St.

Jude College
Dimasalang cor. Don Quijote St.
Sampaloc, Manila

Nursing Enhancement Program

PEDIATRIC NURSING

VI. THE NEW BORN

A. CARE OF THE NEWBORN IN THE DELIVERY ROOM

5. Maintain patent airway
a. Drain secretions
• Put the baby in a trendelenburg position for drainage except when
signs of increase ICP is observed: bulging fontanelles, high-pitched cry
(earliest sign), vomiting (surest sign), increase BP, decrease PR,
decrease RR.

a. Suction newborn
• Suction the mouth first before the nose to prevent aspiration
• Sunctioning should be gentle to prevent laryngospasm
• It should not be more than 1 minute otherwise, it will stimulate vagus
nerve causing bradycardia.

a. Occlude one nostril at a time to test for patency since newborns are nasal
breathers
b. Observe characteristics of respirations

c. Administer oxygen as needed

• Oxygen concentration should be <40% to prevent retinal scarring
which may lead to blindness (retrolental fibroplasia).
• Oxygen is best administered thru a tent

5. Keep the newborn warm

• The body temperature of the newborn at birth is 37.2 C (99 F). Shortly
after birth, if falls below normal because of the immature temperature-
regulating mechanism and heat loss. In addition, the cold temperature of
the delivery room contributes to this.
• A newborn losses heat thru the following mechanisms:
○ Conduction: heat is transferred to a cooler solid object in contact
with the body
○ Convection: heat flows from the body surface to a cool surrounding
air
○ Evaporation: heat loss thru conversion of liquid to vapor (wet
skin).
○ Radiation: heat is transferred to a cooler solid object but not in
contact with the body

• Subcutaneous fats to act as insulators. Shivering is also not present at

birth because of this, they are prone to cold stress which may cause
metabolic acidosis as fatty acids accumulate due to the breakdown of
brown fat
• Dry newborn immediately
• Wrap in a blanket
• Place under a radiant warmer or isolette with a temp of 33-34 C.
• Place under a droplight which should be 12-18” far from the newborn

5. Take the Apgar score

• Done at 1 minute after birth to know the conditions of the newborn. Then
at 5 minutes after to determine how well the newborn is adjusting to
extrauterine life.

Sign Score
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 0 1 2
Heart rate Absent <100 >100
Respiratory effort Absent Slow, irregular Good, strong cry
Weak cry
Muscle tone Limp flaccid Some flexion of extremities Well flexed extremities
Reflex irritability No response Grimace Cry, withdrawal of foot
Color Blue, pale Extremities blue, body is Completely pink
pink (acrocyanosis)

S INTERPRETATION:
T
• 0-3 = This may indicate severe respiratory & CNS depression. The baby is in
J serious danger needing immediate resuscitation
U • 4-6 = Condition is guarded & may need more suctioning & oxygenation
D • 7-10 = Routine care only, no special care needed
E
5. Assess gestational age
C
O Clinical criteria for gestational age assessment
L
L GESTATIONAL AGE
E Finding
0-36 WKS 37-38 WKS 39 WKS
G
Sole creases Anterior transverse crease Occasional creases in Sole covered with
E
only anterior 2/3 creases
Breast nodule 2 mm 4 mm 7 mm
S
diameter
T
Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky
J Ear lobe Pliable, no cartilage Some cartilage Stiffened by thick
U cartilage
D Testes and Testes in lower canal, small Intermediate Test pendulous, full
E scrotum scrotum, few rugae scrotum, extensive
rugae
C
O 6. Cleanse baby with oil to remove blood, mucus, vernix
L
L 7. Cord care
E • Inspect for the presence of 2 arteries & 1 vein
G ○ Absence of 1 artery may indicate kidney problem
E ○ Absence of umbilical blood vessels may indicate heart and kidney
problem
S
T • Assess for possible bleeding
• Dress the cord with alcohol to hasten drying
J • Keep the cord clean and dry
U
D 5. Administer eye care
E • Crede’s prophylaxis to protect newborn against gonorrheal conjunctivitis
acquired from the mother as the infant passes thru the birth canal
C • Dry newborn’s face
O • Open one eye at a time by putting pressure on upper and lower lids
L • Instill 2 drops of 1% silver nitrate into the lower conjunctival sac
L • If erythromycin ointment is used, squeeze a line of ointment along the
E lower conjunctival sac from the inner canthus outward. Close eye to allow
G ointment to spread across conjunctiva.
E
5. Administer Vitamin K
• Vitamin K is normally synthesized in the presence of bacterial flora in the
intestines. Since newborn’s intestines are still sterile, Vitamin K is
administered to facilitate production of clotting factor thus, preventing
hemorrhage.
• Vitamin K (1 mg) is injected into the vastus lateralis (IM). This site is
preferred because gluteal muscles of children below 12 months who have
not yet learned how to walk are still not fully developed.

5. Place proper identification of newborn

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 • This should be done before they are removed from the delivery room
• Take newborn’s footprints

5. Initial feeding
• If to be formula fed: give 1 oz sterile water at 4-6 hours. This is a test
feeding to be certain that the infant can swallow without aspiration.
Formula milk is given on the 4th feeding (rationale: if formula milk is
aspirated, this may cause bacterial pneumonia).
• If to be breast fed: usually 30 minutes after normal delivery, 4 hours after
CS (rationale: ability to suck and swallow in breast fed infants is not
S significant because if colostrums is aspirated, it has no effect on the
T lungs).

J 5. Circumcision
U • Surgical removal of penis foreskin usually done on the 1st or 2nd day of
D life after the baby has synthesized enough Vitamin K to prevent
E hemorrhage.
• Contraindications: hypospadias, epispadias
C • Procedure:
O ○ Place infant in supine position
L ○ Restrain the infant
L ○ Prepare & drape the area around the penis
E ○ Clamp is fitted over the end of penis, stretching the foreskin taut
G ○ Prepuce is separated from the glans & a circle of prepuce is
E existed
• Complications: hemorrhage, infection, urethral fistula formation
S • Nursing responsibilities:
T ○ Observe closely & check for bleeding
○ Wrap penis with a strip of petroleum gauze to prevent the diaper
J
from adhering from the circumcised area
U
○ Don’t want away a film of yellowish mucous which often covers
D
the glans.
E
A.CARE OF THE NEWBORN IN THE NURSERY
C
5. Check ID band (wrist or ankle)
O
L
6. Take vital statistics (anthropometric measurement)
L
a. Weight
E
• Average birth weight is 6.5 – 7.5 lbs. or 3.0 – 3.4 kg or 3000 –
G
3400 gm
E
• Arbitary lower limit is 2.5 kg or 55 lb or 2500 gm. Below this
weight, the newborn is considered low birth weight infant
S
T
• Newborns lose 5-10% of birth weight (6-10 oz) during the first
few days of life (physiologic wt loss) due to:
○ Newborn is no longer in the influence of maternal
J
U hormones
D ○ Newborn voids & passes stools
E ○ If breast fed, they have limited intake because colostrum
has low caloric content
C ○ If bottle fed, sucking is not yet effective
O • Birth weight is doubled by 6 mos, tripled by 1 year, quadrupled
L by 2 ½ years.
L
E a. Length
G • Average length is 19-21.5 inches or 47-53 cm
E
a. Head circumference
• Normal: 33-35 cm
<32—microcephaly
>37—macrocephaly
• measured with a tape measure drawn across the center of the
forehead and the most prominent portion of the posterior head

a. Chest circumference
• Normal: 31-33 cm
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 • Measured at the level of the nipples
• Head circumference >chest circumference till 2 years of age

a. Abdominal circumference
• Normal: 31-33 cm

5. Take vital signs

a. Temperature
• At birth, it is 37.2 C & must be maintained at 35.5– 36.5 C
• Immediately after birth take rectal temp to check patency of
anus
S
T a. Pulse rate
• Immediately after birth, PR is 100-180
J beats per minute as the neonate
U struggles for respiration
D • Normal PR is 120-140 beats/min
E • Palpate femoral pulses because
absence may suggest possible
C coarctation of aorta
O • Radial pulses are not ordinarily
L palpable
L
E a. Respiratory rate
G • Immediately after birth, it may be as
E high as 80/min
• Normal RR is 30-60/min
S • Observe movement of abdomen
T
a. Blood pressure
J • Not routinely taken unless cardiac
U anomaly is suspected
D • At birth, BP is 80/46 mm Hg
E • After 10 days, Bp is 100/50
• The cuff to be used must not be more
C than 2/3 of the length of the upper arm
O or thigh
L • FLUSH METHOD may be used
L ○ Apply cuff to an extremity
E ○ Elevate extremity & apply elastic bandage on the distal
G part of the extremity
E ○ Inflate cuff to 200 mmHg ( extremity is pale)
○ Slowly deflate cuff as you observe extremity
S ○ As soon as the extremity turns pink, read the manometer
T
○ Only 1 reading is obtained which is the average between
the diastolic & systolic pressures
J
○ Normal: 60 at birth
U
75 after 10 days
D
E
5. Physical exam
C a. Skin
• Color- most newborns have a ruddy
O
L complexion due to increased
concentration of rbc in blood vessels
L
E and decrease subcutaneous fats. This
fades slightly over the first month
G
E ○ Acrocyanosis- extremities are blue and the body is pink.
This is normal during the first 2 days of life
○ Pallor- may be due to anemia due to blood loss when cord
was cut; few iron stores due to poor maternal nutrition;
blood incompatibility; fetal-maternal transfusion.
○ Gray- may indicate infection
○ Jaundice- yellowing of the skin & sclerae due to the
inability of the newborn to conjugate bilirubin due to
immature liver function.

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 Globin (reused by body)

Destruction
of RBCs

Iron (reused by body)

Heme
Protopporphyrin Indirect bilirubin
(Fat soluble)

S
T
glucoronyl transferase
J
U
D
Direct bilirubin
E
• Physiologic jaundice (Icterus Neonatorum)
C
• Onset- 2nd or 3rd day
O
• Duration- 5-7 days
L
○ Babies being breast fed have longer duration of
L
E physiologic jaundice because breast milk contain
G pregnandiol which depresses action of glucoronyl
E transferase
○ Management of physiologic jaundice:
S ○ Morning sunlight will stimulate liver to produce glucoronyl
T transferase & convert indirect bilirubin to direct bilirubin.

J • Harlequin sign- due to immature circulation

U ○ Neonate lying on his side will appear red on the
D dependent side of the body & pale on the upper side
E ○ Change position of infant

C • Birthmarks
O ○ Hemangiomas- vascular tumor of the skin
L  Nevus flammeus (port-wine stain)
L  Macular purple or dark red lesion, usually on the
E face
G  Strawberry hemangioma
E  Elevated, thick, hard
 Associated with high estrogen level
S  Cavernous hemangiomas
T  Dilated vascular spaces, elevated

J ○ Mongolian spots- slate gray patches found across the

U sacrum or buttocks, usually disappears by school age.
D
E • Vernix caseosa- white cream cheese-like substance noticeable on
newborn’s skin at birth
C • Lanugo- fine downy hair covering newborn’s shoulders, back &
O upper arms
L ○ Immature newborns has more lanugo than mature infant
L ○ Disappear by 2 weeks
E • Desquamation- drying of newborn’s skin within 24 hours of birth
G which results in areas of peeling
E

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 • Milia- pinpoint white papule (plugged or unopened sebaceous
gland) on cheek or across the bridge of the nose
○ Disappear by 2-4 weeks

• Skin turgor- should be resilient & elastic

a. Head- 1/4 of the total length; disproportionately large

• Large and prominent forehead
• Receding chin which quivers if the infant is started or is crying
• Well-nourished newborns have full-bodied hair while those poorly
nourished or immature newborns have stringy, lifeless hair
• Fontanelles should not be sunken (may indicate dehydration) nor
bulding (may indicate increase ICP)
• Anterior fontanelle (diamond shape) normally closes at 12-18
mos
• Posterior fontanelle (triangular in shape) normally closes by the
end of the 2nd month
• Overriding of suture linens is normal
S due to extreme pressure exerted by
T passage thru the birth canal. Sutures
should never be separated (increased
J ICP)
U • Infant’s head may appear prominent &
D asymmetric due to molding so that it
E can fit the cervix contours. This is
normal and the head will be restored
C to its normal shape within a few days
O • Craniotabes which are localized
L softening of the cranial bones are due
L to pressure of fetal skull against the
E mother’s pelvic bone in utero. It is
G more common in first born infants
E • Caput Succedaneum is edema of the
scalp at the presenting part of the
S head. It may involve both
T hemispheres. Edema will slowly be
absorbed about the 3rd day of life. It
J needs no treatment
U • Cephalhematoma is a collection of
D blood between periosteum of skull
E bone and the bone itself. Unlike caput
Succedaneum, caphalhematoma is
C confined to an individual bone and
O does not cross suture lines. It usually
L takes weeks ofre a cephalhematoma
L to be absorbed.
E
G a. Eyes
E • Newborns cry tearlessly due to
immature lacrimal ducts
S • Iris of newborns are gray or blue till
T the 3rd month of life
• Edema is usually present around the
J orbit or on the eyelids which will
U remain for 2-3 days
D • Cornea should be round and adult-
E sized
○ Larger cornea may indicate congenital glaucoma
C
• Pupils are round, dark and regular in
O
shape
L
○ Key holed pupils- coloboma
L
○ White pupil- congenital cataract
E
G
E

