaluation/Outcomes
1. Maintain cardiac output within acceptable limits
2. Consumes adequate calories for growth
3. Reports minimal pain
4. Maintains mobility of joints
JUVENILE IDIOPATHIC ARTHRITIS (JIA)
Juvenile arthritis is a disease in which there is inflammation (swelling) of the synovium in children
aged 16 or younger. The synovium is the tissue that lines the inside of joints. Juvenile arthritis is
an autoimmune disease. That means the immune system, which normally protects the body from foreign
substances, attacks the body instead (WebMD, 2019).
Database
a. Group of chronic autoimmune inflammatory disease affecting joints and other tissues


TECHONOLOGY
b. Incidence
a. 1 in 1000 children
b. Onset: younger than 16 years; peak ages 1 to 3 years
c. Female predominance: 2:1
c. Classification
a. Systematic: one or more joints associated with 2 weeks of clinical manifestations
b. Oligoarthritic: one to four joints for the first 6 months; may last for more than 6 months
d. Polyarthritis
a. Negative rheumatoid factor: five or more joints for 6 months
b. Positive rheumatoid factor: five or more joints for 6 months
e. Psoriatic arthritis: associated with skin lesions
f. Inflammation f tendons insertion sites (enthesitis): associated with back pain and other clinical
manifestations
Clinical findings
1. Stiffness, swelling, loss o motion in affected joints; most common in the morning and after inactivity
2. Joint enlargement from edema, joint effusion, and synovial thickening
3. Fever, rash, lymphadenopathy, hepatomegaly (systemic arthritis)
Therapeutic interventions
1. Medications
a. First-line drugs- non-steroidal anti-inflammatory drugs: ibuprofen (Advil, Motrin), naproxen
sodium (Aleve), tolmetin sodium (mylan)
b. Second-line drug- antineoplastic/antimetabolite: methotrexate (trexall)
c. Corticosteroids: immunosuppressant used for life-threatening complications.
d. Tumor necrosis factor inhibitor. Etanercept (Enbrel)
e. Slow acting antirheumatic drugs (SAARDs): sulfasalazine (Azulfidine), hydroxychloroquine
(plaquenil)
2. Physical and occupational therapy: individualized to preserve function and prevent deformity
Nursing care for children with juvenile idiopathic arthritis
Assessment/Analysis
1. Status of involved joints
2. Physical restrictions
3. Location and extent of pain
4. Response to illness
1. Emphasize the importance of medication protocol
a. Take medication regularly, even during remissions
b. Give NSAIDs with foods to prevent G.I. irritation
2. Promote functional alignment
a. Perform passive range of motion exercises
b. A use exercise program designed by a physical therapist to limit the impact on joints
c. Discourage prolonged sitting
d. Encourage warm baths of application moist heat compresses to joints early in the day to
decrease stiffness and increase mobility
e. offer a nutritious diet that does exceed energy needs
f. promote adequate rest and sleep
g. provide emotional support
a. encourage parents to accept the child's illness to avoid using it as a means of fostering
dependency or controlling relationship


TECHONOLOGY
b. promote social interaction with peers
c. encourage verbalization of feelings; emphasize abilities rather than limitations
Evaluation/Outcomes
1. reports minimal pain
2. maintain mobility of joints
3. participates in activities with minimal discomfort and sufficient energy
4. participates in self-care to the fullest extent of abilities
5. child and family maintain health care regimen
SCABIES
Scabies is not an infection but an infestation. Tiny mites called Sarcoptes scabies set up shop in the outer layers
of human skin. The skin does not take kindly to the invasion. As the mites burrow and lay eggs inside the skin, the
infestation leads to relentless itching and an angry rash (WebMD, 2019).
Date Base
1. Produce by itch mite Sarcoptes Scabiei
a. Female burrows into stratum corneum of the epidermis to lay eggs
b. Severe itching resulting in scratching may lead to a secondary infection.
2. Clinical findings
a. Pruritus
b. Eczematous eruption; minute grayish-brown threadlike burrows with a black dot at end (mite)
c. Distribution of lesions primarily in folds (axillary, antecubital, popliteal, inguinal), hands/wrist,
feet/ ankles
d. Secondary infection: papules and vesicles
Therapeutic interventions
1. Medications
a. Permethrin 5% cream (Elimite): remains on the skin for 8 to 14 hours before bathing; second
application 7 to 10 days later if needed
b. Crotamiton cream (Eurax): applied once each day for 2 days, followed by a bath.
PEDICULOSIS
Pediculosis is infestation with the human head-and-body louse, Pediculus humanus. There are two
subspecies, the head louse (P. h. capitis) and the body louse (P. h. humanus). They are ectoparasites who's only
known hosts are humans. Recent molecular data suggest that the two subspecies are ecotypes of the same
species and that evolution between the two populations takes place continually (Veracz A, 2012).
Infection Organism Symptoms Treatment

Pediculosis Capitis Head lice Small, white a. Wash hair with shampoo such as lindane
dots on hair (Kwell).
shaft (nits or b. Comb nits from hair with a fine-toothed
eggs of lice) comb.
Extreme c. Wash bedsheets, recently worn clothes.
pruritus d. Vacuum pillows, mattresses, or other items
unable to be washed.
e. Teach children not to exchange combs, hair
barrettes, or other personal items.


TECHONOLOGY
Pediculosis Pubic lice Same as for head Same as for head lice
lice except on
pubic hair
IMPETIGO
Impetigo is only mildly infectious because it seems to be transmitted only by direct contact (Cole &
Gazewood, 2007). It is not uncommon to see several children in a family with identical lesions, however.
Parents may be upset at being told their child has impetigo because, at one time, the lesions (dirty and crusty
appearing) were associated with poverty and poor hygiene.
A. Causative agent: Beta-hemolytic streptococcus, group A (nonbullous); Staphylococcus aureus
(bullous)
B. Incubation period: 2 to 5 days
C. Period of communicability: From the outbreak of lesions until lesions are healed
D. Mode of transmission: Direct contact with lesions
E. Immunity: None
Assessment
Impetigo is a superficial infection of the skin. It begins as a single papulovesicular lesion surrounded
by localized erythema. As more vesicles appear, they become purulent, ooze, and form honey-colored crusts
(Fig. 43.12). They are found most commonly on the face and extremities. They are often seen as secondary
infections of insect bites or in children who have body piercings. If there are several lesions, children may
have local swollen lymph nodes.
Therapeutic Management
Treatment is oral administration of penicillin or erythromycin or the application of mupirocin
(Bactroban) ointment for 7 to 10 days (Box 43.7). The lesions heal most quickly if a parent or the child
washes the crusts daily with soap and water.
PHARMACOLOGY
Mupirocin (Bactroban)
Classification: Mupirocin is a topical antibiotic.
Action: Mupirocin is used to treat impetigo caused by Staphylococcus aureus and Streptococcus pyogenes.
Pregnancy risk category: B
Dosage: Small amount applied three times a day to the affected areas for 10 days
Possible adverse effects: Erythema, dry skin, pruritus, burning, stinging (Karch, 2009)
a. Advise parents to wash the lesions with soap and water and pat dry before applying the ointment
to soften crusts for better absorption.
b. Caution parents that causative organisms are infectious by direct contact. Instruct them to wash
their own hands before and after applying the ointment.
c. Urge parents to continue to use the ointment to ensure eradication of the causative germs. The
lesions may begin to improve before 10 days have elapsed.
d. Instruct the parents to use caution when applying the ointment around the eyes. An ointment is
irritating to the eyes.
e. Teach the parents about the signs and symptoms of secondary fungal infection that may occur and
instruct them to notify a health care provider should any occur.


