PEDIATRIC NURSING

I. A. GROWTH AND DEVELOPMENT

Definition of Terms:
Growth – increase in physical size of a structure or whole quantitative structure

2 Parameters of Growth
1. Weight
- Most sensitive especially in low birth weight
- Weight 2x by 6 months
- 3x by 1 year
- 4x by 2 ½ year
2. Height
- Increase 1 inch/month during first 6 months
- ½ inch/month from 7 – 12 months

Development – increase in the skills or capacity to function qualitative change

How to Measure Development?

1. by simply observing a child doing specific task
2. by noting parent’s description of the child’s progress
3. by DDST (Denver Developmental Screening Test), MMDST (Metro Manila Developmental Screening Test)

4 Main Rated Categories

1. Language – for communication
2. Personal Social
3. Fine Motor Adaptive – pre tensile ability (ability to use hand movement)
4. Gross Motor Skills – ability to use large body movement

Maturation – synonymous with development (readiness)

Cognitive Development – is the ability to learn and understand from experience, to acquire and retain
knowledge to respond to a new situation and to solve problems

I. B. BASIC DIVISION OF LIFE

1. Pre-Natal – begins at conception and ends at birth
2. Period of Infancy
- Neonatal (first 28 days or first 4 weeks)
- Formal Infancy (from 29th day to 1 year)
3. Early Childhood
- Toddler (1 – 3 years)
- Pre-School (4 – 6 years)
4. Middle Childhood – school age 7 – 12 years
5. Period of Adolescent
- Pre-Adolescent/Late childhood (11 – 13 years)
- Adolescent (12 – 21 years)
I. C. PRINCIPLE OF GROWTH AND DEVELOPMENT

1. Growth and Development is a continuous process that begins from conception and ends with
death.
Principle: womb to tomb
2. Not all parts of the body grow at the same time or at the same rate.
Patterns of Growth and Development
1. Renal, digestive, circulatory, Musculo-skeletal (childhood)
2. Neurologic Tissue
- Grows rapidly during 1 – 2 years of life
- Brain (achieve to its adult proportion by 5 years)
- Central Nervous System
- SC
3. Lymphatic System
- Lymph nodes, Spleen, Thymus
- Grows rapidly during infancy and childhood (to provide protection against infxn)
- Tonsils is achieved in 5 years
4. Reproductive Organ – grows rapidly during puberty

3. Each child is unique

2 Primary factors affecting Growth and Development

A. Heredity
Race
Intelligence
Sex
Nationality
B. Environment
Quality of nutrition
Socio-Economic status
Health
Ordinal position in family
Parent-Child relationship

4. Growth and Development occurs in a regular direction reflecting a definite and predictable
patterns or trends
A. Directional Trends – occurs in a regular direction reflecting the development of neuromuscular
functions: these apply to physical, mental, social and emotional developments and includes:
a. Cephalo - caudal (head to tail)
- It occurs along bodies’ long axis in which control over head, mouth and eye movements and
precedes control over upper body torso and legs.
b. Proximo – distal (centro distal)
- Progressing from the center of the body to the extremeties
c. Symmetrical
- Each side of the body develop on the same direction at the same time at the same rate
d. Mass – specific (differentiation)
 - In which the child learns from simple operations before complex function or move from a
broad general pattern of behavior to a more refined pattern.
B. Sequential – involves a predictable sequence of growth and development to which the child normally
passes.
a. Locomotion
b. Language and Social skills

C. Secular – refers to the worldwide trend of maturing earlier and growing larger as compared to
succeeding generations.
5. Behavior is a most comprehensive indicator of developmental status
6. Play is the universal language of a child
7. A great deal of skill and behavior is leaned by practice
8. There is an optimum time for initiation of experience or learning
9. Neonatal reflexes must be lost first before development can proceed
→ Persistent Primitive Infantile Reflex (suspect Cerebral Palsy)

I. D. THEORIES OF DEVELOPMENT

Development Tasks is 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.

THEORISTS
1. Sigmund Freud (1856-1939) – an Austrian neurologist, Founder of psychoanalysis

PHASE OF PSYCHOSEXUAL THEORY

a. Oral Phase (0 – 18 months)
- Mouth is the site of gratification
- Biting, crying or sucking for enjoyment and to release tension
- Provide oral stimulation even the baby is NPO, offer pacifier
- Never discourage thumb sucking

b. Anal Phase (18 months – 3 years)

- Anus
- May show toilet training
- Elimination, defecation
- Principle of
- Holding on (child wins, hard headed, anti social and stubborn)
- Letting Go
- Mother wins (kind, perfectionist, obedient, obsessive – compulsive)

c. Phallic Phase (4 – 6 years)

- Genitals
- May show exhibitionism
- Accept the child fondling his own genital area as the normal area of exploration
- Answer the child’s question early

d. Latent Phase (7 – 12 years)

- Period of suppression
- Because there is no obvious development
- Child’s energy or libido is diverted to more concrete type of thinking
- Help child achieve positive experiences

e. Genital Phase (12 – 18 years)

- Achieved sexual maturity
- Learn to establish satisfactory relationship with opposite sex
- Give an opportunity to relate with opposite sex

2. Eric Erickson
- Trained in psychoanalysis theory
- Transits the importance of culture and society to their development of ones society

STAGES OF PSYCHOSOCIAL THEORY

Trust vs. Mistrust (0 – 18 months)
- Trust is the foundation of all psychosocial task
- To give and to receive is the psychosocial theme
- How trust is developed:
- Satisfy needs on time
- Care must be consistent and adequate
- Give and experience that will add to security (touch, hugs and kisses, eye to eye contact, soft music
Autonomy vs. Shame and Doubt (18 months – 3 years)
- Autonomy is independence or self governance
- How autonomy is developed
- Give an opportunity for decision making such as offering choices
- Encourage the child to make decisions rather than judge
Initiative vs. Guilt (4 – 6 years)
- Learns to do basic things
- Activity recommended are modeling clay, finger painting
- Develop creativity and imagination to facilitate fine motor development
- How initiative is developed:
- Give an opportunity of exploring new places and events
Industry vs. Inferiority (7 – 12 years)
- Learn how to do things well
- How industry is developed:
- Give an opportunity no short assignment and projects
Identity vs. Role Confusion (12 – 20 years)
- Learn how he/she is or what kind of person he/she will become by adjusting to new body image
- Seeking emancipation or freedom from parents
Intimacy vs. Isolation (20 – 40 years)
- Focus on career or looking for lifetime partners

