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CARE OF VULNERABLE GROUPS OF PREGNANT WOMEN  Endocrine disorders (pituitary & adrenal)  Severe heart disease = symptoms can occur at the very beginning of
 Chronic renal diseases with repeated UTI & bacteriuria pregnancy
HIGH RISK PREGNANCY  Chronic hypertension  Woman w/ CV dss should begin prenatal care as soon as she
 a concurrent disorder, pregnancy-related complication or external  Venereal & other infectious diseases suspects that she is pregnanct (1 wk after 1 st missed menstrual
factor jeopardizes the health of the woman, the fetus or both.  Major congenital anomalies of the reproductive tract period or positive home pregnancy test)
 Hemoglobinopathy  Towards end of pregnancy, heart may become so overwhelmed by
1. Demographic Factors  Seizure disorders the increase in blood vol that cardiac output fall to the point vital
 Age  Malignancy organs (inc placenta) can no longer be perfused adequately =>
 Under 16 or over 35 years old  Major Emotional Disorders oxygen & nutritional requirements of cells & fetus are not met
 Optimal age for child-bearing = 20-30 yo  Retardations
 Weight - over/underweight before pregnancy 6. Habituation LEFT-SIDED HEART FAILURE
 Height - less than 5 feet  Smoking during pregnancy
2. Socioeconomic Status  Taking alcohol
 PULMONARY or respiratory
 Inadequate finance  Drug use/abuse
 Most common
 Overcrowding; poor standards of housing
 Mitral stenosis, mitral insufficiency, aortic coarctation
 Poor hygiene Assessment
 LV cannot move the large vol of blood forward that it has received
 Nutritional deprivation 1. Health History
by the LA from the pulmonary circulation
 Severe social problems 2. Determine if the client belongs to the vulnerable grp
 Limited 02 exchange
 Unplanned & unprepared pregnancy (esp among adolescents; root  Unemployed, marginalized, poor educational background, single or
 High risk for
of this problem = poverty & low educational status) separated mothers
 MISCARRIAGE, PRETERM LABOR, OR MATERNAL DEATH
3. Obstetric History 3. Physical Assessment
 SERIAL UTZ & NST = 30-32 weeks to monitor fetal health & rule out
 History of infertility or multiple gestation  Weight, V/S, fundal height = 12 weeks AOG
poor placental perfusion
 Grand multiparity  Pelvic examinations and systemic examinations
 Previous abortion or ectopic pregnancy 4. Laboratory Assessment
 Previous losses s/a fetal death, stillbirth, neonatal or perinatal  CBC Back pressure
deaths  Blood Typing  Occurs due to LHF
 Previous operative obstetrics:  Alpha-feto protein - check for neural tube defect or abdominal  Left side of the heart becomes distended
 CS, forceps delivery defect in fetus  Systemic BP decreases in the face of lowered CO
 Previous uterine or cervical abnormality  Hb surface antigen  Pulmonary hypertension
 Previous abnormal labor (Pre/post-mature labor or  Hepatits B
prolonged)  Gonorrhea culture & syphilis screening Pulmonary edema
 Previous high-risk infants (LBW, macrosomic or LGA infants w/  Rubella titer  Pressure in pulmonary vein reaches 25 MMHG, fluid passes from
neurological deficit, birth injury, or malformation)  Papanicolau smear - done during initial prenatal exam to screen for the pulmonary capillary membranes into the interstitial space
 Previous hydatidiform mole cervical neoplasia or possible sexually transmitted infections surrounding lung alveoli and then into alveoli
 Root of this problem: poverty & low educational status  Prod profound SOB bec it interferes w/ O2-CO2 exchange
4. Current OB Status PREGESTATIONAL CONDITIONS  Productive cough w/ blood-speckled sputum: If pulmo capillaries
 Late or no prenatal care at all rupture under pressure & small amts of blood leak into alveoli
 Maternal anemia
 RH sensitization Cardiac Disease Orthopnea
 Antepartal bleeding (Placenta previa, Abruptio placenta)  Pregnancy taxes the circulatory system of every woman even  Severe pulmo edema => Can’t sleep in any position except w/ head
 Pregnancy-induced hypertension without cardiac disease because both the blood volume & cardiac & chest elevated w/c allows fluid to settle in the bottom of lungs & frees
 Multiple gestation output increases approximately 30%. Half of this increase occurs by space for gas exchange
 Pre/Postmature labor 8 weeks. It is maximized by mid-pregnancy.