TECHONOLOGY
References

Elsevier.


TECHONOLOGY
UNIT 8: HEALTH PROBLEMS MOST COMMON IN ADOLESCENTS
(Patricia M. Nugent, RN, EdD, Judith S. Green, R.N., MA, Phyllis K. Pelikan, RN, MA, Marry Ann Hellmer Saul,
RNCS, PhD., 2014)
SCOLIOSIS
Scoliosis is a lateral (sideways) curvature of the spine. It may involve all or only a portion of the
spinal column. It may be functional (a curve caused by a secondary problem) or structural (a primary
deformity) (Pilliteri, 2010).
A. Spinal curvature deformity causing cosmetic and physiologic alterations in spine, chest, and pelvis
A. It occurs in three planes.
a. Lateral curvature of the spine
b. Spinal rotation causing rib asymmetry
c. Thoracic hypokyphosis
B. Severity
a. The large curve worsens with time.
b. Double curves (S-shaped curves) worsen more than do single curves (C-shaped curves)
c. The thoracic section of the spine worsens more than the upper or lower portion.
B. Incidence: most common spinal deformity; more frequent in girls during a growth spurt
C. Risk Factors: unknown cause (idiopathic); possibly genetic
D. Classification
1. Infantile: birth to 3 years of age
2. Juvenile: during childhood
3. Adolescent: most common during a growth spurt
E. Clinical findings
1. A curve in vertebral spinous process alignment
2. Prominence in one hip
3. The prominence of one scapula; the difference in shoulder or scapular height
4. Deformity of the rib cage; breasts appear unequal in size.
5. Other signs: clothes do not fit; uneven skirt or pants hems
F. Therapeutic Interventions
1. Screening for scoliosis beginning at age 10; diagnosis confirmed by x-ray examinations
2. Mild: orthopedic supervision every 4 to 6 months to monitor the progression of the curve
3. Moderate: bracing of bones still growing
a. Worn for 23 hours each day
b. Can be removed for sports and other physical activities
c. Effectiveness related to the number of hours worn each day
d. Worn until bones have stopped growing; slows the progression of the curve.
1. Girls: about 2 years after the onset of menstruation
2. Boys: when shaving daily is necessary.
e. Exercise to maintain and strengthen spinal and abdominal muscles
f. Types of braces
4. Severe (more than 40°): surgery (e.g., spinal realignment and straightening with external or
internal fixation; instrumentation combined with bony fusion [arthrodesis] of the realigned spine
[e.g., Harrington rods, Luque rod])
5. Most severe: traction devices and exercises before spinal fusion for partial correction to increase
flexibility


TECHONOLOGY
Nursing Care of Adolescents with Scoliosis
1. Asymmetry of shoulders and hips while standing erect, clothed in underpants (and bra if an older girl);
observation from behind
2. Symmetry or prominence of ribs while bending forward with back parallel to the floor; observation
from side
3. Revies of x-rays
1. Maintain spinal alignment per protocol
2. Provide care when wearing a brace
a. Examine skin surfaces in contact with a brace for signs of irritation
b. Implement corrective action to treat or prevent skin breakdown
c. Help select appropriate apparel for wearing over the brace to minimize the altered appearance
d. Encourage wearing low-heeled footwear to maintain balance
3. Reinforce instruction regarding
a. Plan of care
b. Use of appliance
c. Activities permitted or restricted (e.g., encourage activities that do not require twisting od spinal
column)
d. Adolescent’s and parents’ responsibilities associated with therapy
4. Prepare for surgery if required.
Evaluation/Outcomes
1. Demonstrate correct use of a brace
3. Maintains skin integrity
4. Verbalizes feelings and concerns
5. Engages in activities appropriate to limitations and developmental level
BONE TUMORS
Tumors derived from connective tissue, such as bone and cartilage, muscle, blood vessels, or lymphoid
tissue, are called sarcomas. They are the second most frequently occurring neoplasms in adolescents (only
lymphomas occur more often). Bone tumors may arise during adolescence because rapid bone growth is
occurring at this time. Because girls have a puberty growth spurt earlier than boys, bone tumors tend to occur
slightly earlier in girls than in boys (13 compared with 14 or 15 years of age) (Pilliteri, 2010).
A. A neoplastic disease that can arise from tissue involved in bone growth
B. Incidence: less than 5% of all malignant neoplasms; peak ages 15 to 19 years
C. Classification:
1. Osteosarcoma
a. Most frequent bone tumor in children
b. Primary tumor sites: upper part of tibia; lower part of femur; humerus just below the shoulder
c. Arises from osteoid tissue
2. Ewing Sarcoma
a. Most frequent sites: shaft of long bones (e.g., femur, tibia, fibula, humerus, ulna); trunk bones
(e.g., vertebra, scapula, ribs, pelvis, skull)
b. Arises from medullary tissue (marrows)


TECHONOLOGY
D. Prognosis depends on
1. Extent of metastasis
2. Size and location of the tumor
3. Tumor’s response to therapy
4. Age and overall health
5. Tolerance to specific medications, procedures, therapies
E. Clinical Findings
1. Signs and symptoms
a. A localized pain in the affected site
b. Limp; voluntary curtailment of activity
c. Inability to hold heavy objects
d. Weight loss; frequent infections
F. Confirmation of Diagnosis
1. Radiographic examination; C.T. (bone); MRI; prosthetic bone replacement
2. Bone marrow aspiration
3. Surgical Biopsy (Ewing Sarcoma)
G. Therapeutic Interventions
1. Osteosarcoma
a. Limb salvage procedure: resection of the tumor with prosthetic bone replacement
b. Chemotherapy
1. Preoperative: to reduce tumor size
2. Pre- and postoperative: DOXOrubicin, cyclophosphamide (cytoxan), ifosfamide,
carboplatin, cisplatin, high-dose methotrexate with leucovorin; medications singly or in
combination
3. Amputation (rare)
2. Ewing Sarcoma
a. Intensive irradiation of involved bone
b. Surgical removal of the primary tumor
c. Chemotherapy: vinCRIstine, cisplatin, DOXOrubicin, ifosfamide, etosposide
d. Amputation: for severe deformity as a result of radiation, if the limb is useless
Nursing Care of Adolescents with Bone Tumors