Generativity vs. Stagnation (40 – 60 years)

Ego Integrity vs. Despair (65 and above)

3. Jean Piaget – a Swiss psychologist

STAGES OF COGNITIVE DEVELOPMENT

A. Sensorimotor (0 – 2 years)
- Practical intelligence because words and symbols are not applicable
- Babies are communicating through sense and reflex

SCHEMA AGE BEHAVIOR

Neonatal Reflex 1 month - All reflexes
Primary Circular Reaction 1 – 4 months - Activities related to bodies
repetition of behavior (thumb
sucking)
Secondary Circular Reaction 4 – 8 months - Activity not related to body
- Discover object or persons
code and code memory arises
- Anticipate familiar events
Coordination of Secondary 8 – 12 months - Exhibit goal directed
behavior
Tertiary Circular Reaction 12 – 18 months (1 – 1 ½ - Increase sense of
year) separateness
- Use trial and error to
discover change of places and
events
- Code and Code invention of
Invention of new means thru new means
mental combination 18 – 24 months - Capable of space and time
perception
B. Preoperational Thought - Transitional phase to
SCHEMA 2 – 7 years old operational period
Pre-conceptual AGE
2- 4 years
BEHAVIOR
- Egocentric (unable to view
another point of view)
- Their thinking is basically
concrete and static
Intuitive - Their concept of time is only
4 – 7 years now and their concept of
distance is only as far as they
can see
- Not yet aware of the concept
of reversibility
- Concept of animism
(inanimate object is alive)

C. Concrete Operational (7 – 12 years)

- Can find solutions to everyday problems with systemic reasoning
- They have concept of reversibility
- Activity recommended is collecting and classifying

D. Formal Operational (12 and above)

- Period when cognition has achieved its final form
- They are capable
- Can find scientific reasoning (can deal with the past, present and future)
- Capable of abstract and mature thought
- Do abstraction by talk time that will sort

4. Kohlberg (1984) – recognized the theory of moral development as considered closely to approximate
cognitive stages of development

STAGES OF MORAL DEVELOPMENT

INFANCY
Age (Year)
Description
Preconventional
Stage
2-3
(Level I)
1 Punishment/obedience orientation (“heteronomous
morality”). Child does right because a parent tells him/her
to and to avoid punishment.
4-7

2 Individualism. Instrumental purpose and exchange. Carries

out action to satisfy own needs rather than
society. Will do something for another if that person do
something for the child

Conventional
(Level II)
7-10
3
Orientation to interpersonal relations
of mutuality. Child follows rules because of a need to be a
10-2
4 “good” person in own eyes and the eyes of others.
Maintenance of social order, fixed rules and authority.
Childs finds following rules satisfying.
Follows rules of Authority figures as well as parents in an
effort to keep the “system” working

(Level III)
Postconventional
5 Social contract, utilitarian law-making perspectives.
Older than 12
Follows standards of society for the good of all people

Universal ethical Principle orientation. Follows internalized

6 standards of conduct.
I. E. DEVELOPMENTAL MILESTONE

PERIOD OF INFANCY
a. Play
- Solitary play
- Non interactive
- Priority is safety
- Age who appreciate teddy bears
- Attitude: proper hygiene
b. Fear
- Stranger anxiety
- Begin at 6 – 7 months
- Peak at 8 months
- Diminish by 9 months
c. Milestones
E.I NEONATE
- Largely reflex
- Complete head lag
- Hands fisted
- Cry without tears (due to immature larcrimal duct)
- Visual fixation of human face

1 month
- Dance reflex disappears
- Looks at mobile objects

2 months
- Holds head up when in prone
- Social smile
- Baby “coos”
- Cry with tears
- Closure of posterior fontanel by 2 – 3 months
- Head lag when pulled to a sitting position

3 months
- Holds head and chest when in prone
- Follow object past midline
- Grasp and tonic neck reflex are fading
- Hand regards (3 months)

4 months
- Turns from front to back
- Head control complete
- Bubbling sounds
- Needs space to turn
- Laugh aloud

5 months
- Roll over
- Turn both ways
- Teething rings
- Handles rattle well
- Moro reflex disappear by 4 – 5 months

6 months
- Reaches outs in anticipation of being picked up
- Handle bottle well
- Sits with support
- Uses palmar grasp by 6 months
- Eruption of first temporary teeth (2 lower incisors)
- Says vowel sounds “Ah, ah”

7 months
- Transfer objects hand to hand
- Beginning fear of stranger
- Likes objects that are good sized

8 months
- Sits with support
- Peak of stranger anxiety
- Plantar reflex disappear

9 months
- Creeps/crawl
- Needs space for creeping
- Pincer grasp reflex
- Combine two syllables “Papa, Mama”
- Priority: safety

10 months
- Pull self to stand
- Understand word “No”
- Respond to own name
- Peak – a – boo
- Pat a cake since they can clap

11 months
- Cruises
- Stand with assistance

12 months
- Stand alone
- Take first step
- Walk with assistance
- Drink from a cup
- Cooperate in dressing
- Says the 2 words “Mama, Papa”
- Toys: pots and pans, pull toy and learn nursery rhymes

E.2. TODDLER
a. Play
- Parallel (2 toddlers playing separately)
- Provide two similar toys (squawky squeeze toy)
- Waddling duck to pull, pull truck, building block and pounding peg
b. Fear
- Separation anxiety
- Do not prolong goodbye, say goodbye firmly
- 3 Phases of separation anxiety
a. Protest
b. Despair
c. Denial