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 • There is physiologic strabismus due to underdeveloped eye
muscles till 4 mos.

a. Ears
• Pinna, tends to bend easily
• Level of top part of the ear should be in line with the upper
canthus of the eye
○ Ears set lower may indicate chromosomal abnormalities

a. Nose- may appear large for the face

b. Mouth
• Should open evenly when newborn cries, otherwise it may
indicate cranial nerve injury
• Tongue appears large and prominent
• Palate should be intact
• Epstein’s pearls maybe mistaken for oral thrust which are white
or gray patches on the tongue and sides of cheeks due to
candida infection
• It is unusual for a newborn to have teeth but if 1 or 2 are found
(natal teeth), it should be evaluated for stability. Loose teeth
should be extracted to prevent aspiration.

a. Neck
S • Short and chubby, creased with skin
T folds
Rigid neck- cogenital torticollis
J • Strong enough to support the weight
U of the head
D • Trachea may be prominent in front of
E the neck
• Thyroid gland is not palpable
C If palpable, suspect congenital goiter
O
L a. Chest
L • Breast may be engorged due to
E influence of maternal hormones
G • Occasionally, breasts of newborns
E secrete thin, watery fluid (witch’s milk)
due to maternal hormones
S • Should be symmetric in appearance
T • Retractions should not be present

J a. Abdomen
U • contour is slightly protuberant,
D globular
E • scaphiod or sunken abdomen –
missing abdominal contents
C • bowel sounds should be heard with in
O an hour after birth
L • edge of the liver is palpable at 1-2 cm
L below the right costal margin
E • if >3cm – developing CHF
G • edge of the spleen is palpable 1-2 cm
E below the coastal margin
• for the 1st hr of birth, umbilical cord is
S white, gelatinous marked with red and
T blue streaks of umbilical vein and
arteries. After 1 hour, cord begins to
J shrink, dry and be discolored.
U • 2nd or 3rd day – black
D • 6th – 10th day – breaks free, leaving a
E granulating area a few cm across that
heals during the following week
C • right kidney can usually be palpated
O
L
L Pediatric Nursing
E Page 7 of 46
G
E
a. Anogenital Area
• Check for the patency of the anus
• Note the time that the infant passed out meconium. If the
newborn does not pass meconium in the 1st 24 hrs, suspect
imporforate anus or meconium ileus
• Male genitalia
○ scrotum is edematous due to maternal hormones
○ testes should be present in the scrotum
○ Cryptorchidism- undescended testes, may be due to short
vas deferens, closed scrotal sac, ectopic testes, agenesis,
deficient testosterone
○ Penis appears small. Inspect if urethral opening is at the
tip of the glans.
○ If found on the dorsal surface- epispadias
○ If found on the ventral surface- hypospadias
○ Prepuce (foreskin) of the penis should be examined to test
for phimosis (tight foreskin)
• Female genetalia
○ Vulva maybe swollen due to influence of maternal
hormones
○ May have mucous vaginal secretion which is sometimes
blood-tinged, also due to maternal hormones
a.Back
S • Supine appears flat in the lumbar &
T sacral areas
• Curve starts to form when the child
J is able to sit & walk
U
D a.Extremities
E • Arms & legs appear short
• Hands are plump & clenched into
C fists
O • Fingernails are soft and smooth &
L are long to extend over the
L fingertips
E • Arms and legs should move
G symmetrically
E • Check the digits for webbing
(syndactyly), extra toes or fingers
S (polydactyly), lacking toes or
T fingers (oligodactyly)
• Observe for thalidomide effects:
J complete absence of extremities
U (Amelia), absence of distal
D extremities (pocomelia), absence
E of either upper or lower extremity
(hemmelia).
C • Check pulses
O Radial pulses are normally
L nonpapable in the 1st 3 months
L due to decrease peripheral
E resistance from upper extremities.
G If palpable, suspect coarctation of
E aorta.
Femoral pulses are normally
S palpable due to high peripheral
T resistance from lower extremities.
If non palpable, conclusive of
J coarctation of aorta.
U
D • Abnormal rotation & extension of
E foot suggests talipes/club foot
Types: Talipes equinovarus-
C inward rotation of foot, most
O common.
L
L Pediatric Nursing
E Page 8 of 46
G
E
 Talipes equinovalgus- outward rotation of foot
Talipes calcaneous- upward rotation of foot
Talipes equinas- downward rotation of foot

• Abduct hip to 90
Limited abduction to 60- congenital hip dislocation

a. Review of systems
a. Cardiovascular system
• In utero, oxygenation takes place in the placenta not in the fetal
lungs. So, pressure in the left side is less than the pressure in the
right side of the heart.
• Fetal accessory structures:
○ Foramen ovale- opening between the right and left atria
○ Ductus arteriosus- connects pulmonary artery & aorta
○ Ducturs venosus- bypasses the liver
○ Umbilical vein- carries oxygenated blood
○ 2 umbilical arteries- carry deoxygenated blood
• As soon as the cord is clamped, the newborn is forced to take in O2
thru the lungs. This expansion of the lungs will cause the pressure
of the left side of the heart to be higher than the pressure of the
right heart. This in turn will cause:
○ Foramen ovale will close and turn into a ligament (fossa ovalis)
○ Ductus arteriosus changes into a ligament (ligamentum
arteriosum)
○ Ductus venosus changes into a ligament (ligementum
venosum)
○ Umbilical vein & arteries will atrophy & degenerate since no
more blood goes thru it
• A newborn’s blood volume is around 300 ml
○ RBC- 6 million/cubic mm
○ Hgb- 17-18 gg/100ml blood
○ Hct- 45% - 50%
○ Platelets- 100,000- 200,000
○ WBC- 15,000-45,000/cubic mm

a. Respiratory system
• Newborn’s first breath requires tremendous amount of energy to
pull in. Once the alveoli have initially been inflated, breathing
becomes much easier for the baby
• Heart of the newborn takes more space than in an adult so the
amount of lung expansion is limited

a. Gastrointestinal system
• Usually sterile at birth
• Stomach can hold about 60-90 ml
• Has limited ability to digest fat and starch because pancreatic
enzymes are deficient during t he 1st few months of life
• Regurgitates easily due to immature cardiac sphincter
• Usually has low glucose & protein serum level due to immature
liver function
• Stools:
○ Meconium- 1st stool that is usually passed 24 hours after
birth. Sticky, tar-like blackish green, odorless that was
formed from mucus, vernix, lanugo, hormones that
accumulated in utero
○ Transitional stool- 2nd or 3rd day of life which may resemble
diarrhea (bright, green, loose)
○ Stool of breast fed infants—4th day of life; golden yellow,
sweet smelling, mushy stools passed 3-4x a day

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 ○ Stool of formula fed
infants- pale yellow,
S
firm, has a slightly
T
more noticeable odor,
passed 2-3x a day
J
○ Bright green stools—
U
those placed under
D
phototherapy
E
○ Stool with mucus—milk
C allergy or other irritant
O should be suspected
L ○ Gray/clay colored
L stool- bile duct
E obstruction
G ○ Black/tarry stool-
E intestinal bleeding

S
a. Urinary system T
• Newborns void within 24 hours after birth
• J Single voiding is only about 15 ml
• U Daily urine output is 30-60 ml/day
• D Specific gravity- 1.0008-1.010
• E Proteinuria is normal in the 1st 3 mos.
• Light in color & odorless because their kidneys do not
C concentrate urine well
• O Female newborns produce a steady stream when
L voiding
• L Male newborns void with enough force to produce a
E small projected arc
G
a. Autoimmune E system
• Maternal Ab (IgG) cross placenta to the fetus during
S the last 2 weeks of pregnancy (passive natural
T immunity) and serve as protection against 6 childhood
diseases: poliomyelitis, measles, diphtheria, pertussis,
J rubella, tetanus. There is little immunity against
U varicella (Chicken pox) or herpes simplex.
• D Neonate has difficulty forming antibodies against
E antigens until 2 mos. Of age. That is why
immunizations are started at 2 mos.
C
a. Neuromuscular O system
• L Limpness or total absence of muscular response to
L manipulation may indicate narcosis, shock or cerebral
E injury.
• G Reflexes:
E ○ Blink reflex- protects
the eye from any
object coming near
it; rapid eyelid closure; does not disappear.
○ Rooting reflex- the neonate turns head in the direction
where the cheek is brushed or stroked near the corner of
the mouth; helps the baby to fin food; disappear at 6
weeks of life.
○ Sucking reflex- the neonate makes a sucking motion when
the lips are touched; begins to diminish at 6 mos. of age;
disappears if not stimulated, thus an infant on NPO should
be given pacifier to stimulate sucking
○ Swallowing reflex- food placed at the posterior portion of
the tongue is automatically swallowed; it does not
disappear.
○ Extrusion reflex- any substance placed at the anterior
tongue will be spit out; it disappears at about 4 mos. of
age when the infant is ready to eat semi solid foods

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 ○ Palmar grasp reflex- newborns grasp an object placed in
their palm by closing their fingers on it; disappears at 6
weeks to 3 mos.
○ Plantar grasp reflex- when an object touches the sole of
newborn’s foot at the base of the toes, the toes grasp in
the same manner as the fingers do
○ Tonic neck reflex- when lying on his back, the newborn’s
arm and leg are extended on the side where the head is
turned. The arm and leg on the opposite side are flexed;
disappears between the
2nd and 3rd mos. Of life
S ○ Moro (startle) reflex-
T
most important reflex
indicative of neurological
J
status, this is elicited by
U
startling the newborn
D
with loud noise, jarring
E
the bassinet or the head
is allowed to drop
C
backward in a supine
O
position. The newborn
L
will abduct and adduct
L
in his arms and legs.
E
Their fingers assume a
G
typical “C” position. This
E
fades by the end of the
4th and 5th month.
S
○ Babinski reflex- the
T
infant will fan the toes
J when the side of the
U foot is stroked in an
D inverted “J” curve from
E the heel upward. This is
in contrast to the adult
C who flexes the toes. It
O begins to disappear by 3
L mos. of age
L ○ Landau reflex- a
E newborn help in prone
G position should
E demonstrate muscle
tone.
S ○ Deep tendon reflex
T  A patellar reflex can be elicited by tapping the
patellar tendon with the tip of the finger. The lower
J leg will move perceptibly if the infant has a mature
U reflex. This is a test for spinal nerves L2-L4
D  A biceps reflex is elicited by placing the thumb of
E your left hand on the tendon of the biceps muscles.
Tap the thumb as it rests on the tendon. You will
C feel the tendon contract. This is a test for spinal
O nerves C5-C6.
L
a. Senses L
• E Hearing
• G A fetus is able to hear in utero
• E They appear to have difficulty locating sound, not turning
toward it consistently
• They respond with generalized activity to a sound
• They calm in response to a soothing voice & startle at loud noises
• They recognize their mother’s voice as if they have heard it in
utero

• Vision
• Newborns see as soon as they are born

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 • They cannot follow objects past the midline of vision (9-12”)
• They focus best in black & white objects

• Touch- most developed & most sensitive of all the senses

• Taste
• Taste buds are developed & functioning before birth
• Newborns turn away from bitter taste & readily accepts the sweet
taste of milk or glucose water

• Smell
• Present as soon as the nose is clear of mucus & amniotic fluid
• Sensitive to breast milk

a. Discharge planning
• Daily care
○ Bathing
 Should be done prior to, not after a feeding to
prevent regurgitation, spitting up or vomiting
 Bath water should be around 98-100 F (37-38 C)
 Soap should be mild
○ Diaper area care
 When changing diapers, the area should be washed
with clean water & be dried well so that ammonia in
S urine will not irritate the infant’s skin
T  An ointment such as petroleum jelly may be applied

J • Sleep patterns
U ○ A newborn sleeps an average of 16 hrs/day in the first week
D at home & an average of 4 hours at a time
E ○ At 4 mos., the baby sleeps 15 hrs/day & 8 hrs at a time
○ Most typical time for wakefulness- 6:00-11:00 PM
C
O
• Nutrition
L
○ Recommended daily allowance for the newborn
L
E ○ Calories- 120 cal/kg body wt (birth-2 mos.)
G ○ 100 kcal/kg body wt (1 year)
E ○ Protein- 2.2/kg body wt (birth- 2 mos.)