 Polyhydramnios  The danger of pregnancy in women with cardiac disease occurs Paroxysmal nocturnal dyspnea
 Premature rupture of membrane (PROM) primarily because of the increase in circulatory volume.  Suddenly waking @ night w/ SOB
 Fetus inappropriately large or small  The most dangerous time for a woman is in weeks 28-32, just after  Heart action is more effective @ rest so interstitial fluid returns to
 Abnormality in tests for fetal well-being the blood volume peaks. the circulation w/c overburdens circulation and increases left-side
 Abnormality in presentation  As the number of women delaying their first pregnancy until laterin heart failure & pulmonary edema
5. Maternal Medical History life increases, there is an increase in the incidence of CAD &
 Cardiac or pulmonary diseases of the mother varicosities in pregnancy RIGHT-SIDED HEART FAILURE
 Metabolic diseases such as diabetes mellitus or thyroid diseases  CIRCULATORY or systemic
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 RV is overwhelmed by the amount of blood received by the RA from 5. Large quantities of fluid excrete with urine (POLYURIA)
the vena cava Maternal Assessment 6. Dehydration begins to occur = blood serum becomes concentrated &
 Caused by an unrepaired congenital heart defect  Innocent edema of pregnancy = only feet & ankles total blood vol decreases
 Eisenmenger syndrome: Right-to-left atrial or ventricular septal  Edema of PIH or heart failure also begins same w/ normal 7. Reduced blood flow = cells don’t receive adequate O2
defect w/ accompanying pulmonary valve stenosis  Edema of PIH = begins after week 20 of pregnancy 8. Anaerobic metabolic reactions = large stores of lactic acid pour out of
 Back pressure from this results to congestion of systemic venous  If edema is a sign of heart failure = can begin any time w/ irregular muscles into the bloodstream
circulation & decreased CO to lungs pulse, rapid/difficult respirations, and chest pain on exertion 9. To replace needed glucose, fat is mobilized from fat stores &
 Need a pulmonary artery catheter inserted to monitor pulmonary  Record baseline BP, RR, PR in either sitting or lying position @ 1 st metabolized for energy = large amts of acidic ketone bodies pour into the
pressure prenatal visit & at future visits; obtain these at the same position blood stream
 Close monitoring after epidural anesthesia to minimize risk of  Comparison assessment for nail bed filling (<5 secs) and jugular 10. Protein stores are tapped as a final attempt to find a source of energy
hypotension venous distention = reduces amt of protein supply to cells
 BP decreases in aorta bec less blood is able to reach it; High  RHF = assess liver size but liver assessment may be difficult & 11. Cells die = it releases potassium & sodium w/c is lost from the body in
pressure in vena cava from back pressure blood inaccurate late in pregnancy bec the enlarged uterus presses the the extensive polyuria = immediate severe metabolic acidosis
 jugular venous distention & increased portal circulation liver upward under the ribs & is difficult to palpate 12. Long term effects = vascular narrowing w/c leads to kidney, heart, and
 Distended liver & spleen  Additional cardiac status assessment = Electrocardiogram or Chest retinal dysfunction
 Extreme liver enlargement: Dyspnea & pain bec liver is pressed radiograph/echocardiogram @ periodic points
upward by the enlarged uterus & putting pressure on the  ECG measures cardiac electrical discharge; assure Type 1 Diabetes: autoimmune; marker antibodies present; pancreas fails
diaphragm woman that it can’t harm the fetus to prod adequate insulin for body requirements
 Distention of abd & lower extremity vessel: Exudate of fluid from  Echocardiogram uses UTZ = not harmful
the vessels into the peritoneal cavity/ascites or peripheral edema Type 2 Diabetes: gradual loss of insulin prod; some ability to prod insulin
 Fluid moves from systemic circulation into the lower extremity Fetal Assessment will still be present
interstitial spaces or PERIPHERAL EDEMA  Fetal health compromised when maternal blood pressure becomes
 Advised not to become pregnant insufficient to provide an adequate supply of blood & nutrients to Diabetes during Pregnancy
 If pregnancy is planned, they should expect to be hospitalized the placenta  IN ALL PREGNANCIES:
during the last part of pregnancy  LBW or SGA bec of poor gas exchange and nutrients  Glomerular filtration of glucose is increased = massive
 Need O2 admin & frequent ABG assessment to ensure fetal  Preterm labor = exposes NB to hazards of immaturity glycosuria and polyuria
growth  Placenta not filling well = fetus may not respond well to labor (late  glomerular excretion threshold is lowered
 LABOR = need pulmonary artery catheter inserted to monitor deceleration patterns on FH monitor) and cesarean birth (increased  Rate of insulin secretion is increased
pulmonary pressure risk for mother & fetus)  Fasting blood sugar level is lowered
 Need extremely close monitoring after epidural anesthesia to  Develop insulin resistance as pregnancy progresses or insulin
minimize risk of hypotension DIABETES MELLITUS is not as effective due to presence of hormone human placental
 Chronic metabolic disorder characterized by a deficient insulin lactogen (chorionic somatomammotropin) and high lvls of cortisol,
New York Heart Association Functional Classification of Heart Failure production by the islet of Langerhans = improper metabolic estrogen, progesterone, & catecholamines
 Categorizes patients based on what they are limited based on their interaction of carbs, fats, proteins and insulin  Resistance to insulin prevents the maternal blood glucose from falling
physical activity  May be concurrent in pregnancy or occur only in to dangerous limits
 Ask about level of exercise performed, what lvl she can do before going pregnancy(Gestational Diabetes Mellitus)  Pregnant women w/ Diabetes must increase insulin dosage beginning
short of breath, and what physical symptoms she experiences s/a  Endocrine disorder; pancreas can’t produce adequate insulin to wk 24 of pregnancy to prevent hyperglycemia
cyanosis of the lips or nail beds regulate body glucose levels  Guard against hypoglycemia & ketoacidosis due to the constant use of
 Ask if she normally has cough or edema; instruct women w/ cardiac dss glucose by the fetus