1. Location and extent of pain
2. Functional status of the involved area
3. Inflammation at sire; lymph node involvement
4. Systemic Involvement
1. Provide preoperative and postoperative care
a. Offer straightforward, honest explanations
b. Answer questions and clarify misconceptions
c. Avoid overwhelming adolescents or parents with too much in formations
d. Emphasize lack of alternatives if amputation is planned
e. Provide care related to amputations
f. Use a pain rating scale and medicate appropriately during the postoperative period
2. Provide care related to radiation therapy for Ewing Sarcoma
a. Explain procedure; explain side effects


TECHONOLOGY
b. Suggests and/or implement measures to reduce the physical effects of radiotherapy
1. Select loose-fitting cotton clothing over irradiated areas to decrease irritation
2. Protect the area from sunlight and sudden changes in temperature
3. Avoid ice packs, heating pads
c. Help to cope with side effects of radiotherapy
3. Support during chemotherapy
a. Explain the procedure, stressing the importance of chemotherapy
b. Explain probable side effects of antimetabolites (e.g., nausea, hair loss, stomatitis)
c. Administer antiemetics (e.g., ondansetron [Zofran]) to limit the side effects of chemotherapy
d. Use nonpharmacologic means to minimize discomfort from chemotherapy (e.g., soft, non-
irritating foods, a soft-tipped applicator for oral hygiene)
e. Encourage hygiene, grooming. And items to enhance appearance (e.g., wig)
4. Provide emotional support to adolescent and family members
a. Clarify misconceptions and provide technical information as needed
b. Provide time and opportunity for grieving
c. Encourage expression of feelings regarding loss and undesirable effects of therapy
d. Allow dependence while encouraging independence
e. Emphasize the need for continuing regular activities, interactions, and behaviors
Evaluations/ Outcomes
2. Resumes peer relationships and activities commensurate with abilities
3. Adolescent and parents
a. Express feelings and concerns
b. Demonstrate positive coping skills
c. Verbalize understanding of therapies and side effects
d. Adjust to alterations in adolescent’s appearance
ANOREXIA NERVOSA
Anorexia nervosa is a disorder characterized by refusal to maintain a minimally normal body weight
because of a disturbance in perception of the body's size or appearance (Zandian et al., 2007). It includes
three separate features: self-induced starvation to a significant degree; a relentless drive for thinness, a
morbid fear of fatness, or both; and medical signs and symptoms resulting from starvation (Pilliteri, 2010).
A. Etiologic Factors
1. Decreased levels of norepinephrine, serotonin, and dopamine
2. Combination of genetic, neurochemical, developmental, psychologic, social, cultural, and familial
factors cited
3. More common in females
4. Avoidance of food may result from an excessive concern with Obesity
5. Apparent failure to separate from mother and become autonomous, unconscious fear of maturing
6. Onset usually during adolescence through young adulthood; less common in older adults but is
increasing in perimenopausal women
B. Behavioral/ clinical Findings
1. Subtypes


TECHONOLOGY
a. Restricting type: weight loss is accomplished through dieting, fasting, or excessive exercise
b. Binge eating/purging type: weight loss is accomplished through purging (e.g., use of self-induced
vomiting and misuse of laxatives, diuretics, or enemas every week)
2. Weightless than 85% of expected weight: cachexia
3. Distorted self-image: appear fat to themselves even when emaciated
4. Intense fear of becoming fat, even though underweight
5. They have a history of compulsive traits such as rigidity, ritualistic behavior, and meticulousness; they
need to control or prove control
6. Usually, very manipulative
7. Usually high achiever academically
8. Frequent discord in family relationships, especially with mother
9. Often interested in food and cooking in general; serves as a control strategy
10. Cessation of menses for more than 3 months in female (amenorrhea)
11. Inability to sustain self-starvation may result in bulimic episodes (bingeing of food followed by self-
induced vomiting)
12. Fatigue or hyperactivity
13. Gastrointestinal (G.I.) disturbances (e.g., feeling of fullness after small intake, nausea, and
constipation)
14. Hypotension; bradycardia
15. Fluid and electrolyte disturbances; dependent edema
16. Low blood glucose level
17. Anemia
18. Sensitivity to cold
19. Erosion of tooth enamel
20. Lanugo (fine, brittle body hair); dry skin
C. Therapeutic Interventions
1. Unified team approach
2. Behavior modification techniques that focus on the client's responsibility for weight gain
3. Time limit on meals; monitor client after meals
4. Use of enteral feedings if weight loss is so great or fluid and electrolyte imbalance is so severe that it
causes a threat to life
5. Limit on excessive physical activity
6. Psychotherapy focusing on self-image
7. Group and cognitive therapy
8. Family therapy with all members of the family involved
9. The gradual increase in calories and protein under the guidance of a nutritionist
10. Antidepressants are helpful, especially with comorbid depression
Nursing Care of Clients with Anorexia Nervosa
1. Complete physical and dental examination to rule out associated medical complications of eating
disorder; involved systems: G.I., endocrine, cardiovascular, and integumentary
2. Weight and height
3. Signs of fluid and electrolyte imbalance
4. History of amenorrhea
5. Indulgence in excessive exercise
6. Behavior reflecting obsessiveness with food
7. History of stringent control of food intake
8. Depressive mood


