ROUTINE NEWBO RN CARE Assessment: Delivery Room- 15% A. B. C. D. E. F.

Apgar scoring, one and five minutes based on the scoring method Assess for obvious congenital malfunction Check umbilical cord: 2 arteries and 1 vein Look for meconium staining : skin and nails Evaluate abnormal cry or no cry Assess any injuries caused by birth trauma, IE dislocate shoulder, edema of scalp lacerations G. Assess respiratory status: nasal flaring, retractions, and expiratory grant H. Assess neurological status: reflexes, tremors, and twitching I. Check for nasal or nasal patency Assessment: Nursery- 15% A. B. C. D. E. F. G. H. I. J. Observe for jaundice: check general skin color, blanching, sclera of the eyes Check for respiratory difficulty: mucus flaring of the nostrils, grunting, etc. Note tremors, twitching muscle tone, reflexes and irritability Take babys temperature q shift Check babys weight daily Note amount voided and number of stools Check for signs of infection on the skin and cord: redness, drainage, odor, and bleeding Assess formula or breast milk intake each feeding Check sleep patterns Evaluate mothers and infants response to each other

APGAR SCORING- 10% Sign Heart tone Respiratory effort Muscle tone Reflex irritability Color 0 Absent Absent Flaccid No response Blue, pale 1 Slow( less than 100) Slow, irregular Some flexion of extremities Cry Body pink, extremities blue 2 Over 100 Good crying Active motion Vigorous cry Completely pink

Each sign is scored 2 if present and a score of 10 denotes neonate in a healthy condition.

Interpretation: 7-10 4-6 1-3 good Fair O2, suction, resuscitation is needed

PLANNING AND ANALYSIS- 10% A. B. C. D. E. Body temperature is maintained Respiration and cardiovascular functions are stable Infection and injury are prevented Nutrition is maintained and growth is promoted Positive mother-infant relationship is promoted

IMPLEMENTATION: Delivery Room- 15% A. Wipe out mucus from baby and wrap in one blanket B. Place in heated crib or give to m other and or father to hold (mother maybe too tired to receive baby at this time) C. Avoid excessive exposure as body temperature is variable. D. Place infant on side or modified trendelenburg to facilitate drainage of mucous or blood E. Suction secretions as needed with bulb or suction catheter attached to mucous trap F. Provide oxygen as needed G. Apply 1% silver nitrate or antibiotic to eyes (may be delayed until infant is in nursery). Give 2 drops in conjunctival sac of its eye H. Clamp cord if physician has not done so I. Identify baby with bands Nursery-20% a.) b.) c.) d.) Oil bath- to remove vernix Warm bath- to remove blood and vernix Credes prophylaxis- instilled in both eyes (o.u) with terramycin ophthalmic ointment Cord dressing done aseptically

Instrument in Cord Dressing 1. 2. 3. 4. 5. Forcep Scissor Cord tie/clip Cotton balls with Betadine Sterile OS wet with alcohol

Procedures a.) Paint the base of the cord with Betadine or Iodine outward in circular motion three times b.) Paint the cord upward with Betadine three times c.) Place the cord tie in the forcep and clamp the cord d.) Cut the cord one inch from the base e.) Paint the top of the cord with Betadine or Iodine f.) Place the cord tie underneath the forcep then pull the tie g.) Place OS with alcohol 95% h.) Take the temperature of the baby per rectum to know whether the anus is patent 1 inches i.) Take the measurement of the baby and write it in between the footprint form 1. Head circumference HC 2. Shoulder- SC 3. Chest-CC 4. Abdomen-AC 5. Length- L 6. Weight- WGT ( baby is naked ) j.) Take the footprint k.) Place the babys tag at right wrist l.) Inject 1 mg or 0.1 Vit. K for regular babies, 0.05 cc for premature m.) Stimulate the baby to cry by tapping the sole of the foot n.) Place the baby in the crib or bassinet o.) NSD- trendelenburg CS & Forcep Delivery Flat position p.) Place the babys tag on the head of the crib q.) Babys should be placed under droplight

EVALUATION 15% A. B. C. D. E. F. Normal body temperature is maintained and infant shows no signs of cold stress Respirations are between 40-60; heart rate is 120-160 at rest No signs of infection or other complications Weight stabilize, and infant take adequate nutrition Normal cry, sleep patterns, and reflexes present Infants skin color shows signs of adequate circulation, except for possible mind acrocyanosis or mottling on chilling G. Mothers appears relax with baby, and is able to comfort baby. Mother-infant bonding continues Normal Newborn Weight - 6-9lbs Height 49-51 cms Heart Rate 120-160/ minute Physiologic Weight Less 5- 10% Posterior Fontanel 6-8 wks Anterior Fontanel 16-18 mos. Head Circumference - large than chest circumference Respiratory rate 30-50/ minutes Urine within 24 hrs. 12-15 times/ day

Normal Characteristics of a Neonate Measurements: Length- average newborn Boy 20 inches (50 cm) Girl 19.6 inches (49 cm)

Weight weight between 2,700 and 3,850 gm - 6-8.5 lbs Boy 7.5 lbs. Girl 7 lbs

First few days after birth Infant tends to lose about 6-10 ounces, 5-10% of birth weight (withdrawal of hormones originally obtained from the mother, the low intake of fluid, and loss of fluid in feces and urine

Vital signs Temperature immediately drops after birth in adjustment to the temperature of delivery room. (37.2 C) Pulse normally irregular- due to immaturity of the cardiac regulatory center in the medulla. (120-160 bpm) Rate is rapid about 120-150/ minute

Respiratory irregular in depth, rate and rhythm and vary from 35-50/ min. Count them for full 60 seconds Can be observed most easily by watching abdominal movement, since respiratory in the neonate is accomplished largely by the diaphragm and abdominal muscles. (3060) Dyspnea or cyanosis may occur suddenly first indication of presence of congenital anomaly which may cause sudden death Normal cry is lusty, frequent and many times apparently without cause. If does not cry, adequately stimulation should be given to encourage the expansion of the lungs

BP characteristically low Difficult to determine Doppler or flush method may be used (80/46) after 10 days 100/ 50

Hypotension- occurs in the first few hours after birth Hypotension after the first 12 hours- due to congenital heart disease, impending or full blown septic shock or internal bleeding among other conditions

Hypertension- caused by renal disease or congenital renal anomalies Also be due to the size of a wrong cuff size or the temporary severe agitation of the infant

Integument- pinkish in color, soft, covered with lanugo, and overlaid of vernix caseosa Good elasticity, or turgor is evidence that an infant is in good condition

Lanugo- slight downy distribution of fine hair over the body, most evident on the shoulder, back, extremities, forehead and temples Begins to appear on the fetus about 16th week and gestation and disappear after the 32nd

Vernix Caseosa- cheese like greasy yellowish white substance, sometimes likened to cream cheese or cold cream which covers the newborn skin Tissue turgor- refers to the sensation of fullness derived from the presence of hydrated subcutaneous tissue. Desquamation or peeling of the skin- occurs during the first 2-4 weeks of life Milia- tiny white papillae, occurring particularly on the nose and chin, which are caused by the obstruction of the sebaceous glands. These blemishes disappear in a week or two. Physiologic Jaundice- (icterus neonatorum)- definite between 3rd-7th day, appears gradually on the 2nd or 3rd day Birth Marks- Telengiectatic nevi (stork bites), flat red localized areas of capillary dilatation on the upper eyelids, between the eyebrows and on the nose, upper lip or back of the necks They will disappear spontaneously, usually by two years of age

Forceps Marks bruising of tissues Breech delivery there may be edema and extravasations of blood into the tissues of the buttocks and genitals because of the trauma of the presenting part

Mongolian Spot- slate colored spots usually occur on the buttocks or lower portion of the back of infants. Fade during pre-school Acrocyanosis- symmetric cyanosis of the extremities Cutis Mammorata - transitory mottling of the skin sometimes due to the exposure of the skin to cold. Harlequin Color Change- discrepancy in color between the two longitudinal halves of the body where the neonate is placed on the sides for several minutes, the dependent portion of the body becomes pink while the upper part remains pale Erythema toxicum - pink popular rash on which vesicle maybe superimposed. Self limiting condition, appearing 1-2 days after birth and disappearing several days later By 2 weeks of age- typical rash soft dewy skin. Sweat glands become active- end of second week.