to always report coughing during pregnancy bec pulmonary edema Pathophysiology & Clinical Manifestations  Preexisting kidney disease (proteinuria, decreased creatinine clearance,
from heart failure may first manifest as a simple cough  Primary concern: controlling the balance bet insulin & blood glucose & hypertension) = increased risk for hypertension
Class I levels to prevent hyperglycemia or hypoglycemia
 No limitations of physical activity; no heart failure symptoms Risk Factors
Class II 1. If insulin production is insufficient, glucose cannot be used by body cells 1. Family History
 Mild limitation of physical activity; heart failure symptoms w/ 2. Cells register the need for glucose, & liver quickly converts stored 2. Rapid hormonal change in pregnancy
significant exertion; comfortable at rest or w/ mild activity glycogen to glucose to increase serum glucose level 3. Tumor/infection of the pancreas
Class III 3. Insulin is not available so body cells cannot use the glucose, then serum 4. Obesity & stress
 Marked limitation of physical activity; heart failure symptoms w/ glucose levels rise (HYPERGLYCEMIA)
mild exertion; only comfortable at rest 4. If lvl of blood glucose reaches 150 mg/100 ml, kidneys begin to excrete Effects of Diabetes Mellitus to MOTHER
Class IV quantities of glucose in the urine to lower the level (GLYCOSURIA) 1. Infertility
 Discomfort w/ any activity; heart failure symptoms occur at rest **normal level = 80-120 mg/dl 2. Spontaneous Abortion
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3. PIH 8 hrs Fasting 95 mg/dL  Needs for insulin may be tripled in the 3 rd trimester due to
4. Infections 1 hour 180 mg/dL increased tendency for ketoacidosis
 Moniliasis; UTI 2 hours 155 mg/dL  Regular NPH insulin
5. Uteroplacental insufficiency 3 hours 140 mg/dL  Regular insulin @ labor bec long acting insulin is not enough to
6. Premature labor **following a 100 g glucose lead; rate is abnormal if 2 VALUES are prevent ketoacidosis (glucose lvls >300 mg per 100 ml & ketones in
7. Dystocia - difficulty in labor exceeded blood
8. Uncontrolled Diabetes Mellitus - If high risk = end of 1 st trimester or 12 weeks  Rapid acting regular insulin intravenously & IV glucose infusion in
 Hypoglycemia or Hyperglycemia - if not high risk = routine @ 24-28 weeks LABOR
9. Cesarean section indicated 2. Oral Glucose Tolerance Test  Frequent monitoring, adjustment, and additionally boluses as
10. Uterine Atony - lead to PPH  Having 2 of 4 abnormal result & with fasting value above 95 needed
mg/dl => GDM  Infection = stressor = hyperglycemia = increase need for insulin
Effects of Diabetes Mellitus to BABY  Fasting blood glucose 4. Serial UTZ
1. Congenital anomalies - Caudal regression syndrome (failure of lower  100g oral glucose; venous blood sample taken after 1,2, and 3  for fetal growth evaluation & fetal surveillance testing (28-34 weeks
extremities to develop), spontaneous miscarriage, & stillbirth hours gestation; earlier than 26 wks AOG if with additional complications)
2. Polyhydramnios - due to high glucose conc w/c causes extra fluid to 3. Glycosylated Hemoglobin (HbA1C) 5. Provide teaching on s/s of hypoglycemia & hyperglycemia; regular
shift & enlarge the amount of amniotic fluid  Measure of the amt of glucose attached to hemoglobin; to exercise; self-administration of insulin & prompt reporting of danger s/s of
3. Macrosomia (LGA) - >10lb; due to increased insulin that the fetus must detect degree of hyperglycemia present infection
prod to counteract the overload of glucose fetus receives <= acts as a  Reflects the ave blood glucose level over the past 4-6 weeks (the 6. Teach px on infection prevention & stress mgmt
growth stimulant; create problems @ end of pregnancy due to CPD; ha s time the hgb in rbc were picking up the glucose)  Infection is considered a stressor; stress can cause hyperglycemia &
increased risk for shoulder dystocia => CS birth  Upper normal lvl of HbA1c = 6% of total hemoglobin increase the need for insulin.
4. Fetal hypoxia leading to IUFD & stillbirths  Measures long term, up to 3 months, of compliance to treatment  Effects of pregnancy on DM, effects of DM on pregnancy,
5. Neonatal hypoglycemia - common 1 hr after birth  Normal = 4-8% of total hemoglobin = increases during 7. Continued monitoring on mother & fetus during intra-partal period
6. Prematurity hyperglycemia  Electronic fetal monitoring
7. RDS - 6 th hr after birth  Position mother to LLR to prevent supine hypotensive
8. Hypocalcemia Medical Management syndrome
1. Insulin Requirement: (Regular & NPH)  Fluid & electrolyte imbalance = D5 water is needed to
 Insulin resistance = PIH, microvascular changes s/a necropathy &  1 st trimester - stable dose maintain glucose
retinopathy, macrovascular changes s/a heart problems & candidal  2 nd trimester - rapid increase due to increase secretion of HPL  Reg insulin added to IV of 5-10% D5W titrated to maintain
infections  3 rd trimester - rapid increase due to the need glucose bet 100-150 mg/dL
 Insulin shock & ketoacidosis are common  Labor - IV regular insulin 8. Monitor maternal need for postpartal insulin
 N/V = predisposes to ketoacidosis  Postpartum - rapid decrease to pre-pregnancy level; may not need  Increased insulin resistance occuring in pregnancy is usually
insulin in the 1 st 24 hrs postpartum esp if client was placed in a long resolved a few hrs after delivery that IV insulin is usually
Diabetes Mellitus Type 1 Signs & Symptoms NPO discontinued @ time of delivery
1. Polyuria - Increased urination 2. Early labor induction or CS section  Short decline in insulin requirement during the 1 st 24 hrs necessates
2. Polydipsia - increased thirst  Especially if fetus is macrosomic monitoring of insulin dose w/c is titrated to measured blood
3. Polyphagia - increased hunger glucose level in the immediate postpartum period
4. Weight loss Nursing Management  Decreased insulin need to 1/2 or 2/3 pregnant dose on 1 st
5. Fatigue 1. Early detection & regular prenatal visits postpartum day if on full diet
6. Increased frequency of infection  History taking, symptomatology, and prenatal screening 9. Encourage breastfeeding
7. Rapid onset  Encourage early prenatal mgmt & supervision  Has anti-diabetogenic effect
8. Insulin dependent 2. Dietary modification: 1800-2000 kcal/day  Hypoglycemia raises adrenaline level resulting in decreased milk
