Multi-Educational Review Group Experts, Inc.: Child Health Nursing

MULTI-EDUCATIONAL REVIEW GROUP EXPERTS, INC.
*BAGUIO CITY *ILOILO CITY *BACOLOD CITY *DAVAO CITY *CABANATUAN CITY *KIDAPAWAN
CITY *MAKATI CITY *CEBU CITY *GENERAL SANTOS CITY *PAMPANGA *TUGUEGARAO CITY
*ILIGAN CITY *LUCENA CITY * NAGA CITY *CAVITE CITY * BIAN LAGUNA*SM NORTH
*MANILA HEAD OFFICE
www.merge-review.com
CHILD HEALTH NURSING
Growth and Development
I. Growth increase in physical size of the body (quantitative change)
Development progression in skill and or ability to function (qualitative change)
II !rinciples"
A continuous process
B ody systems don#t develop at the same rate
C ephalocaudal
D evelopment proceeds from pro$imal to distal
E levation from gross motor to refined skills
F or play is the universal language of children
G rowth rate varies
H as to follow a definite and predictable pattern of trends
I mportant indicator of development is the behaviour
J ust as each child is unique
III %tages of Growth & Development
'asic Divisions of (hildhood
%tage"
)eonate first *+ days of life
Infant , mo , yr
-oddler , . yr
!reschooler . / yr
%chool 0ge 1 ,* yr
0dolescent ,. *2 yr
0 Infancy !eriod
0 rapid growth and development
, month until , year
3rikson " -rust vs 4istrust
5reud " 6ral (ID)
!iaget#s " %ensorimotor stage (27* years old)
, month" neonatal refle$
,78 months" primary circular reaction (body is center of attention)
87+ months" secondary circular reaction (from body to environment)
+7,* months" coordination of secondary reaction
,*7,+ months" tertiary circular reaction (trial & error)
5ear " %tranger 0n$iety
!lay " %olitary
-oys " mobile9 rattle9 teething rings9 musical toys9 crib9 gym
MERGE-Manila: 28 A.M Bldg. Quezon Ave., Quezon City Tel:(02!"2-0022#!"$-$%%&
1
' -oddler
0ge , to . years
'ow7legged
(haracterized by alternating rapid and slow rate of growth & development
3rickson " 0utonomy vs %hame & doubt
5reud " 0nal (3G6)
!iaget#s " !reconceptual : !reoperational stage (.78 years old)
0 toddler draws conclusion only from the obvious facts that they
see
,+7*8 month" invention of new means through mental combinations
;ohlberg " <evel ," !reconventional
%tage ," (* 7. years old)
!unishment:6bedience orientation
5ear " %eparation 0n$iety
!lay " !arallel
-oys " !ush and pull
( !re school period
0ge . to / years
3rickson " Initiative vs Guilt
5reud " !hallic
!iaget#s " Intuitive stage (/71 years old)
A ssimilation
B y magical thinking
C entering
D on#t aware of reversibility
E gocentrism
F antasy role
;ohlberg " <evel ," !reconventional
%tage *" 87= years old
Individualism
5ear " 4utilation and castration
!lay " 0ssociative & Imitation
-oys " a simple >igsaw puzzle9 dolls9 coloring book9 pencils9 pens9 crayons
D %chool period
0ge 1 to ,* years
'y having a slow period of growth and development
3rickson " Industry vs Inferiority
5reud " <atency
!iaget#s " (oncrete operations (=7,* years old)
0ware of reversibility
'y inductive reasoning
(onservation & (lassification
Development of <ogical thought patterns
;ohlberg " <evel II" (onventional
%tage ." =7,2 years old
6rientation to interpersonal relations of mutuality
%tage 8" ,27,* years old
4aintenance of social order
2
5ear " Displacement from school
!lay " (ooperative & (ollectibles
-oys " ?emote control games9 game ball9 table games
3 0dolescence
0ge ,. to *2 years
0ccelerated growth and maturation influenced by hormonal changes
(haracterized by growth spurt which begins early in girls9 about ,7* years ahead than boys
3rickson " Identity vs ?ole confusion
5reud " !uberty:Genital
!iaget#s " 5ormal stage (,* years old & above)
0bstract thinking
'y deductive reasoning
;ohlberg " <evel III" !ost7conventional
%tage /" ,* years and over
%ocial contract (follows standards of society for the good of all
people)
%tage 1" ,* years and over
@niversal ethical principle orientation
5ear " Displacement from peers
!lay " 0thletic & %ports
-oys " 4usic gadgets etc
IA 4aternal7Infant bonding
A special mutual relationship between mother and infant
B est initiated immediately after birth
C an be achieved within the first .2 minutes or
D uring the first period of reactivity
E $hibited through" 'reastfeeding
?ooming7in
%enses stimulation
A 0ssessment
A. Initial care of the newborn
0ssessment
observe or assist with initiation of respirations
assess apgar score (pls see table below)
monitor for nasal flaring9 grunting9 retractions & abnormal respirations
obtain vital signs
observe newborn for signs of hypothermia or hyperthermia
assess gross anomalies

Interventions
%uction mouth9 then nares with bulb syringe
Dry newborn and stimulate crying by rubbing
4aintain temperature stabilityB wrap newborn in warm blankets and place
stockinette cap on newborn#s head
;eep newborn with mother to facilitate bonding
!lace newborn at mother#s breast if breastfeeding is planned9 or place on mother#s
abdomen
!lace newborn in warmer
!osition newborn on side or abdomen or in modified -rendelenburg position to
facilitate drainange of mucus
3nsure newborn#s proper identification
3
5ootprint newborn and fingerprint mother on identification sheets
!lace matching identification bracelets on mother & newborn

' 0pgar %creening test (by Dr Airginia 0pgar)
7 Done twice at , and / minutes respectively
Criteria ! "
HR# absent C,22 D,22
RR# absent weak cry vigorous cry
Re$le% Irrita&ilit'# no response grimace vigorous cry
()*+le tone# limp:flaccid minimal full fle$ion
S,in +olor# blue acrocyanosis pink
%cores" Interpretation
,. !oor 7 needs immediate (!?