Head- 34-35 cm (13.6-14 inches) circumference

Normal limits of head size are 33-37

Fontanels- opening at the point of the union of the skull bones Anterior fontanel is diamond shaped located at the junction of the two parietal and two frontal bones. 2-3 cm width and 3-4 cm length. Closes at 12-18 months. Posterior fontanel is triangular and located between the occipital and parietal bone much smaller than the anterior fontanel and maybe nearly closed. Closes end of second month. Fontanels bulge when the infants cry or strains Caput Succedanum- swelling or edema of the presenting portion of the scalp

Cephalhematoma- collection or accumulation of blood between the periosteum and a flat skull bone Eyes- change to permanent color in 3-6 months. Movements are not coordinate (may turn inward or upward) Instillation of silver nitrates soon after birth to prevent opthalmia neonatorum (gonococcal conjunctivitis)

Ears- tip of pinna should meet or cross an imaginary line drawn from the lateral aspects of the eye to the occiput. Low set ears maybe an indication of mental retardation, renal anomalies or craniofacial malformation Nose- slightly obstructed from an accumulation of mucus Mouth and throat- examine to determine the presence of minor variations as well as the more serious problems of cleft palate. Neck- neck appears short and is creased Chest- bell shaped, approximately the same circumference on the abdomen and about 1 inch less than the head circumference Hematologic system- blood volume of the newborn infant is about 10-12% of body weight. This percentage is influenced by the amount of blood received from the placenta before clamping the cord. Contains a relatively high levels of RBC and a high hgb level at birth Hct- essential to provide oxygenation in uterus and during the first few postnatal days before lungs expand fully.

WBC- approximately 10,000 per mm increasing to 25,000-30,000 during the first 24 hours of life- falls during the 1st week after birth. Not necessary an indication of infection but with leucopenia ( decrease red blood cell)

Assess any neonate or infant who appears ill or listless and has signs of infectious such as respiratory difficulty, vomiting or diarrhea * Most newborn babies have reduced levels of Vit.K in their blood resulting in prolonged prothrombin-clotting time because their intestinal tracts are sterile at birth .Vit. K is essential for the formation of factors II, VII, IX and X. it is given after delivery Normal flora begin to accumulate at birth therefore, normal synthesis of Vit. K is possible.

Physiologic jaundice maybe seen approximately 55-70% of all newborns on the 2nd- 4th day of life - when the level of bilirubin to the normal level of 1-3 mg/dL in umbilical cord blood to 5-6 mg/dL. It decreases to below 2 mg/dL by the 5th- 7th day of extra uterine existence Urine may become dark, babies may appear sluggish even showing anorexia *Intervention photo therapy

Esophagus, Stomach Intestines Infant should be bubbled several times while having while having fed so that air tht has been swallowed maybe eructed. If air remain in the stomach there will be a danger of vomiting regurgitation will be constant infants fails to gain weight Birth stomach holds from 1-2 ounces 2 weeks 3 ounces 5 weeks 7 ounces 10 weeks 10 ounces Entire formula meal should be out of the infants stomach in 2-3 hours digestion is slowed by food high in CHON and fat

Meconium- the first fecal material sticky, odorless, greenish black to brownish- green, which is passed to 8-24 hours after birth- changes daily in the first week called transitional stools 3rd-5th day loose, contain mucus and are greenish- yellow 5th day nature and frequency of the stools depend on the feeding Stools of breastfed infant- yellow and pasty between 2-4 are passed a day Formula feeding light yellow, hard and are passed once or twice daily. Abdomen - normal: rounded and slight protuberant Cord first day cord begins to dry and shrink Changes in color from a dull yellow to brown-black Sloughs off by 6-10 days after birth- leaving a granulating area that heals in another week base of cord should be dry and clean

If base of cord is moist, redden or warm, or has a foul discharge infection danger entering the blood stream through the abdominal vessels and carrying septicemia

Palpation of abdominal organs liver usually can be felt about 1 inch (2-3 cm) below the right costal margin Tip of spleen maybe palpable by about 1 inch after birth in the LUQ kidneys Femoral pulses are also palpated should be equal on both sides and strong

Anogenital Area infants buttocks are plump and firm Male anal region - there should be no fissure and redness Size of male newborn genitalia, penis and scrotum varies Small white cysts maybe observed on the distal prepuce Testes usually descended into the scrotum by the eight month of intrauterine life

Female- slightly swollen from the action of maternal hormone the labia minor and clitoris appear large. Large amount of vernix caseosa maybe evident. Vagina exudes a mucous discharge that occasionally maybe blood tinged caused by hormone transmitted from mother to newborn daughter Disappears when the hormone are no longer present in the babys body

Urine pink stain maybe be found on the diaper, which is usually due to deposition of uric acid crystals Dehydration most common cause of failure to void in neonate Skeletal structures- bones are soft because they are composed chiefly of cartilage Back normally straight flat when the baby is lying prone Extremities inspected for symmetry and ROM Muscular development healthy infant smooth, hard and slightly resistant to pressure Nurse holds the infants head and back, must be supported

Nervous System and Reflexes if reflex is impaired or absent, possibly the CNS has sustained injury With maturity, certain neonatal reflexes disappear as the cerebrum exercise greater control over the nervous system

Special Senses: Sense of touch most highly developed of the special senses. Most accurate on the lips, tongue, ears and forehead

Failure to grasp the nipple therefore is one indication of brain damage

Vision eyes are half open and lids are swollen Pupils react to light and bright lights appear to be unpleasant to the infant

Hearing - occurs after the first cry Makes some response to sound from birth - there are evidences that ordinary sounds are heard well before the tenth day Responds to sound with eye movements, cessation of activity, startle reaction or crying Fourth week likely to react to the mothers voice more frequently than to a loud voice

Taste fairly well developed Sweet fluids are accepted Acid, sour, or bitter ones are resisted

Smell many newborn infant appear to smell breast milk and search for the nipple Highly sensitive to organic stimulation, since hunger and thirst are the most common cause of crying

State reaction of the neonate to internal and external stimuli is manifested in state related behavior 5 Different States: 1.) Quiet or regular sleep ( no muscular movement, regular respiratory, eyelids closed) 2.) REM (rapid Eye Movement) or active sleep/ minimal muscular movement, irregular respiration eyelids closed, rapid eye movement 3.) Quiet Alert ( no muscular movement eyelids open) 4.) Active Alert (no muscular movement, eyelids open, no fussing) 5.) Crying/ fussing eyelids closed or open Transitional occur between these status (a sixth state) Newborn who are not normal because of metabolic difference, congenital anomalies, or infectious do not have the usual state cycle. Nursing Management of the neonate