S ○ Minerals- calcium is important because of its contribution to

T bone growth. The infant born from a mother with adequate
intake of iron during pregnancy has Fe stores that will last
J for the 1st 3 mos. of life
U ○ Vitamins- Vitamin A,C,D are recommended for the entire 1st
D year of life
E ○ Breastfeeding advantages
 For the mother
C • Release oxytocin aids uterine involution
O • May serve as protective function in preventing
L breast cancer
L • Promotes maternal-infant bonding
E
G  For the infant
E • Contain secretory IgA
• Contains the ideal electrolyte & mineral
S composition for human infant growth
T
○ Difference between human milk & cow’s milk
J  Carbohydrates
U • Human milk has more carbohydrates
D
E  Fats
• Human & cow’s milk has same fat content
C • Linoleic acid needed for growth & skin
O integrity is 3x higher in human milk proteins
L
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G
E
  Protein
• Human milk has less proteins than cow’s milk
• Casein is the main protein in cow’s milk which
is more difficult to digest
• Lactalbumin is the main protein in human milk
and is easier to digest

 Minerals
• Cow’s milk has more minerals but the
newborn’s kidneys are not yet mature enough
and might be overwhelmed by high mineral
content of cow’s milk

 Similarities
• Both are deficient in Iron
• Both contain 20 cal/oz
• Both should be given by demand feeding

○ Similarities
 Both are deficient in Iron
 Both contain 20 cal/oz
 Both should be given by demand feeding

S A. Newborn at Risk
T 2. Premature Babies (low birth weight infants)
b. Anemia of prematurity
J • Normochromic, normocytic anemia
U • Develops during the first 3 to 4 mos. of life due to immaturity of
D the hematopoietic system
E • Blood transfusions may be done to supply needed blood
components until maturity of the hematopoietic system is achieved
C • Is different from Iron-deficiency anemia also occurring in
O premature infants because transfer of Fe stores from the mother to
L the baby occurs during the last 2 weeks of pregnancy.
L • In this type of anemia, Fe supplements may be given to the baby
E
G b.Kernictrus
E • Destruction of the brain cells by indirect bilirubin due to excessive
breakdown of RBC & immaturity of the liver
S • Monitor indirect bilirubin level
T • Phototherapy—done with the use of artificial blue light to convert
indirect bilirubin to its excretable form
J ○ Undress the baby to expose all areas of the body
U ○ Cover genitals & eyes
D
○ Turn the baby every 2 hours
E
○ Assess skin turgor because the infant may lose considerable fluid
thru insensible water loss due to the temperature of the light
C
○ Increase fluid intake to prevent dehydration
O
L ○ Check stools & urine. Their stools usually are frequently loose &
L bright green due to excessive bilirubin excreted. Urine may be
E dark-colored from urobilinogen formation
G
E b. Infection
• This is due to immature immune defenses in premature infants
S • In addition, they have a deficiency in IgG (antibodies) which is usually
T transferred from the mother to the baby during the last 2 weeks of
pregnancy
J
U 2. Post Mature Babies
D • Born after the 42nd week of pregnancy
E • They are at risk because the placenta is timed to be effectively functioning
for 40 weeks, after that, it seems to lose its ability to function
C • Characteristics:
O • Dry, cracked, leather-like skin due to lack of fluid & absence of vernix
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 • Fingernails have grown beyond fingertips
• They may be meconium-stained
• May be alert as a 2-week old baby

• Management:
• Protect baby from chilling
• Monitor vital signs
• Provide emotional support to the mother

2. Hemolytic disease of the newborn

○ Mother develops antibodies against fetal RBC leading to its
destruction of hemolysis. This in turn causes severe anemia and
hyperbilirubinemia.
b. RH incompatibility
• If mother is Rh (D) negative and fetus is Rh positive (has D
antigen), the mother will begin to form antibodies against
the D antigen. However, most AB are formed 72 hours after
the delivery of the baby. So during the 2nd pregnancy, there
will be a high level of AB D to
S destroy fetal RBC. By the end
T of the 2nd pregnancy, the fetus
may be severely compromised.
J
U b. ABO incompatibility
D • Maternal blood type is O and
E fetal blood type is A, B, or AB.
Hemolysis of blood begins with
C birth
O
L Characteristics
L ○ Doesn’t appear jaundiced
E ○ Enlarged spleen and liver
G ○ Edema
E ○ Progressive jaundice within the first 24 hours of life—
hemolytic process
S
T Management:
○ Initiative early feeding to stimulate bowel peristalsis
J
○ Suspend breast feeding for 24 hours to reduce
U
accumulating indirect bilirubin
D
○ Initiate phototherapy
E
○ Exchange transfusion
C  Withdrawing few amounts (2-4 ml) of infant’s
O blood and then replacing it with equal
L amounts of donor blood
L  Monitor vital signs
E  Keep infant warm
G
E 2. Infant of a diabetic mother
Characteristics
S • Typically longer and weighs
T more than other babies
(macrosomic) due to over
J stimulation of pituitary growth
U hormone and extra fat deposits
D due to high level of glucose
E during pregnancy
• Caudal: regression syndrome
C (hypoplasia of lower
O extremities)
L • Cushingoid appearance (fat and
L puffy)
E • Lethargic or limp on the first
G days of life
E

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 • They are usually born by cesarean birth
• Severe hypoglycemia during the 1st 24 hours (blood sugar
<40mg/dl in newborns)

2. Infant of a drug-dependent mother

Characteristics:
• Tends to be small for gestational age
• Has withdrawal symptoms shortly after birth
○ Irritable
○ Disturbed sleep pattern
○ May have tremors
○ May sneeze frequently
○ High-pitched cry
○ Hyperreflexia & clonus (neuromuscular irritability)
○ Tachypnea
○ Vomiting & diarrhea which may lead to dehydration

Management
• Keep infant in an environment free from excessive stimuli
• Maintain fluid & electrolyte balance

2. Infant with fetal alcohol syndrome

• Alcohol crosses the placenta
S • Characteristics:
T ○ Tremulous, fidgety, irritable
○ Weak sucking reflex
J ○ Sleep disturbance
U ○ Mental retardation—most serious, long term effect
D
E 7.Inborn errors of metabolism
• A group of hereditary biochemical disorders affecting
C metabolism
O • May be due to deficiency in a particular enzyme
L • Affect amino acid, protein, carbohydrate & lipid metabolism
L
E a.Phenylketonuria
G
E Phenylalanine
Phenylalanine Tyrosine
S
T • There is absence of phenylalanine hydroxylase which causes
the accumulation of phenylalanine in the blood stream &
J tissues causing permanent brain damage & mental
U retardation
D • Phenylpruvic acid spills into the urine which causes it to
E have a typically musty or “mousey” odor
• Characteristics:
C ○ Child becomes fair-skinned, blonde & blue eyed because tyrosine
O is needed for building body pigment and thyroxine
L ○ Fails to meet average growth standard
L
E • Management
G ○ Put the infant in an extremely low phenylalanine formula
E
a.Galactosemia
S
T
• Disorder of carbohydrate metabolism characterized by an
abnormal amount of galactose in the blood and in the urine
J
• Deficiency in galactose 1- phosphate uridyl transferase
which converts galactose into glucose
U
• Characteristics
D
○ Lethargy
E
○ Hypotonia
C ○ Diarrhea and vomiting
O ○ Hepatomegaly, cirrhosis
L
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 ○ Jaundice

• Management:
○ Place infant in a galactose-free diet

7. Congenital anomalies
a. Cleft lip & cleft palate
• Cleft lip
○ More common among males than females
○ Occurs at approximately 1:1000 live births
○ Has a familial tendency
○ Presence of teratogens during wks 5-8 of intrauterine life
○ Characteristics:
 The defect can be just a small notch in the upper lip or a
total separation of the lip & facial structure up into the floor
of the nose
 Nose is generally flattened
 Gingiva and upper teeth may be absent
 May be unilateral or bilateral

• Management
○ Cleft lip surgery (cheiloplasty) may be done shortly after birth
because early repair will help the infant
S experience pleasure of sucking as soon as
T possible

J • Cleft palate
U ○ More common among females than males
D ○ Occurs at approximately 1:2500 live births
E ○ Cleft lip with cleft palate occurs at
approximately 1:1000 live births
C ○ Genetic, familial, presence of teratogens
O ○ Characteristics:
L  Opening on the palate which may involve the anterior hard
L palate, posterior soft palate or both
E  Usually in the midline
G
E • Management
○ Cleft palate surgery is not done until the
S child is around 4-6 mos. Because it can
T damage the tooth buds
J • Associated problems:
U ○ Altered nutrition
D
Pre-op nursing care:
E
• Support the baby in an upright position (sitting or semi
sitting) while feeding
C
• Use a commercial cleft lip nipple
O
• Be careful when feeding because this may cause aspiration
L
• Burp frequently because they have the tendency to swallow
L
air due to their inability to maintain a closed seal around the
E
nipple
G
E
Post-op nursing care
• Keep on NPO for at least 4 hours
S
• Avoid placing tension on the suture line
T
• Breast feeding or bottle feeding is contraindicated during
the immediate post op period. Use a breck feeder
J
• Do not use straw to drink
U
• After repair of the cleft palate, liquid diet is continued for
D
the first 3-4 days followed by a soft diet until healing is
E
complete
• Never use spoon or fork when feeding
C
• Offer water after feeding to rinse suture line
O
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 ○ Ineffective airway clearance
 Observe for respiratory distress due to local edema in the
immediate post op period
 If suction is really needed, be gentle and don’t touch suture
line
 Post-cheiloplasty, put on side-lying position to drain saliva
 Use of mist tent to liquefy secretions
○ Impaired tissue integrity at incision site
 Avoid tension on the suture line
 A logan bar or an adhesive bandage is used to protect
suture line
 Anticipate infant’s need because crying increases tension on
the suture
 Avoid placing anything hard or sharp (toys) on the suture
line
 Keep elbow restraints in place

○ Infection
 Clean suture line with sterile solution and sterile cotton-
tipped applicators after every feeding
 They are high risk for ear infection so routine screening for
hearing loss is needed
 Teach the parents signs of
infection: pain, fever, ear
S discharge
T
○ Altered communication pattern
J
U
a. Hydrocephalus
D
• Excess of cerebrospinal fluid in the ventricles and subarachnoid
E
spaces of the brain
C
• Causes:
O
 Overproduction of fluid by the
L
choroids plexus
L
 Obstruction of the passage of fluid
E
 Interference with the absorption of
G
fluid from subarachnoid space
E
• Types
S
 Communicating or extraventricular
T
hydrocephalus- there is passage of
fluid between ventricles and spinal
J
cord
U
 Non communicating or
D
intraventricular hydrocephalus-
E
there is block to passage of fluid
C
• Assessment:
O
 Increase head size with bulging
L
fontanelles (first sign)
L
 Papilledema
E
 Edema of optic disk
G
 Scalp becomes shiny, scalp veins
E
prominent
 Sunset eyes
S
 Head lag even after 4 mos.
T
 Shrill, high-pitched cry
 Irritable and lethargic
J
U
• Diagnostic studies:
D
Sonogram, CT scan, MRI, skull x-ray
E
• Surgical management
C
Depends on its cause & extent
O
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G
E
  If caused by obstruction, treatment usually involves bypassing the
point of obstruction by shunting the fluid to normal or artificial
points of absorption

• Management:
 Elevate head of bed
 Put them in a non stimulating environment
 Monitor vital signs
 Watch out for signs of increase ICP: bulging fontanelles, increasing
head circumference, irritability, lethargy, poor sucking, increase
temperature, decrease PR, decrease RR.
 Reposition head every 2 hrs to prevent scalp breakdown
 Monitor head circumference daily

a. Neural tube disorders

• Anencephaly
○ Absence of the cerebral hemisphere
○ Children cannot survive with this disorder because of absence
of cerebral function