c. Milestones
15 months
- Plateau stage
- Walks alone (delay in walking maybe a sign of mental retardation)
- Puts small pellets into small bottle
- Scribbles voluntarily with pencil
- Holds a spoon well
- Seat self on chair
- Creep upstairs
- Speaks 4 – 6 words
18 months
- Hide of possessiveness
- Bowel control achieved
- No longer rotates a spoon
- Run and jump in place
- Walk up and down stairs holding on (typically places both feet on one step before advancing)
- Able to name body part
- Speaks 7 – 20 words
24 months
- Can open doors by turning doorknobs
- Unscrew lids
- Walk upstairs alone by still using both feet on the same step at same time
- Daytime bladder control
- Speak 50 – 200 words
30 months
- 3 year old do tooth brushing with little supervision
- 2 – 3 year old is the right time to bring to the dentist
- Temporary teeth complete and last temporary teeth to appear is the posterior molars
- 20 deciduous teeth by age 2 ½ years
- Can make simple lines or stroke for crosses with a pencil
- Can jump down from the stairs
- Knows full name
- Copy a circle
- Holds up fingers
36 months
- Trusting three
- Able to unbutton
- Draw a cross
- Learns how to share
- Full name and sex
- speak fluently
- Right time for bladder control (night time control)
- Able to ride a tricycle
- Speak 300 – 400 words
- Clues for toilet training
a. Can stand, squat and walk alone
b. Can communicate toilet needs
c. Can maintain himself dry with interval of 2 hours

d. Character Traits
- Negativistic likes to say no (it is their way to search independence)
- Limit questions and offer options
- Temper tantrums (stomping feet and screaming)
- Ignore the behavior
- Rigid ritualistic: stereotype
- Cause: mastering
- Protruded abdomen
- Cause:
- Under development of abdomen
- Unsteady gait
- Physiologic anorexia (give foods that last for a short period of time)

E.3. PRE-SCHOOL
a. Play
- Associative play, Cooperative play
- Play house
- Role playing
b. Fear
- Body mutilation or castration fear
- Dark places and witches
- Thunder and lighting
c. Milestone
4 years
- Furious four (noisy and aggressive)
- Able to button
- Copy a square
- Lace shoes
- Know the 4 basic colors
- Vocabulary of 1500 words
5 years
- Frustrating five
- Copy a triangle
- Draw a 6 part
- Imaginary playmates
- 2100 words

d. Character Traits
- Curious
- Creative
- Imaginative
- Imitative
- Why and How

e. Behavior Problems
- Telling tall tales (over imagination)
- Imaginary friends (purpose: release their anxiety and tension)
- Sibling rivalry (jealousy to a newly delivered baby)
- Bed wetting
- Baby talk
- Fetal position
- Masturbation is a sign of boredom and should divert their attention

E.4. SCHOOL AGE (7 YEARS)

a. Play
- Competitive play
- Tug – o – war
b. Fear
- School phobia
- To prevent phobia orient child to new environment
- Displacement from school
- Significant person is the teacher and peer of the same sex
- Loss of privacy
- Fear of death
c. Significant Development
- Prone to bone fracture (green stick fracture)
- Mature vision
d. Milestones
6 years
- Temporary teeth begins to fall
- Permanent teeth begins to appear (first molar)
- Year of constant motion
- Clumsy movement
- Recognizes all shapes
- Teacher becomes authority figure that may result to nail biting
- Beginning interest with God
7 years
- Age of assimilation
- Copy a diamond
- Enjoys teasing and play alone
- Quieting down period
8 years
- Expansive age
- Smoother movement
- Normal homosexual
- Love to collect objects
- Count backwards
9 years
- Coordination improves
- Tells time correctly
- Hero worship
- Stealing and lying are common
- Takes care of body needs completely
- Teacher find this group difficult to handle
10 years
- Age of special talents
- Writes legibly
- Ready for competitive sports
- More considerate and cooperative
- Joins organization
- Well mannered with adults
- Critical of adults
11-12 years
- Pre adolescent
- Full of energy and constantly active
- Secret language are common
- Share with friends about their secrets
- Sense of humor present
- Social and cooperative

e. Character Traits
- Industrious
- Love to collect objects
- Cant bear to loose they will cheat
- They are modest
SIGNS OF SEXUAL MATURITY
Boys
Girls
Increase size of breast and genetalia Appearance of axillary and pubic hair
Widening of hips Deepening of voice
Appearance of axillary and pubic hair Development of muscles
Menarch (last sign) Increase in size of testes and scrotum (1st
- telarch is the 1st sign of sexual maturity sign)
Production of viable sperm (last sign)
E.5. ADOLESCENT PERIOD
- They have distinctive odor because of the stimulation of apocrine gland
- They have nocturnal emission (wet dreams) the hallmark for adolescent
- Testes and scrotum increase in size until age 17
- Sperm also viable
- Breast and female genetalia increase until age 18

a. Fear
- Acne
- Obesity
- Homosexuality
- Death
- Replacement from friends

b. Significant Person
- Peer of opposite sex
c. Significant Development
- Experiences conflict between his needs for sexual satisfaction and societies expectations
- Core concern is change of body image and acceptance from the opposite sex
d. Personality Trait
- Idealistic (parent-child conflict begins)
- Rebellious
- Very conscious with body image
- Reformer
- Adventuresome

e. Problems
- Vehicular accident
- Smoking
- Alcoholism
- Drug addiction
- Pre marital sex

IMMEDIATE CARE OF THE NEWBORN

A. THE 8 PRIORITIES OF THE NEW BORN IN THE FIRST DAY OF LIFE
1. Initiation and Maintenance of respiration
2. Establishment of extra uterine circulation
3. Control of body temperature
4. Intake of adequate nourishment
5. Establishment of waste elimination
6. Prevention of infection
7. Establishment of an infant-parent relationship
8. Development care that balances rest and stimulation for mental development
1. Initiation and Maintenance of respiration
Alerts
- Second stage of labor initiate airway
- Initiation of airway is a crucial adjustment among newborn
- Most neonatal deaths with in the first 24 – 48 hours is primarily the inability to initiate airway
- Lung function begins only after birth

How
A. Removal of secretions by proper suctioning

B. Proper Suctioning of catheter

- Place baby’s head to side to facilitate drainage
- Suction nose first because neonates are nasal obligates
- Suction for 5 – 10 seconds and should be gentle and quick because prolong deep suctioning may result to
hypoxia, bradycardia (caused by vagal nerve stimulation) and laryngospasm

C. If not effective, requires effective laryngoscopy to open the airway. After deep suctioning, an endotracheal
tube can be inserted and oxygen can be administered by a positive pressure bag and mask with 100%
oxygen at 40 – 60 b/min.

