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The Royal Pentagon Review Specialist Inc.

Pediatric Nursing


Growing  complex phenomenon of a structure or whole

• Increase in physical size of a structure or whole
• Quantitative
• 2 parameters
o Weight
 Most sensitive measurement for growth
Weight gain:
2x = 5 – 6 mos.
3x = 1 year
4x = 2 – 2½ years

o Height
 ESTROGEN  responsible for increase in height in female
 TESTOSTERONE  responsible for the increase in height in male
 Stoppage of height coincide with the eruption of the wisdom teeth

↑ - 1”/ mo – 1 – 6 mos
↑ - 1.5”/ mo – 7 – 12 mos
↑ - 50 % - 1st Year

9 y/o  male = female
12 y/o  Male < Female
13 y/o  Male > Female

• Increase in the skills or capacity to function
• Qualitatively
• How to measure development
o By simply observing the child doing simple task
o By noting parent’s description of the child’s progress
o Metro Manila Developmental Screening Test
o Philippine Based exam
• Main Rated Categories
o LANGUAGE  ability to communicate
o PERSONAL/ SOCIAL  ability to interact
o FINE MOTOR ADAPTIVE  ability to use hand movements
o GROSS MOTOR SKILLS  ability to use large body movements

• Synonymous with development

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Readiness/ learning is effortless

• Ability to learn and understand from experiences, to acquire and retain knowledge, to
respond to a new situation and to solve problems

LEARNING  change of behavior

IQ= [Mental Age/ Chronological Age] x 100
Normal IQ = 90 - 110
GIFTED CHILD  > 130 IQ level


• Prenatal
o Conception to birth
• Infancy
o Neonatal  first 28 days
o Formal Infancy  29th – 1 year
• Early Childhood
o Toddler  1 – 3 y/o
o Preschool  4 – 6 y/o
• Middle Childhood
o School Age  7 – 12 y/o
• Late Childhood
o Pre – adolescent  11 – 13 y/o
o Adolescent – 12 – 13 y/o to 21


• Growth and development is a continuous process (WOMB TO TOMB PRINCIPLE)
 begins from conception and ends with death
• Not all parts of the body grows at the same time or at the same rate
• Each child is unique
• Growth and development occurs in a regular direction reflecting definite and
predictable patterns or trends
o Directional Terms
 Cephalocaudal/ Head to Tail
 It occurs along bodies long axis in which control over head,
mouth and eye movemens and precedes control over upper
body torso and legs
 Proximo – Distal/ Centro – Distal
 Progressing from center of the body to the extremities
 Symmetrical/ Each side of the Body
 Develop at the same direction at the same time and at the
same rate
 Mass – Specific
 Differentiation – SIMPLE TO COMPLEX; BROAD TO

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Sequential Trend
 Involves a predictable sequence of growth and development to which
the child normally passes
 Locomotion
 Creeps → Stands → Walks → Run
 Language and Social Skills
 Cry → coo
o Secular Trend
 Refers to the worldwide tend of maturing earlier and growing larger as
compared to succeeding generation

• BEHAVIOR → most comprehensive indicator of developmental stages

o act @ your age
• PLAY → universal language
• A great deal of skills is learned by practice
• There is optimum time for initiation of experience or learning
• Neonatal reflexes must be lost first before development can proceed
o persistent primitive infantile reflexes is a possible case of cerebral palsy


• Renal → digestive → circulatory → musculoskeletal
o childhood
• Brain → CNS → Neurologic Tissue  rapidly grows with in 1 – 2 years
o Brain achieves its adult proportion @ 5 years
o Rapid growth and development of brain from1 – 2 years
o Malnutrition may result to Mild Mental Retardation
• Lymphatic System (Lymph Nodes)
o Grows rapidly during infancy and childhood
o Provide protection against infection
o TONSIL reach its adult proportion @ 5 years
• Reproductive
o Grows rapidly during puberty


• Fetal and Infancy
o Period of most rapid growth and development
o Prone to develop anemia
• Toddler
o Period of slow growth and development
• Toddler and preschool
o Period of alternating rapid and slow growth and development
• School Aged
o Slower growth and development
o Least to develop anemia
• Adolescent
o Period of rapid growth

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Secondary prone to anemia

Two Primary Factors Affecting Growth and Development

• Heredity
o Race
o Sex
o Intelligence
o Nationality

• Environment
o Quality of Nutrition
o Socio Economic Status
o Health
o Ordinal Position in the family
o Parent – Child Relationship

*Universal Principle: F are born < wt. than M by 1 oz.; F are born < lt. than M by 1 in.


Developmental Task
• A skill or growth responsibility arising at a particular time in the individual’s life.
• The successful achievement of which will provide a foundation for the
accomplishments of the future tasks


• 1856 – 1939
• An Austrian Neurologist
• Founder of Psychoanalysis
• 1st to introduce Personality Development
Phase Age Site of Activities Task
Oral 0 – 18 Mouth • Biting • Provide oral stimulation even if
Phase mos. • Crying baby is place NPO (use
• Sucking pacifier)CBQ
(enjoyment • Never discourage thumb
and release sucking
of tension)
Anal 19 mos. – Anus • Elimination • Help the child achieve bowel
Phase 3 yrs. • Retention/ and bladder control even if the
(stage Defecation child is hospitalized
where of Feces • Principle of holding on and
OC are letting go
develop • Mother wins or child wins
• Child Wins
o Holding on

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Child turns to be
hardheaded, antisocial,
stubborn, unreliable,
• Mother Wins
o Letting go
o Child turns to be kind,
obedient, perfectionist
o Meticulous, OCs, reliable,
Phallic 4 – 6 yrs. Genital • May show • Accept the child fondling his
Phase exhibitionis own genetalia as normal area
m of exploration
• Have or • Divert attention from
increase masturbation
knowledge • Answer the child’s question
of 2 sexes directly
• Human sexuality
Latent 7 – 12 yrs. School • Period of • Help the child achieve (+)
Phase aged suppression experiences so that he’ll be
• No obvious ready to face the conflicts of
developmen adolescents
t, slower
• Child’s
energy or
Libido is
diverted into
type of
Genital 12 – 18 yrs Genitalia • Achieve • Give opportunity to relate to
Phase sexual opposite sex
maturity and
learn to
with the


• Former student of Freud
• Stresses the importance of culture and society to the development of one’s
• “environment”

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

1. Trust vs. Mistrust

• 0 – 18 months
• TRUST is the foundation of all psychosocial tasks
• Theme: Give and Receive
• Trust is developed via
o Satisfying needs of infants on time
o Care must be consistent and adequate
o Give experiences that will add security
 Hugs, kisses, touch, eye to eye contact, soft music
2. Autonomy vs. Shame & Doubt
• 18 mos. to 3 years
• Theme: independence and self – government
• Give opportunity for decision making, offer choices
• Encourage the child to make decision rather than judge
• Parents has a moral obligations to set limits
3. Initiative vs. Guilt
• 4 – 6 years old
• Learns how to do BASIC things
• Give opportunity exploring new places and events
• Right time for amusement park and zoos
• Activity recommended: modeling clay and finger painting
• Enhances creativity and imagination and facilitates fine motor
4. Industry vs. Inferiority
• 7 – 12 years old
• Learns how to do things well
• Give appropriate short assignments and projects
• Unfinished project will develop inferiority
5. Identity vs. Role Confusion
• 12 – 18 or 20 years old
• Learns who he is or what kind of person he will become by adjusting to new body
image and seeking EMANCIPATION/ freedom from parents
6. Intimacy vs. Isolation
• 18 – 25 or 30 years old
• Career focus
• Looking for a lifetime partner
7. Generativity vs. Stagnation
• 30 – 45 years old
8. Ego Integrity vs. Despair
• 45 years old and above


• Reasoning powers
• Swiss Psychologist
• Genetic Epistemologist

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

1. Sensorimotor
• 0 – 2 years old
• Also called Practical Intelligence
o words and symbols are not yet available
o communication through senses

1. Schema 1: Neonatal Reflex

o 1 month
o Early reflexes
2. Schema 2: Primary Circular Reaction
o 1 – 4 months
o Activities related to body; repetition of behavior
 Example: thumbsucking
3. Schema 3: Secondary Circular Behavior
o 4 – 8 months
o Activities not related to the body
o Discover person and object’s permanence
o Memory traces are present and anticipate familiar events
4. Schema 4: Coordination of Secondary Reaction
o 8 – 12 months
o Exhibit goal directed behavior
o ↑ sense of permanence and separateness
o Play activities: Throw and retrieve
5. Schema 5: Tertiary Circular Reaction
o 12 – 18 months
o use trial and error to discover characteristic of places and events
o “Invention” of new means
o capable of space and time perception
6. Schema 6: Invention of New Means thru Mental Coordination
o 18 – 24 months
o Symbolic representation
o Transitional phase to the pre-operational thought period

2. Pre-operational Thought
1. Pre – conceptual Thought
o 2 – 4 years old
o Concrete, literal, static thinking
o CBQ EGOCENTRIC – unable to view anothers viewpoint
o CBQ (-) REVERSIBILITY – in every action there is opposite reaction; cause
and effect
o Concept of time is only now and concept of distance is only as far as they can
o CBQ ANIMISM – consider inanimate object as alive
2. Intuitive Thought
o Beginning of causation

3. Concrete Operational
o 7 – 12 years old

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o SYSTEMATIC REASONING as solution to problems

o Concept of (+) reversibility
o Concept of Conservation – constancy despite of transformation
o Activity recommended: Collecting and Classifying

4. Formal Operational
o 12 years old and above
o Period when cognition achieve its final form
o Can solve hypothetical problem with SCIENTIFIC REASONING
o Can deal with past, present and future
o Capable of ABSTRACT, mature thought and formal reasoning
o Activity recommended: talk time; focus on opinions and current events


• Recognized the theory of moral development as considered to closely approximate
cognitive stages of development
• Stages of Moral Development
o Infancy
o Premoral
o Amoral
o Pre-religious

Age Stage Descritption

o Heteronomous morality
o Child does right because PARENT tells him to and to avoid
4 – 7 yrs. 2 • INDIVIDUALISM
o Instrumental purpose and exchange
o Carries out action to satisfy own needs rather than society
o Will do something for another if that person does something
for the child
o Child follows rules because of need to be a “good person” in
own eyes and eyes of others
o Child finds following rules satisfying
o Following rules of authority figures as well as parents in an
effort to keep the “system” working
o Follows standards of society for the good of the people

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing


o Follows internalized standards of conduct
o Only few people achieved this level
o Only saints and holy

• Major marker of growth and development
• Determines developmental delays

6 mos. Eruption of first temporary teeth 2 LOWER CENTRAL INCISORS
30 mos. Temporary teeth complete
20 decidous teeth
POSTERIOR MOLAR --> last to appear
Time to go to Dentist
Begins to brush teeth
3 years Tooth brushing with minimal supervision
6 years Tooth brushing alone
Temporary teeth begins to fail
1st permanent teeth → 1st MOLAR
Last to appear → WISDOM TOOTH
Bowel Control → 18 months / 1 ½ years
Day Time Bladder Control → 2 years
Night Time Bladder Control → 3 years


• Solitary play
o Consider when choosing a play
 Safety
 Age appropriateness
 Hygiene
• Fear: Stranger Anxiety
o Begins: 6 – 7 months
o Peaks: 8 months
o Diminishes: 9 months

• Complete head lag
• Largely reflex visual fixation for human face
• Hands fisted with thumbs in
• Cries without tears because lacrimal glands are not fully developed

1 month
• Dance reflex disappears

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Looks at mobile; follows midline

• Alert to sound, regards face

2 months
• Holds head up when in prone
• Social smile, cries with tears, cooing sound
• Closure of posterior fontanel (2-3 months)
• Head lag when pulled to sitting position
• No longer clinches fist tightly
• Follows object past midline
• Recognizes parents