• Microcephaly
○ Slow brain growth due to maternal phenylketonuria or
intrauterine infection such as
rubella or cytomegalovirus
S ○ Results in mental retardation
T
• Spina bifida oculta
○ Occurs when the posterior laminae
J
or vertebrae fail to fuse
U
○ More common at the 5th lumbar or
D
E 1st sacral level
○ May appear as a dimple at the
C point of poor fusion; abnormal
O tuffs of hair may be present
• L Meningocele
L ○ Occurs when the meninges
E covering spinal herniates thru
G unformed vertebrae
E ○ Appears as a protruding mass at
the center of the back
S ○ Usually in lumbar region
T
• Myelomeningocele
J ○ The spinal cord, spinal fluid and
U meninges protrude thru the
D vertebral defect
E ○ Results in lower motor neuron
damage
C ○ Flaccid, lack of sensation in lower
O extremities
L ○ Loss of bladder and bowel control
L
• E Management:
G ○ Prevent infection/rupture of
E protruding mass
 Put child on prone position
S  Do not put diaper
T  Cover sac with sterile gauze with NSS or antibiotic
○ Monitor for signs of increase ICP:
J bulging fontanelles, vomiting, high-
U pitched cry, increasing head
D circumference, irritability, increase
E BP, decrease PR, decrease RR
○ Watch out for complications:
C
 Hydrocephalus
O
 Meningitis
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 • Nuchal rigidity
• Photophobia
• Opisthotonus position (arching of the spine)
• Signs of meningeal irritation: vomiting, (+)
kernigs, (+) brudzinski

 UTI
 Bowel incontinence
 Club feet
 Hip dislocation

D. BIRTH RELATED STRESSORS

1. Respiratory distress Syndrome of the newborn (RDS)/Hyaline membrane disease

• Caused by low level of phosphotidyl glycerol & lecithin component of
surfactant which maintains expansion of alveoli

Decrease surfactant increase surface tension lack of expansion of

alveoli

• When this happens, there is less exchange of oxygen and carbon dioxide
leading to: HYPOXIA
• Tissue hypoxia causes the release of lactic acid
• The pathologic feature of RDS is a hyaline-like membrane which prevents
S exchange of O2 & CO2 at the alveolar-blood inter space leading to
T ATELECTASIS
• Assessment:
J ○ Expiratory grunting--a compensatory mechanism
U ○ Cyanosis in room air
D ○ Nasal flaring
E
○ Sternal & subcostal retractions
○ Tachypnea (> 70 breaths/min)
C
○ Rales and diminished breath sounds
O
L
L • Management
E ○ Avoid extreme body temperature because increase in BMR will
G demand for O2
E ○ Give sodium bicarbonate to correct acidosis
○ Monitor VS especially RR every 1-2 hours
S ○ IV fluid may be needed or gavage feeding for hydration because
T the respiratory effort makes the infant too exhausted to suck
○ Administer O2 to maintain normal PO2 and pH levels
J
U 1. Meconium
D • An infant who experienced hypoxia in utero has a vagal reflex relaxation of
E the rectal sphincter releasing meconium into the amniotic fluid. During the
first breath, the baby inhales the amniotic fluid & aspirates meconium. This
C can bring about inflammation of bronchioles or block bronchioles by
O mechanical plugging. Any of these 2 mechanisms will cause severe
L respiratory distress.
• L Characteristics:
E • Has difficulty establishing respirations at birth
G • Tachypnea, retractions, cyanosis
• E Management:
• The infant should be intubated
S • Suction meconium from trachea & bronchi
T • Antibiotic treatment may be given to prevent development of pneumonia

J
U
D VII. PEDIATRIC NURSING
E
D. GENERAL PRINCIPLES OF GROWTH AND DEVELOPMENT
C • Growth- increase in physical size
O quantitative change
L
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 • 2 aspects
○ weight- most sensitive measure of growth
○ birthweight- 2x at 6 mos
3x at 1 year
4x at 2 ½ years

○ height
○ Increase in ht. is 1”/mo from 1 mo- 6 mos.
1/2”/mo from 7 mos. - 12 mos.

○ rate of growth is rapid during infancy and adolescence, slow during

toddler, pre-school, and school age period

○ rapid growth of limb occurs at school age period

• Development- increase in skill or ability to function

- Qualitative change

• Principles of growth and development

○ Growth and development are continuous process from conception till
death
S ○ Growth and development proceed in an orderly sequence
T ○ Different children pass thru the predictable stages at different rates
○ All body systems do not develop at the same rate
J ○ Development is cephalo-caudal
U ○ Development proceeds from gross to refined skills
D ○ Development proceeds from proximal to distal body parts
E ○ There is an optimum time for initiation of experience or learning
○ Neonatal reflexes must be lost before development can proceed
C ○ A great deal of skill & behavior is learned by practice
O
L
L
D. THEORIES IN HUMAN DEVELOPMENT
E
G
1. Psychoanalytic theory (Sigmund Freud)
E
STAGES AGE CHARACTERISTICS
S
Oral 0-1 year Infant sucks for enjoyment or relief of tension as well as
T
for nourishment
Anal 2-3 years Children find pleasure in both the retention & defecation of
J
feces (toilet training
U
Phallic 4-5 years Pleasure zone is genital area, masturbation, children’s
D
E energy is diverted to physical and intellectual activities
Latency 6-12 years Children’s energy is diverted to physical and intellectual
C activities
O Genital 13 & above Energy is directed to attain mature heterosexual
L relationships
L
E 2. Psychosocial development theory (Erikson)
G
E STAGE AGE IMPLICATIONS
Trust vs. Mistrust Birth- 18 Provide experiences that add to security.
S mos. Children learn to love and be loved
T Autonomy vs. 18 mos. Vs. 3 Child learns to be independent & make decisions
Shame and Doubt years for self. Provide opportunity for decision making
J Initiative vs. Guilt 3-5 years Child learns how to do things. Provide
U opportunities for exploring new places and
D activities
E Industry vs. 6-12 years Child learns how to do things well.
Inferiority
C Intimacy vs. 20-25 years Offer support
O Isolation
L
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E
 Generativity vs. 25-65 years
Stagnation
Integrity vs. 65-death
Despair

3. Cognitive development theory (Piaget)

STAGES AGE CHARACTERISTICS

Sensorimotor Birth- 2 Uses reflex behavior; at the end of this stage, infants
years begin to demonstrate goal-directed behavior
Preoperational 2-7 years Thought becomes more symbolic. Child is egocentric.
Language development
Concrete 7-12 years Systematic reasoning. Understands relationships
Operational
thought
Formal 12 years Can solve hypothetical problems with scientific
operational and above reasoning
thought

4. Moral development theory (Kohlberg)

STAGES AGE CHARACTERISTICS

Preconventional
S Level 1 2-3 years Punishment & obedience orientation.
T Level 2 4-7 years Individualism. Instrumental-reletivist
orientation
JConventional
U Level 3 7-10 years Orientation to interpersonal relations of
D mutuality (good boy, nice girl)
E Level 4 10-12 years Law and order situation

C Post conventional
O Level 5 12 & above Social contract. Follows standards of
L Level 6 society. Universal ethical principle
L orientation
E
D. G BEHAVIOR TRAITS/CHARACTERISTICS
1. E INFANTS (0-12 mos.)
• Significant person- mother/caregiver
S • Fear- stranger anxiety
T • Physical growth
• Developmental milestones
J ○ 0-1 month
U  largely reflex
D  keeps hands fisted, able to follow object to midline
E  momentary visual fixation on faces

C ○ 2 months
O  holds head up when prone
L  social smile
L  makes cooling sounds
E  differentiates his cry
G
E ○ 3 months
 holds head and chest up when prone
S  follows objects past midline
T  laughs aloud

J ○ 4 months
U  no longer has head lag when pulled upright
D  bears partial weight on feet when held upright
E  grasps objects & brings to mouth

C ○ 5 months
O  raking grasp
L
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E
  turns both ways

○ 6 months
 reaches out in anticipation of being picked up
 sits unsteadily (with minimal support)
 eruption of first tooth
 palmar grasp

○ 7 months
 transfer objects hand to hand
 beginning fears of strangers

○ 8 months
 sits securely without support
 fear of strangers (peak)

○ 9 months
 creeps or crawls
 says first word (dada)

○ 10 months
 puts self to stand
 uses pincer grasp (thumb to finger)
S
○ 11 months
T
 walks with support
J
○ 12 months
U
D  stands alone
E  walks with help
 holds cup & spoon well
C
O • Play: solitary
L • Appropriate toys: mobiles, rattles, music box, squeeze toys,
L plastic rings, rubber ducks, teething ring, textured toys
E
G 1. TODDLER (1-3 years)
E • Significant person: parents
• Fear: separation anxiety
S • Physical growth:
T ○ Decrease appetite because of slower growth rate
○ Prominent abdomen because abdominal muscles are not
J yet strong enough to support abdominal contents
U ○ All deciduous teeth are generally present by 2 1/2 – 3
D years
E ○ Should start regular dental care by 2 years

C • Developmental milestones
O ○ Critical for language development
L ○ Favorite word is “NO” (a manifestation of developing
L autonomy)
E ○ Negativistic, obstinate, difficult to manage
G ○ Active, curious, motor ability jumps far ahead of his
E judgment
○ By 18 mos., he imitates the things he sees a parent is
S doing
T ○ They have ritualistic behaviors
○ They go into temper tantrum at one time or another.
J
Temper tantrums are a natural consequence of their
U
development. They occur as a response to an unrealistic
D
request by parent, consequence of their development.
E
They occur as a response to an unrealistic request by
parent, or if the parents are saying, “NO” too frequently,
C
O
L
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G
E
 or maybe a response to difficulty making choices, or too much pressure
from activities like toilet training
○ Know the cause of the tantrum
○ Tell the child that they disapprove of the tantrum then ignore the
behavior
○ Keep child away from onlookers
○ Don’t accede to the wish of the child nor punish the child
○ Direct the child to more productive activities
○ Toilet training- one of the biggest task during this period; it is an
individualized task for each child
○ 2 important developmental levels before a child can begin toilet
training
○ control of rectal & urethral sphincters—if the child is able to walk
well independently
○ they must understand what it means to hold urine & stools until
they can release them at a certain place and time—when they
begin to be uncomfortable with their wet diapers
○ at 18 mos. Of age, the toddler has bowel control
○ at 2 1/2 years, he has day time bowel control
○ at 3-4 years, he has night time bladder control

• Play: parallel (side by side)

This is not unfriendly but is a normal developmental sequence
during
toddler period
• Appropriate toys: push-pull toys, trucks, toy telephone, building
blocks, balls, toy hammer with nail, drums, toys to ride on, pots,
pan, swing, slide

1. PRESCHOOLER (3-6 years)

• Significant person: basic family (extended)
• Fear: fear of castration/body mutilation; fear of the dark, ghosts. Witches,
thunder, lightning
• Physical growth
 Definite change in body contour: slimmer, taller
 Slight weight gain (4.5 lb/year)
 Minimal height gain (2-3.5”/year)
 Rarely do new teeth erupt because all 20 deciduous teeth area
present by 3 years of age

• Behaviors
 3 years old
○ undresses self
○ runs
○ climbs steps one at a time
○ walks backwards
○ stands on 1 foot
○ vocabulary of 300- 900 words

 4 years old
○ can do simple buttons
○ jumps, skips
○ uses alternate steps when climbing stairs
○ vocabulary of 1500 words

 5 years old
○ draws a 6-part man
○ throws over hand
○ runs well
○ vocabulary of 2100 words

 Developmental milestones
○ They ask questions constantly
○ Favorite word is “WHY”
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 ○ Answer their questions honestly at the level of their
understanding so that their
S curiosity, vocabulary building &
T questioning are encouraged.