1.) Establishment and maintenance of respiration 2.) Stabilization and maintenance of respiration 3.) Preventions of infections to injury 4.) Provisions of optimal nutrition Reflex Rooting Stimulation to Elicit reflex Touching or stroking the cheek near the corner of the mouth Expected Response Head turns In direction of stimulation so that the neonate can find food When the breast touches the cheek, the neonate turns toward the nipple Age of Disappearance 6th week of life when the source of food can be seen. Disappears when awake 3 to 4 months; when asleep , 7 to 8 months

Sucking

Touching the lips with the nipple of the breast or bottle or other object

Sucking movements that enable the newborn to take in food

Begins to diminish at 6 months. Disappears soon after birth if not stimulated If a neonate cannot take oral feedings, a pacifier may be used to maintain the reflex Does not disappear

Swallowing

Accompanies the sucking reflex When more is taken into the mouth than can be successfully swallowed Foreign substance entering the upper or lower airways

Gagging

Food reaching the posterior of the mouth is swallowed Immediate return of undigested food

Does not disappear

Sneezing and coughing

Extrusion

Substance place on anterior position of

Clearing of the upper air passage by sneezing, the lower air passages by coughing Extrusion of the substance to prevent

Does not disappear

About 4 months

Blinking

Dolls eye

Palmar grasp

tongue Exposure of eyes to bright light from a flashlight or otoscope or sudden movement of object toward eye Turn the newborns head slowly to the right or left side Object placed in newborns palm

swallowing Protection of the eye by rapid eyelid closure

Does not disappear

Normally eyes do not move Grasping of object by closing fingers around it. Reflex may be so strong that a neonate grasping the examiners forefingers can be lifted from the supine to a standing position (darwinlan reflex) Toes grasp around very small object

When fixation develops 6 weeks to 3 months Purposeful grasp is evident at 3 months of age

Plantar grasp

Touching the sole of the foot at the base of the toes

8 to 9 months, in preparation for walking May continue to be present during sleep 3-4 weeks. The neonate soon thereafter can bear some weight on the legs without stepping 3 months of age variable

Dancing (step- inplace)

Hold neonate in a vertical position with feet touching a flat, firm surface Stroking the lateral aspect of the sole of the foot with a relatively sharp object (fingernail) from the heel up toward the little toe and across the foot to the big toe Turning the head quickly to one side while the infant is supine

Rapid alternating flexion and extension of the legs as in stepping Fans the toes (positive Babinski sign) the adult normally flexes the toes. The newborns response is due to an immature level of nervous system development Arm and leg on the side the head is turned toward extend. Arm and leg

Babinski

Tonic Neck (fencing position)

18-20 weeks. Tonic neck reflex is replaced by symmetric positioning of both

Moro (startle)

on the opposite side flex. Both hands may make fists. Startling the infant Generalized muscular with a loud voice or activity. Symmetric apparent loss of abduction and support due to a extension of the arms change in equilibrium. and legs with fanning The neonate is held in of the fingers. The a supine position thumb and index above the table or finger on each hand bed. The nurse form a C shape. The supports the upper extremities then flex back and head with and adduct; the baby one hand and the may cry lower back with the other. The newborns head is suddenly allowed to drop backward an inch or so.

sides of the body

Strong up to 2 months: disappears by 3-4 months

ADVANTAGES OF BREASTFEEDING B- Best for baby R- Reduce incidence of allergies such as asthma and eczema E- Economical, no waste A Antibiotics- greater immunity to some infectious diseases S Stool inoffensive T Temperature always ideal F Fresh milk E Emotional Bonding E Easy once established D Digested easily I Immediately available

N Nutritionally optional G Gastroenteritis greatly reduced

POLICIES OF BREASTFEEDING 1. 2. 3. 4. 5. 6. Early start 24 hrs. rooming-in Demand feeding No bottles No pre-lacteal feeding Helping mothers to attach babies Building mothers self confidence

PRE-LACTEAL FEEDING INTERFERES THROUGH: 1. 2. 3. 4. Nipple contusion Eagerness to breastfeed Allergic sensitization Mother sense of inadequacy

MAJOR CAUSE OF SORE NIPPLE 1. Poor attachment 2. Baby not taking enough breast milk TEN STEPS TO SUCCESSFUL BREASTFEEDING: 1. Have a written breast- feeding policy that is routinely communicated to all health care staff 2. Train all health care staff in skill necessary to implement this policy 3. Inform all pregnant women about the benefits and management of breastfeeding 4. Help mothers initiate breast- feeding within a half hour of birth 5. Show mothers how to breast feed, and how to maintain lactation even if they should be separated from their infant 6. Give newborn infants no food or drink other than breast milk unless medically indicated 7. Practice rooming- in allow mothers and infants to remain together 24 hours a day 8. Encourage breastfeeding on demand 9. Give no artificial teats or pacifiers ( also called dummies or soothers) to breastfeeding infants 10. Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or clinic

CORRECT POSITIONING 1. 2. 3. 4. 5. Find a comfortable place to sit or lie and relax Hold your baby in your arms. Make sure that he faces your breast Hold and offer your full breast. Do not pinch the nipple or areola Touch your babys cheek to make him open his mouth Wait until the babys mouth is open then quickly move the baby onto the breast

SIGNS THAT THE BABY HAS FIXED UNTO THE BREAST IN A GOOD POSITION 1. 2. 3. 4. 5. Babys mouth is wide open Mother and baby is in the tummy- to tummy position Much of the mothers areola is in the babys mouth The baby is relaxed and happy The mother does not fill nipple pain

Overview of Cognitive Development (Jean Piaget) Development of cognition represents a continuous and orderly process

4 Major Stages 1.) Sensory Motor- Birth to age 2 - Child progresses from reflex activity to repetitive behavior and to imitative behavior - Displaying a high level of curiosity child begins to develop a sense of different and separate from environment - Learns that objects have permanence and existence even if they are not visible - Infant imitates patty cake and then peek- a boo, finally realizing that the hidden object is still there 2.) Pre- Operational Age 2-7 - Child interprets objects and events solely in relationship to self - Learning and thinking embrace only what the child sees, hears, feels or experiences - Increasing language skills, imaginative play, questioning and interacting, the child begin to elaborate concepts and correct experiences. Near the end of this stage, reasoning becomes intuitive and the child become begins to work with problems of weight, length, size and time 3.) Concrete Operations - Age 7- 11 - Child can now sort, classify, order, and organize facts about the world. The child collects and saves everything from stamps t crickets and toads. - Can now recognize their point of view, however as evidence for a stronger desire for companionship or teamwork

4.) Formal Operations Age 12-15 - Characterized by flexibility, the adolescent learns to deal and abstractions and abstract symbols - Adolescent may confuse the ideal world with the real world but can never solve problems, develop hypothesis, test them and reach conclusion - Adolescent working through moral, ethical, religious, and social issues begins to achieve an adult identity PHYSICAL MOTOR AND SOCIAL DEVELOPMENT Birth 3 months 1 month infants eyes will follow bright moving objects 2 months crossed eye reflex disappears 3 months social smile response Can rest on her forearms, keeping the head in midline and discovers hands and stares at them Stepping reflex disappear and landau reflex appear Able to lift the head and chest Can hold a rattle and stares at it and can follow moving objects with the eyes Infant expresses demands by crying Enjoys sucking and reacts affectionately to all who approach Infant coos, bubbles, gurgles, and laughs aloud Responds to his or her name Shows pleasure and makes sounds and faces in reaction to the social play of others

4- 6 months infants holds the head up for longer periods Improve eye coordination, and turns from the back to the side At 5 months the infant can sit with support and at six months can turn over completely 5- 6 months weight doubles Can turn the head toward familial sounds 4 months recognizes his/her parents Demands attention by fussing, grasps object with both hands and shows excitement with both hands and shows excitement with the whole body 5 months - playing with the toes and smiling at the mirror image 6 months infants holds out arms to be picked up and shows definite likes and dislikes