Nursing Alerts:
- No smoking sign to prevent combustion
- Always humidify to prevent drying of mucosa
- Mask should cover nose and mouth
- Overdosage of oxygen may lead to scaring of retina which may lead to blindness called
RETROLENTAL FIBROPLASIAS (retinopathy of prematurity)
- When meconium stained never administer oxygen because pressure will force meconium to the alveolar sac
and cause atelectasis

2. Establishing extrauterine circulation

Alerts: circulation is initiated by pulmonary ventilation and is completed by cutting of cord

THE FETO-PLACENTAL CIRCULATION

Placenta (via simple diffusion) – oxygenated blood is carried by the vein – liver – Ductus venosus
Inferior vena cava – right atrium – 70% shunted to Foramen ovale - left atrium – mitral valve – left
ventricle – aorta – lower extremities.

The remaining 30% - tricuspid valve – right ventricle – pulmonary artery – lungs (for nutrition) –
vasoconstriction of the lungs pushes the blood to the Ductus arteriosus to aorta to supply the extremities.
The two arteries carry the unoxygenated blood back to the placenta for reoxygenation.

Alerts: Increase pressure on the left side of heart causes closure of foramen ovale

SHUNTS
1. Ductus Venosus – shunt from umbilical vein to inferior vena cava
2. Foramen Ovale – shunt between 2 atria (begin to close within 24 hours)
3. Ductus Arteriosus – shunt from pulmonary artery to aorta (begin to close within 24 hours)
A. 2 Way to facilitate Closure-of Foramen-ovale
1. Tangential foot slap
- So baby will cry to expand lungs
- Never stimulate baby to cry when not yet properly suctioned
- Check characteristics of cry (strong vigorous and lusty cry)
- Cri – du – chat (meow cry)

2. Proper Positioning
- Right side lying
STRUCTURE APPROPRIATE STRUCTURE FAILURE TO CLOSE
TIME OF REMAINING
OBLITERATION
Foramen Ovale 24 hours complete by Fossa Ovalis Atrial Septal Defect
1 year
Ductus Arteriosus 24 hours complete by Ligamentum Patent Ductus
1 month Arteriosum Arteriosus
Ductus Venosus 2 months
Umbilical Arteries 2 – 3 months Ligamentum Venosum
Lateral Umbilical
Ligament
Umbilical Vein 2 – 3 months Inferior Iliac Artery
Lateral Umbilical
Ligament
Inferior Iliac Artery
Ligamentum Teres
(round ligament of
liver)
B. Best position immediately after birth:
NSD – trendelendberg
CS – supine or crib level position

Signs of increase ICP

1. Abnormally large head
2. Bulging and tense fontanel
3. Projectile vomiting (surest sign of cerebral irritation)
4. Increase blood pressure but widening pulse pressure
5. Decrease respiratory rate
6. Decrease pulse rate
7. High pitch shrill cry (late sign)
8. Diplopia (sign of ICP from 6 months – 1 year)

3. Temperature Regulation
Alerts:
- The goal in temperature regulation is to maintain it not less than 97.7 oF – 36.5 oC
- Maintenance of temperature is important for preterm and SGA because it may lead to hypothermia or cold
stress
A. Factors Leading to the development of Hypothermia
1. Preterm are born poikilothermic (cold blooded) they easily adapt to temperature of environment due to
immaturity of thermo regulating system of body
2. Inadequate subcutaneous tissue
3. Newborns are not yet capable of shivering (increase basal metabolism)
4. Babies are born wet
B. Process of Heat Loss
1. Evaporation – body to air
2. Conduction – body to cold solid object
3. Convection – body to cooler surrounding air
4. Radiation – body to cold object not in contact with body

C. Effects of Hypothermia (Cold Stress)

1. Hypoglycemia – due to utilization of glucose (40 – 45 gm/dl is the normal blood sugar of a newborn)
2. Metabolic Acidosis – due to catabolism of brown fats (best insulator of a newborn)
3. High risk for KERNICTERUS (bilirubin in brain)
4. Additional fatigue to already stressful heart

D. Prevention of Cold Stress

1. Dry and wrapped newborns
2. Mechanical measures
- Radiant warmer
- Isolette (square acrylic sided incubator, must be pre heated first)
3. Prevent unnecessary exposure – cover areas not being examined
4. Use tin foil in absence of electricity
5. Embrace baby (called kangaroo care)

4. Establish Adequate Nutritional Intake

Alerts: Breastfeed immediately for NSD and after 4 hours for CS (Colostrum is present on the 3 rd trimester)
A. Physiology of Breast milk Production
- Decrease in level of estrogen and progestin, stimulates the anterior pituitary gland, that
stimulates the prolactin of the acinar cells (alveoli) to produce the foremilk stored in lactiferous
tubules

B. Advantage of Breastfeeding
- Very economical
- Always available
- Promotes bonding
- Helps in rapid involution
- Decrease incidence of breast cancer
- Breast fed babies has higher IQ
- It contains anti body (IgA) lactobacillus bifidus that interfere attack of pathogenic bacteria in GIT
- Contains macrophages (store in plastic container, good for 6 months when stored in freezer)
- Disadvantages of breast milk and cow’s milk
- Both has no iron
- Possibility of transfer of HIV, Hepatitis B
- Father cannot feed or bond as well

C. Stages of Breastmilk
1. Colostrum – available 2 – 4 days after delivery
Contents:
- Low fats
- Low carbohydrates
- High protein
- High immunoglobulin
- High minerals
- High fat-soluble vitamins

2. Transitional – covering 4 – 14 days

Contents:
- High lactose
- High minerals
- High water soluble vitamins

3. Mature milk – 14 days and above

Contents:
- High fats (linoleic acid responsible for integrity of skin and development of skin)
- High carbohydrates (lactose, easily digested, responsible for sour milk smelling odor of stool)
- Low protein (lactalbumin)

D. Cow’s milk
Contents:
- High fats
- Low carbohydrates (add sugar)
- High protein (casein) has a curd that is hard to digest
- High minerals, has traumatic effect on kidneys of baby
- High phosphorus that may cause inverse proportion with calcium

E. Health Teachings
1. Proper Hygiene
- Importance of hand washing
- Removal of caked colostrum
2. Position
- Upright sitting avoid tension to properly empty breast milk
3. Stimulate and evaluate feeding reflexes
a. Rooting
- touch side of lips or cheek and baby will turn to the stimulus
- purpose: to look for food
- disappear at 6 weeks because baby can already focus
b. Sucking
- by touching the middle of lips then baby will suck
- purpose: take in food
- disappear at 6 months
- easily disappear when not stimulated
c. Swallowing
- food touches posterior portion of tongue automatically swallowed
- never disappear cough, gag, sneeze
d. Extrusion/Protrusion reflex
- food touches anterior portion of tongue and tongue automatically extruded/protruded
- purpose: prevent from poisoning
- disappear by 4 months because baby can already spit out
4. The criteria of effective sucking
a. baby’s mouth is hike well up to areola
b. mother experiences after pain
c. other nipple is flowing with milk