○ J They are self-centered

○ U They have active imaginations, fantasies
○ D Imitative
○ E Age of OEDIPUS COMPLEX (strong emotional attachment of a
preschool boy for his mother) and ELECTRA
C COMPLEX (attachment of a preschool girl to her
O father).
L ○ Each child competes with the
L same sex parent for the love &
E attention of the other parent.
○ G They typically have some speech difficulty. They may begin to
E
repeat words or syllables (broken fluency)
○ Sibling rivalry
S
○ Spend separate time with each other
T
○ Involve the child in caring for the second child
○ J Preschoolers may engage in masturbation
○ Do U not punish the child
○ D Divert their attention (give toys to play with)
E ○ They may question about genital
organs or sex, answer them
C honestly at the level of their
O understanding
L
 L Play: associative, cooperative, dramatic, imaginary playmates
E  Appropriate toys: dolls,
G housekeeping toys, water colors,
E clays, coloring book, dress-up
clothes, simple puzzles.
S
T 1. SCHOOL AGED CHILD (6-12 years old)
• Significant person: peers of the same sex, teacher
• J Physical growth:
 U Mature slowly but steadily
 D Weight gain of 3-5 lbs/years
 E Increase in height of 1-2”/year
 By age 10, brain growth is complete
C  Hypothalamus transmits
O enzyme to anterior pituitary
L gland to produce gonadotropic
L hormones that activate
E changes in testes and ovaries
G (10-14 years of age)
 E Deciduous teeth are lost and permanent teeth erupt

• Developmental milestones
 They are modest, industrious
 They enjoy collecting items
 They are competitive
 Stealing is a common problem
 6 years old
• jumps, skips, stumbles, hops
• talk in full sentence
• play in groups
• first molars may erupt

 7 years old
• central incisors erupt
• difference between sexes become apparent in play
• spends time in quiet play
• can tell time in hours
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  8 years old
• improved coordination
• loves collecting clothes
• prefers playmates of own sex
• best friends develop

 9 years old
• Always on the go
• They play hard
S
• Gang age
T
 10 years old
J
• coordination improves
U
• interest in the opposite sex is apparent
D
• interested in rules and fairness
E
• enjoy privacy
C
 11 years old
O
• more active become increasingly interested in the opposite sex
L
L
 Play: competitive
E
G
 Age-appropriate toys: dolls, table games, comic books,
watching TV, remote control games, collecting items.
E
1. ADOLESCENT (12-18 years old)
S
• Significant person: peers of opposite sex
T
• Fear: fear of acne, homosexuality, obesity, displacement from
friends, death
J
• Physical growth:
U
○ Onset of puberty and cessation of body growth
D
E ○ Physiologic growth is rapid
• Pubertal changes
C ○ Male (testes testosterone)
O  sudden growth spurt
L  deepening of voice
L  increase size of genitals
E  pubic & axillary hair
G  production of viable sperm
E
○ Female (ovary estrogen & progesterone)
S  Sudden growth spurt
T  The larche (increase size of breath).
• Starts at 10 years old and ends at 18 years of age
J • Sign to sexual maturation
U  Appearance of pubic & axillary hair
D  Widening of hips
E  Menarche
• Happens between the time the girl develops pubic and
C axillary hair
O • Ovulation starts 1-2 years before menarche
L
L ○ Behaviors
E  Rebellious, reformers, idealistic, futuristic
G  Use of status symbol
E  Conscious of body image
 Emancipation from parents becomes an issue
 Hero worship (film star, athlete, writer, etc.)

D. IMMUNIZATIONS

Immunity- ability to destroy a particular antigen

IMMUNITY

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 NATURAL ARTIFICIAL

ACTIVE PASSIVE ACTIVE PASSIVE

Suffered the Placental transfer. Receiving vaccines Receiving toxoid

disease. Exposed to Breast feeding for immunizable (IgG serum (Hepa)
the disease carrier diseases

IMMUNIZATION AGE SITE ROUTE DOSE

BCG 1.1 year Right deltoid ID .05 ml
School entrants Left deltoid ID ID 0.1 ml
DPT (3 doses at 1 2 ½ mos. Vastus lateralis IM 0.5 ml
mo. Interval) 3 ½ mos.
4 ½ mos.
OPV (3 doses at 1 ½ mos. Oral Oral 2- drops
1 mo. Interval) 2 ½ mos.
3 ½ mos.
Measles 9 mos. Deltoid SQ 0.5 ml
Hepa B (3 doses) 6 wks. – 11 mos Vastus lateralis IM 0.5- 1 mo.
interval

VIII. CHILDREN AT RISK

d. Respiratory Dysfunction
1. Disorders of the upper respiratory tract
a. Acute nasopharyngitis (common
cold)
• Most frequent infectious disease in children
• Viral in origin
• Assessment
○ Begins with nasal congestion
○ Watery rhinitis
○ Low grade fever
○ Edematous & erythematous nasal mucous membrane
○ May have thick purulent nasal discharge

• Management: no specific treatment, control signs and

symptoms

b. Tonsilitis
• Infection and inflammation of palatine tonsils
• Assessment:
○ Drooling because the throat is too sore for them to swallow saliva
○ High fever
○ Lethargy
• Management:
○ Antipyretic for fever
○ Analgesic for pain
○ Antibiotics
○ Tonsillectomy—removal of palatine tonsils
○ Adenoidectomy—removal of pharyngeal tonsils
• Both are never done while the organs are infected because operation might
spread the pathogens into the blood which may lead to septicemia
• Pre-op nursing care: complete PE, record bleeding & clotting time, CBC &
urinalysis
• Post-op nursing care:
○ Monitor VS

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 ○ Place child on abdomen so that head is lower than the chest to drain
blood & unswallowed saliva
○ Assess for subtle signs of hemorrhage: increase PR, increase RR,
frequent swallowing, throat clearing
○ If bleeding occurs, elevate head & turn to side
○ Frequent sips of clear liquid or ice chips may be given if the patient is
awake because this will increase blood supply to the area thus
reducing edema and pain

b. Epistaxis (nose bleed)

• May be due to trauma, hot dry environment, after a strenuous exercise, or
during a respiratory illness
• Management:
○ Keep in an upright position with head tilted slightly forward to
decrease pressure in the nasal vessels
○ Apply pressure to the sides of the nose with
S fingers
T ○ Calm the child because crying will increase
pressure in the blood vessels of the head
J
U
b.Croup (Laryngotracheobronchitis)
D
• Inflammation of larynx, trachea & major bronchi
E
• Cause is usually viral infection
• Assessment:
C
○ Barking (croupy) cough mostly during the
O
night
L
○ Inspiratory stridor—sharp, high-pitched
L
E sound
G ○ Marked retractions
E ○ May have a low-grade fever
○ Signs of respiratory distress (restlessness,
S increase PR and RR)
T
• Management:
J ○ Supply cool moist air thru a mist tent
U (plastic canopy that stretches over a child’s
D bed)
E ○Note: bedding may become wet & cold easily so keep linens dry
○Monitor VS every 15 minutes
C ○Comfort the child to prevent crying
O ○Dexamethasone is given to reduce edema
L ○Racemic epinephrine for bronchodilation
L
E b.Aspiration
G • Inhalation of foreign object into the airway
E • When a child aspirates an object, the initial
reaction is choking & forceful coughing which
S usually dislodges the object
T • If the cough has no sound or there are signs of
increasing respiratory difficulty, Heimlich
J maneuver (children), back blows & chest thrust
U (infants) should be done.
D ○ Heimlich maneuver
E
• Stand behind the child (if lying on his back, stand
at the head of the bed or table)
C
• Embrace the child & grip your fist with your other
O
hand
L
• Pull back & up with a rapid thrust
L
• Back blows & chest thrusts
E
○Turn the infant prone over your arm
G
○ Using the heel of your hand, give 5 quick
E
back blows between the infant’s shoulder
blades
○ If the object is not expelled, place in a supine position

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 ○ Provide 5 quick downward thrusts in the lower third of the sternum

b. Bronchial obstruction
• Right main bronchus is straighter and has larger lumen than the left
bronchus in children >2 years of age. That is why an aspirated foreign
object may lodge in the right bronchus. The alveoli distal to the
obstruction will collapse (atelectasis)
• Assessment:
○ Cough
○ Dyspnea
○ Hemoptysis
○ Purulent sputum
○ Localized wheezing
• Monitor VS
• Keep on NPO for at least 1 hour
• Liquefy secretions

2. Disorders of the lower respiratory tract

a. Bronchiolitis
• Inflammation of fine bronchioles & small bronchi
• Caused by virus
•Assessment:
S ○ 1 or 2 days of upper respiratory tract infection
T ○ nasal flaring
○ intercostal & subcostal retractions
J ○ increase RR
U ○ wheezing
D
E •Management:
○ Provide adequate hydration to keep respiratory membranes moist
C ○ Give moist oxygen
O ○ IV therapy may be started
L ○ Place in semi-fowler’s position for adequate chest expansion
L ○ Some are more comfortable in prone position
E
G a. Pneumonia
E • Inflammation of the lung alveoli
• May be bacterial or viral in origin
S • Aspiration may also cause pneumonia
T • Classification:
○ Pneumococcal
J
• High fever, nasal flaring, restractions, chills, dyspnea, chest pain,
U
tachypnea, tachycardia, rales
D
• Antiobiotics: Penicillin G
E
• Chlamydial
○ Often seen in newborns up to 12 weeks of age
C
○ Nasal congestion, cough, tachypnea, wheezing, rales
O
L • Viral
L ○ Low-grade fever, non productive cough, tachypnea, diminished breath
E sounds, rales rest
G • Mycoplasmal
E ○ More frequently seen in older children
○ Fever, cough, enlarged cervical lymph odes, rhinitis
S ○ Antibiotic: erythromycin
T • Lipid
○ Caused by aspiration of oily or lipid substance (peanuts)
J ○ Cough, dyspnea, respiratory distress
U • Hydrocarbon
D ○ Furniture polish, kerosene, gasoline, insect sprays, lighter fluid
E ○ Nausea & vomiting, drowsy, dyspnea, increase RR
○ Don’t induce vomiting
C ○ Stomach lavage
O ○ Prevent secondary infection
L
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G
E
 d. Gastrointestinal Disorders
1. Disorders of motility
a. Diarrhea
• Diarrhea in infants is always serious because they have little
extracellular fluid reserve. Sudden losses of water may lead to
dehydration.
• May be bacterial or viral in origin
• Mild diarrhea
○ 2-10 loose watery stools/day
○ fever, anorexia, irritability, dry mucous membrane, increase PR,
warm skin, good skin turgor, normal urine output
○ Management:
○ Rest the gastrointestinal tract for 1 hour then start rehydration.
• Severe diarrhea:
○ Fever, weak & rapid PR, cool skin, pale, apprehension, listlessness,
lethargy
○ With obvious signs of dehydration: increase PR, depressed
fontanelles, sunken eyes, poor skin turgor, weight loss
○ Bowel movement every few minutes
○ Stool is liquid green with mucus and blood
○ Scanty & concentrated urine
○ Management:
S ○ Maintain fluid and electrolyte balance by replacing lost fluids and
T electrolytes by starting IV infusion
○ Provide skin care because diarrheal stool is irritating
J ○ Wet lips with moisturizing to prevent crackling
U
D a. Constipation
E • Difficulty passing hardened stools
• Abdominal pain, pain on defecation
C • As long as the stool is not hard and no discomfort is felt in passing
O the stool, it is not considered constipation
L • Management:
L ○ Enema may initially be needed
E ○ Give stool softeners
G ○ Advise high fiber, high fluid diet
E ○ Encourage to develop regular bowel habits

S 2. Inflammatory diseases
T b. Appendicitis
• Inflammation of the appendix
J • Most common in school age children
U • Cause is unknown
D • Assessment:
E • Anorexia (12-24 hours)
• At first, the child will feel diffused abdominal pain which gradually
C
localizes at the right lower quadrant. The point of sharpest pain is
O
1/3 of the way between anterior posterior iliac crest and umbilicus,
L
referred to as Mc Burney’s point.
L
• Nausea and vomiting
E
• Fever
G
• Leukocytosis
E
• Rebound tenderness
• Reduced bowel sound
S
T
• Management: surgical removal of appendix
• Pre-op nursing care:
J
○ Cathartics & heat are contraindicated because they may cause
U
rupture of appendix
D
○ Shave and wash abdomen & perineum
E
○ Urinalysis and CBC
C ○ Start IV fluid for hydration
O • Post- op nursing care:
L
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G
E
 ○ Children will return with NGT in place. Keep on NPO until return of
peristalsis
○ Maintain IV fluid
○ Monitor I and O
• If with ruptured appendix
○ Semi-fowler’s position so that infected drainage will drain onward
rather than upward into the lungs
○ Start IV fluid
○ Begin antibiotics
○ Post-operatively, penrose drain are maintained in place to drain
infectious material
○ Examine wound carefully
○ Change dressings as ordered
• Complication: Peritonitis
○ Signs: rigid (board-like) abdomen, shallow respiration, increase
temperature.