3 months
• Holds head and chest up when in prone
• Holds hands open at rest
• Hand regard, follows object past midline
• Grasp and tonic neck reflexes are fading
• Reaches for familiar people or object
• Anticipates feeding

4 months
• Head control complete
• Turns front to back; needs space to turn
• Laughs aloud; Babbling sound
• Babinski Reflex disappears

5 months
• Turn both ways (roll over)
• Teething rings, handles rattle well
• Moro reflex disappears (5 – 6 months)
• Enjoys looking around environment

6 months
• Reaches out in the anticipation of being picked- up
• Sits with support
• Puts feet in mouth in supine position
• Eruption of first temporary teeth ( Lower 2 central incisors)
• Vowel sounds “ah, eh”
• Uses palmar grasp; handless bottle well
• Recognizes strangers

7 months
• Transfer objects from hand to hand (6 – 7 months)
• Likes objects that are good sized for transferring

8 months

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Sits without support

• Peak of stranger anxiety
• Plantar reflex disappear (6-8 months)

9 months
• Creeps or crawls; need space for creeping
• Neat pincer grasp reflex, probes with forefinger
• Finger feeds, combine 2 syllables “mama & dada”

10 months
• Pulls self to stand
• Understand the word no
• Respond to name
• Peek – a – boo, pat a cake, since they can clap

11 months
• Cruising, stand with assistance
• Walking while holding to his crib’s handle
• One word other than mama and dada

12 months
• Stands alone
• Walk with assistance
• Drink from cup, cooperates in dressing
• Says two words other than mama and dada
• Pots & pans, pull toys and nursery rhymes
• Imitates actions, comes when called
• Follows one – step command and gesture
• Uses mature pincer graps, throws objects

• Parallel Play – 2 toddlers playing separately
• Provide 2 similar toys for 2 toddlers
• Toys
o Squeaky frogs to squeeze
o Waddling ducks to pull
o Trucks to push
o Building blocks
o Pounding peg
• Fear: Separation Anxiety
o Begins: 9 months
o Peaks: 18 months
o 3 stages
 Protest
 Despair
 Denial

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Prevent:
 Do not prolong goodbye
 Say goodbye firmly
 Say when you’re back

Toddler Characteristic Traits

• Negativistic: says no most of the time
• Saying no – way of developing independence
• Limit questions, offer choices
• Rigid, ritualistic and stereotyped
• Ritualistic – way to gain mastery
• Temper Tantrums
o Stomping of feet
o Holding breath
o Screaming
o Head banging
o NC: Ignore the behavior
• Scaphoid abdomen – underveloped abdominal muscle
• Physiologic Anorexia  food fad, food jag that last for a short period of time due to
the preoccupation to environment

15 Months
• Plateau stage
• CBQ WALKS ALONE – lateness in walking is a sign of mild mental retardation
• Puts small pellets into small bottle
• Creep upstairs
• 4 – 6 words
• Scribbles voluntarily with pencil, holds spoon well, seat self in a chair

18 Months
• Height of POSSESIVENESS – favorite word MINE
• Bowel control achieved
• No longer rotates a spoon
• Can run and jump in place
• Walks up and downstairs holding on to a person’s hand or railing, typically places
both feet on one step before advancing
• Names one body part

24 months
• Turns pages one at a time, removes shoes, pants, etc
• Can open doors by turning door knobs, unscrew lids
• 50 – 200 words (2 word sentences), knows 5 body parts
• Walk upstairs alone, still using feet on the same step at same time
• Daytime Bladder Control

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• CBQ best time to bring the child to dentist: 2 – 3 years or when temporary teeth is

30 months
• Makes simple lines or stroke or crosses with pencil
• Can jump down from chair
• Knows full name, holds up finger to show age
• Copy a circle
• CBQ Temporary teeth complete (posterior molar: last to erupt)
• CBQ 20 deciduous teeth
• CBQ tooth brushing: 2 – 3 years

36 months
• Tooth brushing with little supervision
• Unbutton buttons
• Draws a cross, learns how to share
• Knows full name and sex
• Speaks fluently, 200 – 900 words
• Rides tricycle

• Cooperative play – playhouse
• Role playing is usual
• Fears:
o Castration/ Body Mutilation
o Dark places and witches
o Thunder and lightning
o Ghost
• Curious, creative, imaginative and imitative

Preschooler’s Characteristic Traits

• Telling tall tales
• Imaginary friend  way of relieving tension and anxiety
• Sibling rivalry→ jealousy to a newly delivered baby
• Regression
o Signs: bedwetting
o Thumbsucking
o Baby talk
o Fetal position
• Masturbation
o Sign of boredom
o Divert attention
o Offering toy

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

4 years old
• Noisy, aggressive and stormy
• Buttons button
• Copy square
• Catches ball, jumps, skips
• Alternates feet going downstairs
• Vocabulary of 1500, knows the basic color
• Says song or poem from memory

5 years old
• Jumps over low obstacles
• Spreads with a knife
• Draws 6 part man, copy triangle
• Imaginary playmates
• 2100 words
• Identification with same sex
• Attachment to opposite sex

School – Aged
• Competitive Play: Tug of war
• Fears
o School Phobia  orienting child to his new environment
o Displacement from school
o Death
• Significant Person
o Teacher
o Peer of same sex
• Stoppage of height coincide with the eruption of wisdom tooth
• Prone to fracture: Common Green stick
• Mature vision
o 20/200 legal blindness
• They’ll Cheat → can’t afford to lose

6 years old
• Temporary teeth begins to fall, permanent teeth begins to appear (1st: First Molar)
• Tooth brushing alone
• A year of continuous motion, clumsy moving
• 1st grade teacher becomes authority figure
o nail biting → sign of strict teacher
• Beginning interest with God

7 years old
• Age of assimilation

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Copies a diamond
• Enjoys teasing and playing alone
• Quieting down phase

8 years old
• Expansive age
• Smoother movements
• Normal homosexual
• Loves to collexct objects
• Counts backwards

9 years old
• Coordination improves
• Tells time correctly
• Hero worship
• Stealing and lying are common
• Takes care of body needs completely
• Teachers find their group difficult to handle

10 years old
• Age of special talents
• Write legibly
• Ready for competitive games
• More considerate and cooperative
• Joins organizations
• Well mannered with adults and critical with adults

11 – 12 years old
• Pre adolescent
• Full of energy and constantly active
• Secret languages are common
• Share secrets with friends
• Sense of humor is present
• Social and coopoerative

School – Aged Characteristic Traits

• Industrious
• Modest

Signs of Sexual Maturity in Female

I ncrease in size of breast and genitalia – telarche – 1st sign
W idening of hips
A ppearance of pubic axilliary and pubic hair - adrenarche
M enarche – last sign

Signs of Sexual Maturity in Male

A ppearance of axilliary and pubic hair

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

D eepening of voice
D evelopment of muscle
I ncrease in size of penis and scrotum – 1st sign
P roduction of viable sperm – last sign

• Fear
o Acne
o Obesity
o Homosexuality
o Death
o Replacement from friends
• Peer of opposite sex  significant other
• Experiences conflicts between his needs for sexual satisfaction and societal
• Core Concern
o Change of body image
o Acceptance of the opposite sex
• Nocturnal Emission: Wet dreams
o Hallmark of adolescence
• CBQ distinctive odor due to stimulation of apocrine gland
• Testes and scrotum increases until age 17
• Sperm is viable by age 17
• Breast of female and genitalia increases until age 18
• Signs of sexual maturity
• Characteristic traits
o Idealistic, rebellious, reformers
o Parent child conflict
o Very conscious with body image
o Peer pressure
• Problems
o Vehicular accident
o Smoking
o Alcoholism
o Drug Addiction
o Pre Marital Sex

Concept of Death
6 years old  death is reversible
CBQ 7 – 9 years old  personification of death, permanent loss of the corporal life



1. Initiation and maintenance of respiration
2. Establishment of extrauterine circulation
3. Control of body temperature

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

4. Intake of adequate nutrition

5. Establishment of waste elimination
6. Prevention of infection
7. Establishment of an infant – parent relationship
8. Developmental care that balance rest and stimulation for mental developmental


• Expulsion is @ 2nd stage of labor
• Most neonatal deaths w/in the first 24 hours is due to INABILITY TO INITIATE
• Lung function begins only after birth

• Support head and remove secretion
• Proper suctioning with a catheter
o Place baby’s head to side  facilitates drainage
o Suction the mouth first before nose  newborns are nose breathers
o Period of 5 – 10 seconds, should be gentle and quick
 Prolonged suctioning can cause hypoxia, laryngospasm and
bradycardia due to vagal nerve stimulation
o Evaluate patency
 Cover 1 nostril, if newborn struggles, additional suctioning needed
• If not effective requires effective LARYNGOSCOPY to open airway. After deep
suctioning, and ET tube can be inserted and O2 administration by (+) Pressure Bag
and mask with 100% O2 @ 40 – 60 bpm

Alerts in O2 Administration
• No Smoking  O2 is combustible
• Must be humidified  prevent drying of mucosa
• Cover the nose and mouth only
• Scarring Retina  results Retinopathy (O2 overdose)
• Meconium Stain  never administer O2 with pressure  causes atelactasis


• Circulation id initiated by LUNG EXPANSION and PULMONARY VENTILATION
• Completed by cutting the cord
• Assess characteristics of cry
o Normal  strong, vigorous, lusty cry
o Hypoglycemia/ Increased ICP  high pitched, small cry
o Never stimulate crying before all secretion are remove to prevent aspiration

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

Feto – Placental Circulation

• Placenta → O2 carried by vein → liver → Inferior Vena Cava → Right atrium → 70%
goes to Foramen Ovale →Remaining 30 → tricuspid valve → right ventricle →
pulmonary artery → lungs for nutrition → vasoconstriction of lung tissue pushes the
blood to DUCTOS VENOSUS → supply extremities → 2 arteries carry unO2 Blood
back → placenta

Ways to facilitate closure of Foramen Ovale

• Tangential Footslap
o Cry → expands lung → ↑ pressure from left to right side of the heart
• Proper positioning of the Baby
o Right side lying position → ↑ pressure on left side of heart facilitating closure

Best Position immediately after Birth

• CS → supine, crib – level position

Structure Appropriate Complete Structure Remaining Failure to

Time of Closure Close
Foramen Ovale 1 year W/in 24 hrs Fossa Ovalis Atrial
completed 1 Septal
month Defect
Ductus 1 month W/in 24 hrs Ligamentum Patent
Arteriosus completed 1 Arteriosum Ductus
month Arteriosus
Ductus Venosus 2 2 – 3 months Ligamentum Venosum
Umbilical 2 – 3 month 2 – 3 months Lateral Umbilical Artery
Arteries (Intrerior Iliac Artery)
Umbilical Vein 2 – 3 months 2 –3 months Ligamentum Teres
(Round ligament of the

Signs of Increased ICP

• Abnormal large head
• Bulged & tensed fontanel
• Projectile Vomiting  surest sign of cerebral irritation
• Cushing Triad of ↑ ICP
o ↑ BP
o ↓ PR
o ↓ RR
• High pitched, shrill cry
• Dilopia  normal in newborns, sign of ↑ ICP in older children

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• The goal of temperature regulation is to maintain Temperature not less than 97.7 F or
36.7 C

Factors leading to the development of Hypothermia

• Preterm are born POIKILOTHERMIC (easily adapt the temperature of environment
due to immaturity of thermo regulating center of the body HYPOTHALAMUS)
• Inadequate subcutaneous tissues
• Newborn are not yet capable of shivering
• Newborns are wet

Process of Heat Loss

• Evaporation → body to air
• Conduction → body to solid objects (cold compress)
• Convection → body to a cooler surrounding object (fever, aircon)
• Radiation → body to a cold subject not in contact with the body (thermal shift)