4.6 5air 7 needs further observation & stimulation
=7,2 Good 7 healthy
( 3stimation of 0ge of Gestation by Dr 'allard#s and Dubowitz
(riteria"
, !hysical characteristics
-re.mat)re Term F)ll.term
S,in" very thin9 gelatinous9
& visible blood
vessels
smooth9 thick9 less
visible blood vessels
parchment9
leathery9 cracked9
wrinkled
Lan)/o" 0bundant thinning bald
-lantar
+rea*e*"
anterior transverse *:. with creases entire sole w:
creases
Brea*t" strippled areola raised areola full areola
Ear" flat & folded thin & soft thick & firm
Genital 0(1# undescended testes intermediate fully descended
Genital 0F(1" prominent labia &
clitoris
labia minora & clitoris
partly covered by labia
ma>ora
completely covers
minora & clitoris
* )euromuscular characteristics
-re.mat)re F)ll term
-o*t)re# e$tension fle$ion
S2)are window# E2F angle 2F angle
Arm re+oil# DE2F angle CE2F angle
S+ar$ *i/n# elbow passed midline not passed
-olpliteal an/le# DE2F angle CE2F angle
Heel to ear# positive negative
. )eurological assessment
?efle$es"
4
?ooting" elicited when )' cheek is touched and turns towards the stimulus
3$trusion" food placed on infant#s tongue is thrust forward and out of mouth
-onic neck" as head is turned to one side9 arm & leg on that side e$tends with opposite
e$tremities in fle$ion
!almar grasp" elicited by placing finger in the )' palm
4oro:%tartle" newborn symmetrically abducts and e$tends arms
%tepping" hold the )' in a vertical position allowing one foot to touch a table surface
'abinski" dorsifle$ion of big toe and fanning of all four toes as sole foot is stroked from heel
AI !rofile of a )ewborn
0 'irth weight" */ to .8 kg (// to == lbs)
'G" doubles at 1 months
triples at ,* months
quadruples at * H years
<'G" C *9/22 grams
Aery <'G" C,2
th
percentile
<G0 D89222 grams or DE2
th
percentile
' 'irth length" 81 to /8 cm (,+7** inches)
( Iead (ircumference" .8 to ./ cm (,./7,8 inches)
D (hest (ircumference" .* to .. cm (,*7,.* inches)
3 Aital %igns
-emperature " E=1 to E+1F5 (.1/ to .= F() a$illary
Ieart rate " ,*2 to ,82 bpm
?? " .2 to 12 breaths per minute
'! " +2:81 mmIg
AII !hysical 0ssessment
0 Iead
1. 0nterior fontanel" soft9 flat diamond shaped9 . to 8 cm wide by * to . cm long
7 closes between ,*7,+ months
2. !osterior fontanel" triangular9 , cm wide
7 closes *7. months
3. (aput succedaneum" swelling of scalp caused by prolonged labor
7 crosses over suture line
7 gradually disappears at about third day of life
4. (ephalhematoma" collection of blood caused by increase pressure of birth
7 caused by rupture of periosteal capillary
7 absorbed within .71 weeks
/ (raniotables" localized softening of the cranial bones
7 caused by pressure of the fetal skull against the mother#s pelvic bone in
utero
7 condition corrects itself without treatment in few months
5
B. 5ace" observe for symmetry
( 3yes
A ssume permanent color between . & ,* months of age
B lue or gray irises
C ornea round
D ue until 871 months" strabismus
E rythromycin antibiotic ointment at birth
F or protection against chlamydia infection or ophthalmia neonatorum
G ets subcon>unctival hemorrhage" a red spot on sclera on inner aspect of eye due to
pressure at birth (absorbed in *7. weeks)
D. )ose" nasal flaring indicates respiratory distress
3 3ars
-he pinna normally align from inner to the outer canthus of the eye
-he low set ears indicate"
, (hromosomal disease
* ;idney disease
. (raniofacial lesions
-est newborn hearing by ringing a bell held 1 inches from each ear
5 4outh
( oniliasis (6ral thrush):(andidiasis white cheesy patches in mucous membrane and
tongue
3 bserve for (left lip and palate
U sually blowing bubbles:mucus:drooling indicates tracheoesophageal fistula and
esophageal atresia
T ongue appears large and prominent
T eeth ()atal) must be evaluated for stability9 if loose9 needs e$traction to prevent
aspiration
H aving white glistening well circumscribed cyst commonly seen in palate caused by e$tra
load of maternal calcium 3pstein pearl
G )eck
%hort chubby with creased skin folds
(heck for rigidity of neck (ongenital -orticollis:4eningitis
I (hest
0n engorged breast due to influence of maternal hormones
I 0bdomen
A bdominal contour slightly protruberant
B owel sounds occur , hour after birth
C heck for gastrochisis and omphalocele
D ue after an hour" umbilical cord stump appears white gelatinous9 with red and blue
streaks
E ncourage inspecting cord clamp for bleeding and"
1. ,
st
hour of life J cord is shrinked & dry9 turns brown7like
2. *
nd
to .
