Body System Integumenatry

Sign or Symptom
st nd

1 week and 2 week

Implication Pale skin or pallor may be due to decreased blood supply and anemia [1]. Hbg= 77 g/dL on 1/10/12, Hgb= 105 and 115 g/dL on 1/13/12 and 1/15/12 respectively. Normal value= 115-155 g/dL [3]. Cool skin may accompany arterial insufficiency [1]. Dry skin is seen in dehydration. Excessive dryness suggests poor nutrition [1]. Decreased skin turgor (a slow return of the skin to its normal state taking longer than 2 seconds) is seen in dehydration. Place the child on his back. Locate the area on childs abdomen halfway between umbilicus and the side of abdomen. Pinch using thumb and first finger. Skin pinch goes back immediately. Note that in child with edema, skin may go back immediately even if the child is dehydrated. [2] Dull, dry hair may be seen in malnutrition [1]. Pale or cyanotic nailbeds may indicate hypoxemia or anemia [1]. There is a slow (greater than 2 seconds) capillary nailbed refill (return of pink tone) with hypoxemia and anemia [1].

Skin pale and dry Palms cool to touch Poor skin turgor (> 2 seconds) Hair dull and dry Pale nailbeds Capillary refill time= 2 seconds

Eyes

1st week

2 week

nd

Sunken eyeballs with dark circles under eyes Red and swollen stye on both eyelids approximately 0.5 cm, with scabs at surrounding area Pale conjunctiva Pupil equally round (3mm) reactive to light (constriction) and accommodation

Eyelids have crusts approximately 0.4 cm Pale conjunctiva

The eyes of a child who is dehydrated may look sunken [2]. A sunken appearance in the eyes may indicate chronic wasting illnesses [2]. Hordeolum (stye), a hair follicle infection causes local redness, swelling and pain. Infection sets in when oil or tear gland, or a follicle becomes clogged with dirt or oil, usually due to poor hygiene [4]. Crusting along the lid margin suggest seborrhea due to poor lid hygiene [5]. Pallor or cyanosis in the conjunctiva may be seen in anemia- low haematocrit and cyanosis [5]. The iris is typically round, flat and evenly colored. The pupil is round with a regular border, is centered in the iris. Pupils are normally equal in size= 3mm (normal 3-5mm). The normal direct pupillary response is

Ears

Auricles align with each corner of each eye No excessive cerumen noted.

constriction. Eyes do not converge [1]. Hirschsprungs disease can be found associated in Down syndrome. A sign of Down syndrome is low set ears with an alignment greater than 10-degree angle [6]. A small amount of odourless cerumen is normally present. Cerumen may be yellow, orange, brown or gray. About 85% of Asians have dry earwax. Dry earwax may most likely to become impacted [1]. Romberg Test tests the clients equilibrium. Ask the client to stand with feet together and arms at sides with eyes open, then with eyes closed. He should maintain position for 20 seconds without swaying or with minimal swaying. If the client moves feet apart, this may indicate vestibular disorder. Weight-bearing instability may indicate weakness [1].

Cranial Nerves

1 week

st

CN 8- Acoustic (+) Romberg test due to weakness on the lower extremities. Unable to stand alone without support. Able to hear whispered word color from a distance of 2 feet. (-) Romberg test. Able to hear whispered word lapis from a distance of 2 feet. The rest have unremarkable findings Clear nasal exudate Productive cough expectorating to white phlegm Frontal and maxillary sinuses nontender Sternocleidomastoid muscle used upon breathing. No chest indrawing. Fine cracles on upper and lower lung fields Prominent contour of ribs Chest circumference= 52 cm White nasal exudate Productive cough expectorating to yellow phlegm

2nd week

Respiratory

1st week

2nd week

Exudate is common with infection and may range from large amounts of watery discharge to thick yellow-green purulent discharge [1]. Frontal and maxillary sinuses are normally nontender upon palpation [1]. Sternocleidomastoid muscle, muscles that raise the sternum help facilitate inspiration in cases of acute or chronic airway obstruction. Child under 7 years old are abdominal breathers [1]. Look for chest indrawing when the child breaths in. the child has chest indrawing if the lower chest goes in when the child breaths in. in normal breathing, whole chest and the abdomen moves out when the child breaths in [2]. Fine crackles are high-pitched, short, popping sounds heard during inspiration and not cleared by coughing; sounds are discontinuous and can be simulated by rolling a strand of hair between your fingers near your ear. Source may be inhaled air suddenly opens the small deflated air passages that are coated and sticky with exudate. This may be associated with restrictive diseases