b. Necrotizing Enterocolitis (NEC)

• Bowel develops necrotic patches which interferes with digestion & may lead to
paralytic ileus
• More common in immature infants
• Assessment:
○ Distended & tense abdomen
S ○ Inability to empty stomach on next feeding
T ○ (+) occult blood on stool
○ decrease BP
J
• U Management:
D ○ Temporary colostomy may be needed
E ○ Provide colostomy care
○ Start IV infusion
C
○ Antibiotics may be given to prevent secondary
O
infection
L
L
E
b. Inflammatory bowel disease: Ulcerative colitis & Chron’s
G disease
• E Ulceration in the mucosa & submucosa of the colon & rectum
• Wall of the colon becomes thickened & inflamed which leads to a
S “cobble-stone” appearance of the mucosa
• T In Ulcerative colitis, entire lower bowel is affected
• In Chron’s disease, involved segments are separated by normal bowel
J tissue & usually, areas affected are higher in the intestine
• U Assessment:
D ○ Abdominal pain
E ○ Diarrhea & steatorrhea
○ Blood in the stool
C ○ Weight loss
O ○ Growth failure
L ○ Recurring fever
• L Management:
E ○ Rest
G ○ TPN may be needed
E ○ Provide high protein, high carbohydrate, high vitamin diet
○ Anti-inflammatory drug (Prednisone) may be given
S ○ Provide emotional support
T
2. Obstructive disorders
J
a. Pyloric stenosis
U
• Difficulty of the stomach to empty its contents due to hyperthrophy or
D
hyperplasia of the muscle surrounding the pylorus (valve between the
E
stomach & beginning portion of the intestine)
• Assessment:
C
○ Projectile vomiting after 1 or 2 feedings
O
L
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G
E
 ○ Vomitus smells sour because it has been in contact with stomach enzymes
○ Olive-shaped mass palpated on upper quadrant of abdomen
○ Gastric peristaltic waves passing from left to right as the infant drinks
○ Signs of dehydration: dry mucous membrane of mouth, depressed
fontanelles, fever, decrease urine output, poor skin turgor, weight loss
• Management:
○ Pre-op nursing care:
 Administer IV fluids
 Determine baseline weight
○ Post op
 Frequent feedings of small amount of fluids
 Monitor daily weight
 Report if vomiting occurs

a. Intussusception
• Invagination of the portion of the intestine into another
• Assessment:
• Severe abdominal pain which causes them to draw up their legs &
cry
• They may be symptom-free after the pain
• In approximately 15 minutes, the abdominal pain may strike again
• Vomiting
• Blood in stool after 12 hours (“currant jelly” appearance)
S • Distended abdomen
T • Management: surgery to remove invagated portion or reduce the
intussusception
J • Pre-op nursing care:
U ○ Keep on NPO
D ○ Begin IV infusion
E • Post-op nursing care:
○ Keep NGT & IV infusion in place
C
O c. Volvulus
L • Twisting of the intestines leading to obstruction of the passage feces
L • Assessment:
E ○ Intense crying and pain
G ○ Pulling up the legs
E ○ Abdominal distention
○ Vomiting
S ○ Abdominal mass
T
• Management: surgery to relieve vulvolus and reattach bowel
J
U c. Intestinal obstruction
D • Assessment
E ○ The infant does not pass meconium or may pass 1 stool, then stop
○ Distended abdomen
C ○ Vomiting
O
○ Increase bowel sounds
L
L ○ Character of infant’s cry: hard and forceful
E ○ Increase PR
G
E • Management: this is an emergency to prevent dehydration &
electrolyte imbalance. The area of stenosis is removed and the bowel
S is anastomosed
T
c. Hirschsprung disease (A ganglionic megacolon)
J • Absence of ganglionic innervation to the muscle of a section of the
U bowel so that there are no peristalsic waves to further the passage of
D the fecal material
E • Assessment: Symptoms are apparent after 6-12 mos. Of age.
○ History of chronic constipation of intermittent constipation and diarrhea
C ○ Ribbon-like stools
O ○ Abdominal pain
L
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G
E
 ○ Nausea and vomiting
• Management: surgery (Swenson pull-through) usually done at 12-18 mos of age
because it is difficult to perform the surgery in small abdomen so a temporary
colostomy is done
○ Pre-op nursing care
 Daily enemas to achieve bowel movements. Use normal saline
(isotonic) not tap water (hypotonic) because tap water moves rapidly
to the interstitial and intravascular fluid compartments which may lead
to cardiac congestion or cerebral edema
 Provide colostomy care
 Provide frequent feedings with low residue diet
○ Post-op nursing care
 Keep NGT and IV in place
 Watch out for abdominal distention
 Assess bowel sounds & observe for passage of flatus and stool
 When peristalsis returns, give small frequent feedings

2. Structural defects
a. Hernias
• Diaphragmatic hernia
○ Abdominal organ (usually stomach or intestine) protrudes through a defect in
the diaphragm into the chest cavity. This usually occurs on the left side,
displacing the heart to the right of the chest & the left lung collapses
○ Assessment:
S
○ Respiratory difficulty from the time of birth
T
○ Cyanosis
J ○ Intercostals & subcostal retractions
U ○ Sunken abdomen
D ○ Absent breath sound on affected lung
○ E Management:
○ Elevate head to ease breathing
C ○ Turn the infant so that affected lung is down so
O that the unaffected lung will expand completely
L ○ NGT or gastrostomy tube is inserted to prevent
L distention
E ○ Infants with diaphragmatic needs immediate
G surgical repair
E
• Umbilical hernia
S ○ A portion of the intestine protrudes through an
T opening of the umbilical ring
○ The mass is generally 1-2 cm in diameter but
J
usually gets bigger when the child cries or strains
U
○ If fascial ring is <2 cm, closure is spontaneous and
D
E needs no repair
 If fascial ring is >2 cm, it needs surgery
C which is done to school age
O
• L Inguinal hernia
L ○ Protrusion of a section of a bowel into the inguinal
E ring
G ○ Assessment:
E  Lumpin the groin usually on the right side
 Sometimes, hernia is only apparent when
S crying due to increase abdominal pressure
T  If pain is present, the bowel has become
incarcerated in the sac (emergency
J situation)
U ○ Management: surgery
D
a. E Imperforate anus
• Failure of the 2 sections of the bowel to meet or if the membrane
C between the 2 surfaces doesn’t dissolve during the 7 th week of
O intrauterine life
L
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G
E
 • Assessment:
○ No anal formation
○ Inability to insert rectal thermometer
○ A membrane filled with black meconium is seen protruding from the anus
○ No stool is passed leading to abdominal distention

• Management:
○ Post-op, NGT is inserted for decompression
○ Check bowel sound
○ Small oral feedings are resumed when bowel sounds are present
○ Maintain the suture line clean by irrigating it with normal saline
○ Take temperature thru axilla

a. Peptic ulcer
• Shallow excavation in the mucosal wall of stomach, pylorus or duodenum
• Due to the over secretion of gastric juices or failure of the mucosa to
neutralize gastric secretions
• Causes: administration of adrenocorticotropic hormone or corticosteroids in
neonates: associated with stress (prolonged labor, sepsis: genetic factor
• Assessment:
○ Neonate: hematemesis (blood in vomitus)
Melena (blood in stool)
○ Toddler: feeding problems
Vomiting
○ Pre-school: Pain on arising not relieved be eating, poorly localized
○ Older school age/adolescent: gnawing or aching pain in epigastric
before meals that is relieved by eating, vomiting tenderness in
epigastric region.
• Management:
○ Medications to decrease gastric acidity (Cimetidine) taken with meals
or at bedtime
○ In infants, give frequent small feedings
○ In children, avoid heavily spiced foods
○ Provide emotional support and relieve stress

2. Malabsorption syndrome (Celiac disease)

• Sensitivity or immunologic response to protein, particularly the gluten factor of
protein found in grains
• Upon ingestion of these foods, changes occur in the intestinal mucosa thus
preventing the absorption of foods across the intestinal villi into the blood stream
• Assessment:
○ Anorexia
○ Irritability
○ Distended abdomen
○ Steatorrhea
○ Malnutrition
• Management: gluten-free diet for life
• Foods containing gluten: wheat, oats, barley products

2. Hepatic disorders
a. Hepatitis
• Inflammation & infection of the liver

Hepatitis A Hepatitis B
Causative agent Hepa A virus Hepa B virus
Incubation period 25 days 120 days
Period of communicability 2 weeks before onset of Later part of the incubation
jaundice period, acute stage

Mode of transmission ingestion of contaminated Contaminated blood, plasma

water, sexual transmission or semen, placental
from oral intercourse transmission, contaminated
syringe

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 • Assessment:
○ Headache, vomiting
○ Generalized aching
○ Right upper quadrant pain
○ Icteric sclera
○ Generalized jaundice
○ White or gray-colored stool
○ Low-grade fever, sore throat, nasal discharge
○ Dark-colored urine after 3-7 days

• Management:
○ Maintain a high-caloric diet
○ Strict hand washing & isolation technique
○ Cool bath to reduce discomfort from pruritus
• Complication: Hepatic coma

a. Obstruction of the bile ducts

• Bile cannot enter intestinal tract & accumulates in the liver, bile enters the blood
stream so that infant appears jaundice
• Assessment:
○ Jaundice after 2 weeks
○ Rise in direct bilirubin
○ Elevated alkaline & phosphatase level
S ○ Poor absorption of fat-soluble vitamins
T ○ White stools due to lack of bile pigments
• Management:
J ○ If mucus plug is suspected, give MgSO4 or dehydrochloric acid
U
○ It atresia of bile duct is suspected, surgery is needed
D
○ Pre-op nursing care:
E
 Low-fat, high protein pre-op diet
 Give vitamins A, D, K
C
○ Post-op nursing care:
O
L  Keep NGT in place until peristalsis returns
L  Observe for abdominal distention
E  Monitor stool
G
E 2. Nutritional deficiencies
a. Vitamin A deficiency
S • Night blindness- earliest sign
T • Xerophthalmia- conjuctive becomes dry and lusterless
• Keratomalacia- necrosis of the cornea with perforation, loss of ocular fluid,
J blindness
U • Treatment: administration of supplementary Vitamin A
D Diet rich in Vitamin A
E
a. Thiamine (Vitamin B1) deficiency
C • Beriberi
O • Earliest signs:
L ○ Tingling or numbness of extremities
L ○ Occasional heart palpation
E ○ Exhaustion
G • Treatment: Administration of Thiamine
E Thiamine rich diet

S a. Niacin deficiency
T • Pellagra
• Characteristics (4 Ds);
J ○ Dermatitis
U ○ Diarrhea
D ○ Dementia
E ○ Death

C a. Vitamin C deficiency
O • Scurvy
L
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G
E
 • Characteristics:
○ Muscle tenderness
○ Petechial hemorrhage of the skin
○ Nose bleeding
○ Swollen gums
• Treatment: Administration of supplementary Vitamin C diet rich in fresh fruits
and vegetables.

a. Vitamin D deficiency
• Rickets
• Characteristics:
○ Poor muscle tone
○ Delayed motor development
○ Delayed tooth eruption
○ Gastrointestinal upset
○ Excessive perspiration of the head
○ Swelling of epiphysis of the long bones
○ Bowlegs, knock-knee deformities
○ Spinal deformities
• Treatment: Administration of Vitamin D
Diet rich in Calcium & Vitamin D
Expose children to sunlight

S a. Iodine deficiency
T • Goiter (hyperplasia of the thyroid gland)
• Has difficulty breathing
J • Treatment: supplemental iodine
U Synthetic thyroxine
D High-iodine diet
E
a. Kwashiorkor
C • Caused by protein deficiency
O • More frequently seen in children ages 1-3 years
L • Characteristics:
L ○ Growth failure
E ○ Muscle wasting
G ○ Irritability
E ○ Iron-deficiency anemia
○ Diarrhea
S
• Treatment: high protein diet
T
a. Nutritional Marasmus
J
○ Deficiency of all food groups
U
D ○ Most commonly seen in children younger than 1 year
E ○ Characteristics:
○ Growth failure
C ○ Muscle wasting
O ○ Iron- deficiency anemia
L ○ Diarrhea
L ○ Treatment: diet rich in nutrients
E
G 2.Poisoning
E • More common between the ages of 2-3 years
• Emergency management of poisoning at home:
S ○ Call for help
T ○ Identify the poison
○ Check the respiration
J  If deep, rapid- ACID
U  If slow, shallow- ALKALINE
D ○ Remove poison from the body including vomiting
E
○ Give syrup of ipecac: 15 ml (adolescent, school-age child,
preschooler) 10 ml (infant) followed by 200 ml of fluid
C
O
L
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G
E
 ○ If syrup of Ipecac is not available, induce gagging by placing finger in the
back of the throat
○ Do not induce vomiting if:
 The child is comatose
 The child has seizure
 The poison was caustic, corrosive or hydrocarbon
○ Give antidote (opposite of the poison)
○ Universal antidote (opposite of the poison)
 Burned toast
 Milk of magnesia
 Strong tea
○ Gastric lavage
○ administer saline cathartic (harsh laxatives)
 can cause dehydration & fluid electrolyte imbalance

a. Salicylate poisoning (aspirin)