TECHONOLOGY
9. Motivation to change maladaptive eating patterns
10. Heart rate and rhythm
1. See General Nursing Care of Clients with Eating Disorders
2. Develop a therapeutic environment
3. Establish a behavior modification program
4. Help client identify feelings
5. Briefly discuss dietary modification in a non-threatening manner
6. Provide a diet high in nutrient-dense foods
7. Avoid focusing on eating or weight loss
Evaluation/Outcomes
1. Maintain dietary intake adequate to meet daily caloric requirements
2. Reaches and maintains appropriate body weight
3. develops a realistic body image
4. Identifies and verbalizes feelings
5. Accepts age-appropriate role
6. Resolves separation and individuation issues
SUBSTANCE ABUSE
Substance abuse isn't something you should take lightly. It occurs when you use alcohol, prescription
medicine, and other legal and illegal substances too much or in the wrong way (WebMD, 2019).
A. Substance refers to any mind-altering chemical.
B. Substance abuse: maladaptive pattern of drug use leading to impairment or distress, as manifested by
one or more of the following occurring within 12 months
1. Failure to fulfill major roles
2. Use in hazardous situations.
3. Recurring related legal problems
4. Continued use despite social or interpersonal problems
C. Although not currently classified as addiction diagnoses in the DSM-IV-TR, behaviors such as
compulsive overeating are now being treated as addictive disorders.
D. Substance intoxication: a reversible substance-specific syndrome caused by recent ingestion of, or
exposure to, a substance resulting in maladaptive behavior or psychological changes from an effect on
CNS
E. Substance withdrawal development of a substance-specific syndrome resulting from cessation or
reduction in substance use that has been heavy or prolonged
1. Impairment in role functioning (e.g., social, school, or occupational)
2. Symptoms are not associated with another mental disorder.
3. Substance withdrawal is more risky with drugs that are CNS depressants or have a short half-life
(e.g., alcohol) than those with a long half-life (e.g., marijuana); withdrawal is not lethal with some
(e.g., cocaine)
4. Withdrawal may cause more problems in the older adult (Veracz A, 2012)s because they possess
fewer physiological reserves.
F. Substance tolerance: the need for significantly increased amounts of the substance to achieve the
desired effect with the continued use of the same amount of substance; substance tolerance does not
occur with all substances.
G. Polysubstance abuse: abuse of three or more drugs or alcohol and drugs


TECHONOLOGY
H. Potentiation: two or more substances interact in the body to produce an effect more significant than
the sum of the effects of each substance taken alone
I. Substance dependence: the continued use of a substance despite significant related problems in
cognitive, physiologic, and behavioral components, spending more time in getting, taking, and
recovering from the substance; continuous abuse despite knowledge of physical or psychologic
problems or awareness of complications resulting from continued use of the substance; dependency
can be both psychological (discontinuance results In withdrawal signs and symptoms)
OBESITY
Most overweight adolescents have obese parents, suggesting that both inheritance and environment
play a part in the development of adolescent Obesity (Pilliteri, 2010)
Nursing Diagnoses and Related Interventions:
Nursing Diagnosis: Ineffective individual coping by overeating related to stresses of an adolescent period has
led to Obesity.
Outcome Evaluation:
Adolescents identify stressful situations in life that lead to overeating; they describe ways to avoid situations
or methods that would help cope with them.
Related Intervention:
1. They may need to visit a health care facility once or twice a week for encouragement and praise for
their efforts. National weight-control organizations are good if other adolescents also attend the
meetings.
2. Adolescents who use overeating as their main reaction to Stress may require psychological counseling
rather than diet counseling to develop a more mature emotional response.
3. Behavior modification is sometimes successful with adolescents to help them lose weight, but it is
rarely recommended for Obesity alone.
4. If Obesity is causing serious body image problems, lowered self-esteem, and depression, behavior
modification might be suggested.
5. General measures to help adolescents decrease overeating include:
a. Making a detailed log of the amount they eat, the time, and the circumstances (including how they
felt while they were eating), and then changing those circumstances
b. Always eating in one place (the kitchen table) instead of while walking home from school or
watching television.
c. Slowing the process of eating by counting mouthfuls and putting the fork down beside the plate
between bites, and being served food on small plates so helpings look larger These measures may
be of little use, however, unless they are combined with a suitable diet and adequate exercise.
Despite all these interventions, weight reduction may not always be effective with adolescents. For
some, a more realistic goal might be to prevent additional weight gain until they reach adulthood.
SUICIDE
Suicide is a deliberate self-injury with the intent to end one's life (Pilliteri, 2010).
A. Successful suicide occurs more frequently in males than in females, although more females attempt
suicide than males (about 8:1).
B. Adolescent suicides are attempted most often in the spring or the fall, reflecting school stress at these
times of the year, and between 3 PM and midnight, reflecting depression increases with the dark.


TECHONOLOGY
Suicide is so common in adolescents that it ranks third as a cause of death in the 15- to 19-year-old
group (CDC, 2008a).
Assessment
1. Assessment Adolescents need to have thorough physical examinations at health maintenance visits to
assure them they are in good physical health.
2. Assess for signs of depression such as anorexia, insomnia, excessive fatigue, or weight loss. In younger
adolescents, depression may be manifested by behavior problems such as disobedience, temper
tantrums, truancy, and running away from home. Self-destructive behavior or accident proneness may
be noted.
3. Difficulties in school, acting out with chemicals, alcohol, or sexual promiscuity; or trouble with legal
authorities may be further clues.
4. Occasionally, depressed adolescents find it so hard to be alone; they seek constant activity as a means
of escape. In contrast, others may withdraw from contact with other persons and become completely
isolated.
5. Assess for these lifestyles as well. Suppose another member of a family or a close friend committed
suicide. In that case, the chance that an adolescent will do so is more significant than usual, as
adolescents then see suicide as a method of coping and use it about suicide do not attempt it) but has
a definite, well-thought-out plan to accomplish it.
Nursing Diagnosis:
The risk for violence, self-directed, related to symptoms of depression or expressed desire to hurt oneself
Outcome Evaluation:
The client expresses feelings of depression to health care providers or other adults; she states she will contact
a support person should the desire to commit suicide become overwhelming.
1. Crisis intervention for adolescents who are contemplating suicide includes trying to alleviate their
pain and depression and counseling them to help them change their perspective on life's value.
2. Be aware that establishing expected outcomes with adolescents who are contemplating suicide or who
have made an attempt will be difficult because they are often too depressed to develop an alternative
solution to their problems (their goal is to kill themselves, not solve problems).
3. Try to find out the things in the child's life that are still viewed as necessary; build a plan that will help
view life as worth living enough to work through problems.
4. Show them no one can change everything, but everyone can make one or two changes that can make
a difference. After these small changes are made, a domino effect can change more and more of one's
circumstances.
5. For an adolescent's safety, a period of observation in a hospital setting is desirable after a suicide
attempt to prevent the adolescent from inflicting personal injury again and to allow assessment in a
neutral setting, away from the Stress that precipitated the attempt.
6. Antidepressant medicine alone, a therapy used with depressed adults, may be of little value in treating
depressed adolescents.
7. Tricyclic antidepressants generally are ineffective and may cause serious adverse effects. Evidence for
the effectiveness of selective serotonin reuptake inhibitors is limited.
8. Continuing evaluation by both history taking and physical examination is necessary because the young
person who has attempted suicide may attempt it again if support people and better problem-solving
ability are not available at another time.