Effects of Hypothermia (COLD STRESS)

• ↑ RR → first sign of hypothermia
• Hypoglycemia → due to utilization of glucose
o Normal  45 – 55 mg/ dl
o Average/ borderline → 40 mg/ dl
• Metabolic Acidosis → due to the catabolism of BROWN FAT (vest-like, best
insulators of newborns) leading to the formation of ketone bodies
• High risk for KERNICTERUS (bilirubin in the brain)
• Additional fatigue added to already stressful heart

Prevention of Cold Stress

• Dry and wrap the newborn
• Mechanical measures ( radiant warmer, acrylic sided incubator)
• Prevent unecesarry exposure→ cover areas not being examined
• In case of no electricity
o Cover baby with thin foil
o Skin to skin contact → human blanket/ kangaroo care


Best time
• CS – after 4 hours

Physiology of Breastmilk Production

↓ Estrogen, ↑ Progesterone → releases PROLACTIN → acts on ACINAR/ ALVEOLI CELLS

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

Sucking → stimulates posterior pituitary gland → release oxytocin → causes Contraction of

smooth muscles of Lactiferous Tubules → milk ejection reflex → let down reflex

Advantages of Breastfeeding
• Economical
• Promotes bonding
• Contains LACTOBACILLUS BIFIDUS → interfere the attack of pathogenic bacteria
in the GIT
• Helps in early involution of uterus → oxytocin causes contraction
• Always available
• ↓ Incidence of breast cancer
• Breastfed babies have higher IQ than bottle fed ones
• Antibody → IgA
• Macrophages

Disadvantages of Breastfeeding
• No iron
• Possibility of transfer of Hepa B, HIV, CMV (13 – 39% possibility)
• Father can’t bond with the mother and baby → instead, father can sing, suddle, kiss,
put baby to sleep

• Freezer → good for 6 mos./ don’t reheat
• Should be stored in a sterile plastic container
• Pre – Colostrums → 6 weeks
• Colostrums → 3

Stages of Breastmilk
o Present 2 – 4 days
o Contents
 ↓ fats
 ↓ CHO
 ↑ Immunoglobulin
 ↑ protein
 ↑ fat soluble vitamin
 ↑ minerals
o Present 4 – 14 days
o Contents
 ↑ Lactose
 ↑ minerals
 ↑ water soluble vitamins
o Lactose Intolerance → deficiency in enzyme

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

Lactase → responsible for digestion of Lactose →sour milk/ smelling

of stool
o Present 14 days and above
o Contents
 Linoleic Acid → responsible for the development of brain and
integrity of skin
 ↑ CHO (Lactose)
 Protein (lactabulmin)

• ↑ fats – almost similar to mature milk
• Causes constipation
• Content
o ↑ fats
o ↓ CHO → add sugar
o ↑ CHON → casein → hard to digest
o ↑ Minerals (has traumatic effect to kidneys of babies)
o ↑ PHOSPHORUS ( causes inversely proportional effect of Calcium
• ↑ water to prevent kidney stones

Health Teachings
1. Proper Hygiene
• Hand washing, clean areola with cotton and water or NSS
• Cleanse the area with CAKE COLOSTRUM
2. Position while Breastfeeding
• Upright Sitting (best position)
3. Stimulate and Evaluate Feeding Reflexes
• Rooting Reflexes
o Stimulate by touching the side of the cheek or side of flip then the
baby will turn to the syimulus
o Purpose: to look for food
o Disappear by 6th weeks
• Sucking Reflexes
o Stimulate the middle part of the lips and the baby will suck
o Disappear by 6 months
• Swallowing Reflexes
o When the food touches the posterior part of the tongue, the baby
will automatically swallow
o Never disappears
• Extrusion Reflexes
o When food touches anterior part of tounge, it will extrude/ protrude
o Purpose: prevent poisoning
o Disappears @ 4 moths
4. Criteria for effective sucking
• Baby’s mouth is hiked well – up @ areola

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Mother experiences after pain → sign of releasing oxytocin thereby

contracting uterus
• The other nipple is also flowing with milk
5. To prevent from crack nipples and initiate proper production of oxytocin
• Begin initially for 2 – 3 mins/ breast
• ↑ the time 1 min/ breast/ day until it reaches 10 minutes/ breast/ feeding
or 20 min/ feeding
6. For proper emptying and continuous milk production per feeding
• Feed the baby at the last breast that you fed him/ her

Problems experience in Breastfeeding

o Feeling of fullness and tension in the breast (3rd Day)
o Breastfeeding mother → apply warm compress
o Bottle – Feeding → apply cold compress, wear supportive bra


o Crack, red, painful nipple
o Causes
 Breastfeeding @ one side only
 Unhealthy sexual practices
o Management
 Breastfed using the unaffected side
 Manually express milk @ affected side
 Antibiotic (continue breastfeeding)

o Inflammation of breast
o Management
 Avoid wearing lined/ wired bra
o 4 weeks – Breast Involution

Contraindications for Breastfeeding

• Maternal Conditions
o Hepa B
o Coumadin/ Warfarin taking moms → give heparin instead
• Newborn Conditions
o Erythroblastocis Fetalis
o Inborn errors of metabolism
 Hydrofetalis
 Phenylketonuria
 Galactosemia
 Tay- Sach’s Diseas

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing


GIT Obstructions
• Hirshsprung Disease
• Imperforate Anus
• Meconium Ileus (common with Cystic Fibrosis)

Different Stools
o Blackish green
o Odorless (sterile intestine)
o Normally passed within 24 hours
o Tar like
o Sticky

o Present 4 – 14 days
o Green
o Loose
o Slimy that may appear like diarrhea to the untrained eyes

o Golden yellow
o Occur almost nearly after feeding
o With sour milk smell
o Mushy
o Soft

o Pale yellow
o Hard → due to casein
o Formed
o Typically offensive odor
o Seldom passed 2 – 3 days
Light Stool With jaundice
Bright Green Under phototherapy
Mucus –mixed Milk Allergy
Clay Colored Bile Duct Obstruction
Black GIT Hemorrhage
Blood – Flecked Anal Fissure
Curant Jelly Intussuception
Fatty, bulky, foul Suspect malabsorption
smelling/ Steatorrhea syndrome/ Cystic Fibrosis/
Celiac Disease
Ribbon – like Hirshsprung disease

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing


Apgar Scoring
• Virginia Apgar

Special Consideration
• 1st 1 minute → determines general coneral condition of the baby
• Next 5 Minute → determines the capability of the baby to adjust extrauterinely (most
• Next 15 minutes → optional → depndent on the 5 minutes apgar score

A ppearance Color upon birth is slightly cyanotic
After first cry baby will be pink
P ulse Rate Take apical pulse at the lower left nipple
G rimace Determines reflex irritability using tangential foot slap and catheter
A ctivity To determine the degree of muscle tone
R espiration

Newborns will cry within 30 seconds upon expulsion

ASPHYXIA NEONATORUM → failure to cry within 30 seconds because mother received
NARCAN → antidote of Demerol

Criteria 0 1 2
Heart Rate Absent < 100 > 100
Respiratory Effort Absent Slow RR/ Weak Good strong cry
Muscle Tone Flaccid Extremities Some reflexes Well Flexed
Reflex Irritability
Catheter No Response Grimace Cough or sneeze
Tangential FS No Response Grimace Cry
Color Blue / Pale Acrocyanosis Pink
• High score means healthy baby

• Severely depressed
• Needs CPR
• Admission at NICU
• Moderate depression
• Additional suctioning

7 – 10
• Good and healthy

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• CPCR → cardiopulmonary and cerebral resuscitation
• 5 minutes of 02 deprivation will cause irreversible brain damage
• Priority: Airway, Breathing, Circulation

• Clear the airway
• Shake the baby
• If no response, call help
• Immediately do 1 minute CPR before calling for help
• Flat on bed, put a board if the bed is soft
• Head tilt – chin lift maneuver
• No head tilt for suspect of cervical damage
• Overextension may cause occlusion

• Ventilating the lungs
• Check breathlessness
• If breathless → give 2 breaths
• If newborn → mouth and nose
• If child → mouth and pinch the nose
• Force → puff only
• Use one way mask to prevent contact with the secretion

• By cardiac compression
• Check if pulseless
• Use brachial pulse → children
• No breath + No pulse → CPR
• Infant → 1 finger breadth below nipple line, 2 finger
• 1 year old → heal of the palm

Adult → 2:15
Infant → 1:5


Criteria 0 1 2
Chest movement Synchronized Long on inspiration See-saw
Intercoastal retraction No retraction Just visible Marked
Xiphoid Retraction No retraction Just visible Marked
Nares dilatation No dilatation Minimal Marked
Expiratory Grunt None Heard by stet only Heard by ear

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

Low score means Good condition of the baby

0 – 3 → normal, no RDS
4 – 6 → with moderate RDS
7 – 10 → with severe RDS


Criteria Less 36 weeks 37 – 38 Weeks 39 weeks and up
Sole creases Anterior transverse Occasional 2/3 Sole cover with
only crease
Breast nodule (dm) 2 mm 4 mm (3 – 5 cm) 7 mm (>5cm)
Scalp Hair Fine and fuzzy Fine and fuzzy Course and silky
Ear Lobe Pliable Some Thick
Testes and Scrotom In lower canal, Some intermediate Testes pendulous,
covered testes with scrotum full,
rugae extensive rugae

• babies delivered after 20 weeks and before 37 weeks
• sign of preterm – less 36 weeks according to Ballatrd and Dubowitz
• plus frog legs or lax position
• Hypotonic – prone to repiratory infection
• There is a Scarf Sign → elbow passes midline
• Square window – wrist 90 deg. Angle
• Heal to ear sign
• Anterior traverse crease
• Abundant lanugo
• Prominent labia minora and clitoris


• Delivered after 42 weeks
• Old mans face – classic sign
• Desquamation – pealing of skin
• Long and brittle fingernails
• Wide and alert eyes


Nursing Responsibilities upon Receiving the Baby

1. Proper identification
o Foot print of the baby and the thumb mark of the mother
2. Take anthropometrics measurement
o Length
 19. 5 – 21 inches Ave: 20 inches
 47.5 – 53 cm Ave: 50 cm.