rd
day J black
3. 1
th
to ,2
th
day J breaks free
6
(leaves a granulated area that heals following a week)
F or presence of"
, peristalsis and palpable olive shaped mass ( !yloric stenosis)
* palpable sausage shaped mass (Intussusception)
K Imperforate anus
-ypes of stools"
1. 4econium ,
st
stool passed by the newborn
sticky9 greenish black9 or tar7like (odourless)
2. -ransitional passed by )' beginning *
nd
or .
rd
day of life
greenish yellow & loose (odourless)
. 4ilk stool
a) 'reast7fed baby stool" light yellow and soft (sweet smelling)
b) 5ormula7fed baby stool" bright yellow and formed (noticeable odor)
; Genital
, 4ale genitalia
A genesis absence of organ
B y urinary meatus of penis located"
a) Dorsal (above) epispadias
b) Aentral (below) hypospadias
C ryptorchidism undescended testes9 may lead toL
D# following complications"
a) Inguinal hernia
b) %terility
c) -esticular cancer
E ctopic testes inability of testes to enter scrotum due to closure of
scrotal sac
* 5emale genitalia
%wollen due to effect of maternal hormone
!seudomenstruation
< 3$tremities
A rms and legs appear short
B y clenched & fisted hands
C rease (simian) associated with down syndrome
D igits (fingers & toes) assessment"
, %yndactyly webbing
* !olydactyly e$tra fingers & toes
. 0dactyly absence of one or more digits
E $tra pad of fat in sole of foot flat sole (normal)
F eet is plantar fle$ed indicates clubfoot
G ets bowed & short )' legs (normal)
H ip dislocation or Dysplasia by 6rtolani test
I n abducting the hips of the newborn"
both hips should abduct completely so they lie almost flat
against the mattress ,+2F
4 'ack
A mass9 tuft of hair9 dimple (incomplete closure of vertebrae) indicates %pina 'ifida
B y normally flat and straight
C urve of back usually develops at /71 months
7
) %kin
0ssessment"
A red pink skin (normal)
B lue hands and feet acrocyanosis
C yanosis hypo$ia
D# colors"
1. pallor anemia
2. yellow >aundice (within *8 hours J pathologic)
AIII 4a>or Developmental 4ilestone
* months head lag
social smile
cooing
. months lifts head & shoulders
8 months lifts chest
/ months roll over
1 months sit with support
palmar grasp
= months transfer ob>ect hand to hand
+ months sit without support
E months crawls
,2 months pulls self to standing
,, months cruises (walks with support)
,* months stands alone
holds cup & spoon
,/ months walks alone
,+ months run & >ump in place
*8 months open doors by turning door knobs
.2 months can >ump down from stairs
-ediatri+ Di*order*
I )eurological Disorders
0 Iydrocephalus e$cess of (%5 in the ventricles or the subarachnoid space
D (ommunicating hydrocephalus or e$traventricular hydrocephalus" fluid can reach the spinal
cord
D 6bstructive hydrocephalus or intraventricular hydrocephalus" with blockage on passage of
fluid
7 (auses of 3$cess (%5" 6verproduction of fluid by choroid ple$us in ,
st
or *
nd
ventricle
6bstruction of the passage of fluid in the narrow aqueduct of sylvius
(most common)
Interference with the absorption of (%5 from subarachnoid space
7 %:%$" A nterior fontanel bulging
B ones of the head are widely separated that produces a cracked7pot sound J
4acewen#s sign
B row bulges (bossing)
C heck for sun7setting eyes
D# increase in I(!
E rritability shrill high pitched cry
7 4anagement"
,) acetazolamide (Diamo$)" promote e$cretion of fluid
*) Aentriculoperitoneal shunt" fluid drains into the peritoneum
D headache & lack of appetite" earliest common signs of malfunction
8
7 )ursing Diagnosis with Intervention:s"
,) ?isk for Ineffective (erebral -issue !erfusion r:t I(!
5lat on bed prevent rapid drainage of (%5 leading to rupture of cerebral arteries
0void lying on side w: shunt prevent pressure on valve
(arefully elevate ,/ .2 degrees if I(!
*) ?isk for Imbalance )utrition9 less than body requirements r:t I(!
%upport heads when feeding hold head w: whole palm to avoid puncture of the skull
Gatch out for poor9 ineffective sucking sign of I(!