5. To prevent from crack nipples and initiate proper production of oxytocin

- begin 2 – 3 minutes per breast
- increase 1 minute per day each breast until you reach 10 minutes each breast or 20 minutes per feeding
6. For proper emptying and continuous milk production per feeding
- feed baby on the last breast that you fed him

PROBLEMS EXPERIENCED IN BREASTFEEDING

a. Engorgement
- soft and non tender (1 day)
- feeling of tension and fullness of breast
- while feeding warm compress
- bottle feeding cold compress and wear supportive bra
b. Sore nipple
- cracked, wet and painful nipple
- exposure to air is the management or 20 watt bulb
- avoid wearing plastic liner bra, instead wear cotton bra
c. Mastitis
- inflammation of breast
- causative factor: staphylococcus aureus
- improper breast emptying
- unhealthy sexual practices
- breast feed on unaffected breast
- express your breast on affected side
- take antibiotic
- increase 500 calories when breastfeeding
- involution of breast is 4 weeks

CONTRAINDICATIONS IN BREASTFEEDING
Maternal Conditions
- HIV, Hepatitis B, CMV, comadin/warfarin sulfate intake

Newborn Conditions
- erythroblastosis fetalis
- hydrops fetalis
- phenylketonuria (PKU)
- galactosemia
- tay-sachs disease

5. Establishment of waste-elimination

A. Different stools
1. Meconium
- Physiologic stool
- Blackish green
- Sticky
- Tar like
- Odorless (because of sterile intestines)
- No bacteria
- Passed with in 24 – 36 hours
- Failure to pass meconium suspect GIT obstruction
a. hirschsprung
b. imperforate anus
c. meconium ileu (cystic fibrosis)

2. Transitional
- Become green, loose and slimy that may appear to be a slight diarrhea to the untrained eye

3. Breastfed stool
- Golden yellow, soft, mushy with sour milk smelling odor frequently passed occurring almost nearly every
feeding

4. Bottle-fed stool
- Light yellow, formed, hard with a typical offensive odor seldom passed 2 – 3 times a day

5. With supplementary foods added

- Brown and odorous

B. Indication of Stool Changes

- Light stool: jaundice baby
- Bright green: phototherapy
- Mucous mixed with stool: allergy
- Clay colored: obstruction to bile duct
- Chalk clay/whitish clay: barium enema
- Black stool: GIT hemorrhage
- Blood flecked: anal fissure
- Curant jelly: intususeption
- Ribbon like: hirschsprung
- Steatorrhea: fatty, bulky, foul smelling – suspect malabsorption a case of cystic fibrosis or celiac
disease

ASSESSMENT FOR WELL-BEING

A. APGAR SCORING
Special Considerations
- Taken on first 1 minute, shows the general condition of baby
- 15 minutes is optional
- Taken again after 5 minutes, to determine baby’s capability to adapt/ adjust extrauterinely
Components
Appearance
- Color: slightly cyanotic, after first cry baby becomes pinkish
Pulse rate
- Apical pulse (left lower nipple)
Grimace
- Reflex irritability (foot slap, catheter insertion)
Activity
- Degree of flexion (muscle tone)
Respiration

APGAR SCORING CHART

Score
Criteria 0 1 2
Heart rate Absent Less than 100 More than 100
Respiratory effort Absent Slow irregular weak Good strong cry
cry
Muscle tone Flaccid extremities Some flexion Well flexed
Reflex irritability
Catheter No response Grimace Cough or sneeze
Tangential Footslap No response Grimace Cry
Color Blue/Pale Acrocyanosis Pink
(body and extremities
blue)

Interpretation of APGAR Result

0-3: severely depressed, need CPR, admission to NICU
4-6: moderately depressed, additional suction and oxygen administration
7-10: good/healthy

CARDIO PULMONARY-RESUSCITATION
Airway (Clear Airway)
1. Shake, no response call for help
2. Place flat on bed
3. Head tilt – chin lift maneuver
- Contraindicated to spinal cord injury
- Over extension may occlude airway
Breathing (Ventilating the lungs)
4. Check for breathlessness
5. Administer 2 rescue breaths
Circulation (by cardiac compression)
6. Check for pulselessness
7. Do CPR (when breathless and pulse less)

B. RESPIRATION EVALUATION
SILVERMAN ANDERSON INDEX CHART
Score
Criteria 0 1 2
Chest movement Synchronized Lag on respiration See saw
Intercostal retraction No retractions Just visible Marked
Xiphoid retraction None Just visible Marked
Nares dilation None Minimal Marked
Expiratory grunt None Stethoscope Naked ear

Interpretation of Result
0 – 3: Normal no respiratory distress syndrome
4 – 6: Moderate RDS
7 – 10: Severe RDS

C. ASSESSMENT OF GESTATIONAL AGE

BALLARD AND DOBOWITZ CLINICAL CRITERIA
Gestational Age (Weeks)
Findings Less THAN 36 37-38 39 and up
Sole creases Anterior transverse Occasional creases in Sole covered with
crease only 2/3 creases
Breast nodule (dm.) 2 mm 4mm or 3 – 5 mm 7 mm – 7.5 mm
Scalp hair Fine and fuzzy Fine and fuzzy Coarse and silky
Ear Lobe Pliable Some Thick
Testes Scrotum Testes and scrotum in Intermediate Testes pendulous,
lower canal, scrotum scrotum full with
is small with few extensive rugae
rugae

PRE TERM BABIES

- 28 – 32 weeks
- Frog leg or lax position
- Hypotonic muscle tone
- Scarf sign (elbow passes the midline)
- Square window wrist (90o angle)
- Heel to ear sign
- Abundant lanugo
- Prominent labia minora and clitoris

Post term Babies

- More than 42 weeks
- Old mans face (classic sign)
- Desquamation (peeling of neonate skin characterized by extreme dryness than begin from sole and palm
within 24 hours

D. Neonate in the Nursery

*Special and Immediate Interventions
1. Upon receiving
- Proper identification (foot print with mothers thumb print)
- Take antropometric measurement