TECHONOLOGY
AMENORRHEA
Amenorrhea, or absence of a menstrual flow, strongly suggests pregnancy but is not definitive because
it can also result from tension, anxiety, fatigue, chronic illness, extreme dieting, or strenuous exercise (Pilliteri,
2010).
A. Risk Factors:
1. Competitive swimmers, long-distance runners (50 to 75 miles weekly), and ballet dancers notice that
intensive training causes their periods to become scant and irregular
2. Amenorrhea also occurs among females who diet excessively, partially as a natural defense
mechanism to limit ovulation and as a means of conserving body fluid.
3. Adolescents with anorexia nervosa or bulimia often develop amenorrhea after approximately 3
months of excessive dieting or binging and dieting; as in athletes, this is caused by an increase in
prolactin.
4. Amenorrhea also occurs among females who diet excessively, partially as a natural defense
mechanism to limit ovulation and as a means of conserving body fluid.
5. Adolescents with anorexia nervosa or bulimia (eating disorders described in Chapter 54) often
develop amenorrhea after approximately 3 months of excessive dieting or binging and dieting; as in
athletes, this is caused by an increase in prolactin.
Management:
1. Menstrual cycles usually return to normal within 3 months after discontinuation of strenuous training
and conditioning.
2. Adolescents who wish to maintain a normal cycle while training for a sports event may take
bromocriptine (Parlodel), reducing high prolactin levels by acting on the hypothalamus and initiating
menstruation each month.
3. If a menstrual flow is delayed and pregnancy is suspected, bromocriptine should be discontinued
because it is potentially teratogenic.
SEXUALLY TRANSMITTED DISEASE

Sexually transmitted infections (STIs) are diseases that are spread through sexual contact with an
infected partner. They range in severity from easily treated infections, such as trichomoniasis, to human
immunodeficiency virus (HIV) infection, which, despite advances in therapy, is life-threatening (Pilliteri,
2010).
A. STIs may be spread among women having sex with women or men having sex with men (Evans et al.,
2007). Male circumcision does not appear to reduce the spread (Box 47.9).
B. STIs are becoming more difficult to treat because the causative organisms are becoming more and more
resistant to antibiotics. Always reinforce the fact that little immunity develops from STIs so that such
diseases can be contracted repeatedly.
Kinds of STI’s
Candidiasis
Candidiasis is a vaginal infection spread by the fungus Candida, an organism that thrives on glycogen.
Candidiasis is so common that as many as 90% of women will have it sometime in their life. As many as 40%
of sexually active females have asymptomatic candidal vaginal infections; this rate rises even higher during
pregnancy when high estrogen levels lead to glycogen levels that produce a favorable environment for fungal
growth. Because oral contraceptives produce a pseudopregnancy state, women using oral contraceptives also
have frequent vaginal candidal infections (Pilliteri, 2010).


TECHONOLOGY
Assessment
1. An adolescent will notice vulvar and vaginal reddening, burning and itching, and even bleeding from
hairline fissures.
2. The vagina sometimes shows white “patches” on the walls. The patches are adherent and cannot be
scraped away without bleeding.
3. A thick, cream cheese-like discharge can usually be observed at the vaginal introitus.
4. There may be pain on coitus or tampon insertion.
5. Candidal infections may also be present at other body sites, such as the oral cavity, or in a moist area
such as the umbilicus.
6. In immunosuppressed individuals, it can become systemic (Blyth, Palasanthiran, & O’Brien, 2007).
Diagnostic Procedure:
1. Candidal infections are diagnosed by removing a sample of the discharge from the vaginal wall and
placing it on a glass slide; three or four drops of a 20% potassium hydroxide (KOH) solution are then
added coverslip protects mixture. Under a microscope, typical fungal hyphae indicate the presence of
Candida organisms.
2. An at-home test kit (Vagasil Screening Kit) is available that gives results instantly. A woman inserts a
pH wand into her vagina and compares the color of the swab to a pH color chart in a few seconds. If
the reading is above 5.0, it suggests that she may have a bacterial infection and see a doctor. A normal
pH level of 4.5 plus itching and/or burning, unusual discharge, or a yeasty odor suggests a yeast
infection, and it would be all right for her to use an over-the-counter treatment.
Therapeutic Management Therapy
1. Vaginal suppositories or cream applications of antifungal preparations such as miconazole (Monistat)
or clotrimazole (Lotrimin), once a day for 3 to 7 days.
2. Oral fluconazole (Diflucan) can be administered as a one-time oral dose (Box 47.10). Antifungal
creams are purchased over the counter.
3. Teach women to insert these or antifungal suppositories at bedtime so the drug does not immediately
drain from the vagina afterward.
4. A girl may want to wear a sanitary pad to avoid staining from vaginal discharge during the day.
Treatment should not be interrupted until it is complete, even during a menstrual period.
5. Because miconazole and clotrimazole are available without a prescription, be certain that adolescents
know how to differentiate a candidal infection from other infections or to consult a health care
provider for assistance and treatment if they are not sure.
6. If a girl has frequent candidal infections, her urine should be tested for glucose to rule out diabetes
mellitus. If she is using an oral contraceptive, she might be counseled to use another contraceptive
method. If an adolescent is sexually active, the male partner's treatment may be necessary to break a
reinfection cycle.
Trichomoniasis
A. Trichomonas vaginalis is a single-cell protozoan spread by coitus and affects between 3% and 13% of
adult men and women in the United States (Sutton et al., 2007).
B. The incubation period is 4 to 20 days. Assessment: A trichomonal infection, females, notices vaginal
irritation, and a frothy white or grayish-green vaginal discharge.
Assessment
1. The frothiness of the discharge is an important typical finding.
2. The upper vagina is reddened and may have to pinpoint petechiae.
3. Extreme vulvar itching is present. By contrast, males with the same infection rarely report any
symptoms.