' )eural -ube Disorders
,) %pina 'ifida 6cculta posterior laminae of vertebra fail to fuse during embryonic
development
%:%$" Dimpling at the point of poor fusion
w: abnormal tufts of hair or discolored skin on site
*) 4eningocele meninges covering the spinal cord herniate through unformed vertebrae
%:%$" !rotruding mass at the center of the back
(overed by a layer of skin or clear dura mater
.) 4yelomeningocele spinal cord & meninges protrude through the vertebrae
%:%$" 5laccid & lack of sensation of the lower e$tremities
<oss of bladder and bowel control
7 (auses" <ack of folic acid
Ieredity
,) ?isk for Infection r:t rupture or bacterial invasion of neural tube sac
!rone keeps flow of feces & urine away from the disorderB put folded towel under the
abdomen to fle$ infant#s hips reducing pressure to sac
%ide lying put rolled blanket or diaper behind upper & separate one behind their lower
back (no pressure on the lesion)
7 put folded diaper between the legs (prevents skin surface from
touching & rubbing)
!lace a sturdy plastic wrap below the meningocele
%terile9 wet compress w: )%% over the lesion do not remove9 >ust add fluid
*) ?isk for Imbalance )utrition" less than body requirements r:t difficulty assuming normal
feeding position
3nsure lesion is not pressed by supporting arm during feeding
Ghen bubbling infant9 advise not to pat back over the disorder
If lesion is large prone or side lying when feeding w: pillow or folded diaper under the
head
( 4eningitis 7 infectious process of the meninges due to bacteria9 viruses9 trauma & infections
7 D$" (%5 analysis obtained by lumbar puncture
7 %:%$" A nuchal rigidity
B rudzinski#s
4 ernig#s sign
7 )ursing Intervention" ?espiratory isolation within *8 hrs during antibiotic treatment
D (erebral !alsy 7 neuromuscular disability in which the voluntary muscles are poorly controlled
7 (auses" <ow birth weight
9
'irth in>ury
!remature birth
7 %:%$" - osture is abnormal9 rigid & fi$ed
A rching of the back (6pisthotonus)
L imp or floppy body posture
S cissoring of legs
5 et crawls instead of walking
7 -ypes"
,) %pastic e$cessive tone in the voluntary muscles
*) Dyskinetic or 0thetoid involves abnormal involuntary movement
.) 0ta$ic w: awkward9 wide based gait
8) 4i$ed spastic M athetoid or ata$ic M athetoid
7 )ursing Interventions" % afety
% elf 3steem
% upport groups
II ?espiratory Disorders
0 !haryngitis infection and inflammation of the throat
,) Airal
%:%$" sore throat9 fever & general malaiseB enlarged regional lymph nodes9 erythema in the back
of pharyn$ & palatine arch
7 4anagement"
a) acetaminophen9 ibuprofen
b) Garm heat to the e$ternal neck area for comfort
c) Gargle w: warm water
*) %treptococcal caused by G0'I%
7 %:%$" eythema in the back of throat & palatine tonsils9 enlarged tonsils9 white e$udates in
tonsillar crypts9 petechiae on palate9 high fever9 e$tremely sore throat9 difficulty
swallowing9 overall lethargy9 headache
7 4anagement"
a) 5ull ,2 days antibiotic treatment (!enicillin G or (lindamycin)
D advise parents to strictly follow the course to prevent hypersensitivity or autoimmune
reaction to group 0 strep causing rheumatic fever or glomerulonephritis
' -onsillitis 7 infection and inflammation of the palatine tonsils
7(auses"
in <. y:o" viral
in school age" G0'I%
7 %:%$" drooling9 difficulty swallowing9 high fever9 lethargy9 enlarged9 bright red palatine tonsils
7 0%6 -iter
7 4anagement"
,) 0ntipyretic9 analgesic
*) 5ull ,2 days antibiotic treatment (!enicillin or 0mo$icillin)
.) -onsillectomy (for chronic tonsillitis)
D done when organs aren#t infected
7 !rone or side lying position" head lower than chest to drain blood
7 (heck signs of bleeding" pulse & ??9 frequent swallowing9 throat clearing9 feeling of
an$iety
7 ?estrict child#s activity (no gymnastics & swimming) until after =
th
day
D ,
st
day" clots form on area
D /7= days" clots lyse:dissolve)
7 6ffer sips of clear liquid9 popsicles or ice chips
10
7 0void acid & carbonated beverages
7 0void red fluid such as ;ool 0id
( (roup or <aryngotracheobronchitis inflammation of laryn$9 trachea & ma>or bronchi
7 (ause" 1 mos7. y:o parainfluenza virus
7 %:%$ happens at night" C rackles:Gheezes
R uddy9 brassy spasmodic cough
?etractions
3 bstruction of airway
U sually a hoarse voice
- ersistent laryngospasm
7 4anagement"
,) ?un shower or hot water tap in bathroom" keep child in this warm9 moist environment
*) (ool moist air w: de$amethasone or racemic epinephrine
,) Ineffective 0irway (learance r:t edema & constriction of airway
Do not elicit a gag refle$
;eep child from crying
D 3piglottitis inflammation of the epiglottis
7 (auses" pneumococci9 streptococci9 staphylococci
7 %:%$" 6D7*#
Drooling
Dyspnea
Dysphagia
7 4anagement"
,) )ever attempt to visualize the epiglottis directly w: a tongue blade or obtain a throat
culture to prevent gagging and obstruction of glottis
*) -ripod position
.) 3ncourage Ii' vaccine
8) 6* hood9 4ist tent9 (roupette9 (ool 6*
/) cephalosporin ((efuro$ime)
1) !rophylactic tracheostomy to prevent total obstruction
=) !rophyla$is for siblings
3 0sthma chronic inflammatory disease of the airways
7 %:%$"
Difficulty e$haling Gheezing
Dyspnea (opious w: white casts mucus
<ong e$piratory rate Dehydration
7 4anagement"
,) 0void cough suppressants
*) 5or mild but persistent asthma" inhaled anti7inflammatory corticosteroid (fluticasone)
4oderate persistent symptoms" long acting bronchodilator M fluticasone
%evere persistent" oral & inhaled corticosteroid M long acting bronchodilator M short acting
beta * agonist bronchodilator (albuterol or terbutaline)
.) (romolyn sodium mast cell stabilizer
D prevent bronchoconstriction thereby preventing symptoms of asthma
8) montelukast (%ingulair) leukotriene receptor antagonist
D used as prophyla$is & for chronic asthma
/) theophylline:aminophylline
D %:3" tachycardia
D 0:3" hypotension
11
1) Increase fluid intake
D avoid milk & milk products (causes thick mucus & difficulty swallowing)
5 !neumonia infection & inflammation of alveoli
7 (auses" 'acterial pneumococcal9 streptococcal9 staphylococcal9 chlamydial
0spiration of lipid or hydrocarbon subs
)ewborn born >*8 hrs after rupture of membranes
)ewborn who aspirated amniotic fluid & meconium
,) !neumococcal abrupt9 follows an @?-I
7 %:%$"
'lood tinged sputum b8 *8 hrs ?etractions )asal flaring
-hick purulent sputum after *878+ hrs (hest pain Dyspnea
Iigh fever (hills -achypnea
Dullness on percussion (rackles
7 4anagement"
a) ampicillin or .