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Head Circumference
 13 – 14 inches
 33 – 35 cm Ave: 34 cm
o Chest Circumference
 12 – 13 inches
 31 – 33 cm Ave: 32 cm
o Abdominal Circumference
 12 – 13 inches
 31 – 33 inches Ave: 32 cm
3. Bathing the baby
o Give oil Bath
 To cleanse the baby and spread the vernix caseosa
 2 functions of vernix caseosa
• insulator
• bacteriostatic
o Full bath is given when cord falls off
o Babies of HIV + mothers will be given a full bath immediately after the birth to
lessen the transmission of HIV
4. Dressing the Umbilical Cord
o Strict asepsis to prevent tetanus neonatorum that is why mothers are given
tetanus toxoid while pregnant
 CHN – 3 Cleans
• Hand
• Surface
• Cord
o Betadine (Povidone Iodine)
 Check 3 vessels (AVA)
 If only 2 vessels is seen suspect that the baby has a kidney
 1 inch above the base of the cord when cutting
 But if IV infusion or blood transfusion is going to be given to the
newborn, leave at least 8 inches of the umbilical cord
 Umbilical cord is the best site for IV and blood transfusion because it
has no nerve and no pain
 OMPHALAGIA → bleeding of the cord for more than 30 cc, suspect
 The umbilical cord turns black by the 3rd day and falls of 7 – 10th day
 UMBILICAL GRANULATION → failure of the cord to fall after 2
weeks without foul odor, bring the baby to the hospital and will be
given Silver Nitrate or will be cauterized
 Clean the umbilical cord with saline or 70% alcohol
 It should be dry
 PATENT URACHUS → itf the cord is always moist, suspect a fistula
between the bladder and the umbilicus, do NITRAZINE PAPER TEST
(+ for urine if it turns yellow)
5. Crede’s Prophylaxis
o Purpose: to prevent opthalmia neonatorum or gonnorheal conjeunctivitis

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o If mother has an untreated gonorrhea and passed the baby vaginally

o ERYTHROMYCIN OPTHALMIC OINTMENT → drug of choice, inner to outer
o Before 1989 – 2 drops of 2% silver nitrate at lower conujunctival sac
o It should be washed immediately after 1 minute to prevent burning
6. Administration of Vitamin K
o Purpose: to prevent hemorrhage related o physiologic hypoprothrobinemia
o Other name
 Aquamephyton, Phytomenadone, Konakion
 0.5 – 10.5 mg IM @ vastus lateralis or lateral anterior thigh
o Preterm → give 0.5 mg
o Vit. K is synthesized at the intestine
o On the 7th day, there is ↑ prothrombin
7. Weight Taking
o Normal Weight
 3000 – 3400 gm
 3 – 3.4 kg
 6.5 – 7.5 lbs
o Arbitrary Lowe Limit → 2,500 grams
o Low Birth Weight
 < 2,500 g
 it is not the same for gestational age
o Small for Gestational Age
 Less than the 10th % rank
o Large for Gestational Age
 > 90% rank
 Macrosomia – baby delivered 4,000 g or 4 kilos
 Diabetic mother
o Appropriate for Gestational Age
o Physiologic Weight Loss
 5 – 10% physiologic weight loss 10th days after birth


Important Consideration
• If the client is a newborn, cover areas that is not being examined (prevent
• If the client is an infant, he first vital sign to take is the RR because of fear of
stranger will change the normal respiration. Begin from at least intrusive to the
most intrusive procedure.
• If the client is a toddler and preschooler, le them handle the instruments like
stethoscope or play syringe. If the client has security blanket (like stuffed toy)
give it to them to lessen anxiety
• If the client is a school age and adolescent, explain the procedure and respect
their modesty

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Temperature
o Temperature of the newborn is taken rectally
o Rectal temperature taking is done only once to rule out imperforated anus
o Insert thermometer 1 inch inside the anus

o Types of Imperforated Anus

 No Anal Openning
• AtreticAgenetice
o These two is the most dangerous because there is
failure to pass meconium after 24 hours
o There is abdominal distention
o Foul odor breath
o Vomitus of fecal material which might result in
aspiration and casue respiratory problems
o Management: Surgery with temporary colostomy
 With anal openning
• Stenos
• Membranous
• Cardiac Rate
o Newborn → 120 – 160 bpm irregular
o Radial pulse of a newborn is normally absent
o If radial pulse is prominent suspect that there is a PDA
o Femoral pulse is normally palpable, if absent suspect Coarctation of Aorta


• Common in Boys
o Transposition of the great artery (TOGA)
o Truncus Arteriosus
o Tetralogy of Fallot

• Common in Girls
o Patent Ductus Arteriosus
o Atrio Septal Defect

• Causes
o Familial tendency
o Exposure to rubella/ German measles – 1st month
o Failure of the Heart Structure to progress

Two Major Types

• Acyanotic Heart Defects  shunting from left to right
• Cyanotic Heart Defects  from right to left

Acyanotic Heart Defects with Increase Pulmonary Blood Flow

1. Vetricular Septal Defect

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Opening Between 2 ventricles

• Signs and symptoms
o Systolic murmur at lower border of the sternum and no other
significant sign
o Cardiac catheterization reveals increase oxygen saturation at the
right side of the heart
o ECG reveals hypertrophy of the right side of the heart
o Only 50% of the oxygenated blood will go to the aorta
• Management
o Open heart surgery
o Placing the client on a long tern antibiotic therapy to prevent the
development of sub-acute bacterial endocarditis
o Protect site of catheterization (right femoral vein)
o Avoid flexion of joints

2. Atrial Septal Defect

• Failure of the foramen ovale to close
• Signs and symptoms
o Systolic murmur at the upper border of the sternum with no
significant sign
o Cardiac catheterization reveals increase oxygen saturation at the
right side of the heart
o 50% of the blood goes to the right atrium
• Management
o Open heart surgery
o Placing the client on a long tern antibiotic therapy to prevent the
development of sub-acute bacterial endocarditis

3. Endocardial Cushion Defect

• AV canal affecting both the tricuspid and the mitral valve
• Signs and symptoms
o Only confirmed by cardiaccatheterization
o Valves are closed
4. Patent Ductus Arteriosus
• Failure of the Ductus Arteriosus to close
• Signs and symptoms
o Prominent radial pulse
o Continuous machinery like murmur
o ECG reveals hypertrophy of the left ventricle
• Management
o Indomethacine – prostaglandin inhibitor that facilitate closure of
o Ligation of PDA by 2 – 4 years old

Acyanotic Heart Defects with Decrease Pulmonary Blood Flow

1. Pulmonary Stenosis
• Narrowing of valve of pulmonary artery

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Signs and symptoms

o Typical systolic ejection murmur
o S2 sound is widely split
o ECG reveals right ventricular hypertrophy
o Only 50% of the blood goes to the lungs
• Management
o Balloon Stenotomy

2. Aortic Stenosis
• Narrowing of valve of aorta
• Signs and symptoms
o Typical systolic ejection murmur
o Murmur
o ECG reveals right ventricular hypertrophy
o Only 50% of the blood goes to the body
o Angina like symptoms may be present when active
• Management
o Balloon stenotomy

3. Duplication of Aortic Arch

• Doubling of arch of the aorta causing compression to the trachea and
• Signs and symptoms
o Dysphagia – due to esophageal compression
o Dyspnea – due to tracheal compression
o Left ventricular hypertrophy
o Only 50% of the blood goes to the body
• Management
o Close heart surgery

4. Coarctation of Aorta
• Narrowing of ach of aorta
• Outstanding signs
o Absent femoral pulse
o BP is higher on the upper extremities and ↓ on the lower
o Epistaxis
o Lesser blood goes to the lower extremities
• Management
o Take BP on 4 extremities
o Close hear surgery

Cyanotic Heart Defects with Increase Pulmonary Blood Flow

1. Transposition of Great Arteries

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Aorta is arising from the right ventricle while the pulmonary artery is
arising from the left
• Signs and symptoms
o Cyanosis after 1st cry
o Polycythemia because of increase production of RBC, a
compensatory mechanism to the ↓ oxygen supply to the body, the
blood become viscous
o Polycythemia will lead to:
 Thrombuis
 Embolus
 Stroke (CVA)
o ECG reveals Cardiomegaly
• Management
o Palliative repair – Rash Kind repair
o Complete repair – Mustard repair

2. Total Anomalous Pulmonary Venous Return

• Situation wherein pulmonary vein instead of entering the left atrium enters
the right atrium or superior vena cava
• Signs and symptoms
o Open foramen ovale
o Mild – moderate cyanosis
o Absent spleen
• Management
o Restructuring of the heart

3. Truncus Arteriosus
• Situation in which pulmonary artery and aorta is arising in one common
trunk or a single vessel with ventricular septal defect
• Signs and symptoms
o Cyanosis after 1st cry
o Polycythemia because of increase production of RBC, a
compensatory mechanism to the ↓ oxygen supply to the body, the
blood become viscous
o Polycythemia will lead to:
 Thrombuis
 Embolus
 Stroke (CVA)
• Management
o Restructuring the heart

4. Hypoplastic Left Heart Syndrome

• Non functioning left ventricle
• Signs and symptoms
o Cyanosis after 1st cry

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Polycythemia because of increase production of RBC, a

compensatory mechanism to the ↓ oxygen supply to the body, the
blood become viscous
o Polycythemia will lead to:
 Thrombuis
 Embolus
 Stroke (CVA)
• Management
o Heart transplant

Cyanotic Heart Defects with Decrease Pulmonary Blood Flow

1. Tricuspid Atresia
• Failure of the tricuspid valve to open
• Signs and symptoms
o Open foramen ovale
o Cyanosis
o Polycythemia because of increase production of RBC, a
compensatory mechanism to the ↓ oxygen supply to the body, the
blood become viscous
o Polycythemia will lead to:
 Thrombuis
 Embolus
 Stroke (CVA)
• Management
o Fontan Proledum

2. Tetralogy of Fallot
• 4 Anomalies Present (PVOR)
o Pulmonary Stenosis
o Ventricular Septal Defect
o Overriding of Aorta
o Right Ventricular Hypertrophy
• Signs and symptoms
o High degree of Cyanosis  outstanding Sign
o Polycythemia because of increase production of RBC, a
compensatory mechanism to the ↓ oxygen supply to the body, the
blood become viscous
o Polycythemia will lead to:
 Thrombuis
 Embolus
 Stroke (CVA)
o Severe dyspnea  relieved by squatting position because it will
prevent venous return and facilitate maximum lung expansion
 Knee chest position in infants
o There is growth retardation
o TET Spells – blue spells or short episode of hypoxia

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Syncope – faintaing
o Mental retardation
o Clubbing in fingernails because of tissue hypoxia – late and last
o X – ray reveal a boot shape heart
• Management
o Oxygen therapy
o Morphine sulfate – for hypoxic episode
o Propanolol (inderal) – decrease heart spasm
o Palliative repair – BLT or Blalock Taussig Shunt Procedure
o Complete repair – Brock Procedure


Rheumatic Heart Disease

• Inflammatory disease following an infection caused by Group A Beta Hemoilytic
• Affected body parts
o Musculoskeletal
o Cardiac muscle
o Integumentary system
• Tonsillitis due to love of sweets with no oral hygiene serving a good medium for
bacterial growth causing inflammation
• Group A Beta Hemolytic Streptococcus will release toxin and enters circulation
• Group A Beta Hemolytic Streptococcus is an anaerobic organism and will stay at the
left side of the heart or the mitral valve as an ASCHOFF BODIES
• ASCHOFF BODIES – round nodules with multi nucleated cell and fibroblast that
stays in the miral valve
• Left sided heart failure because of mitral stenosis due to increase in the size of
Aschoff Bodies
• Diagnostic Exam: JONE’S CRITERIA
Major Minor
Polyarthritis – multi joint pain Low grade fever
Athralgia – joint pain Diagnostic Exams
CHOREA/ Sydenhamm’s Chorea/ • Antibody
St. Vitous Dance – involuntary, • C reactive protein
purposeless movement of the hand • ESR
and shoulder accompanied by
• Anti Streptolysin Titer
Carditis – signs of tachycardia
Erythema Marginatum – macular
Subcutaneous nodules
Presence of 2 major or 1 major and 2 minor plus a history of sore throat
will confirm diagnosis

• Management

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Bed rest
o Avoid contact sports
o Throat swab for C & S
o Antibiotics – purpose is to prevent recurrence
o Aspirin Therapy or salicylates – act as an anti-inflammatory agent in RHD
o Side effect: Reye’s Syndrome  encephalopathy accompanied by fatty
infiltration of the organs such as the heart and liver

• Normal Values = 30 – 60 bpm irregular
• Either abdominal or diaphragmatic breathing with short period of apnea without
• Normal apnea in newborn is 15 seconds or less

Age Rate
Newborn 40 – 90
1 year old 20 – 40
2 – 3 years old 20 – 30
5 years old 20 – 25
10 years old 18 – 22
15 and above 12 – 20