9. Familial tendency  Carbs: 200 mg per day supply & letdown reflex
10. Peak incidence from 10-15 years  Protein: 70 g daily  Prevent complications in postpartum s/a infections & hemorrhag,
 Unsaturated fats & regular time in taking food insulin shock or hypoglycemia (sweating w/ cold clammy skin, pallor,
 Monitor maternal blood glucose levels several times daily tremors, hunger)
Diagnostic Tests  Maintaining maternal glucose w/in normal range during prenatal&  Hypoglycemic shock usually occurs @ time of peak action of
1. Oral Glucose Challenge Test intranatal period is important to prevent stimulation of fetal insulin
 24-28 wks AOG pancreas w/c results to fetal or neonatal hypoglycemia  Regular insulin = peak action 2-4hrs after admin
 50g oral glucose  Cornerstone of DM mgmt and control 10. Hospitalization for poorly controlled Diabetes & concominant
 Finding: plasma glucose of >140 mg/dl = perform OGTT  Promote adherence to dietary mgmt hypertension & treatment of infection
Test Type Pregnant Glucose LEvel (mg/dL) 3. Insulin administration
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11. Early induction of labor and CS section in the presence of fetal distress  Symptoms first appear in childhood  Marked thrombocytopenia = 20,000/mm3
may be indicated  Treatment focuses on combating anemia thru folic acid  Prone to frequent nosebleeds, minute petechiae, large ecchymoses
12. Delivery timing is individualized & ideally occurs around term supplementation & blood transfusion to infuse hemoglobin-rich  1-3 month limited course
 Macrosomia = CPD; induction of labor @ 36-37 weeks; depending RBC  Assoc w/ HELLP Syndrome
on utz monitoring of fetal size & evidence of pulmonary maturity  Should not take iron supplement during pregnancy bec they could  Hemolysis, elevated liver enzymes, low platelet count
13. Postpartum induced hypertension = monitor BP receive an iron overload bec iron is infused w/ BT  Antiplatelet factor can cross placenta w/c causes platelet
14. Encourage to have 1 hr OGTT @ 6-8 wks postpartum to ensure return destruction in NB or NB is born w/ the illness
to normal glycemia Malaria
15. Encourage contraception; enforce physician’s orders for any family  Protozoan infection transmitted to people by female Anopheles Maternal serum analysis
planning method mosquitoes  Detect if fetus has coagulation disorder during pregnancy
 Causes RBC to stick to the surface capillaries causing obstruction of  Determine if fetus has coagulation defect before internal FHR
HEMATOLOGIC DISEASE these vessels w/c results in end-organ anoxia & blood not reaching monitor or fetal scalp blood sampling is done (CI = cause extensive
True Anemia organs effectively fetal blood loss)
 Less than 11 g/dl or hematocrit less than 33% during 1st & 3rd  Can be transmitted to fetus; high risk for blood clotting
trimester  Incubation Period: 12-14 days RENAL & URINARY DISESASES
 Less than 10.5 g/dl or hematocrit less than 32% during 2nd  S/S: fever, malaise, headache
trimester  Altered blood cells, thrombocytopenia (low PLT count), anemia, Urinary Tract Infection
Pseudoanemia renal failure  Ureters dilate from the effect of progesterone so stasis of urine
 blood vol expands slightly ahead of red cell count in pregnancy  Prevented by wearing clothing w/c covers most of the body, using occurs + abnormal amts of glucose in the urine (glycosuria) that
 Experienced by most women in pregnancy insect repellent, sleeping @ night w/ mosquito net, keeping occurs w/ pregnancy provides an ideal med for growth for any
 Physiologic anemia of pregnancy is considered hemodilutional = windows closed, delay travel to endemic areas organism present
increase in blood volume 30%-50% higher before labor causing  Treatment: Antimalarial drugs  Asymptomatic infections are dangerous bec it can progress to
disproportionate increase in blood volume & blood cells =  Stop the course of the dss & reduce incidence of LBW & pyelonephritis (infection of the pelvis of the kidney or renal pelvis)
physiologic anemia preterm birth w/c is assoc w/ preterm labor & PROM
 Vesicourethral reflux - backflow of urine into the ureters; more
Iron Deficiency Anemia COAGULATION DISORDERS prone to UTI & pyelonephritis
 Most common anemia in pregnancy **all inherited blood disorders  Organism responsible: Escherichia coli from an ascending infection;
 Due to a diet low in iron, heavy menstrual periods, or unwise 1. von Willebrand disease most commonly responsible organism
weight reducing programs  Inherited as an autosomal dominant trait  May also begin as descending infection w/c begins in the kidneys
 Iron stores are also low in women who were pregnant <2 years  Normal platelet count but bleeding time is prolonged from the filtration of organisms present from other body infections
before the current pregnancy or those from low socioeconomic  Reduced lvl of factor VIII-related antigen (VIII-R) & factor VIII  Streptococcus B present = obtain vaginal culture bec this infection
levels who have not had iron-rich diets coagulation activity (VIII-C) of the genitla tractis assoc w/ pneumonia in NB
 Hemoglobin <12 mg/dl = iron deficiency is suspected  Menorrhagia or frequent episodes of epistaxis noticed as a child
 Can go undiagnosed until pregnancy when woman experiences Signs & Symptoms & Assessment:
Iron Supplementation spontaneous miscarriage or PPH  Frequency & pain on urination
 60 mg/day for healthy pregnant women  Replacement of missing coagulation factors by infusion of  Pyelonephritis = pain in lumber region usually in right side w/c
 120-200 mg/day if diagnosed w/ IDA cryoprecipitate or fresh frozen plasma before labor = PREVENT radiates downward & tender upon palpation
 Best absorbed in acid medium - w/ orange juice or vit C supplement EXCESSIVE BLEEDING W/ BIRTH  N/V, malaise, pain
(supplies ascorbic acid) 2. Hemophilia B  Temp may be elevated slightly or 39-40C
 May have constipation & gastric irritation  Christmas disease or factor IX deficiency  ** infection usually starts @ the R side bec there is greater
 Increase roughage in diet  Sex-linked disorder compression & urinary stasis on the R ureter from the uterus
 Take pills w/ food  Only in males but female carriers may have a reduced level of factor being pushed that way by the large bulk of the intestine on