rd
gen cephalosporin
b) amo$icillin7clavulanate (0ugmentin) for penicillin resistant organisms
c) 'ed rest
d) ?eposition child frequently avoid pooling of secretions
e) Iumidified 6* alleviate labored breathing & hypo$emia
f) (!- encourages movement of mucus
g) 3ncourage to cough
h) %mall9 frequent feedings
*) (hlamydial common in newborns up to ,* weeks
7 %:%$"
)asal congestion -achypnea ?ales
%harp cough Gheezing
7 4anagement
a) 4acrolide antibiotic erythromycin
.) Airal ?%A9 my$ovirus9 adenovirus
7 %:%$"
<ow grade fever -achypnea
)on productive cough Diminished breath sounds
7 4anagement"
a) 'ed rest
b)0ntipyretic
c) IA5
III (ardiovascular Disorders
0 (ongenital Ieart Disorders
7 (auses" 5ailure of heart to progress beyond embryonic development
4aternal rubella
Ieredity
. !
*t
Cla**i$i+ation*# (according to effect)
,) 0cyanotic heart disease has stricture to blood flow or shunt that moves blood from arterial to
venous system (o$ygenated to uno$ygenated or left to right shunts)
*) (yanotic venous to arterial (uno$ygenated to o$ygenated or right to left shunts)
. "
nd
Cla**i$i+ation*# (addresses the hemodynamic & blood flow patterns)
,) Disorders w: increased pulmonary blood flow left to right through abnormal opening or
connection between * systems:arteries
a) Aentricular %eptal Defect w: opening in septum of * ventricles
12
D results to right ventricular hypertrophy & pressure to pulmonary artery
7 %:%$" 3asy fatigability
<oud9 harsh pansystolic murmur
!alpable thrill:vibration
7 4anagement"
,) (ardiac catheterization
*) 6pen heart surgery" < * y:o to prevent pulmonary artery hypertension
D put %ilastic or Dacron patch
D post op" be alert for arrhythmias
b) 0trial %eptal Defect abnormal communication between * atria
D results to right ventricular hypertrophy & pressure to pulmonary artery
7 %:%$" Iarsh systolic murmur
5i$ed splitting diagnostic of 0%D
7 4anagement"
,) %urgery between ,7. y:o
D put %ilastic or Dacron patch
D post op" watch out for arrhythmias
*) (ardiac catheterization
c) !atent Ductus 0rteriosus blood shunt from aorta to pulmonary artery
D results to right ventricular hypertrophy
7 %:%$" Gide pulse pressure
<ow diastolic pressure
(ontinuous machinery like murmur
7 4anagement"
,) IA indomethacin assess side effects (reduced glomerular filtration9 impaired
platelet aggregation9 diminished GI & cerebral blood flow)
*) ibuprofen fewer side effectsB prophyla$is for preterm infants
.) (ardiac catheterization insert Dacron coated stainless steel coils (1 mos7, y:o)
8) Ductal ligation
*) Disorders with obstruction to blood flow
a) !ulmonary %tenosis narrowing of pulmonary valve or pulmonary artery
D results to right ventricular hypertrophy
7 %:%$" (yanosis -hrill
%ystolic e>ection murmur Gidely split *
nd
heart sound
7 4anagement"
,) 'alloon angioplasty
b) 0ortic %tenosis stricture of aortic valve
D results to pressure & hypertrophy of left ventricle & pulmonary edema
7 %:%$" ?ough systolic murmur (hest pain
-hrill
If severe faint pulses9 hypotension9 tachycardia9 inability to suck
7 4anagement"
,) 'eta blocker or (a channel blocker for stabilization
*) 'alloon valvuloplasty
.) 0rtificial valve replacement
13
c) (oarctation of the 0orta narrowing of the aorta
7 %:%$" '! in heart & upper body 4oderately loud systolic murmur
Ieadache )o palpable femoral pulses
<eg pain )odules on ribs enlarge collateral arteries
Aertigo
7 4anagement"
,) 0ngiography by balloon catheter
*) %urgery digo$in & diuretics b8 surgery to reduce (I5 (done by * y:o)
.) Disorders with mi$ed blood flow
a) -ransposition of Great 0rteries aorta arises from right ventricle instead of the left9
pulmonary artery arises from the left instead of the right
7 %:%$" (yanotic birth
7 4anagement"
,) !G3 prostaglandin
*) 'alloon atrial septal pull through
.) 0rterial switc" , wk 7. mos age
8) Disorders w: decreased pulmonary blood flow
a) -etralogy of 5allot with pulmonary stenosis9 A%D9 overriding of the aorta & right
ventricular hypertrophy
7 %:%$" !olycythemia (lubbing of fingers
%evere dyspnea %quatting:knee7chest position when resting
Growth restriction -et spells:hypo$ic episodes
7 4anagement"
,) 'lalock7-aussig procedure no '! & venipunctures on right arm after
procedure
*) ;eep hypo$ic episode to minimum 6*9 squatting:knee7chest9 morphine or
propanolol
.) 'rock procedure repair pulmonary stenosis9 A%D & overriding aorta
' ?heumatic 5ever autoimmune that occurs as a reaction to a G0'I% infection
%igns & %ymptoms (Kones (riteria)
(inor (a8or
!rolonged !? & N- interval
3levated sedimentation rate
(7reactive protein
<eukocytosis
0rthralgia
5ever
!olyarthritis
3rythema marginatum
(arditis
(horea
%ubcutaneous nodules
7 4anagement"
,) penicillin erythromycin
*) benzathine penicillin I4 ('icillin)