 Cardiovascular Bounding pulse 3+ Non pitting edema on lower extremities

Genito-urinary

1st week

such as pneumonia [1]. In severe malnutrition, the outline of childs ribs is easily seen [2]. Pulses should be regular in rate and rhythm 4+ = bounding 3+ = increased 2+ = normal 1+ = weak 0 = absent The presence of edema is characteristic of isotonic fluid volume excess. As the vascular volume increases, the pulse becomes full and bounding [7]. Edema caused by decreased capillary colloidal osmotic pressure usually is the result of inadequate production or abnormal loss of plasma proteins, mainly albumin. In starvation and malnutrition, edema develops because there is a lack of the amino acids needed in plasma protein synthesis [7]. Total protein= 60.8 (normal= 65- 86 g/L) albumin= 19.5 (normal= 32-50 g/L) A scale of 1+ to 4+ is used to grade the severity of pitting edema [1]. Tanners Sexual Maturity Rating For Boys [8]. a) Stage 1- no pubic hair except for fine body hair. Penis, testes and scrotum same size and proportions as in childhood. b) Stage 2- sparse growth, slightly curly pubic hair. Penis slight or no enlargement. Testes and scrotum both larger, reddened, exhibiting textural changes. c) Stage 3- pubic hair darker, coarse, sparse hair over symphysis pubis. Penis larger and longer. Testes and scrotum have further enlargement. d) Stage 4- coarse, curly hair that does not extend to medial thighs. Penis increased length and width, development of glans. e) Stage 5- adult hair in texture and quantity extends to medial aspects of thigh. Penis, testes and scrotum adult in size and shape.

2nd week

Scanty tea-colored urine Tanner stage 1 Yellow urine approximately 60 cc

Gastrointestinal System

1st week:

2nd

Endocrine System Musculoskeletal System

Lips, tongue, and buccal mucosa pale and moist Tonsils grade 1 Distended abdomen Abdominal girth= 54 cm Double loop ileostomy at RLQ draining to yellow watery stools; with red surrounding Anus patent but without stool passage Normoactive bowel sounds but barely audible on RLQ Bulging of abdominal contents Abdominal girth= 55 cm Varicosities noted Stoma is red and moist with light brown mushy stool On NPO week: Abdominal girth= 55 cm Ileostomy with light brown mushy stool Able to pass ribbon like stool approximately 2 inches On DAT Thyroid gland midline and nontender

Pale skin or pallor may be due to decreased blood supply and anemia [1]. Hbg= 77 g/dL on 1/10/12, Hgb= 105 and 115 g/dL on 1/13/12 and 1/15/12 respectively. Normal value= 115-155 g/dL [3 DISTENDED ABDOMEN Redness around the stoma is due to enzyme secretions

No significant findings noted

1st week:

Ectomorph Weight= 10 kg Height= 100 cm BMI= 10 Mid-arm circumference= 10 cm Quadriceps circumference= 14 cm DTR= +2 on all extrtemities Muscle strength= 4/5 on all extremities Able to do full range of motion with verbalization of weakness With prominent bony contour MUSCLE WASTING NOTED

Ectomorph Ideal weight for children at age 7 is 18 kg. A weight of 10 kg signifies being underweight. Ideal BMI is 18.50 - 24.99. A BMI of 10 cm signifies severe thinness[. Ideal mid-arm circumference for children at age 7 is ____. A mid-arm circumference of 10 cm signifies ____. Ideal quadriceps for children at age 7 is ____ cm. A quadriceps of 14 cm signifies ____. Deep tendon reflex responses are often graded on a scale of 0 to 4. 2indicates an average or normal response. Muscle Strength=4, full range of motion against gravity and a moderate amount of resistance

2nd week:

Weight= 12 kg

Height= 100 cm BMI= 12 Mid-arm circumference= 10.5 cm Lymph nodes nontender and nonpalplable Capillary refill time= 2 seconds No excessive bruising noted No significant findings noted

Lymphatic System Hematopoeitic System

There is a slow (greater than 2 seconds) capillary nailbed refill (return of pink tone) with hypoxemia and anemia [1].

Sources: 1. 2007. Weber, J., Kelly, J. Health Assessment in Nursing, 3rd Ed. LWW 2. 2008. Divinagracia, C. Integrated Management of Childhood Illness. 3. 2007. Wongs Nursing Care of Infants, 8th Ed. 4. 2001. Health Guide Philippines. Vivendi Universal Publishing 5. 2008. Smeltzer, S., Bare, B. Brunner and Suddarths Medical-Surgical Nursing, 12th Ed. 6. 2007. Piliterri, A. Maternal and Child Nursing: Care of the Childbearing and Childrearing Family, 5th Ed. LWW 7. 2005. Porth, C.M. Pathophysiology: Concepts of Altered Health States, 7 th Ed. 8. 1962. Tanner. Growth at Adolescence, 2nd Ed. Oxford: Blackwell Scientific Publications