 Turns stool black IX that hemorrhage w/ labor or spontaneous miscarriage can be a the L side
serious complication  Urine culture = 100,000 organisms per ml of urine
Folic Acid Deficiency  Carriers should be identified before pregnancy
 Anemia common in multiple gestation because of increased fetal  Infusion of factor IX concentrate or fresh frozen plasma Medical mgmt:
demand 3. Idiopathic thrombocytopenic purpura  Antibiotic
 Decreased num of platelets; not inherited; any time in life  Amoxicillin, ampicillon, cephalosporins
Thalassemia  Occasionally occur during pregnancy; cause is unknown - safe antibiotics during pregnancy; effective against most
 Group of autosomal recessively inherited blood disorders that lead  Symptoms occur shortly after viral invasion; autoimmune rxn organisms causing UTI; should be ordered by the doctor
to poor hemoglobin formation & severe anemia  Normal PLT count = 150,000/mm3
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 Sulfonamides - used early in pregnancy but not near term bec SUBSTANCE ABUSE 2. Diabetes Mellitus
they can interfere w/ protein binding of bilirubin w/c leads to  Misuse or overuse of substances which interferes w/ organogenesis 3. Substance Abuse
hyperbilirubinemia in NB esp during the 1 st trimester 4. HIV/AIDS
 Tetracyclines - C/I in pregnancy as they case retardation of bone 5. Rh sensitization
growth & staining of fetal teeth Assessment findings: 6. Anemia
 Obtain clean-catch urine sample for culture & sensitivity from  Parental neglect GESTATIONAL CONDITIONS
women w/ possible symptoms of UTI  Malnutrition
 Sensitivity test after a culture will determine w/c antibiotic will best  Presence of other infectious dss or STIs HYPEREMESIS GRAVIDARUM
combat the infection  Prolonged nausea & vomiting past 16th week of pregnancy
Management  Unknown cause
 Therapy depending on substance used  Pernicious or persistence vomiting
Nursing considerations:  Counseling & rehabilitation  May be so severe that dehydration, ketonuria, and significant
 Void frequently at least q2h weight loss occur within 1 st 12 weeks of pregnancy
 Wipe front to back after voiding & bowel mvmts
 Wear cotton & not synthetic fiber underwear  Increase in thyroid function because of thyroid stimulating
 Void immediately after sexual intercourse INFECTIOUS DISEASES properties of HCG
 Increase oral fluids - Give a specific amount to drink everyday 1. Hepatitis B  Associated with Helicobacter pylori (same bacteria that causes
up to 3-4 L for 24 hours and do not only simply tell her to  Caused by Hepatitis B virus w/c is transmitted thru blood & body peptic ulcers)
drink more water; to flush out infections in the urinary fluids  Can no longer provide nutrients for growth of fetus if left untreated
tract  Acute infection affects permanent liver damage or carcinoma
 Assume knee-chest position for 15 mins morning & evening;  In pregnancy there could be a possible mother to infant Signs & Symptoms
weight of uterus shifts forward w/c releases the pressure transmission  Severe weight loss due to severe N/V - cannot maintain usual
on the ureter & allowing urine to drain more freely  Transplacental transmission - cause spontaneous abortion or nutrition
 Ensure compliance of antibiotic treatment preterm labor  Ketonuria - Urine test is positive for ketones due to the breakdown
 Intranatal & postanatal part = transmission thru contaminated of stored fat and protein for cell growth
RESPIRATORY DISEASES surface & breastmilk/colostrum  Elevated hematocrit concentration - Inability to retain fluid has
 Range from mild (common cold) to severe (pneumonia) to chronic  Hep B immunoglobulin & 1 st of the 3 injections of Hepatitis B resulted in hemoconcentration;may lead to thromboembolism
(TB or COPD) vaccine before discharge from the hospital  Dehydration - if left untreated
 Any respiratory condition can worsen in pregnancy because the  Electrolyte imbalance - Concentration of sodium, potassium, &
rising uterus compresses the diaphragm, reducing the size of the 2. HIV - AIDS chloride may be reduced because of a woman’s low intake
thoracic cavity & available lung space.  Caused by retrovirus, human immunodeficiency virus or HIV that  Hypokalemic alkalosis may develop from loss of hydrochloric acid
 Any respiratory disorder can pose serious hazards to the fetus if infects helper T lymphocytes and presents in infected person’s from the stomach
allowed to progress to the point where the mother’s oxygen-carbon blood, semen, and other body fluids  Ataxia and confusion - due to vit B1/thiamine deficiency
dioxide exchange is compromised.  Sexual contact, contaminated blood & blood products, placental
transfer thru breastmilk Medical Management
Nursing considerations:  Proper precautions to prevent transmitting it from person to baby  Need to be hospitalized for 24 hrs to document & monitor I&O, and
 Rest & sleep or baby to person blood chemistries and to restore hydration
 Foods rich in vit C - orange juice & fruits to boost immune  Standard precaution:  IV hydration - PLR w/ added vit B1
system  wear gloves to prevent transmission of blood borne infections;  NPO - 1 st 24 hrs
 Room humidifier - esp @ night to moisten nasal secretions & change gloves between patient  Antiemetic - Metoclopramide (Reglan); Pregnancy Class B category;
help mucous drain  fluid-resistant gown, mask & goggles, face shield in all to control vomiting
 Antibiotic (Category A) - check w/ health care provider for situations in w/c splashing of bodily fluids is likely
OTC meds such as cough drops  Wear gown & gloves when handling NB until after a full bath Nursing Management
 Oxygen therapy - severe disease, ventilation to remove all blood and amniotic fluid  Taper diet from NPO to clear fluids then small quantities of dry
 Keep away from allergens  No mouth to mouth contact during resuscitation & suctioning, toast, crackers or cereal
 Nebulization use protective equipment  If there is no vomiting after the 1 st 24 hrs of NPO, small
 TB: R-I-E - Rifampacin/Rifampin, Isoniazid, Ethambutol;  No breastfeeding amounts of clear fluid can be started 7 can be discharge w/
nonteratogenic  Diagnosed based in criteria and positive HIV antibody test or ELISA referral for home care
 If she can continue taking clear fluid w/o vomiting, small
PREGESTATIONAL CONDITIONS quantities of dry toast, crackers or cereal can be added