TECHONOLOGY
The infection is diagnosed by microscopic examination of a sample of the vaginal discharge after it is combined
with lactated Ringer’s or normal saline solution. Trichomonads typically appear as rounded, mobile
structures. Be aware that Trichomonas infections cause such inflammatory changes in the cervix or vagina
that a Pap test taken during this time may be misinterpreted as showing abnormal tissue.
Therapeutic Management:
Oral metronidazole (Flagyl) eradicates trichomonas infections. Treatment with Flagyl and Use of condoms by
sexual partners help prevent recurrence of Trichomonas in both parties.
Bacterial Vaginosis
A. Bacterial vaginosis is the invasion of an organism such as Gardnerella vaginalis. This organism
thrives in the vagina, a body area with a reduced oxygen level.
Assessment:
1. When the infection is present vaginal discharge appears milk-white to gray and has a fishlike odor.
2. Pruritus can be intense.
Microscopic examination of the discharge in normal saline solution shows gram-negative rods adhering to
vaginal epithelial cells, which are termed clue cells (Burke & Rogers, 2007).
The treatment is oral or vaginal metronidazole for 7 days; the woman’s sexual partners should also be treated
to prevent recurrence of the infection.
Chlamydia trachomatis Infection

A. Chlamydia trachomatis infections have become the most common bacterial cause of STI in the United
States (Wendel & Zenilman, 2007).
B. Incubation Period: incubation period is 1 to 5 weeks.
Assessment:
1. heavy, grayish-white discharge
2. vulvar itching.
The culture makes the diagnosis of the organism.
Therapy is oral doxycycline or tetracycline for 7 days or azithromycin in a single dose.
Possible Complication:
The long-term effects of chlamydial infections are PID, possibly leading to subfertility. Because there is a
strong association between gonorrhea and Chlamydia, if the chlamydial infection is documented, women are
usually tested for gonorrhea. Home tests are available for both Chlamydia and gonorrhea. Encouraging women
to use these could increase the number of infections treated yearly (Cook et al., 2007)
Human Papillomavirus
A. The human papillomavirus (HPV) causes fibrous tissue overgrowth (sometimes called genital warts)
on the external vulva, vagina, or cervix (condyloma acuminatum).


TECHONOLOGY
B. Risk factor. The infection may be present in as many as 10% to 30% of women and is most common
in women with multiple sexual partners (Howley & Lowy, 2007).
Assessment:
1. At first, lesions appear as discrete papillary structures; they then spread, enlarge, and coalesce to form
large, cauliflower-like lesions.
1. Therapy for such lesions is aimed at dissolving the lesions and also ending any secondary infection
present. Small growths may be removed by applying podophyllin (Podofin).
2. Large lesions may be removed by laser therapy, cryocautery, or knife excision. With cryocautery,
edema at the site is evident immediately; lesions become gangrenous, and sloughing occurs in 7 days.
3. Healing will be complete in 4 to 6 weeks with only slight depigmentation at the site.
4. Sitz baths and a lidocaine cream may be soothing during the healing period.
5. Women who have had one episode of infection should be conscientious about having yearly Pap tests
for the rest of their lives.
6. The vaccine, Gardasil, is recommended to be routinely administered to early teenage girls in three
doses.
7. A second dose is 2 months after the first dose, and the third dose is 6 months after the first dose.
8. Immunizing young teenage girls against HPV infection should reduce the incidence of HPV infections
in the future and the rate of cervical cancer (Deglin & Villarand, 2009).
Herpes Genitalis (Herpes Simplex Type 2)

A. Genital herpes is caused by herpesvirus hominis type 2 (also called herpes simplex virus type 2, or
HSV-2). This is one of four similar herpesviruses: cytomegalovirus, Epstein-Barr, varicella-zoster,
and herpes types 1 and 2.
B. Unlike most other STIs, although the virus can be contained, there is no known cure. Therefore, the
disease involves a lifelong process, and, although it is not a precursor to cervical cancer, women with
cervical cancer tend to have more antibodies against herpes genitalis than others or probably have
been exposed to the virus more than others. The virus is spread by skin-to-skin contact, entering
through a break in the skin or mucous membrane.
C. Incubation Period: The incubation period is 3 to 14 days.
Assessment
Herpes is diagnosed by culture of the lesion secretion from its location on the vulva, vagina, cervix, or penis or
by isolation of HSV antibodies in serum. The incubation period is 3 to 14 days.
1. On the first contact, extensive primary lesions originate as a group of pinpoint vesicles on an
erythematous base.
2. Within a few days, the vesicles ulcerate and become moist, painful, draining open lesions.
3. An adolescent may have accompanying flulike symptoms with increased temperature; vaginal lesions
may cause a profuse discharge.
4. Pain is intense in contact with clothing or acidic urine.
5. After the primary stage that lasts approximately 1 week, lesions heal, but the virus lingers in a latent
form, affecting the sensory nerve ganglia.
6. The condition will flare up and become an active infection during illness, just before menstruation,
fever, overexposure to sunlight, or Stress.
7. A secondary response usually produces only local lesions rather than systemic symptoms.


TECHONOLOGY
Herpes is diagnosed by culture of the lesion secretion from its location on the vulva, vagina, cervix, or penis or
by isolation of HSV antibodies in serum.
1. Acyclovir (Zovirax) is an example of an antiviral that controls the virus by interfering with
deoxyribonucleic acid reproduction and decreasing symptoms (Watkins, 2008).
2. Sitz baths three times a day may be helpful to reduce discomfort.
3. An emollient (A&D Ointment) can also reduce discomfort, but its moisture tends to prolong the lesions'
active period.
4. Topical imiquimod (Aldara) or Foscarnet (Foscavir) may be prescribed for resistant lesions.
5. Condoms (male or female) help prevent the spread of herpes among sexual partners.
6. Valacyclovir (Valtrex) may be prescribed as a preventive measure to help limit the disease spread.
Hepatitis B and Hepatitis C

Both hepatitis B and hepatitis C can be spread by semen and blood and therefore are considered STIs. These
are discussed in Chapter 45, with other forms of hepatitis. Because hepatitis B can be spread by sexual
intercourse, adolescents who did not receive immunization against this infant need immunization against this
updated (Pilliteri, 2010).
Gonorrhea
A. Gonorrhea is transmitted by Neisseria gonorrhoeae, a gram-positive diplococcus that thrives on the
columnar transitional epithelium of the mucous membrane.
B. Incubation period: Symptoms begin after a 2- to the 7-day incubation period.
Assessment:
1. In males, they include urethritis (pain on urination and frequency of urination) and a urethral
discharge. Without treatment, the infection may spread to the testes, scarring the tubules and causing
permanent sterility.
2. It often occurs concurrently with chlamydial infection (Wendel & Zenilman, 2007), although
Bartholin's glands' symptoms may become inflamed and painful. If left untreated, the infection may
spread to pelvic organs, most notably the fallopian tubes (PID). Tubal scarring can result in permanent
sterility. In both males and females, untreated gonorrhea can lead to arthritis or heart disease from
systemic involvement.
Diagnostic procedure:
Urine culture for the gonococcal bacillus, in addition to vaginal and urethral cultures, should be obtained from
all children with vulvovaginitis or a urethral discharge. In males, a first voiding may reveal gonococci if a
midstream urine specimen is inconclusive.
1. oral cefixime (Suprax) or intramuscular ceftriaxone (Rocephin) plus oral doxycycline (Vibramycin) for
7 days is the currently recommended therapy.
2. Sexual partners should receive the same treatment. Approximately 24 hours after treatment,
gonorrhea is no longer infectious. Approximately 7 days after treatment, a client should return for a
follow-up culture to verify that the disease has been completely eradicated (few adolescents take this
precaution).