○ Toxic dose: 150-200 mg/kg body weight
○ Indicative signs:
○ Hyperventilation leading to respiratory alkalosis
○ Metabolic acidosis
○ High fever
○ Dehydration
○ Tachycardia
S ○ Vomiting
T ○ Diarrhea
○ Restlessness
J ○ Confusion
U
○ Tinnitus
D
○ Management
E
○ Remove poison from the body
C  Give syrup of ipecac
O  Gastric lavage
L ○ Offer fluid orally to dilute poison and prevent dehydration
L ○ Give sodium bicarbonate to create alkaline urine
E ○ Tepid sponge bath, cooling blanket
G ○ Start IV fluid
E ○ Monitor VS, signs of hypoglycemia, metabolic acidosis

S a. Caustic poisoning
T ○Lye in washing powder, toilet bowl cleaners, hair care products
○S/Sx:
J ○ Pain in mouth & throat
U ○ Drooling
D ○ Mouth turns white due to burn and later turns brown due to edema &
E ulceration
○ Vomiting of blood & mucus
C
○ Tachycardia
O
○ Tachypnea
L
L ○ Pallor
E ○ Hypotension
G ○Management:
E NOTE: Vomiting should never be induced because the corrosive substance will
burn as it moves along the GI tract
S ○Dilute poison with milk or water
T ○Start steroid therapy to decrease chance of permanent
esophageal scarring
J ○Monitor VS
U
D a. Lead poisoning
E ○Interferes with RBC function
○Effects:
C  CNS: lethargy, impulsiveness, mental dysfunction
O  Hematology: Hypochromic, microctic anemia
L
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G
E
  GI: constipation, abdominal pain, vomiting
 Kidney: hematuria
○ Management:
○ Chelation therapy to remove lead from soft tissue and bone & eliminate it in the
urine
 EDTA (Edetate Calcium Disodium)
 BAL (Dimercaprol)

A. CARDIOVASCULAR DYSFUNCTION

Normal Blood Flow

Different parts of the body aorta Left Ventricle

Unoxygenated blood

Inferior & Superior Mitral valve

Vena Cava

Right atrium Left Atrium

Tricuspid valve Pulmonary vein

Oxygenated blood

Right ventricle Pulmonary artery lungs

1. Congenital heart disease

a. A Cyanotic Heart Disease
There is a presence of left to right shunt. There is a defect that allows the blood to
flow from the left side of the heart (higher pressure) back to the right side (lower
pressure). Thus, the right heart is subjected at a greater pressure. Also, there is less
oxygenated blood being delivered to the different parts of the body which will cause the
left heart to compensate by pumping harder. This condition might eventually lead to
heart failure.

○ Ventricular Septal Defect

○ Most common of all congenital cardiac defects
○ 2 in every 1,000 live births
○ There is an opening in the septum between the left and right ventricles.
Because of this, the oxygenated blood which is supposed to b e delivered to
the different parts of the body is shunted back to the to the right ventricle
and into the pulmonary circulation for reoxygenation. Thus, there is less
oxygenated blood being delivered to the body.
○ Assessment:
○ Loud, harsh systolic murmur along left sternal border at the 3rd or 4th ICS at
about 4-8 weeks of age
○ A thrill may be palpable
○ Diagnostics: x-ray, MRI, UTZ which will reveal right ventricular hypertrophy
○ Management:
○ Around 60% of small ventricular septal defects will spontaneously close while
the remaining 40% requires open heart surgery

○ Atrial Septal Defect

○ There is an abnormal communication between left and right atriums. Because
of this, oxygenated blood from left atrium will go back to the right atrium, so
that oxygenated blood which is supposed to be delivered to the body is
diminished.
○ Assessment:
○ Harsh systolic murmur over 2nd or 3rd ICS (pulmonic area)

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 ○ Split heart sound (fixed splitting) which is almost always diagnostic of Atrial
Septal defect.
○ Diagnostics: Echocardiography reveals enlarged right side of the heart and
increase pulmonary circulation
S ○ Management: Open heart surgery
T
○ Patent Ductus Arteriosus
J ○ The ductus arteriosus is an accessory fetal vessel that closes at
U birth or be completed at 3 mos. of age in some infants. It connects
D the pulmonary artery and aorta. If it fails to close, oxygenated
E blood from the aorta will go back to the pulmonary artery back into
the lungs for reoxygenation. This puts additional strain on the left
C ventricle causing hypertrophy.
O ○ Assessment:
L
○ Wide pulse pressure
L
○ Continuous “machinery” murmur on upper right sternal border or
E
G under the left clavicle in older children
E ○ Diagnostics: ECG or x-ray reveals ventricular hypertrophy
○ Management:
S ○ Administration of oral or IV Indomethacin
T ○ Ligate patient ductus arteriosus
○ If surgery is not done, there is increased risk of Congestive Heart
J Failure and infectious endocarditis.
U
D ○ Pulmonary Stenosis
E ○ Narrowing of pulmonary valve or pulmonary artery distal to the
vavle. Due to this, the right ventricle cannot effectively empty
C blood by the way of pulmonary artery which will lead to right
O ventricular hypertrophy
L ○ Assessment:
L ○ Systolic ejection murmur at upper left sternal border
E ○ Thrill may be present in left upper sternal area or the suprasternal
G notch
E ○ Diagnostics: ECG reveals right ventricular hypertrophy; cardiac
catheter will reveal degree of stenosis
S
○ Management: balloon stenotomy
T
○ Aortic Stenosis
J
U ○ Narrowing of aortic valve which prevents left ventricle from
D effectively emptying blood to the aorta. This causes increase
E pressure in the left ventricle as it attempts to force blood to the
stenosed valve.
C ○ Assessment:
O ○ May be asymptomatic
L ○ Murmur loudest at the 2nd right ICS
L ○ Thrill may be present at the suprasaternal notch
E ○ Diagnostics: ECG reveals right ventricular hypertrophy; cardiac
G catheter reveals degree of stenosis
E ○ Management: balloon stenotomy, surgical repair

○ Coarction of Aorta (COA)

○ There is narrowing of the aorta so that oxygenated blood which is supposed
to be delivered to the different parts of the body cannot pass thru. This will
also cause the left ventricle to pump harder which will eventually lead to
ventricular hypertrophy.
○ Assessment:
○ Absence of femoral pulse
○ BP in upper extremities is higher than in lower extremities. Normally, there is
higher BP in lower extremities because of peripheral resistance.
○ Vertigo, headache
○ Exceptional irritability in a child <3 years old
○ Epistaxis

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 ○ Leg pain on exertion because of decreased blood supply to the lower
extremities
○ Murmur may occasionally be present
○ Diagnostics: x-ray, ECG reveals left side hypertrophy
○ Management: surgery between 3-4 years of age

b. Cyanotic heart disease

○ There is presence of right to left shunt. There is a defect that allows an
oxygenated blood to enter the general circulation.

○ Transposition of great vessels

○ The pulmonary artery arises from the left ventricle instead of the right while
S the aorta arises from the right ventricle instead of the left. Thus, blood
T entering the right atrium goes to the right ventricle, then the aorta, to the
different parts of the body which is completely unoxygenated. On the left side
J of the heart, oxygenated blood from the lungs enter the pulmonary vein to
U the left atrium to the left ventricle and out to the pulmonary artery to the
D lungs for re-oxygenation.
E ○ Assessment:
○ Cyanotic from birth
C ○ Murmur may be present or not
O ○ Diagnostics: x-ray film reveals enlarged heart
L
○ Management: Surgery
L
E
G
○ Tetralogy of Fallot
E ○ 4 anomalies:
○ Pulmonary stenosis- because of this, un-oxygenated blood cannot pass thru it
S thus increasing the pressure on the right ventricle
T ○ Ventricular septal defect- there is an opening between the left and right
ventricles. Because of the increasing pressure on the right ventricle, un-
J oxygenated blood will flow thru this opening to the heart to the left ventricle
U ○ Overriding aorta- un- oxygenated septal defect to be delivered to the different
D parts of the body
E ○ Right ventricular hypertrophy- because of pulmonary stenosis, the right
ventricle will pump harder so as to force blood to the stenosed artery.
C ○ Assessment:
O ○ Cyanosis
L ○ Polycythemia (increase in number of RBC) -- an attempt of the body to
L provide adequate RBC to supply oxygen to the body. However, this causes
E the blood to become too thick, predisposing the child to thrombophlebitis,
G embolus, CVA
E ○ Severe dyspnea relieved by squatting
○ Clubbing of fingers & toes
S
○ Growth and mental retardation
T
○ A loud, harsh murmur may be present
J ○ Diagnostics: x-ray reveals enlarged heart
U ECG reveals right ventricular hypertrophy
D Cardiac catheter
E
○ Management: surgery at 2-3 years of age
C
O 1. Congestive Heart Failure (CHF)
L •
Occurs when the heart cannot pump enough blood to supply oxygen &
L nutrients to body cells. There is pooling of blood in the pulmonary or venous
E systems
G • Assessment:
E ○ Right-sided heart failure:
 Tachycardia
 Hepatomegaly
 Irritable, restlessness due to abdominal pain
 Edema-late sign in children
 Weight gain
○ Left-sided heart failure:

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  Tachycardia
 Tachypnea, dsypnea
 Rales
 Bloody sputum
 Easy fatigability
 Feeding difficulty
 Cyanosis
• Diagnostics: chest x-ray, echocardiography & fluoroscopy reveals an enlarged heart.
On PE, apical heart beat is displaced laterally & downward
• Management:
○ Reduce workload of heart:
 Provide rest, minimal handling
 Small frequent feedings
S ○ Evacuate accumulated fluids:
T  Diuretics
 Low-Na diet
J ○ Improve cardiac contractility:
U  Digitalis
D
E 1. Rheumatic fever
• An autoimmune disease caused by group-A-beta-hemolytic streptococcal
C infection. This often follows an attack of Group-A beta-hemolytic strep
O infection like tonsillitis, phrayngitis, scarlet fever or impetigo
• L This disease is diagnosed if there are 2 major or 1 minor symptoms present
L plus a previous history of streptoinfection (Jone’s criteria)
E ○ Major manifestations:
G  Chorea:
E • most striking symptom
• loss of voluntary muscle control
S • dysfunctional speech
T • weak hand grasp
 Carditis- most serious; presence of systolic murmur
J  Erythema marginatum- macular rash over the trunk & extremities
U  Subcutaneous nodules painless lumps on joints
D  Polyarthritis- large joints becomes red, swollen, hot & tender
E ○ Minor manifestations:
 Fever
C  Previous strep infection
O  Arthralgia
L  Elevated ESR (inflammation)
L  (+) C reactive protein
E  Leukocytosis
G  Prolonged P-R interval (ECG)
E
• Management:
S ○ Bed rest to reduce cardiac workload until ESR, C reactive
T protein, PR return to normal
○ Take VS especially apical pulse
J ○ Provide diet high in protein and calorie
U
○ Drugs:
D
 Penicillin to eliminate group-A-beta-hemolytic streptococcus
E
 Salicylates to reduce inflammation & pain
 Phenobarbital to reduce purposeful movements of chorea
C
 Corticosteroids to reduce inflammation
O
L
A.HEMATOLOGIC DYSFUNCTION
L
1. RBC Disorder: Anemia
E
• Decrease in the number or function of erythrocytes
G
E
a. Normochromic, normocytic anemias
• RBCs are normal in both color and size but too few in
number
• Acute blood-loss anemia
○ May be caused by trauma such as accident, acute nephritis,
placenta previa; abruptio placenta