6 moths 7 months 8 months 9 months 10 months 11 months child is creeping, with the abdomen off the floor Can stroll while holding to a person or an object Able to put objects into a container and remove them Begins to drop objects deliberately either to marvel at their sound or to gain the attention of others crawling most of the time, can step foot if supported by a person or object Fear of strangers increases and scolding elicits a strong reaction continues to imitate (bye bye) looks and follows picture in a book. pull to standing position, upper lateral incisors may erupt Exhibits a fear of being left alone infants shows increased bowel and bladder regularity, sits steadily, releases objects at will and exhibits a beginning pincer grasp Social development is primary characterized by the infants dislikes, such as getting dressed or having a diaper changed can sit and lean forward on the hands and can transfer objects from one hand to the other Upper central incisors typically erupt during this period Socially, the infant begins to display a fear to strangers Oral aggressiveness is evident (biting) The infant will reject disliked foods by keeping the mouth closed can raise the chest and upper abdomen, keeping the weight on the hands, and can sit in a high chair with a straight back Can able to turn back to the abdomen Can hold a bottle or eat a cracker independently and can grasp the feet and pull them to the mouth Teething may begun at this time Social development - characterized by loud laughter, ability to distinguish familiar and strange faces, desires to be picked up and held Enjoys rattles and stuff toys, displays frequent mood swings and begins imitating others (coughing or sticking out tongue)

12 months -

Begins to learn self feeding and will help with dressing Playing games such as peek a boo and shaking the head no are common

tripled in weight Can sit alone and can roll over Has eight teeth by the end of the first year Develops a fear of strangers and clings to mother Understands simple commands Help with dressing and points to indicate desired objects Social play skills become more sophisticated Child discriminates in giving affection and shows fear, anxiety and sympathy Learned to repeat behaviors that elicit laughter Continues to imitate, wave bye bye and shake the head no

10-14 months Creeping and crawling for locomotion, can pull up to a standing position independently, and can stand for extending period with support Child is walking with a broad stiff legged gait Attempts self feeding with a spoon, poking and probing with the index finger and a fondness for finger foods

13-15 months Likes to empty containers and fill boxes, drops objects intentionally Can put a spoon to the mouth and drink from a cup and hands objects to people Creep upstairs, child cannot come down, attempts back downstairs begin at 15-16 mos. Can build two-block towers and put a round peg in a round hole Wants to be with adults but also enjoys playing alone, exploring kitchen cupboards and imitating housekeeping duties Displaying fondness for kissing pictures and mirrored reflections Removes shoes and performs self feeding Wants and enjoys an audience and is capable of affection and sympathy, especially in the form of sympathetic crying

16-24 months Child explores the physical world widely and is all over the house Falling loss frequently Child walks backward with a broad based gait Walks forward and runs with a stiff wide based gait; and stops to pick up toys Can throw a ball and unzip zippers

2 years old 3 years old 4 years old -

Loves to push, pull, tug, bang, carry and hug toys; and manages a spoon with rotation 15-18 months, the anterior fontanel closes Profoundly ritualistic and exerts control with temper tantrums 18 mos. sphincter control begins Likes to clean up messes, flush the toilet, run the water and put things in their place Uses push and pull, noisy toys Points to body parts or request Find security in thumb- sucking or in favorite blanket or toy Become easily frustrated and angry Personal identity begins, with differentiation between you and me

Put on shoes and pants Wash and dry hands Begins to scissors and string large beads and undress Tries to dance, pinches, kicks, bites Goes up and down steps one at a time Can turn pages Imitates older children Uses three words phrases Shy with strangers (negativism peaks at 2 years ) Develops tears of bed wetting, animals and being deserted. Displays slower growth

Can ascend steps with alternating feet Ride a tricycle, copy a circle PR- 95 bpm RR-24 cpm BP 100/67 Develop vocabulary of about 900 words Displays telegraphic speech, and constantly asking questions Knows his or her own sex Can better tolerate brief separation from the parent or the primary caregiver

Hops on one foot, skips, catches ball, throws overhand, uses scissors and can lose (but not tie) shoes Questioning reaches a peak during this time Exaggerated stories are typical Developing sense of right and wrong

5 years old 6 years old Childs appetite increases, plain food, snacking and eating on the run Begins to dislike bathing In constant motion Temper tantrums reappears More self centered, boastful and bossy Child enjoys dramatic play exert feelings and often is fresh rush and ready to fight Tears to develop concerning the supernatural, unusual noises, the mothers death, and any self injury and persistent night terrors are common Eruption of permanent teeth may begin Jumps rope and can tie shoe laces Social development- identifying coins and name at least four colors knows the days of the week Engages in cooperative play Attempts to resolve fears and anxieties Through play, tries to behave and is independent in self care activities, such as bathing and dressing

7-9 years old Begins to lose baby teeth at age 6-7, with first molars coming in at about age 7 Develop better coordination of physical and motor skills and practices to achieve perfection Movement is more graceful More likely to shout than act out Resents bathing less and shows little interest in clothes, prefers to pay with the same sex Compete but does not like to lose Withdraws from situation rather than resist Can be moved with sad stories and becoming real family member with chores and responsibilities Gang stage begin, close relationships with peers begins to take shape Begins to collaborate and compromise Major fear is failure

10-12 years old Rapid changes in weight, height, body contour Begins to envision adulthood Requires adequate explanation of body changes He/she compares body changes with those of classmates and friends Girls seems wiser and more poised than boys

For both sexes companionship becomes more important than play as a social behavior Likes to run errands, enjoys crafts and music, and seeks others ideas and opinions

13-16years old Early teenager maybe awkward and uncoordinated Preference for fast foods and fad diets can lead to poor nutrition and lethargy Physiologic problems include acne, increase perspiration and propensity to blush easily Develop a tall growth of pubic hair and axillarys hair They like parties, dances, movies, daydreaming, telephone conversation, books and hobbies

17-19 years old young man has a beginning beard, his structural growth is near completion, and that his physique is that of a mature male, including genital size and pubic hair Young woman may grow 2-4 inches taller after menarche Breast and pubic hair have reached adult development Capable of reproduction bout 1 year after menses begin Both have more energy as the growth spurt slows More mature and begins to enjoy an interdependent relationship with the parent while finding increasingly less satisfaction from the peer group Learn to balance pleasure and responsibility Engages in romantic love affairs and may still daydream about adult life but also begins to establish career goals and plan how to achieve them Parents may used assistance facing the loss of their dependent child

20-30 years old Physical strength and physio-reserve are at a maximum, health needs usually are not significant Selection of marriage partner- perhaps the decision to have children Marriage and parenthood necessarily entail period of adjustment taught with increased stresses, such as changing ones lifestyle to accommodate children and socializing the children into the family

30-40 years old Physical strength, physiologic reserve and systemic functioning begin to diminish, proper nutrition becomes more important Requires fewer fats and calories in the diet and requires more vitamins and iron Exercise is essential to regulate appetite, release tension, enhance rest and sleep, increase muscle tone, and improve the persons well being.