Breath Sounds Heard on Auscultation

Vesicular • Soft, low pitched, heard over periphery of lungs, aspiration is longer
Normal than expiration
Bronshovesicular • Soft, medium pitched heard over major bronchi, inspiration equals
Normal expiration
Bronchial • Loud, high pitched, heard over the trachea, expiration is longer than
Normal inspiration
Ronchi • Snoring sound made by air moving through mucus in bronchi
Rales • Crackles (like Celophane) made by air moving through fluid in alveoli
Abnormal • Denotes pneumonia, fluid in the lungs or pulmonary edema
Wheezing • Whistling on expiration made by air being pushed through narrowed
Abnormal bronchi
• Denotes children with asthma or foreign body airway obstruction
Stridor • Crowing or roster like sound made by air being pulled through a
constricted larynx
• Indicative of Respiratory Obstruction
Resonace • Loud, low tone, percussion sound over normal lung tissue
Hyper • Louder, lower sound than resonance, percussion sound over
Resonance hyperinflated lung tissue


• Lack of surfactant within 24 hours of life
• Aka Hyalin Membrane Disease
• Common in preterm babies

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• The alveoli cannot expand properly

• Signs and symptoms
o Present within 4 hours of life
o Using the Silverman Anderson Scoring to determine RDS
o ↑ RR with retraction (1st sign of RDS)
o Expiratory Grunting (major sign)
o Xiphoid retraction
o Flaring nasal flares
o Cyanosis
o Respiratory acidosis
• Management
o Head elevated
o Proper suctioning
o O2 administration with ↑ humidity
o Client placed on
 CPAP Continuous Positive Airway Pressure
 PEEP Positive End Expiratory Pressure
 Purpose id to maintain the alveoli partially open and
prevent alveolar collapse
o Monitor for acidosis
o Surfactant replacement


• Most common form of croup
• Viral infection of the larynx, trachea and bronchi
• Signs and symptoms
o BARKING or CROUPY COUGH  outstanding sign
o Inspiratory Stridor
o Respiratory acidosis
o Cyanosis
o Death
• Diagnostic Exams
o Throat swab for c & s
o Chest and x-ray to ruyle out epiglotitis
• Management
o Racemic Epinephrine – bronchodilator
o Humidified Oxygen

• Inflammation of the bronchioles characterized by production of tenacious
• FLU – LIKE SYMPTOMS – outstanding sign
• ↑ RR
• Causative Agent: Respiratory Syncitial Virus
• Drug: Antiviral – Ribavirin

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

LTB and Bronchiolitis ends with Epiglotitis

• Inflammation of the epiglotitis
• Sudden onset
• The child always assume the tripod position
• Less than 18 months cannot cough – must be placed on mist tent or “Croup
tie” – make sure that the edges are tucked in
o Provide washable plastic toys or materials
o Avoid toys that crate friction
o Avoid toys that are hairy or furry

Blood Pressure
• Newborn – 80 – 46 mmHg
• After 10 days – 100/ 50 mmHg
• BP taking begins by 3 years old

• If cyanotic after the first cry suspect Transposition of the Great Arteries

1. Acrocyanosis → body is pink, extremities are blue

2. Generalized Mottling due to the immaturity of the circulatory system
3. Birthmarks
a. Mongolian Spots
• Slate grya or bluish discoloration/ patches commonly seen across
the sacrum or buttock
• Related to ↑ melanocyte which is common in Asian newborn
• Usually disappear by 1 – 5 years old (preschool)
b. Milia
• Plugged or unopened sebaceous glands usually seen as a white
pinpoint patches at the nose, chin and cheeks and will disappear by
2 – 4 weeks
c. Lanugu
• Fine downy hair which is common in preterm
d. Desquamation
• Peeling of the newborn’s skin within 24 hours characterized by
extreme dryness that begin in the sole and palm, common in post
term babies
e. Stork Bites (Talengeiclasis Nevi)
• Pink patches at the nape, never disappears
f. Erythema Toxicum (Flea Bite Rash)
• First self limiting rash to appear sporadically and unpredictably as to
time and place
g. Harlequin Sign
• Dependent part is pink, independent part is blue because of the
immaturity of circulation, the RBC settles down

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

h. Cutis Memorata
• Transitory motlling of the neonates skin when exposed to cold
i. Hemangiomas
• Vascular tumors of the skin
• Types:
o Nevus Flammeus/ Port Wine Stain
 Macular purple or dark red lesions usually seen on
the face or thigh, disappears and be removed
o Nevus Vasculosus/ Strawberry Hemangioma
 Dilated capillary in the entire dermal or subdermal
area continuing to enlarge but disappear after 10
years old
o Cavenous Hemangiomas
 Consist of communicating network of venules in the
subcutaneous tissue that never disappear with age
j. Vernix Caseosa
• White cream cheese – like substance that serves as skin lubricant


1. Blue  cyanosis , hypoxia
2. White  edema
3. Gray  infection
4. Yellow  jaundice or carotinemia
5. Pale  anemia

Burn Trauma
• Injury to body tissues caused by excessive heat
1st Degree Involves only the superficial epidermis characterized by erethema,
Partial Thickness dryness and pain
Ex: Sunburn – heals by regeneration in 1 – 10 weeks
2nd Degree Involves the entire epidermis, and portion of the dermis,
Partial Thickness characterized by erythema, blistered and moist from exudates
which is extremely painful
Ex: Scalds
3 Degree Involves skin layers, epidermis and dermis, may involve adipose
Full Thickness tissue, fascia, muscle and bone. It appears to be leathery, white or
black, not sensitive to pain since nerve ending had been destroyed
Ex: Lava Burn

• First Aid
o Put out the flames by rolling the child on a blanket
o Immerse the burned part on cold water
o Removed burned clothing (sterile material)
o Cover burned part with sterile dressing
• Maintainance of patent airway

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Suction PRN
o O2 administration with ↑ humidity
o Endotracheal Intubation
o Tracheostomy
• Prevention of shock and flued and electrolyte imbalances
o Colloids to expand blood volume
o Isotonic saline to replace electrolyte
o Dextrose in water to provide calories
• Booster dose of Tetanus Toxoid
• Relief pain such as IV analgesic (morphine sulfate)
• Prevention of wound infection
o Cleaning and debriding the wound
o Open or close method of wound care
o Whirl pool therapy
• Skin grafting
o 3rd degree burn
o get skin from buttocks or pig skin (xenograft) or from frozen cadaver
• Diet  ↑ CHON and calories

Atopic Dermatitis
• Skin disease characterized by papulo-vesicular eruthematous lesions with weeping
and crusting
• Usually caused by food allergen
o Milk
o Eggs
o Citrus Juice
o Tomatoes
o Wheat
• Signs and symptoms
o Extremely pruritus – outstanding sign
o Linear excoriation
o Crusty
o Lichenification  dry and shinny, scaly white skin
• Management
o Avoid allergens
o Prosobes/ Isomil – hypoallergenic milk
o Prevent infection by proper handwashing, cut the fingernails
o Hydrate with a burrows solution
o Topical steroid – 1% hydrocortisone cream

• Skin disease caused by Group A Beta Hemolytic Sreptococcuscharacterized by
papulovesicular lesions surrounded by localized erythema becoming purulent and
ooze forming honey colored crust
• Before the development, the baby should always been exposed to Pediculosis
Capitis (kuto)
• Management

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Proper handwashing
o Treated with antibiotic
• Complication: AGN

• Self limiting inflammatory disease involving sebaceous gland, common in
• Comadones – composed o sebum that is mainly causing white heads
• Sebum – composed of lipids
• Management
o Proper handwashing wild mild soap (sulfur soap) and water, leave for 5 – 10
minutes or use tretenoin or Retin A – anti acne

Anemia/ Pallor
• Caused by
o Early cutting of the cord
o Bleeding disorders/ blood dyscarias


• Sex – linked (X) Recessive disorders
• The mother is the carrier
• The son is affected
• The father transmits to daughter
• Deficiency in clotting factor
o Hemophilia A  factor 8  classic hemophilia
o Hemophilia B  Factor 9  Christmas disease
o Hemophilia C  Factor 11
• OMPHALAGIA  earliest sign
o >300 cc loss of blood during cutting of the cord
• the maternal clotting factor is present in the new born that is why there is a delayed
diagnosis of hemophilia
• in toddlers  sudden bruising
• HEMARTHROSIS  major sign repeated bleeding, bleeding of the synovial
• Diagnostic exam: PTT
• Nursing Diagnosis: High Risk for Injury
• Goal: Prevention of injury
• Health Teaching
o Avoid contact sports
o Determine the case before doing any invasive procedure
 In immunization  change the needle into a smaller one
o In case of fracture/ injury

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

 Immobilize and elevate

o Cold compress
o Gentle pressure
o Blood transfusion of cryoprecipitate

• Group of malignant disease characterized by rapid proliferation of immature RBC
• Ratio is 500 RBC : 1 WBC
• The client is immunocompromised
• Classification of Leukemia
o Lympho – affects the lymphatic system
o Myelo – affects the bone marrow
o Acute/ Blastic – affects the immature cells
o Chronic/ cystic – affects the mature cells

Acute Lymphocytic Leukemia

• Most common in children
• Increase immature WBC
• Signs and Symptoms
a. Infection
i. Fever
ii. Poor wound healing
b. Bone weakness and causes fractures
c. Signs of bleeding
i. Blood in the urine
ii. Emesis
iii. Petechiae
iv. Epistaxis
d. Signs of anemia
i. Pallor
ii. Body malaise
iii. constipation
e. Invasion of the organs
i. Hepatomegaly  abdominal pain
ii. Spleenomegaly
2. Diagnostic examinations
a. Peripheral Blood Smear  reveals immature WBC
b. CBC  reveals anemia and thrombocytopenia; neutropenia
c. Lumbar Puncture
i. To determine CNS involvement
ii. Fetal position without flexion of the neck because it will cause airway
iii. C position or shrimp position
d. Bone Marrow Aspiration
i. Determines the presence of blast cells
ii. Site of bone marrow aspiration  iliac Crest  post op : prevent
iii. Lie on affected site
e. Bone Scan  determines the degree of bone involvement

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

f. CT Scan  determine the degree of organ involvement

3. Management Triad
a. Surgery
b. Irradiation
c. Chemotherapy
d. Bone marrow transplant
4. 4 Levels of Chemotherapy
a. Induction
i. To achieve remission
ii. Drugs
 IV – Vincristine
 L – Asparagine
 Oral Prednisone
b. Sanctuary
i. To treat the leukemic cells that has invaded the testes and CNS
ii. Drugs
 intrathecal methotrexate – via spine
 cytocine
 arabinase
 steroids
 irradiation
c. Maintainance
i. To continue remission
ii. Drugs
 oral methotrexate
 oral 6-mecaptopurine
 cytarabine
d. Reinduction
i. Give anti-gout agent To
ii. To treat leukemic cells after relapse occurse
iii. Treat hyperurecemic neuropathy
 Alopurinol or zylo[rene
5. Nursing Management
a. Assess for common side effects of chemotherapy – nausea and vomiting
b. Assess for stomatitis ulceration and abcess of oral mucosa
i. Oral care
ii. Alcohol free mouthwash
iii. Cotton piedgets
c. Diet – give food acoording to child’s preference
d. Alopecia – temporary side effect of chemotherapy


Rh Incompatibility
• Rh = monkey  foreign body
• Mother (-) – no antigen; no protein factor
• Fetus (+), Father (+) – has antigen and protein factor
• 4th baby is severely affected

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Erythroblastocis Fetalis
o hemolysis/ destruction of RBC leading to ↓ O2 carrying capacity leading to
IUGR with pathologic jaundice w/in 24 hours
• ALERT! Baby is small and yellowish
• Management
 Vaccine given to Rh(-) mothers within the first 24 hours or within 72 hours
 Given once
 If pregnancy was aborted and the mother udergo D & C, RHOGAM must
be given w/in 24 hours, if not given within 24 hours, mother will produce
 Action: destroys RBC preventing antibody formation
• Diagnostic Test  Coomb’s Test