1. Rheumatic heart disease q2-3hrs
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 Soft diet to regular diet afterwards  Shock or circulatory collapse  History of abortion
 Monitor I/O  Sharp localized pain when cervix is touched  History of Clomiphene therapy
 Provide pleasant & small portions of food  Used to induce ovulation
 Monitor amt of vomitus & degree of hydration Laboratory  Drug for women who do not produce eggs but wish to
 If vomiting occurs at any point, enteral or total parenteral nutrition  Low Hemoglobin and hematocrit due to HCG become pregnant or used to treat infertility
may be prescribed to ensure that she receive adequate nutrition  Low HCG  Ovulatory stimulant
together w/ the fetus  Elevated WBC  Works similarly to estrogen (female hormone that causes
eggs to develop in the ovaries and be released)
ECTOPIC PREGNANCY Diagnostic tests
 Pregnancy develops outside the uterine cavitycould happen w/in  Pelvic UTZ - no embryonic sac inside the uterine cavity Signs & Symptoms
the cervix, interstitial or fimbrial, isthmus, or ampullar portion  Culdocentesis - aspiration of non clotting blood from the cul-de-sac  Brownish or reddish, intermittent or profuse vaginal bleeding by 12
(most common), infundibular, or inside ovaries, in the peritoneum, of Douglas = positive tubal rupture weeks
abdominal cavity  Laparoscopy is not common & requires direct visualization  Spontaneous Expulsion of molar
cyst =16 th - 18 th week of
Risk Factors Medical Management pregnancy
 Constriction or narrowing of  Methotrexate - can treat unruptured ectopic pregnancy; oral  Rapid uterine enlargement
fallopian tube adminstration; folic acid antagonist chemo therapeutic agent w/c inconsistent w/ AOG
 PID - salpingitis, attacks and destroys fast growing cell; because trophoblast &  Symptoms of PIH before 20
endometriosis zygote growth is so rapid, the drug is drawn to the site of ectopic weeks
 Puerperal & postpartum pregnancy = can be administered directly; leaves the tube intact  Excessive HCG = excessive
sepsis with not surgical scarring that could cause a second ectopic nausea & vomiting; 1-2 million IU/liters for 24 hours
 Surgery or congenital pregnancy implantation ***normal = 400,000 IU/liter/24hrs
anomalies of the fallopian  Salpingectomy - surgical removal of the ruptured tube  Positive pregnancy test
tube  Blood transfusion - mgmt of profound shock if ruptured  No fetal signs - heart tones or mvmt and abdominal pain
 Adhesions, spasms, tumors  Antibiotics
 Use of IUD - prevent pregnancy by preventing normal implantation Diagnosis
Nursing Management  Passage of vesicles - 1 st sign that aids the diagnosis
Types  Assess for shock  Triad: enlarged uterus, vaginal bleeding & HCG > 1 million
1. Tubal - most common; 90-95%; may lead to tubal rupture before 12  Position on modified Trendelenburg - shock position  UTZ reveals no fetal sac, no fetal parts
weeks  Infuse IV fluids as ordered - D5LR for plasma administration, blood  Flat plate of the abd done after 15 wks shows no fetal skeleton
2. Cervical transfusion or drug adminstration
3. Abdominal  Moniotr V/S, I/O, and bleeding Prognosis
4. Ovarian  Provide physical & psychological support (pre-op & post-op)  15% remission after D&C and may progress to CA of the chorion or
 Anticipate grief, guilt responses, fear related to potential choriocarcinoma
disturbance in childbearing capacity in the future
Signs & Symptoms Complications
 Amenorrhea or abnormal menstrual period or spotting GESTATIONAL TROPHOBLASTIC DISEASE  Choriocarcinoma - most dreaded
 Tubal rupture: sudden acute sharp, low abd pain radiating to  Hydatidiform mole or H mole  Hemorrhage - most serious during the early treatment phase
shoulder = KEHR’S SIGN  Benign neoplasm of the chorion  Uterine perforation & infection
 Neck pain  Chorion fails to develop to a full term placenta and instead
 Nausea & vomiting degenerates and becomes fluid filled vesicles Medical Management
 Positive pregnancy test  Cause unknown  Methotrexate
 Cullen’s sign: bluish navel due  Uterus is distended by thin-walled translucent grape-like vesicles of  Evacuation: Dilatation & Curettage or hysterectomy (if there is no
to blood on the peritoneal different sizes spontaneous evacuation, >45 yo, no future pregnancy desired,
cavity; characterized by edema,  These are degenerated chorionic villi filled with fluid w/c enlarged increased chorionic gonadotropin lvls after D&C)
bruising, and discoloration of overtime = woman may think she is pregnant w/ a fetus  Chest X-ray - detect early lung metastasis
the fatty tissues surrounding the umbilicus or navel; may arise due  HCG titer monitoring for 1 yr = no pregnancy for 1 yr
to pancreatitis (inflammation of the pancreas), cancer of the Risk Factors  Contraception is a must bec signs of pregnancy can mask early signs
pancreas, ectopic pregnancy, liver problems, thyroid CA or other  Increased or decreased maternal age of choriocarcinoma
sources of internal bleeding in the abd  Low socioeconomic status  Medical replacement of blood, fluid, and plasma as indicated
 Rectal pressure bec of the blood in the cul-de-sac  Low protein diet  Chemotherapy for malignancy with the use of methotrexate
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 Temporary closure of the cervix  Uterine/abd cramps
Nursing Management  Suture is removed at term in preparation for vaginal delivery  Passage of tissues orproducts of conception
 Bed reast  Signs related to blood loss or shock = pallor, tachycardia, tachypnea,
 Monitor I/O, blood loss, V/S, molar tissue passage cold clammy skin, restlessness, oliguria, air hunger, and
 Maintain fluid & electrolyte balance - plasma & BV thru hypotension
replacements as ordered
 Prepare for D&C or hysterectomy as indicated Types Bleeding Abd Cervical Tissue Feve
 Provide psychological support - anticipate fear related to potential cramps Dilation Passage r
development of CA, disturbances for carrying an abnormal Threatene Slight May/ may none none Non
pregnancy d not be e
 Reinforce instructions on no pregnancy for 1 yr present
 Teach px on contraceptive use esp for 1 yr Inevitable Moderat moderate open none Non
 Emphasize the need for follow-up HCG titer determination for 1 yr e e
Complete Small to Moderate Close or Complete Non
Nursing Management negative partially placenta e