Choose of vocation and career successes and failures largely determine the persons social status and roles Unemployment of unsatisfying employment may lower self esteem Hectic schedules and limited income may contribute to an unhealthful diet To attain career goals, the person may work or worry excessively at the expense of needed sleep and relaxation

40-65 years old Physical strength, physio reserve and systemic functioning continues to diminish Exercise should be less strenuous Concerns about stiff joints, wrinkles, gray hair, baldness, dentures, poor hearing or vision, osteoporosis, nervousness ore depression Diseases are common Sexual problems may also develop Mutilating surgery, chronic disease or menopause can dramatically lower the persons self esteem, particularly if the sexual partner does not provide emotional support Responsible not only for the self, spouse, children but for the parents, co-workers and community members Emptiness syndrome may occur causing depression Sees this period to continue education and enter to resume a career; man may need to prepare for a second vocation

65 and over Physical strength, physio- reserve and systemic functioning decline Hearing and vision loss may be more pronounced, cataracts may require surgery Immobility, constipation, indigestion arteriosclerosis, stroke, peri- vascular disease, HPN, coronary occlusions and cancer and common geriatric problems Man-prostatic hypertrophy Woman-may have osteoporosis resulting in bone fractures Chronic illnesses Lack of exercise can impair digestion, circulation, muscle and joint function and mental alertness Decrease sensitivity of taste buds Wants to enjoy carefree leisure of retirement Pursuing hobbies, spending time with family and friends can result in grieving, loneliness and depression during this stage Withdraw from society (disfigurement)

Erik Erikson- postulated a theory of personality Psychosocial / psycho analytic theory

Sense of Trust vs. Mistrust Birth to age 1 Infancy Development of basic trust is the most important aspect of a healthy personality Consistent loving care by a caregiver who touches, holds, caresses, feeds and clean the infant builds his sense of trust When care is inconsistent, deficient or lacking, or when basic needs remain unmet, the infant learns mistrust Basic trusting relationship with primary caregivers, the infant develops self trust and trust in others (oral stage Sigmund Freud)

Sense of Autonomy vs. Shame and Doubt Age 1 3- toddlerhood Infant who develop basic trust can then proceed to autonomy (independence) and body control (trust) Child has physical and motor ability to get around independently Increasingly ability to manipulate environment and other people Sphincter control- child can dominate a household with toileting, wants to use their new powers and skills to do things Ecoporesis- involuntary discharge of urine or wetting after control Encopresis- uncontrolled passage of stool and fecal incontinence after age 4 Rituals, negativism, and temper tantrums reflect uncertainties associated with gaining mastery and control Lingering feelings of shame and doubt will result if the child is made to feel, small, shamed or unnecessarily dependent (anal stage- Freud)

Sense of Initiative vs. Guilt Age 3-6 Pre-school Age Vivid imagination, magical thinking, a budding sense of right and wrong, and increased awareness of body parts characterize this period of personality development Childs imagination engenders fantasies and stories that the childs believes Oedipus Complex refers to the strong attachment of a preschool boy by his mother Electra Complex- attachment of a preschool girl to her father Anxiety may give rise to night terror, fears of bodily mutilation physical aggression and acting out behaviors (phallic stage) Favorite word I and Mine

Nursing Planning and Intervention for Pre-Schooler Providing concrete explanation and demonstration of treatments and procedures and opportunity for acting out participatory play Avoid terminology as cutting off a body part when explaining a surgical procedure Encourage outward expression of fear, anxiety, anger and pain

Sense of Industry vs. Inferiority Age 6-12 School Age The child becomes a successful oriented worker and producer Aspiring to be best in everything- games, school, making friends, building models, and completing projects. Child begins tasks and activities that can be seen through to conclusion and gradually learns the social skills of cooperation compromise, negotiation, completion and achievement Child learn to play and live by rules Winning and being successful are so important; child does not like to fail or to get behind in school work. The child is very sensitive Feeling wronged, having failed in some way or having not met someones expectation at school, the child avoid going to school Feelings of inadequacy may lead to feeling of inferiority

Nursing Intervention Promoting activities that the child can complete independently and fostering the childs self esteem by praising achievements and appropriate behavior Basic tools by achieving sense of industry a.) Communication b.) Mathematical abilities

Sense of Identity vs. Role Confusion Age 12-19 Adolescence Similar to the toddler searching for autonomy Seeking to gain personal identity, often demonstrates negativism (resistance to parental authority and values), ritualism,( a desire for brand name clothing, stereotyped vocabulary, peer social activities), emotional liability. Questions who Am I Peers significantly influence adolescent values and decision making Unresolved answer to the complex questions of adolescence lead to role confusion Nursing care focus on involving the adolescent in decision making- setting goals and encouraging the adolescent active participation in implementing a care plan Supply needs to enhance body image (shampoo/ hair dryer) readily available to the hospitalized adolescent. Awareness of the potential impact of any threat to body image whether temporary (pimple) or permanent (amputation) also mandates the nurses use of therapeutic communication skills

Sense of Intimacy vs. Isolation Age 20-40 Early Adulthood Developmental tasks involve the ability to share and to form commitments with other persons without fearing the loss of ones own identity

When they do not achieve intimacy individuals focus on their own needs to the exclusion of all other interest Nurse assesses the stresses and changes experienced during this period and provides teaching and resources to help the client maintain health Client who requires hospitalization, especially prolonged hospitalization, may face lost employment benefits, a disrupted life style, and decreased self-esteem. The nurse must not be judgmental of the clients needs and lifestyle and must refrain from imposing personal attitude

Sense of Generativity vs. Stagnation Age 40-65 Middle Adulthood Helping the next generation become adult Individual assumes work, family and community responsibility Individual who fail to develop responsibilities become egocentric, care only about themselves and do not develop further Nurse should consider many responsibilities and stresses affecting the client during this period, assessing the client relation to these stresses and providing resources and emotional support not only to the client but also to clients family and friend

Sense of Integrity vs. Despair Age 65 years and older Later Adulthood People review their life events if it satisfy them they are content; if not they become hopeless and desperate Nurse should recognize the physical and social changes occurring during this period and the limitations they may place on an individual Nurse should promote independence and the use of skills that the client retains Nurse needs to encourage each client to perform self care at the clients own pace Stimulation of functioning senses become highly important Nurse must treat each client as an adult even if the client behaves like an adolescent or child The elderly event whose friends, relatives and contemporaries die will need emotional support when evaluating lifes events

Epispadias- is a rare congenital (present from birth) defect in the location of the opening of the urethra. In boys with epispadias, the urethra generally opens on the top or side (rather than the tip) of the penis, though it is possible for the urethra to be open the entire length of the penis. In girls, the opening is usually between the clitoris and the labia, but may be in the abdomen. Causes and Risk Factors The causes of epispadias are unknown at this time. It is believed to be related to improper development of the pubic bone.

Signs and Symptoms In males: Abnormal opening from the pubic symphysis to the area above the tip of the penis Bladder exstrophy (may or may not be present) Widened pubic bone Short, widened penis with chordee (abnormal curvature of the penis) Urinary incontinence Reflux nephropathy Urinary tract infections

In females: Abnormal opening from the bladder neck to the area above the normal urethral opening Bladder exstrophy (may or may not be present) Widened pubic bone Bifid clitoris, rudimentary labia Urinary incontinence Reflux nephropathy Urinary tract infections

How does epispadias affect boys? In affected boys, the penis is typically broad, shortened and curve toward the abdomen. The penis may be attached to the pelvic bones, which are widely separated, resulting in a penis that is pulled back toward the body. Normally, the meatus is located at the tip of the penis; however, in boys with epispadias, it is located on top of the penis. From this abnormal position to the tip, the penis is split and is opened, forming a gutter. It is as if a knife was inserted into the normal meatus and the skin stripped away on the top of the penis. Classification of epispadias is based on the location of the meatus on the penis. It can be positioned on the glans, along the shaft of the penis or near the pubic bone. The position of the meatus important in that it predicts the degree to which the bladder can store urine (continence). The closer the meatus is to the top base of the penis, the more likely the bladder will not hold urine. How does Epispadias Affect girls? Epispadias is much rarer in girls. Those who are affected have public bones that are widely separated to varying degrees. This causes the clitoris not to fuse during development, resulting in two halves of the clitoris. Furthermore, the bladder neck is almost always affected. As a consequence, girls with epispadias invariably leak urine with stress. Fortunately, in most cases, early surgical treatment can resolve these problems.