ABO Incompatibility
• Mother – Type O; Fetus – Type A  most common
• Mother – Type O; Fetus – Type B  most severe
• Hydrops Fetalis
o Common in abo incompatibility
o Newborn is edematous, on lethal state, accompanied by pathologic jaundice
w/in 24 hours
• Difference from Rh Incompatibility
o First pregnancy is affected
o NB is yellow and edematous
• Management
o Initiation of breastfeeding, then temporary suspension of breastfeeding after 4
days ( breastfeeding realeses prenanediole causing kernicterus)
o Pregnanediole  delays actions of Glucoonyl transferase ( liver enzyme that
converts indirect bilirubin into direct bilirubin)
 Indirect bilirubin
 Fat soluble
 Can’t be excreted by kidneys
 Causes hyperbilirubenemia causing jaundice
 Direct Bilirubin
 Water soluble
 Can be excreted by the kidneys
o Use phototherapy
o Exchange transfusion for Rh and ABO affectations that tend to casue a
continuous decrease in hemoglobin during the first 6 months because the
bone marrow fails to produce erythrocytes in reponse to the continuous

• More than 12mg of indirect bilirubin among full terms
• Normal Indirect Bilirubin Level: 0 – 3 mg/dl

Kernicterus/ Bilirubin Encephalopathy

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Irreversible brain damage

• > 20 mg/dl of indirect bilirubin among full terms
• > 12 mg/ dl of indirect bilirubin among preterm because of immaturity

Physiologic Jaundice Pathologic Jaundice Breastfeeding Jaundice

Normal Within 24 hours Within 6th – 7th day
Within 48 – 72 hours Yellow upon birth Due to glucoronyl
Mx: transferase
Expose to early morning Possible Rh/ ABO
sunlight incompatibility

Assessment of Jaundice
• blanching of forehead, nose and sternum
• yellow skin, sclera
• light stool
• dark urine

• Phototherapy/ Photooxygenation
o Nursing Responsibilities
 Cover the eyes – prevents retinal damage
 Height of light from baby – 18 – 20 inches
 Increase Fluid intake
 Cover genetalia – prevent priapism ( painful continuous erection
 Change position
 Avoid lotion and oils
 Monitor I&O – best way is to weigh the baby
 Monitor VS

Bronze Baby Syndrome

• Transient bronze discoloration of the skin
• Minor side effect of phototherapy

• ¼ of its legth
• Structures
o sutures
o fontanels
 anterior/ bregma – 3 x 4 – 12 – 18 mos
 posterior/ lambda - 1 x 1 – 2 – 3 mos
• Noticeable structures of the Head
o Craniotabes
 Localized softening of the cranial bone common to first bone chiold
due to early lightening
 If present in older children; sign of rickets or Vit. D deficiency
o Seborrheic dermatitis/ Cradle Cap

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

 Scaling, greasing, appearing salmon – colored patches

 Usually seen at the scalp, behind ears and umbilicus
 Usually caused by improper hygiene
 Management
• Application of baby oil the night before shampooing the child
o Caput Succedaneum
 Edema of the scalp due to prolonged pressure at birth
 Present at birth
 Crosses the suture line
 Disappears 2 – 3 days
 Disappears without treatment
o Cephalhematoma
 Collection of blood due to rupture of capillaries of poriosteal capillaries
 Present after 24 hours
 Does not cross the suture line
 Disappears after 4 – 6 weeks
 Disappears without treatment
o Hydrocephalus
 Excessive accumulation of CSF
 Types
• Communicating/ extraventricula hydrocephalus
• No-communication/ intraventricular hydrocephalus/ obstructive
hydrocephalus – caused by tumor
 Signs and symproms
• Signs of increased ICP
o Diplopia – eye deviation @ 6th mos and above
o Management
 Low semi – fowlers (30 degrees) best position
• Frontal bossing 9 prominent forehead)
• Sunset eyes
• Prominent scalp vein
 Therapeutic management
• Osmotic Diuretic
o Mannitol
o Diamox / acetazolamide
• Seizure precautions
• Surgery – Shunting
o AV Shunt - atrioventricular
o VP shunt – ventriculoperitonial – most common
 Best time to shave the head – just before the surgery – prevent
 Post VP Shunt management
• Position – sidelying on non-operated side ( applicable to all
eyes and head surgeries)
• Sign of good shunting – sunken fontanel
• Sign of blocked shunting – bulging fontanel

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Catheter is changed as the child is growing

• Child with BP shunt is prone to infection


Sense of Sight
• Sclera
o Normal – light blue
o Later Color – dirty white
• Pupils
o Normal – round and adult size
o Coloboma – key hole pupils part of the iris is missing
o Congenital N Cataract – whiteness/ opacity of the lens
• Cornea
o Normal – round and adult size
o Congenital Glaucoma – larger than normal

Test for Blindness

Age Common Test
Newborn General appearance
Can see @ a Check ability to follow object pass midline
distance of 10 – 12 DOLL’S EYE TEST – done at approximately 10th day
inches with visual GLADELLAR TEST – test for blink reflex, not blinking is a
acuity of 20/200 to 20/ sign of blindness
Infant and children ALLEN’S CARD – test for visual acuity
- familiar pictures are flashed 20 ft away from the
ISHIARA PLATE – test for color blindness
3 years old School age Cover testing test – for strabismus
School age – adult Snellen’s test

• malignant tumor of the eye
• signs and symptoms
o cat’s eye reflex (whitish glow of pupil)
o red, painful eye usually accompanied by glaucoma
• Management
o Surgery  innucleation - removal of the eyeball
o Irradiation
o Therapy

• Normal nasal membrane - pinkish
• Check for sense of smell
• Check for nasal flaring

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

Sign of Cocaine User

• Ulceration and abscess of nasal mucosa
• Absence of hair

• Nose bleeding
• Management
o Position, upright, sitting, head trilted, slightly forward
o Gentle pressure
o Cold compress
o Epinephrine – last resort

• Normal should be aligned with the outer canthus of the eye
• Low Set Ears is a sign of
o Kidney malformation
• Renal agenesis
• Absence of kidney
o Chromosomal Abnormalities
• Due to advance maternal age - >35y/o

• Types
o Nondisjunction (uneven divison)
• Trisomy 21
• Down Syndrome
• Most common type
• Extra chromosome 21
• 47xx + 21/ 47xy + 21
• can be related to advance paternal age
• signs and symptoms
o broad nose
o protruding tongue
o low- set ears
o puppy’s neck
o hypotonia prone to URTI
o simian crease single traverse line in palm
o mental retardation – ranging from educable to
• Trisomy 18
• Has 3 numbers of 18 chromosomes
• Severely cognitively impaire SGA
• Low set ears, small jaw, CHD, index finger crosses over the
other fingers, rounded soles of feet
• Trisomy 13

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Patau’s syndrome
• Extra chromosome 13
• Severely cognitively impaired
• Signs and symptoms
o Microcephaly
o Micropthalmia
o Cleft-lip and palate
o Low-set ears
o Do not survive
• Turners
• Gonadal Dysgenesia
• One functional x chromosome
• Short in stature
• Neck appear to be webbed and short
• COA and kidney problems
• Only 1 streak (nonfunctional) gonads
• Secondary sex characteristic does not develop except for
pubic hair
• Lack ovarian function – sterility
• Cognitively challenged but mostly normal intelligence
• Klinefelter’s syndrome
• Males with a XXY chromosome pattern
• @ puberty child has poorly developed secondary
characteristics and small testes that produces ineffective
• boys tend to develop Gynecomastia
o Deletion Abnormalities
• Cri – du – chat Syndrome
• Result of a short arm on chromosome 5
• Cat’s cry
• Small head, wide set eyes, downward slant to the palbepral
fissure of the eyes
• Severe cognitive impairment
• Fragile X Syndrome
• X linked pattern
• One arm of x chromosome is weakened
• Most common cause of cognitive impairment in boys
• Before puberty, boys typically have maladaptive behavior like
hyperactivity and autism
• Large head, long face with high forehead, prominent lower jaw,
large protruding ears
o Translocation abnormalities
• Balance translocation Carrier
• Unbalanced Translocation Syndrome
o Others

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Mosaicism
• A situation wherein the nondisjunction of chromosome occurs
during mitotic cell division after fertilization resulting to different
cells contains different numbers of chromosome
• Isochromosomes
• A situation wherein the chromosome instead of dividing
vertically it divides horizontally resulting to chromosomal

Otitis Media
• Inflammation of the middle ear
• Common to children due to wider and shorter Eustachian tube
• Predisposing factors
o Bottle propping
o Cleft lip/ palate
 Signs and symptoms
o During otoscopic exam, reveals bulging tympanic membrane
o Observe for passage of purulent, foul – smeeling odor discharge
 Management
o Positioning – sidelying on the affected side
o Supportive care
 Medical management
o Massive dosage of antibiotics
o Mucolytics
o Ear drops
 < 3 y/o – down and back
 >3 y/o – up and back
o Surgery
 Myringectomy – slight incision of tympanic membrane to prevent
hearing loss
 Side effect – bacterial meningitis


• Check for symmetry

Bell’s palsy/ Facial Nerve Paralysis

• 7th CN injury
• usually related to forceps delivery
• risk for URTI
• Signs and symptoms
o Continuous drooling of saliva
o Inability to open one eye and close the other

• Management
o Artificial tear
o Self limiting

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Refer to PT for rehabilitation

• No connection between esophagus and stomach
• There is a blind pouch
• Hydramnios – earliest sign intrauterine
• Signs and symptoms
o Coughing
o Chocking
o Cyanosis
o Continuous drooling
• Management
o Emergency surgery

Epstein Pearls
• White glistening cyst
• Usually seen on palate, gum
• Related to hypercalcemia

Natal Tooth
• Tooth at the moment of birth
• Related to hypervitaminosis
• Management
o Manual extraction if rootless

Neonatal Tooth
• Appearance of tooth within 28 days of life

Oral Thrush
• White cheese-like, curd like patches
• Usually seen in mouth and on toingue
• Causative agent  C. Albicans – fungi
• Management
o Do not remove – can cause wound
o Wash with cold, bottled water
o Medical – Mycostatin/ Nystatin

Kawasaki Disease
• Discovered in Korea
• Strawberry tongue
• Common in asian countries
• Criteria for diagnosis
o Fever lasting for more than 5 days
o Bilateral conjunctivitis
o Changes in lips and oral cavity
 Dry red fissure lips
 Strawberry tongue

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

 Diffuse erythema of mucos membrane

o Changes in the peripheral extremities
 Erythema on the palms and soles
 Erythema on the hands and feet
 Membranous desquamation from fingertips
o Polymorphous rash (primarily at trunk)
o Acute non purulent sweeling of the cervical lymph nodes to > 1.5 cm in
• Drug of Choice : ASPIRIN

Cleft Lip
• Failure of the median maxillary nasal process to fuse
• Common to boys
• Surgery – cheiloplasty
o Done w/in 1 – 3 months
o To save sucking reflex
• Signs and symptoms
o Evident at birth
o Milk from nostrils spills
o Cold is common
o Frequent URTI and otitis media
• Post cheilo – sidelying
• Nutrition – use rubber tip syringe

Cleft Palate
• Failure of the palate to fuse
• Common to girls
• Surgery – Uranoplasty
o Done w/in 4 – 6 months
o To save speech
• Signs and symptoms
o Evident at birth
o Milk from nostrils spills
o Cold is common
o Frequent URTI and otitis media
• Post cheilo – prone
• Nutrition – use paper cup/ plastic cup/ soup spoon

Condition to consider for suspension of operation

• If child has a cold/ nasopharyngitis – may lead to general septicemia

General management
• Maintainance of patent airway
• Proper nutrition
o NPO 4 hours post op
o Clear liquid

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

 Popsicle except red and brown in color

 Flavore gelatin
 No ice cream
• Observe for bleeding
o Frequent swallowing
• Protect suture lines specially LOGAN BAR
o Clean using hydrogen peroxide, bubbles traps microorganism, more bubbles
more microorganism trapped
o Prevent crying by attending to needs