.) (orticosteroid" %:3" hirsutism9 round moon face9 susceptibility to infection
8) !henobarbital & diazepam" for chorea
,) ?isk for nonadherance to drug therapy
Drug level must be maintained for ,27,8 days
14
!rophylactic antibiotic therapy for atleast / yrs after initial attack
& when having dental or tonsillar surgery
( ;awasaki Disease mucocutaneous lymph node syndrome
D vasculitis is the principal & life threatening finding because it can lead to 4I or aneurysm
Criteria $or Dia/no*i* o$ 4awa*a,i Di*ea*e
1. 5ever / days duration
* 'ilateral congestion of ocular con>unctivae
. (hanges of mucous membrane of @?- (red
pharyn$9 lipsB Ostrawberry tongueP)
8 (hanges of peripheral e$tremities
(peripheral erythema & edema9
desquamation of palms & soles)
/ ?ash truncal9 polymorphous
1 (ervical lymph node swelling
7 4anagement"
,) aspirin or ibuprofen
*) abci$imab platelet receptor inhibitor
.) IA Ig
8) 0void steroids 7 aneurysm formation
,) ?isk for Ineffective !eripheral -issue !erfusion
6bserve for signs of heart failure tachycardia9 dyspnea9 rales & edema
Inspect e$tremities for color & warmth
(heck capillary refill
*) !ain r:t swelling of lymph nodes & inflammation of >oints
!rovide rocking & holding
!rotect edematous areas from pressure
;eep child free from heavy blankets or clothing
@se a soft padded toothbrush for brushing
IA Iematologic Disorders
0 %ickle (ell 0nemia presence of abnormally shaped ?'(s
D autosomal recessive inherited disorder
7 %:%$" 5ever !rotruding abdomen Aomiting
%welling of hands & feet Qellowed sclera 3nlarged liver
3nlarged spleen 0cute back pain
R %ickle (ell (risis" sudden9 severe onset of sickling
D occurs when dehydrated or w: respiratory infection that results in lowered 6*
e$change & low arterial 6* level or after e$tremely strenuous e$ercise
7 4anagement"
,) !ain relief acetaminophen
*) 0dequate hydration
.) 6$ygenation
8) Iydro$yurea
/) 3$change transfusion
,) Ineffective -issue !erfusion r:t generalized infarcts due to sickling
6* therapy
'ed rest
15

' -halassemia 4a>or:(ooley#s anemia autosomal recessive anemia associated with abnormal beta
chains of adult hemoglobin
E$$e+t* o$ Thala**emia (a8or
Bod' 3r/an or S'*tem E$$e+t
'one 4arrow Increased facial mandibular growth
%kin 'ronze colored
%pleen %plenomegaly
<iver & Gallbladder (irrhosis & cholelithiasis
!ancreas Destruction of islet cells & D4
Ieart 5ailure from circulatory overload
7 4anagement"
,) digitalis9 diuretics9 low sodium diet
*) -ransfusion of packed ?'(
.) defero$amine remove e$cess 5e
( Iemophilia
,) Iemophilia 0 factor AIII deficiency
D se$ linked recessive trait
7 %:%$" 3$tremely bruised lower e$tremities when bumped
%wollen & warm >oints
7 4anagement"
a) 5resh whole blood or frozen plasma
b) desmopressin
*) Aon Gillebrand#s Disease:0ngiohemophilia inherited autosomal dominant
D with factor AII defect (platelets unable to aggregate)
7 %:%$" epista$is (ma>or problem)
heavy menstrual flow
7 4anagement"
a) arginine desmopressin
.) (hristmas Disease or Iemophilia 'B factor IS deficiency
D se$ linked recessive trait
8) Iemophilia ( factor SI deficiency
D or thromboplastin antecedent deficiency
D autosomal recessive
A GastroIntestinal Disorders
0 (left <ip fusion of ma$illary and median nasal processes fail
D normal" fuse between /7+ weeks intrauterine life
D more common among boys
(left !alate closes at E7,* weeks intrauterine life
D involves anterior hard palate and:or posterior soft palate
D more common among girls
7 4anagement"
(left <ip" (heiloplasty between 17,* weeks
(left !alate" @ranoplasty between ,7* y:o
,) ?isk for Imbalance )utrition9 less than body requirements r:t feeding problems
16
R(left lip
%upport baby in upright position and feed gently using commercial cleft lip
nipple ('reck feeder or Iaberman)
'reastfeed =7,2 days after surgery
'ubble well the infant after feeding
6ffer sips of fluid between feedings (keeps mucous membrane moist & prevents cracks &
fissures)
R(left palate
(ommercial cleft palate nipple with rubber
6ffer soft food (if surgery is delayed beyond 1 mos)
*) ?isk for Ineffective 0irway (learance r:t oral surgery
%uction (be gentle9 don#t touch suture lines)
.) Impaired -issue Integrity at incision line r:t surgery
R(left lip
-urn infant lateral to the repair or on back (to prevent pressure on suture line)
%uture line is held by a <ogan bar
0void infant crying as much as possible
R(left !alate
;eep elbow restraints
)o spoon & straw during feeding
;eep on prone position
' -racheoesophageal 0tresia & 5istula trachea & esophagus are connected
3sophageal 0tresia obstruction of the esophagus
7 (ause" -eratogens
7 %:%$" 6C7*
Coughing
Cyanosis
Choking
7 4anagement"
,) %urgery prevent pneumonia & dehydration
D close fistula & anastomose esophageal segments