2. Then take anthropometric measurements

a. Length = 19.5 – 21 inches/47.5 – 53.75 cm average of 50 cm
b. Head Circumference = 33 – 35 cm average of 34 cm/13 – 14 inches
c. Chest Circumference = 31 – 33 cm average of 32 cm/12 – 13 inches
d. Abdominal Circumference = 31 – 33 cm average of 32 cm/12 – 13 inches

3. Bathing Baby
- Normal oil bath
- Cleanse and spread vernix
- Babies of HIV positive mothers are given full bath to lessen transmission of infection
- Insulator
- Bacteriostatic
- Full bath is safely given when cord falls

4. Dressing the umbilical cord

- Follow strict asepsis to prevent infection/tetanus
- Use Povidone iodine
- Check for 3 vessels (2 arteries and 1 vein)
- AVA (2 vessel cord suspect kidney malformation)
- Leave about 1 inch of cord
- 8 inches if anticipating IV or BT
- Check for the cord q 15 minutes for the first 6 hours
- For bleeding:
- 30 cc is bleeding to newborn
- Hemophilia is excessive bleeding
- Ompalagia is bleeding of the cord
- Cord turns black on the third day
- Falls by 7th – 10th day
- Failure to fall is umbilical granulation (silver nitrate)
- Use saline to clean

5. Credes Prophylaxis
- Purpose: prevent opthalmia neonatorum (use erythromycine ophthalmic ointment)

6. Administration of Vitamin K
- Action: prevent hemorrhage
- Related to physiologic hypoprothrombinemia
- Give Aquamephyton, phytomenadione, konakoib (.5 – 1.5 mg, IM)

7. Weight-taking
Normal Weight: 3000 – 3400 grams/3 – 3.4 kg/6.5 – 7.5 lbs
Arbitrary Lower Limit: 2500 grams
Low Birth Weight: below 2500 grams
Small for Gestational Age: less 10 percentile rank
Large for Gestational Age: more than 90 percentile rank
Appropriate for Gestational Age: within the 2 standard deviation of the mean
Physiological Weight Loss: 5 – 10 percent occurs a few days after birth

E. PHYSICAL EXAMINATION AND DEVIATIONS FROM THE NORMAL

A. Important Considerations
a. If the client is new born, cover areas that is not being examined
b. If the client is infant, the first vital sign to take is RR (due to fear of stranger)
- Begin at east intrusive to the most intrusive
c. If the client is toddler and preschool, let them handle an instrument play syringe, stethoscope,
d. If the client is school age and adolescent explain procedure
COMPONENTS:
1. Vital signs
- Temperature is taken rectally to rule out imperforate anus and thermometer is inserted 1 inch
- Don’t force insertion because it may lead to pruritus
- Types of imperforate anus
a. Atretic – no anal opening, causing failure to pass meconium
b. Agenetic
- no anal opening, causing failure to pass meconium
- abdominal distention
 - foul smelling stool
- vomitus of fecal materials
- respiratory problems
- Management: surgery with temporary colostomy
c. Membranous

CARDIAC RATE 120-160/min

- Irregular
- Radial pulse is absent, if present suspect PDA

RESPIRATION
- Abnormal/diaphragmatic
- Short period of apnea without cyanosis
- Normal apnea of newborn is less than 15 seconds
Respiration Check
Newborn 40-90 5 years 20-25
1 year 20-40 10 years 17-22
2-3 years 20-30 15 and above 12-20

Breath Sounds Heard on Auscultation

Sound Characteristics
VESICULAR Soft, low pitched, heard over periphery of lungs, inspiration longer
than expiration, normal.

BRONCHOVESICULAR Soft, medium-pitched, heard over major bronchi, inspiration equals

expiration, normal.

BRONCHIAL Loud, high-pitched, heard over trachea, expiration longer than

inspiration, normal.
RHONCHI Snoring sound made by air moving through mucus in bronchi,
normal.
RALES
Crackles (like cellophane) made by air moving through fluid in
alveoli. Abnormal; denotes pneumonia or pulmonary edema which
is fluid in alveoli.
WHEEZING
Whistling on expiration made by air being pushed through narrowed
bronchi. Abnormal; seen on children with asthma or foreign-body
STRIDOR obstruction.

Crowing or rooster like sound made by air being pulled through a

RESONANCE constricted larynx, Abnormal, seen in infants with respiratory
obstruction.
HYPERRESONANCE
Loud, low tone, percussion sound over normal lung tissue.

Louder, lower sound than resonance, a percussion sound over

hyperinflated lung issue.
RESPIRATORY DISTRESS SYNDROME
- Hyaline membrane disease
- Cause: lack of surfactant
- Common in preterm infants
- Hypoxic
- Formation of hyaline
- Causing atelectasis
Signs and Symptoms
- Definite within 4 hours of life
1. Increase RR with retractions (early sign)
2. Expiratory grunting (major sign)
3. Flaring alae nassi
4. Xiphoid retractions
5. Intercoastal retractions
6. Respiratory acidosis

Management
1. Keep head elevated
2. Proper suctioning
- Oxygen administration
- Place on continuous positive airway pressure
- Positive end expiratory pressure (maintain alveoli partially open and prevent collapse)
3. Monitor skin color, vital signs, ABG
4. Surfactant replacement and rescue

LARYNGOTRACHEOBRONCHITIS
- Infection of larynx, trachea and bronchi
Assessment
- Barking cough/croupy cough
- Respiratory acidosis
Laboratory Studies
a. ABG
b. Throat culture
c. CBC
Diagnostic Studies
a. Chest and neck x-ray (to rule out epiglotitis)
Management
a. Bronchodilators
b. Oxygen with increase humidity
c. Prepare tracheostomy set when necessary

Broncholitis
- Inflammation of bronchioles characterized by production of thick tenacious mucous
Signs and Symptoms
- Cold like/flu like symptoms
- Causative agent: respiratory syncitial virus
- Drug: Ribavirin (anti viral drug)
- End stage epiglotitis (emergency condition or URTI), sudden onset
Management
- Tripod position (leaning forward with tongue protrusion)
- Never use tongue depressor
- Prepare tracheostomy set
- Encircle age
- Mist tent “croup tent”, croupette
- Nursing management
a. Check edges if properly tucked
b. Washable plastic material
c. Avoid toys that cause friction and hairy and furry materials