Therapeutic Management
• Emotional support
• Proper Nutrition
• Cleft lip nipple (long tip, made by silicon)
• Prevent Colic
o Burp frequently
o One at the middle of the feeding
o Another at the end of the feeding
o Upright sitting position
o Pat at the back – lower to upper
o Prone position
o Right – sidelying position – facilitates gastric emptying
• Educate parents
• Apply elbow restraints so the baby can easily adjust post –op

• Check for symmetry

Congenital Torticollis/ Wry neck

• Birth injury of sternocleidomastoid due to excessive traction during cephalic delivery
• A case of incompetence to the one giving birth
• Management
o Passive stretching
o Exercise daily
o Surgery
• Complication
o Scoliosis

Congenital Critinism/ Congenital Hypothyroidism

• Absence or non – functioning thyroid gland
• Causes
o Due to delayed diagnosis, thyroid is covered by sternocleidomastoid muscle
o Hypothyroidism
o Thyroid dysgenesis (absence of thyroid)
o Baby receive maternal thyroxine
• Earliest Signs and Symptoms

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Change in sucking
o Change in crying
o Excessive sleeping (16-20 hours/ day)
o Constipation
o Edema – moon faced baby
o Mental retardation – late sign
• Diagnostic Test
o Radioimmunoassay Test
o Protein bounbd iodine
• Treatment
o Synthroid / sodium levothyroxine for life


Witch Milk
• Transparent
• Liquid coming out from newborns breast related to hormonal changes


Abdominal Assessment
• Inspection
• Ausculation
• Percussion
• Palpation

Diaphragmatic Hernia
• Protrusion of stomach contents through a defect in diaphragm due to failure of
pleuroperitoneal canal to close
• Signs and Symptoms
o Sunken abdomen
o Signs of RDS
o Right to left Shunting
• Treatment – diaphragmatic repair w/in 24 hours

• Protrusion of stomach content between the the junction of abdominal wall and
• If small – surgery
• If large – suspend surgery
• Apply wet dressing

• Functions

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Assist in maintaining fluid and electrolytes and acid and base balance
o Processes and absorbs nutrients to maintain and support growth and
o Excrete wasted products from the digestive process

Supplementary Feeding
• Begin 4 – 6 months
• As early as 4 months
• Usually at 6 months
• Principles
o Solid food are often according to the following sequence
 Cereals  rich in iron
 Fruits
 Vegetables
 Meat
o Begin with small quantities
o Finger food are offered @ 6 months
o Soft table food is offered @ 1 year
o Diluted citrus/ fruit juices @ 6 months
o Offer new food one at a time with an interval of 4 – 7 days or 1 week
o Never offer half cooked egg  may lead to gastroenteritis/ salmoneliosis

Major Concepts of Fluid and Electrolyte Balance

• Distribution of Body Fluids
o Fluids are greater in ECF in infant and children
o Newborns are candidate for dehydration
o Total Body fluid is 65 – 85% of their body weight in infants and children

Acid – Base Imbalance

• Depending upon the following
o Chemical buffers
o Renal and respiratory system involvement
o Dilution of strong acids and bases in blood
• Imbalance of Acid
o Respiratory Acidosis
 Carbonic acid excess
 Hypoventilation – COPD
o Respiratory Alkalosis
 Carbonic acid deficit
 Hyperventilation
 Fever, encephalitis
o Metabolic Acidosis
 Base bicarbonate deficit
 Diarrhea
 Severe malnutrition and dehydration
 celiac

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Metabolic Alkalosis
 Base bicarbonate excess due to uncontrolled vomiting
 NGT aspiration
 Gastric lavage
 Pyloric stenosis

Conditions that Produce Fluids and Electrolyte Imbalance

• Forceful expulsion of stomach content
• Signs and symptoms
o Nausea
o Abdominal crumping
o Flushing of face
o Watery eyes
• Assessment
o Frequency
o Forces
 Projectile – increase ICP/ Pyloric stenosis
 Non – projectile
• Alerts
o Vomiting is an initial symptom of GI Obstruction
o Vomitus of upper GI can be blood tinged but bot bile streaked
o Vomitus of lower GI is bilous
o Projectile vomiting is ewither a sign of increased ICP or GI Obstruction
o Abdominal distention is the major symptom of lower GIT obstruction
• Management
o Banana
o Rice cereal
o Apple sauce
o Toast

• Exaggerated excretion of intestinal contents
• Acute diarrhea is associated with the following
o Gastroenteritis/ salmonelliasis
o Antibiotic use – penicillin, tetracycline
o Dietary indigestion
• Chronic non specific diarrhea
o Food intolerance
o CHO/ CHON malabsorption
o Excessive fluid intake
• Assessment
o Frequemcy
o Consistency (best criteria)
o Appearance of green colored stool
• Complications

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Mild dehydration – 5% weight loss

o Moderate dehydration – 10% weight loss
o Severe dehydration – 15% weight loss
• Signs of dehydration
o Tachycardia – earliest sign
o Tachypnea
o Hypontension
o Increase temp
o Sunken fontanel
o Sunken eyeball
o Poor skin turgor
o Absence of tears
o Scanty urine
o Oliguria – severe dehy=dration
o Weight loss
o Prolonged capillary refill time
• Management
o IV infusion
o KCl – given by doctors
 Assess child for ability to void before giving KCl – may lead to
 Normal K Value – 3.5 – 5.5
o Order Na Bicarbonate, administer slowly to prevent cardiac overload

Gastric Motility Disorders

Hirschprung’s Disease/ Congenital Aganglionic Megacolon

• Absence of ganglion cells needed for peristalsis
• Assessment
o Neonatal Period
 Abdominal distention
 Failure to pass meconium within 24 hours
o Early childhood
 Ribbon like stool
 Constipation
 Foul smelling stool
 Diarrhea
 Vomitus of fecal materials
• Diagnostic Procedures
o Barium enema – reveals narrowed portion of the bowel
o Rectal biopsy – reveals absence of ganglion cells
o Abdominal x- ray – reveals dilated loops on intestines
o Rectal manometry – reveals failure of intestinal sphincter to relax
• Therapeutic Management
o NGT Feeding
 NGT Measurement

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Infant – nose-ears – middle of xiphoid process and umbilicus

• Adult – nose – ears – xiphoid process
o Surgery
 Temporary colostomy
 Anastomosis and pull through procedure
o Diet
 Increase CHON
 Increase Calorie
 ↓ residue diet – pasta foods
 no raisin/ prunes

Gastroesophageal Reflux
• presence of stomach content on esophagus
• Assessment
o chronic vomiting
o failure to thrive syndrome – organic
o esophageal bleeding manifested by melena and hematemesis
• Complications
o esophagitis
o aspiration pneumonia
o esophageal cancer
• Diagnostic Procedure
o barium esophogram
o esophageal manometry – reveals lower esophageal pressure
o intraesophageal pH content – reveals pH of distal esophagus
• Medications
o anticholinergics
 bathanechol/ urecholine
• ↑ esophageal tone and peristaltic activity
 Methachlopromide (Reglan)
• ↓ esophageal pressure by relaxing pyloric and duodenal
• ↑ peristalsis without stimulating secretions
 H2 Blocker/ histamine Receptor Antagonist
• ↓ gastric acidity and pepsin secretion
 Maalox/ Cimetidine (Tagamet)/ Ranitidine (Zantac)
• Neutralizes gastric acid between feedings
• Surgery: Nissen Fundoplication
• Diet
o Thickened feeding with rice cereal  prevents vomiting
o Feed slowly
o Burp often every 1 oz
o Positioning
 < 9 mos – infant sit/ infant supine
 > 9 mos – prone with head on mattres slightly elevated on a 30° angle

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

Obstructive Disorders

Pyloric Stenosis
• hypertrophy of the muscle of pylorus causing narrowing and obstruction
• Assessment
o Projectile vomiting
o Failure to gain weight
o Metabolic alkalosis
o Peristaltic wave visible from left to right across epigastrum
o Palpation of olived shaped mass
• Diagnostic Procedure
o Serum Electrolyte - ↑ Na and K, ↓ Cl
o Ultrasound
o X-ray of upper abdomen with barium swallow
• Management
o Pyloromyotomy/ Fredet – Ramstedt Operation

• Telescoping or invagination of one portion of the bowel into the other
• Peritonitis – danger of intussusception
• Emergency for URT – epiglotitis
• Emergency for GIT – peritonitis
• Signs and symptoms
o Acute paroxysmal abdominal pain
o Currant jelly stool caused by inflammation and bleeding
o Sausage shaped mass
• Non congenital
• Caused by fast eating and positioning
• Management
o Hydrostatic reduction with barium enema
o Surgery – Anastomosis

Inborn Errors of Digestion

Phenylketonuria/ PKU
• Deficiency of the liver in Phenyalanine Hydroxylase Transferase (PHT)
• PHT is a liver enzyme that coverts protein into amino acid
• 9 Essential Amino Acids
o Tyrosine / phenylalanine
o Histidine
o Isoleucine
o Leucine
o Lysine
o Methionine/ cysteine
o Threonine
o Tryptophan

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Valine
• Tyrosine or Phenylalanine – responsible for the melanin production
• Signs and Symptoms
o Fair complexion
o Blond hair
o Blue eyes
o Infantile eczema
o Mousy/ musty odor urine
o Seizure – due to Phenyl Pyruvic Acid goes to brain
o Mental retardation
• Guthrie Test
o Specimen – Blood
o Preparation – Increase Fluid Intake
• Management
o Diet
 ↓ phenylalanine diet indefinitely
 Chicken, meat, peanuts, milk, legumes, cheese – contraindicated
 Lofenalac – special formula

Celiac Disease/ Malabsorption Syndrome; Gluten Induced Enteropathy

• Sensitivity or immunologic response to protein
• Assessment
o Early signs
 Diarrhea, failure to regain weight following diarrheal episode
 Constipation
 Vomiting
 Abdominal pain
 Steatorhea
o Late signs
 Behavioral changes: irritability and apathy
 Muscle wasting and loss of subcutaneous fats
o Celiac Crisis
 Development of infection by a child having a celiac disease
 Acute vomiting and diarrhea
• Diagnostic Procedure
o Stool analysis
o Serum antiglandin and antireticulin antibodies
o Sweat test
• Therapeutic management
o Vitamin supplements
o Mineral supplements
o Steroid

• Common accident in toddlers – poisoning

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Common accident in infants – falls

• Principles
o Determine the substance taken and assess LOC
o Unless poisoning was corrosive, caustic (strong alkali, such as lye) or
hydrocarbon, vomiting is the most effective way to remove the poison from
the body
 Strong acid poisoning – give weak acid to neutralize strong acid
o Syrup of ipecac – oral antiemetic to cause vomiting after drug overdose or
 15 ml – adolescent, school age and preschool
 10 ml – infant
o Universal Antidote
 Activated charcoal
 Milk of magnesia
 Burned toast
• Charcoal absorbs toxic substance
o Never administer the charcoal before ipecac because giving charcoal first will
absorb the effect of ipecac
o Antidote for acetaminophen poisoning : Acetylcysteine (mucomyst)
o Kerosine/ Gasoline poisoning: Give mineral oil to coat the intestine and
prevent poison absorption
• Tracheostomy set will be at bed side

Lead Poisoning
• Pencil, paint, crayon Lead

Destruction of RBC Functioning

hyupochromic Microcytic Anemia

Destroys Kidney Function

Accumulation of ammonia

Leading to Encephalitis (Late stage)

Severe mental retardation
• Assessment
o Beginning symptoms of lethargy
o Impulsiveness and learning difficulty
o As lead ↑, severe encephalopathy with seizure and permanent mental
• Diagnostic procedure
o Blood smear
o Abdominal x-ray
o Lone bone
• Management
o Chelation – binds with the lead and excreted via kidneys