D observe closely for =7,2 days to check for leaks
*) Gastrostomy empty secretions & prevent reflu$ into the lungs
,) ?isk for Imbalance )utrition9 less than body requirements
Gastrostomy feeding
after feeding" keep the end of the tube elevated with covered sterile gauze
*) ?isk for Infection r:t aspiration
!re6p" position in an upright position or on right side to prevent gastric >uice from
entering the lungs
5requent oropharyngeal suctioning
;eep infant from crying
!ost 6p" suction shallowly
17
-urn frequently
( Gastroesophageal ?eflu$ called achalasia in infants
D cardiac sphincter & lower portion of the esophagus are la$ & allow easy regurgitation
7 %:%$" 3ffortless vomiting
Irritable
3pisodes of apnea
7 4anagement"
,) 5ormula thickened rice cereal , tbsp cereal:, oz formula or breast milk
D hold infant in upright position & keep them upright in an infant chair for , hour
*) ranitidine or omeprazole
.) -ightening:suturing of esophageal sphincter
8) 5undoplication
/) Do not lie down * hrs after eating
D !yloric %tenosis hypertrophy of the muscle surrounding the pyloric sphincter
7 %:%$" !ro>ectile vomiting immediately after feeding 7 sour9 no bile
Dehydration lack of tears9 dry mouth9 sunken fontanels9 fever9 urine output9 poor skin
turgor9 weight loss
0lkalosis
Iypopnea slowed respiration
6live shaped mass
7 D$" 'arium %wallow
7 4anagement"
,) !yloromyotomy electrolyte imbalance9 dehydration & starvation must be corrected first
*) )o oral feedings
,) ?isk for 5luid Aolume Deficit r:t inability to retain food
4onitor weight & urine output
3 Intussusception invagination of one intestine to another
7 (auses" 4eckel#s diverticulum Iypertrophy of !eyer#s patches
!olyp 'owel tumors
7 %:%$" %udden drawing up of legs & cry because of pain
Aomiting with bile
(urrant >elly stool
0bdominal distention
%ausage shaped mass (@?N)
7 4anagement"
,) %urgery
*) Instillation of water soluble solution9 barium enema or air (pneumatic insufflation)
7 )ursing Diagnosis"
,) !ain r:t abnormal abdominal peristalsis
*) ?isk for 5luid Aolume Deficit r:t bowel obstruction
5 (eliac Disease sensitivity or abnormal immunologic response to gluten found in BR39 (barley9
rye9 wheat & oat)
18
7 %:%$" %teatorrhea 0bdominal distention
Ait 0D3; deficiency 4alnutrition
7 4anagement"
,) Gluten free diet for life
*) Gater soluble forms of Ait 0 & D
.) 5e & folate
,) Imbalanced )utrition9 less than body requirements r:t malabsorption of food
?ecord characteristics of stools
?ead food labels carefully
0void spaghetti9 pizza9 hotdogs9 cake9 cookies
G Iirschsprung#s Disease:0ganglionic megacolon
D absence of ganglionic innervation to the muscle of a section of the bowel
D no peristaltic waves
7 %:%$" (hronic constipation 0bdominal distention
?ibbon like stools 5ailure to pass meconium by *8 hrs
,) (onstipation r:t reduced bowel function
)ormal saline for enemas" * tsp noniodized salt M , quart water
*) Imbalanced )utrition9 less than body requirements
)o fried foods & highly seasoned foods
!ost 6p" assess for bowel sounds & passage of flatus
I Imperforate 0nus stricture of the anus
7 %:%$" 0bdominal Distention
4embrane filled w: black meconium protruding from anus
5ailure to pass meconium in the ,
st
*8 hrs after birth
0bsent OwinkP refle$
%tool in vagina or urine
,) Imbalance )utrition9 less than body requirements r:t bowel obstruction and inability for oral
intake
)G- to relieve vomiting & pressure to abdominal organs
<ow residue diet (rice cereal9 strained fruits & vegetables)
*) Impaired -issue Integrity at rectum r:t surgical incision
0void rectal temperatures9 enemas9 suppositories
(lean suture lines with normal saline after bowel movements
!lace diaper under9 not on9 the infant to cleanse at once the bowel movements
!lace in side lying position to avoid tension in the perineal area
?ectal dilatation ,$ or *$:day
AI @rinary -ract Disorders
0 Iypospadia urethral opening is on the ventral (lower) aspect of the penis
3pispadia opening is on the dorsal surface of the penis
7 %:%$" (obra head appearance
19
(ryptorchidism
7 4anagement"
,) )o circumcision portion of foreskin may be used during repair
*) 4eatotomy
.) In>ectable testosterone for penis growth
' Glomerulonephritis inflammation of glomeruli that occurs as a immune comple$ disease after
G0'I% infection
7 %:%$" Iematuria ?eddish brown:%moky urine Iypertension
!roteinuria 6liguria 0bdominal pain
5ever 3dema !rolonged !? interval
Aomiting Ieadache - wave inversion
0nore$ia
7 4anagement"
,) furosemide
*) %emi fowlers9 digitalization & 6* if w: heart failure
.) (a channel blockers
8) ;aye$alate for ; & !hosphate
/) )ormal salt & protein diet
1) Geigh child daily
( )ephrotic %yndrome abnormal loss of protein from the urine due to altered glomerular