TECHONOLOGY
Nursing Diagnoses and Related Interventions
Nursing Diagnosis: Anxiety related to having contracted a reportable STI
Outcome Evaluation:
Adolescents voice confidence inability to cope with this problem and demonstrates an understanding of the
illness, the treatment regimen, and future prevention options.
1. People who seek treatment for an STI need to believe that they can trust health care personnel and
reveal information without fear of criticism.
2. Assure the adolescent of absolute confidentiality in naming sexual contacts.
3. Reassure people that the treatment is not prolonged and as simple as taking medication.
Syphilis
A. Syphilis is a systemic disease caused by the spirochete Treponema pallidum. It is transmitted by sexual
contact with a person who has an active spirochete-containing lesion (Tanner & Alexander, 2007).
Like gonorrhea and Chlamydia, it must be reported to public health departments.
B. Incubation period: After an incubation period of 10 to 90 days.
Assessment:
1. the atypical lesion appears, usually on the genitalia (penis or labia) or the mouth, lips, or rectal area
from oral-genital or genital–anal contact.
2. The lesion (termed a chancre) is a deep ulcer and is usually painless despite its size.
3. Swollen lymph nodes may be present, but these are unlikely to be noticed by the affected person.
4. A lesion in the vagina may not be detected.
5. Approximately 2 to 4 weeks after the chancre disappears, a generalized, macular, copper-colored rash
appears. Unlike many other rashes, it affects the soles and the palms.
6. There may be secondary symptoms of generalized illness, such as low-grade fever. (With or without
treatment, this stage of syphilis also fades).
7. The final stage of syphilis is a destructive neurologic disease that involves major body organs such as
the heart and the nervous system. Typical symptoms are blindness, paralysis; severe, crippling
neurologic deformities; mental confusion; slurred speech; and lack of coordination. This third stage
must be identified before the disease becomes fatal.
1. Syphilis is diagnosed by recognition of the various symptoms of the three stages and by serologic
serum tests, usually the
2. Venereal Disease Research Laboratory test (VDRL),
3. the automated reagin test (ART), the rapid plasma reagin test (RPR), or the fluorescent treponemal
antibody–absorption test (FTA-ABS).
1. Benzathine penicillin G, given intramuscularly in two sites, is an effective therapy.
2. For the adolescent sensitive to penicillin, either oral erythromycin or tetracycline can be given for 10
to 15 days.
3. Sexual partners are treated in the same way as the person with an active infection.
4. After therapy, adolescents may experience a sudden hypotension episode, fever, tachycardia, and
muscle aches. This is called a Jarisch-Herxheimer reaction and is caused by the sudden destruction of
spirochetes. The reaction lasts about 24 hours and then fades (Wendel & Zenilman, 2007).


TECHONOLOGY
5. In particular, adolescents need accurate information about syphilis to become aware of the symptoms
and safer sex practices.
6. They should believe that they can report the disease to health care personnel and name sexual contacts
without fear of being criticized (Leung-Chen.
Human Immunodeficiency Virus (HIV)

A. HIV is carried by semen and other body fluids, so infection with this virus is considered an STI.
B. HIV Infection and AIDS is the end stage of acquired immunodeficiency caused by infection with the
RNA human immunodeficiency retrovirus HIV (McFarland, 2008). The virus has at least two divisions,
HIV-1 and HIV-2, with a variety of further subtypes. The virus acts by attacking the lymphoreticular
system, in particular CD4-bearing helper T lymphocytes. The virus enters, substitutes its RNA and DNA
for the cell's DNA, and replicates in these lymphocytes, destroying them in the process. There is no
defense against the virus, so it remains in the body for life—infection results in loss of CD4
lymphocytes and the ability to initiate an effective B-lymphocyte response. A CD4 cell count in the
laboratory determines how many cells are still present and functioning. Because B-lymphocyte or
humoral immune function, which initiates antibodies' production, is affected, antibody formation will
be decreased (hypogammaglobulinemia).
C. Incubation Period: HIV has a long incubation period of about 10 years in adults.
Assessment
1. Category A, Mildly Symptomatic:
a. Two or more symptoms such as enlarged lymph nodes, liver, or spleen, or recurrent or persistent
upper respiratory infections, sinusitis, or otitis media
2. Category B, Moderately Symptomatic:
a. More serious illnesses such as oropharyngeal candidiasis, bacterial meningitis, pneumonia, or
sepsis, cardiomyopathy, cytomegalovirus infection, hepatitis, herpes simplex virus (HSV),
bronchitis, pneumonitis, or esophagitis, herpes zoster (shingles), lymphoid interstitial pneumonia
(LIP), pulmonary lymphoid hyperplasia complex, or toxoplasmosis
3. Category C, Severely Symptomatic (AIDS),
a. Serious bacterial infections such as septicemia, pneumonia, meningitis, bone or joint infection, or
abscess of an internal organ or body cavity; candidiasis (esophageal or pulmonary),
encephalopathy, herpes simplex lasting over 1 month, histoplasmosis, lymphoma, tuberculosis,
Mycobacterium or Pneumocystis carinii pneumonia. In addition to these symptoms, a patient may
develop a malignant neoplasm, most noticeably Kaposi's sarcoma or non-Hodgkin's lymphoma
(Engels et al., 2008).
Nursing Diagnosis: Risk for infection related to decreased immune function
Outcome Evaluation: The child's temperature is within normal parameters; no cough or skin lesions are
present.
1. Teens with HIV infection and their families must maintain strict personal hygiene by measures such
as frequent handwashing and avoiding close contact between the child and anyone who has a
respiratory infection to prevent the child from contracting dangerous opportunistic infections.
2. It is important to assess children's oral cavity with AIDS for herpes and thrush lesions (Gennaro,
Naidoo, & Berthold, 2008). When infections do occur, antiviral and antifungal treatment should be
prompt and aggressive. Combating the infection requires specific antiretroviral medications to