Diagnosis The diagnosis of epispadias is typically made at birth. Although, on occasion when the malformation may not be drastic, epispadias has been missed at birth and only becomes apparent when the child (usually female) remains wet after toilet training. Treatment Surgical Technique in males: Cantwell technique, which involve partial disassembly of the penis and placement of the urethra in a more normal position. Mitchell technique, involves complete disassembly of the penis into its three separate components two corpora cavernosa and a single corpus spongiosum. This technique has a lower complication rate and facilitates bladder and bladder neck repair.

Surgical technique in females: Genital reconstruction in girls with bladder exstrophy is less complex compared to the reconstruction in boys. Children with the exstrophy-epispadias complex require surgery to improve the urethral resistance. There are several different methods to achieve this and still preserve normal urination function. An initial approach night involves injecting a bulking material around the bladder neck so that urine cannot leak from the bladder. Other surgical methods involve more complex procedures, like the creation of longer urethral tube or wrapping various materials around the bladder neck. Cyptorchidism or undescended testicles, is a congenital condition of infant males characterized by one or both testicles that havent moved into the scrotum by birth. Etiology The gonad becomes a testicle under the influence of a gene called testis determining factor on the short arm of the Y chromosome at 7 weeks of gestation. The testicle must then migrate from the level of the kidney through the belly and groin, and into the scrotum. It can get stuck anywhere along this path between the kidney and the scrotum. Signs and Symptoms The major symptom of cyptorchidism is not being able to feel one or both of the testicles in the scrotum. The testicles appear to be either missing or lopsided. If your doctor cant feel the testicles inside the scrotum, its called a nonpalpable testicle. Cyptorchidism can cause other complications, including infertility and testicular cancer. It is reported that changes

in an undescended testicle occur as early as six months of age, with the reported cancer rate in cyptorchidism at 22 times higher than in general population. Pathophysiology Sperm work better when they hang in the cooler environment of the scrotum. The undescended testicle is 10-40X more likely to form than the testicle in the scrotum. Diagnosis Ultrasounds or x-rays are of little help, since if they dont see the testicle, you still have to look with the laparoscope. Early diagnosis and management of cyptorchidism is needed to preserve fertility and improve early detection of testicular cancer. To diagnose cyptorchidism, an urologist, may palpate the scrotum and the abdomen to locate the testicles while the patient is in the squatting position or in a warm bath. The doctor may also test plasma testosterone concentrations to confirm the presence or absence of abdominal testicles. Presence of undescended testes can also be detected by measuring the amount of gonadotropin hormone in the blood. Treatment If a doctor diagnosis cyptorchidism in a patient over three years of age, treatment will usually follow. I left untreated, an undescended testicle can lead to sterility and an increased risk of testicular cancer. The doctor may recommend hormonal injections to help the testicles descend. The success of treatment depends on the position of the testicles at diagnosis. If hormone therapy is not successful, the doctor may perform a surgery called orchiopexy through a small cut in the groin. Recent improvement in surgical technique, including laparoscopic approaches to diagnosis and treatment, may improve the outcome. While orchiopexy may not protect patients from developing testicular cancer, the procedure allows for earlier detection through self- examination of the testicles. The doctor may also prescribe the hormone called hCG, which will help the testicles make male hormones. A higher level of male hormones might move the testicle down into the scrotum. In adults with an undescended testicle, moving the testicle to the scrotum probably wont improve the ability to make sperm, so the undescended testicle is usually just taken out. Doctors will often not treat an undescended testicle in men over 40. Hydrocele is a fluid- filled sack along the spermatic cord within the scrotum Hydroceles are common in newborn infants. The fluid buildup can be on one or both sides of the scrotum. During normal development, the testicles descend down a tract (tube) from the abdomen into the scrotum. Hydroceles result when this tube fails to close. Peritonel fluid drains from the abdomen through the open tube. The fluid accumulates in the scrotum, where it becomes trapped. This causes the scrotum to enlarge.

Hydroceles normally go away a few months after birth, but their appearance may worry new parents. Occasionally, a hydrocele may be associated with an inguinal hernia. Hydroceles can be easily demonstrated by shining a flashlight through the enlarged portion of the scrotum. If the scrotum is full of clear fluid, as in a hydrocele, the scrotum will light up (transillumination) Hydroceles may also be caused by inflammation or trauma of the testicle or epididymis, or by fluid or blood blockage within the spermatic cord. This type of hydrocele is more common in older men. Symptoms The main symptoms is a painless, swollen testicle, one or both sides, which feels like a water-filled balloon. Treatment Hydroceles are usually not dangerous, and they are usually only treated when they cause discomfort or embarrassment, or they get so large that they threaten the testicles blood supply. One option is to remove the fluid in the scrotum with a needle (a process called aspiration). However, aspiration can cause infection, and it is common for the fluid to reaccumulate. Therefore, aspiration is not routine and surgery is generally preferred. On the other hand, aspiration may be the best alternative for people who have certain surgical risks. Injection of sclerosing (thickening or hardening) medications may be performed after needle aspiration to close off the opening through the scrotal sac. This helps prevent reaccumulation of fluid. The medications include tetracycline, sodium tetradecyl sulfate, or urea. Possible complications after aspiration and sclerosing include infection, fibrosis, mild to moderate pain the scrotal area, and recurrence of the hydrocele. Surgery Hydrocelectomy is often performed to correct a hydrocele. This is a minor surgical procedure performed on an outpatient basis using general or spinal anesthesia. A cut may be made in the scrotum or the lower abdomen. The procedure may require a scrotal drainage tube or a large bulky dressing to the scrotal area. You will be advised to wear a scrotal support for some time after surgery. Ice packs should be kept on the area for the first 24 hours after surgery to reduce the swelling. Varicocele In all guys, theres structure that contains arteries, veins, nerves, and tubes called the spermatic cord that provides a connection and circulates blood to and from the testicles. Veins carry the blood flowing from the body back toward the heart, and a bunch of valves in the veins keep the blood flowing one way and stop it from flowing backward. In other words, the halves regulate your blood flow and make sure everything is flowing in the right direction.

But sometimes these valves can fail. When this happens, some of the blood can flow in reverse. This backed-up blood can collect in pools in the veins, which then causes the veins to stretch and get bigger, or become swollen. Causes A varicocele develops when the valve that regulates blood flow from the vein into the main circulatory system becomes damaged or defective. Inefficient blood flow causes enlargement (dilation) of the vein. Signs and Symptoms Most men who have a varicocele have no symptoms. Cases are often diagnosed during a routine physical examination. Signs and symptoms may include the following: Ache in the testicle Feeling of heaviness in the testicle(s) Infertility Shrinkage (atrophy) of the testicle(s) Visible or palpable (able to be felt) enlarged vein

Diagnosed Large varicoceles may be seen with the naked eye. Medium- sized varicoceles may be detected during physical examination by feeling (palpating) the area. A patient suspected of having a varicocele should be examined while standing up, as a varicocele-

Reproductions Altered Reproductive Development 1. Ambiguous genitalia - External sexual organs in the child did not follow normal course of development, so that at birth the external sexual organs are so incompletely or abnormally formed that it is impossible to clearly determine the childs set by simple observation. Ex. Male infant with hyposphadias (urethral opening on the underside of the penis) and cyptorchidism (undescended testes) may appear more female than male on first inspection. A child maybe hermaphrodite (having both ovaries and testes) and consequently, malformed external genitalia. Children with ambiguous genitalia are often termed pseudo hermaphrodite because are infants they have some external features of both sexes, although only either ovaries or testes are present.