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 ○ Assessment:
 Pallor
 Tachycardia
 Tachypnea
 Gasping respiration
 Sternal retractions
 Cyanosis
○ Treatment:
 Control bleeding
 Place in a supine position to provide circulation to the brain
cells
 Keep child warm with blanket
 Blood transfusion may be necessary

• Aplastic Anemia
S ○ Results from depression of hematopoietic activity in bone marrow
T ○ Formation of WBC, RBC and platelets are affected
○ Maybe due to excessive exposure to radiation, drugs, chemicals
J which cause bone marrow damage (chloramphenicol, sulfonamides,
U arsenic, benzene, quinine)
D ○ Assessment:
E  Pallor
 Easy fatigability
C  Anorexia
O  Petechiae
L  Nose bleeding
L  GI bleeding
E  Prone to infection
G ○ Management:
E  Suppress abnormal bone marrow with anti-thymocyte
globulin (ATG) or anti-lymphocyte globulin (ALG)
S  Packed RBC & platelet transfusion may be necessary
T  Corticosteroids & testosterone may be given
 Strict hand washing to prevent infection
J
U a. Hypochromic anemias
D • RBCs are pale
E • Iron deficiency anemia
• Most common anemia of infancy & childhood due to poor intake
C of dietary iron
O • Causes: dietary deficiency, chronic blood loss, low birth weight
L infants, excessive demands
L • Assessment:
E ○ Pale mucous membranes
G ○ Poor muscle tone
E ○ Reduced activity
○ Heart may be enlarged
S
○ Spleen may be slightly enlarged
T
• Management:
○ Treat underlying cause
J
U ○ Diet rich in Iron
D ○ Give Ferrous sulfate—should be taken after meal to reduce GI
E irritation. Vitamin C may be given together with Fe to increase
absorption.
C ○ Imferon (Iron-dextran injecton) given IM
O ○ Stains skin
L ○ Irritating unless given by deep Z-track technique
L
E a. Macrocytic (Megaloblastic) Anemia
G ○ RBCs are abnormally large and immature
E • Folic Acid deficiency
○ Anemia, neutropenia, thrombocytopenia
○ Oral administration of Folic acid
• Pernicious anemia

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 ○ Caused by deficiency or inability to use
Vitamin B12 due to lack of intrinsic factor
in the gastric mucosa
○ Assessment:
 Pallor, anorexia
 Irritability
 Chronic diarrhea
 Ataxia, hyporeflexia, paresthesia
○ Treatment: lifelong monthly injection of Vitamin B12 (IM)

1. Neoplastic disorder: LEUKEMIA

○ Distorted & uncontrolled proliferation of WBC
○ Most common type of cancer in children

• Acute Myelogenous Leukemia (AML)

S ○ Most common type in adulthood
T ○ Over proliferation of granulocytes
• Acute Lymphocytic Leukemia (ALL)
J ○ Most common type in children
U ○ Highest incidence is in children between 3-5 years of age
D ○ Unknown cause: may be due to prenatal exposure to
E radiation, drugs and chemicals: family predisposition.
○ Due to rapid proliferation of abnormal WBC:
C  Decrease RBC- anemia
O - Pallor, lethargy
L  Decrease platelets- thrombocytopenia
L - Petechiae, bleeding, bruise easily
E  Decrease normal WBC- leukopenia
G - Prone to infection
E
○ Other s/sx: headache, vomiting, ataxia, abdominal
S distention, abdominal pain, anorexia, hepatomegaly,
T splenomegaly, bone pain, painless generalized
adenopathy
J ○ Management:
U
D
 Prevent infection: strict hand washing, skin care,
oral hygiene
E
 Prevent injury
 Provide proper nutrition
C
 Assist in diagnostic procedures: blood
O
transfusion, bone marrow biopsy, chemotherapy
L
L
A. RENAL DYSFUNCTION
E
1. Urinary Tract Infection (UTI)
G
• Occurs from ascending spread from the urethra to the bladder
E
• Occur more often in girls because their urethra is shorter & is
located closer to the anus
S
• Assessment:
T
○ Pain on urination
J ○ Frequency
U ○ Burning
D ○ Hematuria
E • Cystitits: low-grade fever, abdominal pain, enuresis (bedwetting)
• Pylonephritis: fever, abdominal or flank pain, vomiting, malaise
C • Management:
O ○ Antibiotics (Amoxicillin, ampicillin)
L ○ Drink large amount of fluids to “flush” infection out of
L the urinary tract
E
G 1. Acute Glomerulonephritis (AGN)
E ○ Inflammation of the glomeruli of the kidney that usually occurs as
a hypersensitivity reaction to group-A beta-hemolytic bacterial
infection
○ Assessment:

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 ○ Has a history of recent respiratory infection or impetigo
○ Gross hematuria, proteinuria, oliguria
○ Hypertension
○ Abdominal pain
○ Low-grade fever
○ Periorbital edema
○ Anorexia
○ Vomiting, headache
○ Diagnostics:
○ Hypoalbuminemia
○ Mild anemia
○ Increase ESR
○ Increase BUN and creatinine
○ Elevated antistreptolysin O
○ Management:
○ Place in semi-fowler’s position
○ Oxygen administration may be necessary
○ Diet should be low in protein, low salt
○ Weigh daily
○ Medications: antihypertensive, digitalis, penicillin

S
T 3. Nephrotic Syndrome (Neprhosis)]
• Increased glomerular permeability which causes abnormal loss
J of protein in the urine
U • May be caused by hypersensitivity to Ag-Ab reaction of an
D autoimmune process
E
Increase glomerular permeability

C
O
L
L Protein lost in urine
E
G
E PROTEINURIA HYPOALBUMINEMIA

S
T Fluid shifts from Liver
intravascular to compensates by
interstitial increase
J tissue production of
U lipoproteins
D
E

C
O EDEMA
HYPEREDEMA
L
L
E A.NEUROLOGIC DSYFUNCTIONS
G 1. Cerebral Palsy
E ○ Group of disorders affecting the upper motor neuron resulting
in motor dysfunctions
S ○ Frequently caused by brain anoxia leading to cell destruction
T ○ May be caused before, during or shortly after birth (placenta,
previa, abruptio placenta, maternal infection, nutritional
J
deficiency, prematurity, prolonged labor, forceps delivery, RDS,
U
neonatal infections, traumatic head injury)
D
○ Types:
E
○ Spastic—hyperactive, hypertonic muscles, exaggeration of deep
C tendon reflexes, abnormal reflexes
O ○ Athetoid type- abnormal involuntary movement, limp, flaccid
L early in life, worm-like movement, drooling
L
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E
 ○ Ataxic type—awkward, wide-based gait, primary incoordination
○ Mixed type
○ Assessment:
○ Delayed motor development
○ Abnormal head circumference (may be smaller due to slow brain growth)
○ Abnormal postures
○ Abnormal reflexes
○ Abnormal motor performance
○ May have sensory disturbances: strabismus, visual problems, speech problem
○ Irritable, impulsive, short attention span
○ May have mental retardation
○ Management:
○ Maintain safe environment & prevent injuries
○ Facilitate passive & active ROM exercises
○ Prevent contractures
○ Assist in doing self-care (dressing)
○ Provide adequate nutrition
○ High roughage to prevent constipation
○ Soft diet to children who cannot chew or swallow well
○ Be patient because these children take longer time eating

1. Meningitis
S ○ Infection of the cerebral meninges
T ○ Caused by H. Influenzae, Neisseria meningitides, group-B streptococcus
○ Assessment:
J ○ May occur insidiously or suddenly
U ○ 2-3 days of upper respiratory tract infection
D ○ Irritability
E ○ Headache
○ Convulsion
C In newborns:
O ○ Poor sucking
L
○ Weak cry
L
○ Lethargy
E
○ Convulsion
G
E ○ Apnea
○ Bulging and tense fontanelles
S Signs of meningeal irritability:
T ○ Nuchal rigidity
○ (+) Kernigh’s sign (pain on extending the knee when thigh is bent on the
J abdomen)
U ○ (+) Brudzinski’s sign
D ○ Opisthotonus (back is arched & neck hyperextended)
E ○ Diagnostics:
○ Lumbar puncture reveals:
C ○ Increase WBC
O
○ Increase protein
L
○ Decrease glucose
L
○ Increase ICP
E
G ○ Management:
E ○ Antibiotic therapy (Ampicillin, Chloramphenicol) given IV for rapid effect
○ Corticosteroid may be given to decrease ICP
S ○ Provide rest & quiet environment
T ○ Monitor VS, level of consciousness & motor activity
○ Weigh child daily
J ○ Avoid sudden change in position
U
D 3. Encephalitis
E • Inflammation of brain tissues
• Caused by protozoa, bacteria, fungi, virus
C • Assessment:
O ○ Headache
L
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G
E
 ○ Fever
○ Signs of meningeal irritation
○ Muscle weakness
○ Paralysis
○ Confusion
○ Irritability
• Management:
○ Antipyretic to control fever
○ Antibiotic treatment
○ Anticonvulsant
○ Provide rest
○ Monitor VS, LOC, motor activity & signs of increase ICP

3. Seizures
• Involuntary contraction of muscle due to abnormal electrical brain discharges
• Causes:
In newborns:
○ Trauma at birth
○ Metabolic disorder (hypoglycemia, hypocalcemia, lack of Vitamin B6)
○ Neonatal infection
○ Kernicterus
In infants and toddlers:
○ Infantile spasms
S ○ Poisoning or drugs
T ○ Febrile convulsions (38.9-40 C)
• Active tonic-clonic pattern lasting
J
15-20 seconds
U
○ Types: Psychomotor seizure
D
E • Sudden change in posture (arm
dropping)
C • Child slumps to the ground
O • Unconscious
L • Regains consciousness in less than 5
L minutes
E ○ Focal seizure
G • Originate from a specific brain area
E • Begins in the fingers & spreads to
the wrist, arm & face in a clonic
S contraction
T • May progress to a generalized
seizure
J ○ Absence seizure (Petit Mal)
U • Staring spell lasting for a few
D seconds
E • Rhythmic blinking
• Twitching of mouth or extremity
C • After seizure, child resumes activity
O unaware of what happened
L ○ Tonic-clonic seizure (Grand Mal)
L 4 stages:
E • Prodromal period
G ○ Drowsiness, dizziness, malaise, lack of coordination,
E tension
• Aura- may reflect portion of the
S brain affected
T ○ Smelling unpleasant odors- medial portion of temporal
lobe
J ○ Seeing flash lights- occipital area
U ○ Repeated hallucinations- temporal lobe
D ○ Numbness of extremities- parietal lobe
E ○ “Cheshire cat grin” – frontal lobe
• Tonic-clonic convulsion
C Tonic (20 seconds)
O • All muscles of the body contract
L
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G
E
 • Falls to the ground
• Extremities stiffen
• Saliva collects in the mouth
• May bite his tongue
• Clonic (20 seconds)
• Muscles rapidly contract & relax
• Quick jerky motions
• May blow bubbles or foamy saliva
• Post-ictal period
• Child falls into a sound sleep for 1-4 hours
• When he awakens, he appears drowsy, has severe
headache & has no memory of the seizure
○ Status epilepticus
• Occurs in rapid succession without pause
• A medical emergency because the child does not have the time
to aerate the lungs & may lead to brain damage due to
decrease O2 supply
• Management:
○ Protect the child from hurting himself (remove chairs and other objects
that may harm the child)
○ Do not restrain the child
○ Remain calm
○ Loosen clothes
○ Keep the head on 1 side to prevent tongue
S
T from obstructing the airway
○ Ketogenic diet (high fat, low protein and
J carbohydrate)
U ○ Medications:
D • Drug depend on the type of seizure
E • Psychomotor- Phenytoin, Carbamazepine, Primidone
• Absence (Petit Mal)- Ethosuximide (Zarontin), Valproate
C • Tonic-clonic (Grand Mal)- Phenytoin Sodium (Dilantin)
O • Do not discontinue drug abruptly because it may result in
L severe seizure
L • Periodic blood sampling to monitor blood levels of the medicine
E
A. G MISCELLANEOUS
1. E Infantile Eczema (Atopic Dermatitis)
• Skin allergic reaction mainly from food allergy (milk, eggs, wheat,
S citrus, juices, tomatoes)
• T Common in formula-fed infants
• May begin in the 2nd month of lasting until 2-3 years of age
J
U
D
E

C
O
L
L
E
G
E

S
T

J
U
D
E

C
O
L
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G
E