TECHONOLOGY
prevent progressive deterioration of the immune system and provide prophylactic measures against
opportunistic infections.
3. Three classes of drugs are the mainstay of therapy: nucleoside reverse transcriptase inhibitors
(NRTIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), and protease inhibitors. NRTIs are
designed to block the production of viral DNA, limiting the virus's ability to infect cells; zidovudine is
an example (Box 42.4). NNRTIs also inhibit the DNA synthesis of viruses but act at different sites on
the viral enzyme; nevirapine and efavirenz are examples. Protease inhibitors stop the virus's ability to
produce protease, limiting metastasis; amprenavir, nelfinavir, atazanavir, and ritonavir are examples
of protease inhibitors used in children (Chadwick et al., 2008).
4. Yearly influenza vaccinations should be given (CDC, 2008b).
Nursing Diagnosis: Risk for a compromised family coping related to the diagnosis of HIV infection in a child
Outcome Evaluation: Parents state ability to continue providing child’s physical care; identify outside
resources for help with care and decision making.
1. One of the first nursing priorities in the care of such a family should be to help the family re-establish
their previous level of functioning so they can turn their attention to their child's emotional and
physical care needs and their own needs.
2. Physical care requirements for the child with HIV infection may be extensive, depending on their
symptoms and disease progression.
3. No matter the child's physical needs, however, love and emotional support are essential to the child's
well-being and psychological health. Parents or caregivers need extensive support, education, and
anticipatory guidance from nurses and other healthcare team members.
4. Encourage parents to seek medical care for their child at the first sign of illness or infection to prevent
unnecessary hospitalization and pain.
DYSMENORRHEA
A. Dysmenorrhea is painful menstruation. It was thought to be mainly psychological for generations, needing
no treatment other than reassurance that it was a normal phenomenon and something women should endure.
Today, it is known that the pain is caused by the release of prostaglandins in response to tissue destruction
during the ischemic phase of the menstrual cycle (Harel, 2007). Prostaglandin release causes smooth muscle
contraction and pain in the uterus. Dysmenorrhea can also be a preliminary symptom of an underlying illness
such as PID, uterine myomas (tumors), or endometriosis (abnormal formation of endometrial tissue).
Assessment.
During the first year or two of menstruation, dysmenorrhea rarely occurs because early menstrual
cycles are usually anovulatory (without ovulation). As ovulation begins, typical menstrual discomfort also
begins. Dysmenorrhea can be categorized.
Mild (no interference with normal activities), moderate (some interference), or severe (interference with the
majority of everyday activities).
1. Symptoms may begin with a “bloated” feeling and light cramping 24 hours before menstrual flow.
2. Pain is mainly noticed, however, when the flow begins.


TECHONOLOGY
3. Colicky (sharp) pain is superimposed on a dull, nagging pain across the lower abdomen.
Accompanying this is an “aching, pulling” sensation of the vulva and inner thighs.
4. Some adolescents have mild diarrhea with abdominal cramping. Mild breast tenderness, abdominal
distention, nausea and vomiting, headache, and facial flushing may also be present.
Therapeutic Management.
Painful symptoms can usually be controlled by an analgesic such as acetylsalicylic acid (aspirin) or
ibuprofen (Advil, Motrin). Acetylsalicylic acid (aspirin) works well as an analgesic for dysmenorrhea because
it is a mild prostaglandin inhibitor. Although adolescents are usually advised not to take aspirin because of its
link to Reye's syndrome, girls may take it safely at the beginning of a menstrual period as long as they do not
have additional flulike symptoms. Ibuprofen is a stronger prostaglandin inhibitor and relieves more severe
menstrual pain. Naproxen sodium (Aleve) is also effective. Be certain that girls know not to take these drugs
on an empty stomach because they can be extremely irritating to the gastric mucosa. Low-dose oral
contraceptives to prevent ovulation may also be effective if pregnancy is not desired. One disadvantage of this
therapy is the possible adverse effects of long-term estrogen administration. Adolescents may choose to be
prescribed long-acting oral contraceptives to have menstrual periods only every 3 months (Pavone & Burke,
2007). Several alternative therapies such as imagery and transcutaneous electrical nerve stimulation (TENS)
are also effective to relieve menstrual pain (Proctor et al., 2009
Nursing Management and Related Interventions
Nursing Diagnosis: Pain related to dysmenorrhea Outcome Evaluation: The client states that she has some
control over pain through nonpharmacologic or pharmacologic methods.
Related Intervention”
1. Several nonpharmacologic solutions, such as yoga and exercise, may help relieve dysmenorrhea (Hall,
2009).
2. Decreasing sodium intake for a few days before an expected menstrual flow by omitting salty foods
such as potato chips, pretzels, ham, and other luncheon meats and not adding salt to foods may help
reduce "bloated" feelings.
3. Abdominal breathing (breathing in and out slowly, allowing the abdominal wall to rise with each
inhalation) may also be helpful.
4. Applying heat to the abdomen with a heating pad or taking a hot shower or tub bath may relax muscle
tension and relieve pain.
5. Acupressure, although short-lived, might also be of help (Jun et al., 2007).
6. Caution young girls not to apply heat to their abdomen for abdominal pain until their menstrual flow
begins; if the pain results from an inflamed appendix, heat can cause rupture of the appendix and life-
threatening peritonitis.
7. Resting may relieve vulvar pain; abdominal massage (effleurage or light massage) may feel soothing.
8. Adolescents who remain sexually active during their menses may discover that orgasm helps relieve
pelvic engorgement and cramping.


TECHONOLOGY
1. Choose three diseases/cases from this chapter and, in diagram format, illustrate the pathophysiologic
sequence of changes that occur in your chosen diseases/cases. An outline format is acceptable as long
as the cause-and-effect sequence can be seen.
References

Patricia M. Nugent, RN, EdD, Judith S. Green, R.N., MA, Phyllis K. Pelikan, RN, MA, Marry Ann Hellmer Saul,
Elsevier.
Veracz A, R. D. (2012). DPDx - Laboratory Identification of Parasites of Public Health Concern. Retrieved from
www.cdc.gov: https://www.cdc.gov/dpdx/pediculosis/index.html
WebMD. (, 2019). WebMD. Retrieved from https://www.webmd.com/:
https://www.webmd.com/rheumatoid-arthritis/diagnosing-juvenile-arthritis


TECHONOLOGY

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UNIT 1: Nursing Care Of A Family With A High-Risk Newborn.............................................. 11

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

Girlie de Luna Tayao, MAN, RN

Mark Denver V. Manuel, MAN, RN

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

Predisposing factors for the respiratory Drugs Used in Resuscitation

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

Common Birth Injuries

Subgaleal hemorrhage is bleeding into the subgaleal compartment

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF

No medical intervention is necessary. The paralysis usually disappears

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF SCIENCE AND

Post discussion activities:

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF SCIENCE AND

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF SCIENCE AND

ACUTE AND CHRONIC PEDIATRIC NURSING

UNAUTHORIZED REPRODUCTION IS PUNISHABLE BYLAW BY NUEVA ECIJA UNIVERSITY OF