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Ca EDTA/ BAL/ Dimercapro

 Nephrotoxic


• Pseudomenstruation
o Slight vaginal bleeding related to hormonal changes
• Rape/ Child Abuse
o If the client came with a laceration and bleeding at the perineum
o Report rape within 48 hours
o Preschool are proneto rape because of their innocence
o CBQ Report rape cases to barangay chairman first or bantay bata

• Cryptochirdism
o Undecended testes or empty scrotum or ectopic testes
 Common in preterm babies
 Testes is palpable at lower quadrant
 Surgery: Orchioprexy
• Preop – warm the room and hands
• Epispadias
o Urinary meatus is located at the dorsal or above the glans penis
• Hypospadias
o Urinary meatus is located at the ventral or below the glans penis
o Hypospadias is usually accompanied by Chordee ( A fibrous band causing
penis to curved downward)
o Both are manage by surgery
• Phimosis
o Tight foreskin
o This will cause infection
o Circumcision as management
• Hydrocele
o Fluid filled scrotum
o Flashlight/ transillumination test to determine
• Varicocele
o Enlarged vein opf the epididymis


Renal Causes Assessment Treatment Nursing Care

Disorder Findings
Nephrotic Infection Anasarca Prednisone Skin Care
Syndrome Massive proteinuria Weigh the client saily
Microscopic or no with the same clothing
hematuria ↑ CHON(Normal Diet)
↓ serum CHON ↓ Na
↑ serum lipid ↑K

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

Normal or ↓ BP
Acute Autoimmun Primary pheripheral AntiHPN Monitor weight
Glomerul e perioprbital edema Hydralazine Skin Care
onephritis Group A Moderate Proteinuria Apresoline Monitor BP and
beta Goss hematuria neurologic status
hemolytic (smokey urine) Complication ↓K
streptyococ ↑ serum K Hypertensive ↑ Fe
cus Fatigue Encephalopat ↓ Na
HPN hy

• Check for flatness and symmetry of the back

Spina Bifida Occulta

• Failure of the posterior lamina or vertebral to fuse
• Sampling of the lower back
• Abnormal tufts of hair

Spina Bifida Cystica

• With Sac
• Types
o Meningocele – protrusion of CSF and Meninges
o Myelomeningocele – CSF, Meninges and Spinal cord
o Ecephacele
 cranial meningocele - CSF and meninges
 Myelomeningocele - brain, CSF , meninges
• Common Complication
o Infection
o Rupture of Sac
• Treatment
o Surgery to prevent infection: post op – prone position

• Lateral curvature of the spine, common in school age because of heavy bags
• Uneven hemline
• Tell the child to bend forward, one hip higher than athe other and one shoulder is
most prominent
• Types
o Structural
o Postural
• Management
o Conserbvative
 Exercise
 Avoid obesity
o Preventive

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

 Milwaukee Braces worn 23 hours a day

o Corrective: Surgery

• Count the number of digits

• Syndactyl – webbing of the digits (foot – ginger –like foot)
• Polydactyl – extra digits
• Olidactyl – lacks digits

Erb – Duchennse Paralysis/ Brachial Plexus Injury

• Birth injury of breech delivery
• Signs
o Inabiluity to abduct the arm fronm the shoulder, rotate the arm extremely and
supinate the forearm
o Assymetrical oor absence of moro reflex
• Management
o Abduct the arm from the shoulder with the elbow flexed

Congenital Hip Dislocation

• Congenital hip dysplacia
• When the head of the femus is outside the scetabulum
• 2 types
o subluxated – most common
o dislocated
• Signs and Symptoms
o Shortening of the affected leg
o Assymetrical gluteal fold
o Limited movement – earliest sign
o + ortolanis sign – abnormal clicking of during abduction
o when able to walk the child limps (Trendelenburg sign) – late sign
• Management – facilitate abduction
o Triple the diaper
o Carry the baby
o Frejka Splint
o Pavlik Harness
o Hip Spica Cast

• Club foot
• 4 types
o Equinos – plantar rotation/ horse foot (most common)
o Calcenuous – dorsiflexion/ the heel is held lower than the foot/ the anterior
portion of the foot is flexed towards the anterior leg
o Varus – foot turns in

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

o Valgus – foot turns out

• Assessment
o Make a habit of straightening the legs and flying it to the midline position
• Management
o Corrective shoes : Dennis Brown Shoes
o Spica Cast
 For immobilization
 Maintain bone alignment
 Prevent muscle spasm
 If there is a blood mark on the cast – mark a pen to determine
whether there is a hemorrhage
 Neurobvascular check
• Circulation
• Motion
• Sensation

• Wait is on the palm not the axilla
• Exercise – squeeze ball

Different Crutches and Gait

Swing Through
• Advance both crutches
• Lift both feet/ swing forward/ land feet in front of crutches
• Advance both crutches
• Lift both feet/ swing forward/ land feet in front of crutches

Swing To
• Advance both crutches
• Lift both feet/ swing forward/ land feet next to crutches
• Advance both crutches
• Lift both feet/ swing forward/ land feet next to crutches

Three point gait

• Advance left foot and both crutches
• Advance right foot
• Advance left foot and both crutches
• Advance right foot

Four Point Gait

• Advance right crutch
• Advance left foot
• Advance left crutch
• Advance right crutch

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

Two Point Gait

• Advance left foot and right crutch
• Advance right foot and left crutch
• Advance left foot and right crutch
• Advance right foot and left crutch

Other Crutch – Maneuvering Technique

To Sit Down
• Grasp the crutches at the hand pieces for control
• Bend forward slightly while assuming a sitting position
• Place the affected leg forward to prevent weight bearing and flexion

To Stand Up
• Move forward to the edge of the chair with the strog leg slightly under the seat
• Place both crutches in the hand on the side of the affected extremity
• Push down on the hand piece while raising the body to a standing position

To Go Downstairs
• Walk forward as far as possible to the step
• Advance the crutches to the lower step. The weaker leg is advanced first and then
the stronger leg. In this way, the stronger extremity shares the work of raising and
lowering the patient’s body weight with the arms

To Go Upstairs
• Advance the stronger leg first up to the next step
• Then advance the crutches and the weaker extremity ( strong legs goes up first and
comes down last.)
• A memory device for the patient is “UP WITH THE GOOD, DOWN WITH THE BAD”

• A walker provides more support than cane andf crutches
• The patient is taught to ambulate with a walker as follows
o Patient must hold the walker on the hand grips for stability
o Lift the walker, placing it in front of you while leaning your body slightly
o Walk into the walker, supporting your body weight on your hands while
advancing the weaker leg, permitting partial weight bearing or non weight
bearing leg as prescribed
o Balance yourself on your feet
o Lift the walker and place it in front of you again and continue the pattern of

• Used to help patient walk with greater balance and support and to relieve the
pressure on the weight bearing joints by redistributing the weight.

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• Quad Cane (four – footed cane) is hold on the hand of affected extremity.


• Weight bearing transfe4r from bed to chair. The patient stands up, pivots his back is
opposite the new seat and sits down.
• (Left) Non weight bearing transfer from chair to bed. (Right) With legs braced.
• (Left) Non weight bearing transfer combined method. (Right) Non weight bearing
transfer, pull up method.

Exercise Description Purpose Action
Passive carried out by the To retain as much Stabiolize the
therapist or the nurse joint range of motion proximal joinyt, and
without assistance as possible support the distal
from the patient To maintain part. Move the joint
circulation smoothly, slowly and
gently through its full
rang of motion
Avoid producing
Active Assistance Carried out by the To encourage normal Support the distal
patient with the muscle function part and encourage
assistance of the the patient to take
therapist or the nurse the joint actively
through its ROM.
Give no more
assistance than is
necessary to
accomplish the
action. Short periods
of activity should be
followed by adequate
rest periods.
Active Accomplished by the To increase muscle When possible,
patient without strength active exercise
assistance, activities should be performed
include turning from against gravity. The
side to side and from joint is moved
back to abdomen through full ROM
and moving up and without assistance.
down in bed (make sure that the
patient does not
substitute another
joint movement for
the one intended)

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

Resistive An ective exercise To provide resistance The patient moves

carried out by the to increase muscle the joint through its
patient working power ROM while the
against the therapist resist
resistance produced slightly at first and
by either manual or the progressively
mechanical means increasing
Sandbagws and
weights can be used
and are applied at
the distal point of the
joint involved. The
movement should be
performed smoothly.
Isometric/ Muscle Alternately To maintain strength Contract or tighten
Setting contracting and when a joint is the muscle as much
relaxing a muscle immobilized as possible without
while keeping the moving the joint.
part in fixed position; Hold for several
performed by the seconds, and then let
patient go and relax. Breath

• Use to reduce dislocation

Principles of Traction
• The client should be in dorsal or supine position
• For every traction, there is always a counter traction
• Line of pull should be in line with deformity
• For traction to be effective it must be continuous
• Weight must be freely hanging

Types of Traction
• Straight traction – weight of the body serves as counter pull
• Skin traction – applied directly to the skin
o Bryant’s Traction
 use to immobilize for < 2 years old at a 90 ° angle with buttocks off the
o Buck’s extension
 For > 2 years old
• Halo traction – immobilize the spine
• Skeletal traction
o Nursing responsibilities

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

 Assess for circulatory and neurology impairment

 It can lead to HPN
 Be careful to carry out nursing functions by not moving the weights

• Types of Immunity
o Passive Natural
 Developed via exposure to a disease
o Active Natural
 Transplacental transfer, IgA from breastmilk
o Passive Artificial
 Vaccination
o Active Artificial
 Anti Rabies Serum



Blink reflex
• Rapid eye closure when strong light is shown to protect the eyes; never disappears
Palmar Grasp Reflex
• When a solid object is placed on the palm then the baby will grasp the object
• To cling to the mother for safety
• Disappears at 3 months
Step – in/ Walk – in Place Reflex/ Dance Reflex
• Neonate placed on a vertical position with their feet touching on hard surface will
take a few quick alternating steps
• Placing reflex  almost the same with the dance reflex except that is when you are
touching the anterior surface of newborns leg
Plantar Grasp Reflex
• When an object touches the sole of the newborn’s foot at the base of his toes, the
toes grasp in the same manner as the fingers do
• Disappears @ 8 – 9 months in preparation for walking
Tonic Neck Reflex/ Fencing/ Boxing reflex
• When the newborn lies on its bact, their heads usually turns to one side, the arm and
the leg on the side to which the head turns extend to the opposite arm and legs
Moro Reflex/ Startle Reflex
• With a loud voice or by a jarring the base of the crib, the baby will assume a c
• Test for neurologic integrity
Magnet Reflex
• When there is pressure at the sole of the foot, the baby pushes back against the
Crossed extension Reflex

Jomar Anthony D. Maxion, BSN, RN BSN 2009

The Royal Pentagon Review Specialist Inc. Pediatric Nursing

• While supine and the sole of the foot is stimulated by a sharp object, it causes the
foot to raise and the other foot to extend
• Test for spinal nerve integrity
Trunk Incurvation Reflex/ Galant Reflex
• While in prone position and the parabvertebral area is stimulated, it causes flexion of
the trunk and swing his pelvis towards the touch
Landau reflex
• While the infant is placed on a vertical position with the hand underneath supporting
the trunk the baby exhibit some muscle tone
• Present at 3 months
• Test for muscle tone
Parachute Reflex
• When the infant is placed on a vertical suspension with the change in equilibrium, it
causes the extension of the hands and legs
• Present at 6 – 9 months
Babinski Reflex
• When the sole of the foot is stimulated by inverted j, it causes fanning of the toes
• Disappears by 2 months but may persist till 2 years old

Jomar Anthony D. Maxion, BSN, RN BSN 2009