BLOOD PRESSURE

- 80/46 mmHg after 10 days 100/50

- Normal blood pressure taking begins by 3 years old

Alerts
- BP cuff must cover 50 – 75% (2/3) of upper arm
- To large cuff results to false low BP
- To small cuff results to false high BP
SKIN

- Acrocyanosis (body pink extremities blue)

- Generalized mottling due to the immaturity of the circulatory system

BIRTHMARKS
1. Mongolian Spots – slate-gray-or-bluish discoloration/patches commonly seen across he sacrum or
buttocks
- Due to increase melanocytes
- Common in asian newborn
- Disappear by 1 year, preschool, 5 years old
2. Milia – plugged unopened sebaceous gland usually seen as white pinpoint patches on nose, chin and
cheek, disappears by 2 – 4 weeks
3. Lanugo – fine downy hair
4. Desquamation – peeling of the newborn skin within 24 hours, common among post term
5. Stork bites (telengiectasis nevi) – pink patches at the nape of the neck
- Never disappear but is covered by hair
6. Erythema Toxicum (flea bite rash) – first self limiting rash to appear sporadically and
unpredictably as to time and place.
7. Harlequin sign – dependent part is pink, independent part is blue (RBC settles down)
8. Cutis marmorata – transitory motling of neonates skin when exposed to cold
9. Hemangiomas – vascular tumors of the skin
3 TYPES
a. Nevus Flammeus – macular purple or dark red lesions usually seen on the face or thigh
- Portwine stain: never disappear but can be removed surgically
b. Strawberry hemangiomas (nevus vasculosus)– dilated capillaries in the entire dermal or
subdermal area continuing to enlarge but disappear after 10 years old.
c. Cavernous hemangiomas – Consist of communicating network of venules in the
subcutaneous tissue that never disappear with age.
- Dangerous type may lead to internal hemorrhage

10. Vernix Caseosa – white cheese like substance for lubrication; Color of vernix is same as
amniotic fluid

SKIN COLOR AND THEIR SIGNIFICANCE

Blue – cyanosis/ hypoxia
White – edema
Gray – infection
Yellowish – jaundice/ carotinemia (increase carotin)
Pale – anemia
ATOPIC DERMATITIS
- Infantile eczema
- Skin disease characterized by maculo vesicular errythematous lesion with weeping and crusting
- Cause: allergens (main), milk, eggs, citrus juices, tomatoes and wheat
- Characterized by extreme pruritus
- Sign: linear excoriation, lichenified – scaling
Management
- Treat main cause
- Prosorbbee or Isomil (milk)
- Hydrate skin with burrow’s solution
- Prevent infection
- Cut short the nails

IMPETIGO
- Cause: group A beta hemolytic streptococcus
- Characterized by populo vesicular surrounded by localized errythema becoming purulent and ooze
forming a honey colored crust
- Pediculosis capitis (kuto)
- Give oral penicillin
- AGN complication
ACNE
- Self limiting inflammatory disease affects sebaceous glands common in adolescence
- Signs: Comedones (sebum causing white heads)
- Sebum is composed of lipids
Management
- Proper hygiene
- Wash face with soap and water
- Use sulfur soap or mild soap
- Retin A
HEMOLYTIC DISORDER

a. Rh Incompatibility
- Mother negative, fetus positive
- 4th baby affected
- Mother negative, no antigen (no protein factor)
- Erythroblastosis fetalis: hemolysis leading to decrease oxygen carrying capacity with pathologic jaundice
within 24 hours
- Test: Comb’s Test
- Vaccine: Rhogam
- Given to RH negative mother within first 72 hours to destroy fetal RBC therefore preventing antibody
formation
b. ABO Incompatibility
- Mother is type O, fetus is type A, B, AB
- Most common is O, and A
- Severe O and B
- First pregnancy can be affected

Assessment
- Common is Hydrops fetalis, edematous on lethal state with pathologic jaundice within 24 hours
Management
1. Initiation of feeding, temporary suspension of breast feeding to prevent kernikterus
2. Pregnandiole – delays action of glucoronyl transferace (liver enzyme that converts indirect
bilirubin to direct bilirubin)
3. Use of Phototherapy
4. Exchange Transfusion of Rh or ABO affectations that tend to cause continuous decrease in hemoglobin
during the first 6 months because bone marrow fails to produce erythrocytes in response to continuing
hemolysis.

Yellow – Jaundice
Hyperbilirubinemia
- Normal: indirect bilirubin 0 – 3 mg/dl
- More than 12 mg/dl of indirect bilirubin in fullterm
Kernicterus
- Bilirubin encephalopathy more than 20 mg/dl indirect bilirubin in fullterm
- Less than 12 mg/dl in preterm because of immature liver
Physiological Jaundice
- Icterus neonatorum
- 48 – 72 hours
- Expose to sunlight
Pathological Jaundice
- Icterus gravis neonatorum
- Clinical jaundice within 24 hours
Breastfeeding Jaundice
- Pregnandiole
- 6 to 7 days

Assessment
- Blanching the neonates forehead , nose or sternum
- Yellow skin and sclera
- Light stool
- Dark urine
Management
Phototherapy
- Photo oxidation
- Height of 18 – 20 inches away from baby
Nursing Responsibilities
1. Cover the eyes – prevent retinal damage
2. Cover genitals – prevent priapism (painful continuous erection)
3. Change position – for even exposure to light
4. Increase fluid intake – to prevent dehydration
5. Monitor I & O – weigh baby 1 gram:1 cc
6. Monitor Vital Signs
- Avoid use of lotion or oil because it may result to bronze baby syndrome
HEAD
Structures
Sutures: 3
Fontanels: 12 – 18 months close
Anterior fontanel
- Craniostenosis/ craniosinostosis (premature closure of anterior fontanel)
Posterior fontanel
- 1 x 1 cm
- Closes by 2 – 3 months
Microcephaly
- Small/slow growing brain
- Fetal alcohol and HIV positive
Anencephaly
- Absence of cerebral hemisphere

Noticeable Structure of the head

1. Craniotabes
- Localized softening of cranial bones to 1st born child due to early lightening
- Ricketts in older children

2. Caput Succedaneum
- Edema of scalp due to prolonged pressure at birth
- Characteristics
- Present at birth
- Crosses the suture line
- Disappear after 2 – 3 days