Assessment a.) Karyotype Test- help to establish whether the child is genetically male or female Drawing a specimen of blood, allowing the white blood cell to reach a division stage. b.) Laparoscopy- introduction of a narrow laparoscopy into the abdominal cavity through a half inch incision under the umbilicus maybe determines if undescended testes are present. c.) Intravenous pyelography is used to establish whether a male has a complete urinary tract. Exploratory surgery maybe necessary to establish whether gonads are present. Therapeutic Management: Reconstructive surgery - Correction of hyposphadias/cryptorchidism - Removal of labial adherence or surgical removal of an enlarged clitoris - Nonfunctioning ovaries or testes are generally removed to prevent malignancy later in life - If an infant is chromosomally male but does not have an adequate penis, a decision to raise the child as a female might be made, although construction of an artificial penis is more likely.

2.) Precocious Puberty - Development of breast or pubic hair before age 8 years or menses before 9 years is considered precocious sexual development - Occurs more often in girls than in boys

- Cause by early production of gonadotrophins by the P6 stimulates the ovaries or testes to produce sex hormones. It occur because of a pituitary tumor cyst, or traumatic injury to the third ventricle next to the pituitary gland - Can also occur because of estrogen secreting cysts or tumor of the ovary or testosterone- secreting cysts of the testes - Occurs because of an estrogen or testosterone secreting adrenal tumor Assessment Increase breast development and accelerated skeletal maturation Girls have vaginal bleeding with little pubic or axillary hair because of still low androgen secretion Boys have obvious genital growth Confirmed by serum analysis for estrogen androgen adult levels

Therapeutic Management Synthetic Analogue to LHRH administration desensitizes the pituitary to the childs own prematurely elevated hypothalamic LHRH Administered SC daily When discontinued at age 12-13 years, puberty progresses normally

3.) Delayed Puberty - Failure of pubertal stages to occur at the usual age - Family history of many children reveals a family tendency of late maturation Girls- menstrual cycles can be started by administering estrogen Boys- receive testosterone supplements to stimulate hair and genital growth. Imperforated Hymen Totally occludes the vagina, preventing the escape of vaginal secretions and menstrual flow Before menarche, a child with an imperforated hymen generally has no symptom with onset menstrual flow is obstructed builds up in vagina causing increase pressure in vagina and uterus pain Palpation reveal lower abdominal mass Vaginal exam an intact bulging hymen is evident

Treatment: Surgical incision or removal of hymenal tissue

Toxic Shock Syndrome (TSS) An infection usually caused by toxin producing strains of staphylococcus aureus organism enters the body through vaginal walls damaged by the insertion of tampons at the time of menstrual period

Assessment Fever with diarrhea and vomiting during a menstrual period

Therapeutic Management Women or adolescents with suspected TSS need a careful vaginal exam and cervical cultures for S. Aureus, Iodine douches, Penicillin but not penicillinase resistant antibiotic (Cephalosporins, oxacillins or clindamycin) to restore circulating bed volume and increase BP, Diuretics

Hydrocele - presence of abdominal fluid in the scrotal sac. Assessment: Non Communicating Hydrocele a.) Occurs when residual peritoneal fluid is trapped with no communication to the peritoneal cavity b.) Usually disappears by age 1 year Communicating Hydrocele a.) Associated with a hernia that remains open from the scrotum tot eh abdominal cavity b.) Assessment includes a bulge in the inguinal area or the scrotum that increases with crying or straining and decreases when the child is at rest. Implementation post operatively a.) Provide ice bags and a scrotal support to relieve pain and swelling b.) Instruct the child and parents to avoid tub bathing until the incision heals c.) Instruct the child and parents to avoid strenuous physical activities Phimosis foreskin is tight at birth and even when held by adhesions cannot be retracted it interferes with voiding may develop ________ (inflammation of the glans penis and prepuce) because the foreskin cannot be retracted for cleaning can be corrected by circumcision

Varicocele abnormal dilatation of the veins of the spermatic cord often occurs on the left side identifying a varicocele is important in adolescents because although asymptomatic, the increased heat and congestion in the testicles can lead to infertility no treatment is necessary unless fertility becomes a concern, at which time varicocele can be surgically removed

Fibroadenoma Tumors consisting of both fibrotic and glandular components that occur in response to estrogen stimulation. Tumors may increase in size during adolescence pregnancy and lactation, or when a woman takes an estrogen source such as an oral contraceptive. Feeling firmer and rubbery than fluid filled cyst. They calcify and extremely hard, painless, freely movable and tend not cause skin retraction. They do not become malignant can be surgically excised

Undescended Testicles (Cryptorchidism) A. General Information 1. Unilateral or bilateral absence of testes in scrotal sac 2. Testes normally descend at 8 months of gestation, will therefore be absent in pre mature infants 3. Incidence increased in children having genetically transmitted disease 4. Unilateral cryptorchidism most common 5. 75% will descend spontaneously by age 1 year B. Medical management 1. Whether or not to treat is still controversial if testes remain in the abdomen, damage to the testes (sterility) is possible because of increased body temperature 2. If not descended by age 8 or 9, chorionic gonadatropin can be given 3. Orchipexy: surgical procedure to retrieve and secure testes placement; performed between ages 1-3 years C. Assessment findings: unable to palpate testes in scrotal sac (when palpating testes be careful not to elicit cremasteric reflex, which pulls testes higher in pelvic cavity) D. Nursing Intervention 1. Advise parents of absence of testes and provide information about treatment options 2. Support parents if surgery is to be performed 3. Post-op, avoid disturbing the tension mechanism (will be in place for about 1 week) 4. Avoid contamination of incision.

Hypospadias A. General Information 1. Urethral opening located anywhere along the ventral surface of penis 2. Chordee(ventral curvature of the penis) often associated, causing constriction 3. In extreme cases, childs sex may be uncertain B. Medical Management 1. Minimal defects need no intervention 2. Neonatal circumcision delayed, tissue may be needed for corrective repair 3. Surgery performed at about age 6-18 months C. Assessment Findings 1. Urinary meatus misplaced 2. Inability to make straight stream of urine D. Nursing Intervention 1. Diaper normally without extra care (voiding presents no problem) 2. Provide support for parents who will be distraught over defect and sexual overtones; refer for counseling as needed. 3. Provide support for child at time of surgery; fears of mutilation are prominent 4. After surgery check orders for dressing changes; monitor catheter drainage. Epispadias similar defect in which the opening is on the dorsal surface of the penis.