INCOMPETENT CERVIX  Provide psychological support who have negative feelings, fear open w/ fetus
 Characterized by a related to inability to complete pregnancy, guilt, or anticipatory Incomplet Severe Severe Open w/ Fetal or Non
mechanical defect in grief related to loss of expected baby e (bleeds tissue in incomplete e
the cervix causing  Provide post-cerclage care the most) cervix placental
cervical effacement  Advise limitation of physical activities w/in 2 weeks after treatment tissue
& dilation &  Routine prenatal care Missed None to None; no None None Non
expulsion of the  Instruct client to report promptly signs of labor severe in FHT w/ e
product of conception in midtrimester of pregnancy  Assess for signs of labor, infection, or premature rupture of coagulop UTZ
 NORMAL: with mucus plug in the cervix to keep the fetus and prods membranes athy
of conception intact inside the uterine cavity  Post-McDonald Cerclage - prep stitch removal set during labor in Habitual: May present signs of any of the above; usually detected in
 Absent mucus plug & cervix would easily efface & dilate w/c causes addition to labor set 3+ threatened phase; cervical closure (McDonald & Shirodkar
preterm or premature labor cerclage) may be done
SPONTANEOUS ABORTION Septic Mild to Severe Close or Possible, Yes
Risk Factors  It is a termination of pregnancy before the age of viability usually severe Open w/ foul
 Increased maternal age before 20-24 weeks AOG. or w/o discharge
 Congenital defect of the cervix  Induced abortion is a termination of pregnancy with medical or tissue
 Trauma - forceful dilatation in currettage in difficult delivery mechanical intervention.
 Cervical lacerations - conization & cauterization  Spontaneous abortion means without medical or mechanical
 History - abortions interventions.
Threatened miscarriage
Signs & Symptoms Abortion  Characterized by scant, bright red vag bleeding and slight cramping
 Painless contractions - results in a dead or nonviable fetus  Medical term for any interruption of a pregnancy before a fetus is pain
 Pink-stained show viable (more than 20-24 wks gestation or weighs at least 500 g)  No strenous activity 24-48 hrs
 Relaxed cervical os upon pelvic examination - history of abortion;
 No coitus for 2 weeks
Etiology  Slight cramping but no cervical dilatation
Medical Management  Defective ovum or presence of congenital defect
Cerclage  Other causes are unknown
 14-16 wk AOG or prior to next pregnancy; suture or ribbon is placed  Maternal factors: viral infection, malnutrition, trauma (phys or Imminent/Inevitable Miscarriage
to close the cervix mental), incompetent cervix (most common cause of habitual  characterized by threatened miscarriage with labor
 Purse-string suture on the cervix by the vag route under regional abortion), hormonal or decreased progesterone production,  Instruct woman to save any tissue problems that she has passed
anesthesia increased temp as in febrile conditions, systemic dss in the mother and bring to the hospital for examination
 To strengthen the cervix & prevent it from dilating until the end of such as DM, thyroid dysfunction, severe anemia, envi hazards, Rh  May undergo D&C or D&E
pregnancy incompatibility  Continue to monitor products of conception and severity of
a. Shirodkar - permanent
bleeding
 Subsequent deliveries are done thru CS Signs & Symptoms
b. McDonald - temporary  Vaginal bleeding or spotting from mild to severe
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Complete Miscarriage  Prevention of abortion: avoid coitus or orgasm esp around normal 3. Marginal placenta previa - w/c may be considered as low-lying type;
 Entire products of conception are expelled spontaneously w/o time of menstrual period placenta lies over the margins of the internal OS
assistance 4. Low-lying placenta previa- placenta at the lower third of the uterus
 No specific treatment; only monitor the bleeding 2. Inevitable abortion and does not cover the internal OS
 Save or monitor clots, pads & tissues for correct diagnosis
Incomplete miscarriage  Monitor VS, blood loss, I&O, change in status & signs of infection & Risk Factors
 part of the conception is expelled but membranes are retained refer any deviation  Multiparity - single most important
 woman is at risk for hemorrhage  Institute measures to treat shock as necessary: replace blood, factor
 D&C or suction and curettage plasma & fluids as ordered  Scarring & tumor in upper uterine
 Prepare for surgery segment - decreased vascularity
Missed miscarriage  Provide psychological support - be nonjudgemental, encourage  Increased maternal age - >35 yo
 An early pregnancy failure verbalization of fears, frustrations and concerns, reduce anxiety,  Multiple pregnancy
 Fetus dies in utero, but not expelled. offer your presence in a calm judgmental reassuring way
 May have no signs or symptoms  Allow patient to cry reassuring her that crying is healthy Signs & Symptoms
 Diagnosed thru UTZ - no FHR detected  Painless vag bleeding - Fresh, bright
 D&C or D&E 3. Inevitable abortion red external in 3rd trimester or 7 th
 may be induced for labor if more than 14 weeks pregnant  Prevent isoimmunization: administer RhoGAM as offered if: month
 Mother is Rh negative; abortus if Rh positive  Flaccid uterus - soft
Habitual miscarriage  Coomb’s test result is negative - no iso immunization yet = no  Intermittent pain - if it happens in labor secondary to uterine
 Recurrent pregnancy loss w/ 3 or more consecutive abortions antibodies formed yet contractions
 Or habitual aborters  Observe client for 48-72 hrs  Intermittent hardening - if in labor
 Cause is autoimmune uterine infection, deviation in the uterus,  Provide psychological & physical support care  Bleeding my be slight or perfused which may come after an activity,
hormonal, defect in sperm or ovum coitus, or IE
PLACENTA PREVIA
Septic abortion  Premature separation of abnormally low implanted placenta Diagnosis
 Caused by any infection resulting to the termination of pregnancy  Placenta in lower segment of the uterus  UTZ
 Upon passage of prods of conception, there could be foul smelling  The most common cause of bleeding in the third trimester.  Gives 95% accurate result & it detects the site of placenta
discharge  Lower Uterine Implantation/Placenta Previa: Possible cervix  Uterus is normally positioned on the higher corner of the uterus.