permeability
7 (auses" 0ntigen70ntibody reaction
0utoimmune
- lymphocyte dysfunction
7 %:%$" !roteinuria Iypoalbuminemia
3dema Iyperlipidemia
7 4anagement"
,) (orticosteroids monitor protein loss
D can cause cushingoid appearance (moon face9 e$tra fat at base of neck9 body hair)
D do not stop abruptly" can cause adrenal insufficiency
*) cyclophosphamide ((yto$an)
.) Diuretics & ; supplement
7 )ursing Diagnosis with Intervention"
,) Imbalanced )utrition9 less than body requirements r:t poor appetite & protein loss
Good protein & potassium intake
4onitor fluid intake
4onitor weight daily (same clothing9 time & scale)
Compari*on o$ Feat)re* o$ AGN : Nephroti+ S'ndrome
Fa+tor AGN Nephroti+ S'ndrome
(ause Immune reaction to G0'I% IdiopathicB Iypersensitivity r$n
6nset 0brupt Insidious
Iematuria !rofuse ?are
3dema 4ild 3$treme
Iypertension 4arked 4ild
Iyperlipidemia ?are or mild 4arked
!eak age frequency /7,2 y:o *7. y:o
Interventions <imited activityB (orticosteroidB cyclophosphamideB
20
antihypertensivesB symptomatic
therapy for (I5
diureticsB ; supplement
Diet )ormal for age Iigh protein9 low sodium
!revention !revention or thorough t$ of
G0'I% infection
)one known
AII 3ndocrine or 4etabolic Disorders
0 !;@ autosomal recessive
D no phenylalanine hydro$ylase" phenylalanine in the blood
7 D$" Guthrie blood test
7 %:%$" 4ousy odor <ight blonde hair
Aery fair skinned 'lue eyes
7 4anagement"
,) <ofenalac low phenylalanine formula
*) <ow protein diet
.) 0void )utrasweet w: aspartane
' (ystic 5ibrosis w: generalized dysfunction of the e$ocrine glands
D autosomal recessive trait
7 D$" !ilocarpine Iontophoresis" >12 m3q:< (M (ystic 5ibrosis)
7 %:%$" -enacious secretions in pancreas & lungs
(l concentration of sweat salty perspiration
'locking of the vas deferens (tenacious seminal fluid)
-hick cervical secretions
%teatorrhea
4econium ileus
4alnutrition
5at soluble vitamin deficiencies
?espiratory acidosis
,) ?isk for Imbalance )utrition9 less than body requirements r:t inability to digest fat
Iigh calorie9 high protein9 moderate fat diet
0dequate salt intake
Gater miscible Ait 09 D9 3
'reastfeeding w: supplemental formula soybean formula for milk allergy or !robana
-ake synthetic pancreatic lipase ((otazym or !ancrease) with meals or within .2 minutes of
eating
add to a teaspoonful of food9 no hot foods9 don#t add to formula milk
6ffer water frequently
Guard against overe$ertion or heat e$posure
*) Ineffective 0irway (learance r:t inability to clear mucus
)ebulization or aerosol therapy then (!-
Iumidified 6*
0dd acetylcysteine (4ucomyst) to mist
)o cough suppressants
5requent reposition
'ed rest plan activities & rest period b8 meals
AIII %keletal Disorders
21
A. -alipes Disorders or clubfoot
7 -ypes"
,) plantarfle$ion equinus or horsefoot position9 forefoot lower than heel
*) dorsifle$ion heel is held lower than forefoot or anterior foot is fle$ed toward anterior leg
.) varus deviation foot turns in
8) valgus deviation foot turns out
/) equinovarus combination of all types
1) calcaneovalgus child walks on heel with foot elevated
7 4anagement"
,) (ast" foot placed in an overcorrected position
e$tends above the knee to ensure firm correction
change diapers frequently to prevent soaking of cast w: urine or meconium
check infant#s toes for coldness9 blueness & circulation
*) Denis 'rowne splints" shoes attached to metal bar to maintain position
.) %urgery
' Developmental Iip Dysplasia often referred to as (ongenital Iip Dysplasia
D improper formation & function of the hip socket
D sublu$ation or dislocation of the head of femur
D acetabulum of pelvis is flat or shallow
7 (auses" Ieredity
@terine position
7 %:%$" 0ffected leg is shorter9 knee is lower than the other
@nequal skin folds on posterior thighs
6rtholani#s sign (click heard on abduction)
7 4anagement"
,) %plints9 Ialters9 or (asts" position hip into fle$ed9 abducted positionB traction for older
children
5re>ka splint" keep in place at all times e$cept when bathing the infant & changing
diapers
Good diaper area care" change diapers frequently9 wash area w: clear water9 apply
ointment after each diaper change
!ad edges of braces to decrease irritation
!avlik harness" ad>ustable chest halterB worn continually e$cept bathing
%pica cast or 5rog <eg cast" assess for circulation
*) %urgery" pin is inserted to stabilize the hip
22

Multi-Educational Review Group Experts, Inc.: Child Health Nursing

Hochgeladen von

Dokumentinformationen

Originalbeschreibung:

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Multi-Educational Review Group Experts, Inc.: Child Health Nursing

Hochgeladen von

Copyright:

Verfügbare Formate

MULTI-EDUCATIONAL REVIEW GROUP EXPERTS, INC.

Das könnte Ihnen auch gefallen