3. Cephalhematoma
- Collection of blood due to rupture of periostial capillaries
- Characteristics
- Present after 24 hours
- Never cross the suture line
- Disappear after 4 – 6 weeks

4. Seborrheic Dermatitis
- Cradle cap
- Scaling, greasy appearing salmon colored patches usually seen on scalp, behind ears and umbilicus
- Primary cause: improper hygiene
- Management: proper hygiene, apply oil the night before shampooing (use baby oil or coconut oil)

5. Hydrocephalus
- Collection of CSF
2 types
a. Communicating – extra ventricular hydrocephalus
b. Non communicating – intra ventricular hydrocephalus also called obstructive
Signs and Symptoms
- Sign of increase ICP
- Sign of frontal bossing (prominent forehead)
- Prominent scalp vein
- Sunset eyes
Therapeutic Management
- Place client in low semi fowlers position (30o)
- Osmotic diuretic
- Diamox (Acetazolamide) to decrease CSF production
- Seizure precaution
- Surgery (AV shunt, VP shunt)
- Shave just before surgery
- Place in side lying position on non operated side
- Monitor for good drainage
- Sunken fontanel is a good sign
- Mental retardation depend on extent of hydrocephalus
SENSES

Sense of Hearing (Ears)

- First to develop and last sense to disappear
- Properly aligned to outer canthus of eye
OTITIS MEDIA
- Inflammation of middle ear, common in children due to wider and shorter Eustachian tube
- Common with cleft lip and palate
- Bottle propping, may also result to dental caries
- Otoscopic: bulging tympanic membrane and absence of light reflex
- Observe for passage of milky, purulent and foul smelling odor discharge
- Observe for URTI
Management
- Side lying on affected side to facilitate drainage
- Supportive care (TSB, antipyretic)
- Massive dosage of antibiotic (may lead to bacterial meningitis)
- Apply ear ointment
a. below 3 years down and back
b. above 3 years up and back
- Mucolytics to shrink mucous
- Myringotomy: surgical procedure done by making a slight incision of the tympanic membrane
- Place client on the operated side
- To prevent permanent hearing loss
MOUTH AND TONGUE

CLEFT LIP
- Failure of the median maxillary nasal processes to fuse by 5 – 8 weeks of pregnancy
- Common in boys
- Can be unilateral or bilateral
CLEFT PALATE
- Failure of the palate to fuse by 9 – 12 weeks of pregnancy
- Common in girls
Signs and Symptoms
a. Evident at birth
b. Ultrasound/3 dimensional UTZ
c. Milk escape to the nostril
d. Common URTI (otitis, cholic)

Therapeutic Management
- Surgery
- Cleft lip: cheiloplasty done as early as 1 – 3 months to save sucking reflex
- Cleft palate: uranoplasty done 4 – 6 months to save speech

Nursing Responsibility
(Pre Op)
- Emotional support
- Proper nutrition
- Use Rubber tipped medicine dropper
- Prevention of cholic
a. Feed upright position
b. Burp twice
c. Prone position/on abdomen
- Orient parents to feeding technique
Cleft Lip
- Use rubber tipped syringe
Cleft Palate
- Use paper cup, plastic cup, soup spoon
- Use elbow restraints (pre op)
- So baby can easily adjust post op
(Post Op)
- Maintenance of airway
- Side lying (cheiloplasty)
- Prone (uranoplasty)
- Facilitate drainage
- Monitor for developing RDS
- Proper nutrition
- NPO 4 hours post op
- Check for colds or nasopharyngitis
- May cause septicemia
- Begin with clear liquid
- Observe for signs of hemorrhage (frequent swallowing)
- Usually happens 6 – 7 days post op
- Protect site of operation
- Maintain integrity of logan bar
a. Half strength hydrogen peroxide and saline
b. Prevent baby from crying
c. Prevent cholic
d. Check for wet diaper
GASTROINTESTINAL SYSTEM

INBORN ERRORS OF METABOLISM

- Deficient liver enzyme
PHENYLKETONURIA
- Deficiency of liver PHT (Phenylalanine Hydroylase Transferase)
- No tyrosine, melanin, tyroxine – basal metabolism

Signs and Symptoms

- Fair skin
- Blonde hair
- Blue eyes
- Accumulation of phenyl pyrobic acid in the blood
- Musty or mousy odor urine
- Atopic dermatitis
- Seizure
- Mental retardation
Diagnostic Tests
a. Guthrie test
Management
- Low phenylalanine indefinitely
- No food rich in protein (chicken, eggs, meat, legumes, peanut)
- Lofenalac = milk form for PKU
NEUROMUSCULAR SYSTEM
Reflexes
a. Blink reflex – rapid eyelid closure when strong light is shown

b. Palmar grasp reflex – solid object is placed on palm and baby grasp object
- Purpose: cling to mother for safety (disappear by 6 weeks – 2 months)

c. Step in/Walk-in Place Reflex – neonate placed on a vertical position with their face
touching a hard surface will take few quick, alternating steps.
- Placing Reflex: almost the same with step in place reflex only that you are touching anterior
surface of a newborn’s leg.
d. Plantar grasp reflex – when an object touches the sole of a newborn’s foot at the base of
toes, the toes grasp in the same manner as fingers do (disappear by 8 – 9 months in
preparation for walking)

e. Tonic-neck-reflex – when newborns lie on their backs, their heads usually turn to one side
or the other. The arm and the leg on the side to which the head turns extend, and the opposite
arm and leg contract.

f. Moro reflex – test for neurological integrity (jarring crib, loud voice) assume a letter C
position (disappear by 4 – 5 months)

g. Magnet reflex – when there is pressure at the sole of the foot he pushes back against the
pressure.

h. Crossed extension reflex – when the sole of foot is stimulated by a sharp object, it causes
the foot to rise and the other foot extend (test for spinal cord integrity)

i. Truck Incurvation reflex – while in prone position and the paravertical area is stimulated, it
causes flexion of the trunk and swing his pelvis toward the touch.

j. Landau reflex – while prone position and the trunk is being supported, the baby exhibit some
muscle tone (test for muscle tone and present by 6 – 9 months)

k. Parachute reaction – while on ventral suspension with the sudden change of equilibrium, it
causes extension of the hands and legs (present by 6 – 9 months)
l. Babinski reflex – when the sole of foot is stimulated by an inverted “J”, it causes fanning of
toes (disappear by 2 months but may persist up to 2 years)