SEXUALLY TRANSMITTED DISEASE Infection occurring predominantly in the genital area and spread by sexual activitiesor contact A.k.a Venereal Disease (VD), Sexually Transmitted Infection (STI) Five widely known: Chlamydia Gonorrhea Syphilis Genital Herpes Genital Warts Characteristics Can be transmitted by any sexual activity between opposite sex or same sex partners Having one STD confers no immunity against future re- infection with that STD or with any other STD Sexual partners of infected clients need to be assessed for treatment

 STDs affect people from all socioeconomic classes, cultures, ethnicities, and age groups Women bear a disproportionate number of the effects of the STDs Frustrations, anger, anxiety, fear, shame, and guilt are common emotions associated with an STD diagnosis STDs frequently coexist in the same client Risk Factors IV drug use High-risk sexual activity Younger age and sexarche Poverty Poor nutrition Poor hygiene Prevention and Health Promotion Education Detection of active disease Evaluation and treatment of sexual partner Pre- exposure vaccination if available ABCD (Abstinence, Be faithful, Condom, do not penetrate) Health Maintenance Screening high risk people Maintaining a high index of suspicion for asymptomatic infections Providing accurate, timely diagnosis and treatment Performing follow-up after treatment when indicated Reporting cases of STD Identifying and treating sexual partners of clients with STD Assessment 1. General health assessment and examination 2. Sexual history, preference, and practices 3. Previous history of STD 4. Specific complaints 5. Genital hygiene practices 6. Contraceptives history 7. Infection barriers used Goals 1. Disease process will be identified and treated 2. Affected others will be identified and treated 3. Complications will be prevented

Interventions 1. Collect specimens for tests 2. Implement isolation technique if indicated 3. Teach transmission and prevention techniques 4. Assist in case findings 5. Administer medications as ordered 6. Informed client of any necessary life-style changes Evaluation 1. Client receiving treatment appropriate to specific order, understands treatment regimen 2. Client demonstrate knowledge of disease process and transmission 3. Affected others have been identified and treated GENITAL WARTS

Causative Agent Human Papillomavirus

Clinical Manifestation Tiny, gray or red swellings in genital area Several warts close to each other Itching or burning Discomfort, painful intercourse Foul odor

Diagnostic Test Pap Smear Acetic Solution Colposcopy Biopsy

Medical Management Treatment Imiquimod (Aldara) Podofilox (Condylox)- abortifacient Trichloroacetic acid (TCA) Carbon Dioxide Laser Simple Surgical Excision

Nursing Management Inform clients with genital warts that no cure exists and that female clients are at risks for genital malignancy GRANULOMA INGUINALE Causative Agent Calymmatobacterium Granulomatis Donovanosis

Clinical Manifestation Pimple or lumpy eruption on the skin Sore Bleeding Pink or dull red granulation Foul-smelling ulcers

Diagnostic Test Biopsy Blood Test Light staining

Treatment Erythromycin Streptomycin Tetracycline Ampicillin AIDS Lymphadenopathy Associated Virus- 1983 Human T-Cell Lymphotropic Virus Type III- 1984 Human Immunodeficiency Virus- 1986 HIV 1 HIV 2 Genetic Promiscuity

Transmission Sexual intercourse Needle sharing Occupational exposure Organ transplant taken from an HIV- infected donor

A contaminated blood transfusion Through blood, semen or vaginal fluid Perinatal transmission( Vertical Transmission)

Clinical Manifestation Category A Fever Fatigue Lymphadenopathy Nausea and vomiting Headache Hepatomegaly Myalgia Truncal rash Ulcers Thrush Pharyngitis Diarrhea Anemia Leucopenia Thrombocytopenia

Category B Bacterial endocarditis, Meningitis, Pneumonia, Sepsis Candidiasis, Vulvoovaginal Candidiasis oropharyngeal Cervical dysplasia Fever Diarrhea Herpes Zoster Thrombocytopenia Purpura PID Peripheral neuropathy

Category C Candidiasis of bronchi, trachea, or lungs Candidiasis, esophageal Cervical cancer Loss of vision Liver, spleen nodes Herpes Simplex Toxoplasmosis of brain

 Mycobacterium diseases Lymphoma Diagnostic Test ELISA Western Blot HIV RNA Blood Test (Viral Load Testing) Results: Positive HIV infected but it does not predict future course of disease Negative HIV antibodies were not detected Indeterminate ELISA (+) but Western Blot did not confirm

Medical Management Maintain Health Antiretroviral therapy Nucleoside reverse transcriptase inhibitors (NRTIs) Zidovudine/ Lamivudine (Combivir) Didanosine (Videx, ddI) Stavudine (Zerit,d4T) Abacavir (Ziagen) Zalcitabine (Hivid, ddC) Zidovudine (Retrovir) Protease Inhibitors (PIs) Saquinavir ( Invirase, Fortovase) Ritonavir (Norvir) Indinavir (Crixivan) Nelfinavir (Viracept) Amprenavir (Agenerase) Non- nucleoside reverse transcriptase inhibitors (NNRTIs) Nevirapine ( Viramune) Efavirenz (Sustiva) Delavirdine (Rescriptor) HAART (Highly Active Anti-retroviral Therapy) Nursing Management Help client with health maintenance behaviors Provide education Initiate and maintain antiretroviral Therapy Promote self care and self-awareness by having the client keep daily fatigue diary

Maintain comfort and safety Provide physical therapy Encourage Complementary therapies INFERTILITY

A situation in which regular, unprotected intercourse does not result in a pregnancy over a 12- month period Inability to deliver a live infant after three consecutive pregnancies Inability to impregnate a female partner within the same conditions Primary infertility- no previous conceptions; Secondary infertility- has been a previous viable pregnancy but the couple in unable to conceive at present 30%-40% man who is infertile, 10% ovulatory failure, 40%-50% tubal or vaginal involvement or endometriosis, 5%-10% no cause Etiology and Risk Factors Male Factors Hormonal causes involve endocrine dysfunction (e.g. pituitary and adrenal tumors, thyroid disorders, diabetes, and cirrhosis) Disturbance in spermatogenesis Obstruction in the seminiferous tubules, ducts (mumps) Vessels that prevents motility Abnormalities (hypospadias,epispadias) Problem in ejaculation(psychogenic infertility) Inadequate sperm count Cryptorchidism Trauma to testes Surgical procedures Varicocele Gonadotoxins Formation of anti-sperm antibodies Female Factors Anovulation occur from Turners syndrome Tubal Transport Problems Uterine Problems (tumors, inadequate endometrium formation) Endometriosis Cervical problems (infection) Vaginal problems

Diagnostic Examination Laboratory tests MALE Sperm Analysis Normal: Semen Volume 1.5 5 ml Concentration - >20 million sperm/ml Total Sperm Count - >50-60 million Mortality 60% grade 2 or higher (on scale of 1-4) Morphology 60% normal Urinalysis, CBC, Rh factor, sonogram, sedimentation rate, serum endocrine studies, testicular biopsy FEMALE Basal body temperature Ovulation Determination by Test Strip Ovulation Determination by Cervical Mucus - Fern test- high estrogen level - Spinnbarkeit Test at height of estrogen secretion - Postcoital Test time of ovulation is predicted from woman basal body temperature Surgical Testing Uterine Endometrial Biopsy receptivity of endometrium Laparoscopy Visual exam of pelvic/ abdominal organs Hysteroscopy Visual inspection of the uterus through insertion of a hysteroscope

Medical Management MALE Impotence- may helped by psychologic counseling / penile implants Low/abnormal sperm count no good therapy, use of hormone therapy has little success Varicocele- ligation Infection antibiotic Social habits changing habits FEMALE Congenital anomalies surgical treatment Anovulation endocrine therapy with clomiphene citrate (Clomid/) menotropins (Pergonal)

 Tubal factors antibiotic, surgery Uterine Conditions removal of IUD, antibiotic or surgery Vaginal/cervical antibiotics, proper vaginal hygiene or artificial insemination ALTERNATIVES Artificial insemination by husband or donor In vitro fertilization Adoption Surrogate parenting Embryo transfer

Nursing Management Assist with assessment including a complet history, physical exam, lab work, and tests for both partners Monitor psychologic reaction to infertility Support couple through procedures and tests Identify and existing abnormalities and provide couple with information about their condition Help couple acknowledge and express their feelings both separately and together Prevent infertility Avoid gonadotoxins Decrease exposure to occupational and environmental hazards Keeping scrotum cool Eating well balanced nutritious diet