obstruction or the passageway for fetal delivery; usually detected  However in placenta previa, it is implanted in the lower segment of
Medical Management late, CS the uterus.
 Surgery: Dilatation & Suction Curettage  Unusually deep attachment of the placenta to the uterine
 Antibiotic - specially for septic type myometrium that the placenta will not loosen and deliver Medical Management
 Fluid replacement: blood & plasma if bleeding is present  IE = C/I  Watchful waiting
 Habitual abortion: need to determine etiology, and treat underlying  Bleeding is caused by pressure  Expected management & conservative if the mother is not in
cause labor.
 Cerclage for incompetent cervix  Fetus is premature stable & not in distress & bleeding is not
severe.
Nursing Management  Amniotomy
 An artificial rupture of the bag of water which causes the fetal
1. Threatened abortion head to descend causing mechanical pressure at placental site
 Symptoms begin as BRIGHT RED vag bleeding controlling bleeding.
 May notice slight cramping but no cervical dilatation on vag  Double Set-up
examination  Setting up for vaginal delivery & another for classical cs.
 HCG is drawn at the start of bleeding & again after 48 hrs; if  This is to prepare for an internal examination in suspected placenta
palcenta is still intact, the lvl in the blood stream should double (if it  Complications: hemorrhage, prematurity, obstruction of birth canal previa in the following condition
doesn’t double, poor placental fx is suspected & pregnancy mightbe  term gestation
lost) Types:  Mother in labor & progressing well
 Advice on complete bed rest for 24-48 hrs 1. Complete/total placenta previa - placenta totally covers the  mother & fetus are stable
 Teach to save all blood clots passed & perineal pads used internal OS  woman is not in labor or in shock & or the fetus is distressed =
 Advice prompt reporting to the hospital if bleeding persists or 2. Partial placenta previa - placenta partly covers the internal OS only one setup is to be prepared = emergency classical
increases cesarean section setup.
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 Delivery - if conditions for watchful waiting are absent, then vaginal Complications Time Cause
delivery if the birth canal is not obstructed could be done.  Hemorrhagic shock 1 st & 2 nd trimester Miscarriage; Ectopic pregnancy
 Classical CS  Couvelaire uterus 2 nd trimester H-mole; Premature cervical
 If placental placement prevents vaginal birth.  the bleeding behind the placenta & may cause some of the blood dilatation
 In previa, classical cs is indicated as the lower uterine segment is to enter the uterine musculature causing uterine muscles not to 3 rd trimester Placenta previa; Abruptio placenta;
occupied by the placenta. contract well once the placenta is delivered Preterm labor
 Future pregnancies will then be terminated by another cs  Disseminated Intravascular Coagulopathy (DIC)
because a presence of classical cs scar is a contraindication to  Cerebrovascular accident (CVA) SIGNS OF SHOCK
vaginal delivery  Hypofibrinogenemia Early Signs
 leading cause of uterine rupture.  Renal failure 1. Normal BP
 Prematurity or IUFD, fetal distress 2. Increased PR
Nursing Management  Infection 3. Normal skin color
 Bed rest - LLR - left lateral recumbent with head pillow 4. Cool/moist skin temp
 No internal examination or vag exam 5. Anxious
 Monitor for profuse bleeding, V/S, onset and progress of labor, FHT 6. Increased rate & depth of respirations
 Provide psychological & physical comfort
 Monitor for postpartum bleeding Late signs
 Prepare client for diagnostic ultrasonography 1. <90 mmHg systolic
 Prep for conservative mgmt, double set up or classical CS 2. Increased PR but weak
 Institute shock measures as needed 3. Pale
 Initial bleeding is very life threatening but may be perfuse with IE 4. Cold skin temp
 Observe for bleeding after delivery 5. Coma
 The lower uterine segment as a site of placental detachment is not 6. Increased RR but shallow
as contractile as the fundal portion Concealed Covert/Central Type/Classic Type (A/C):
:
 Bleeding happens under the placenta;
Immediate Assessment
ABRUPTIO PLACENTA  Placenta separates at the center causing blood to accumulate
behind the placenta; 1. Confirmation of pregnancy
 A complication of late pregnancy or labor characterized by  Does the woman know for certain that she is pregnant (positive
premature, partial, complete separation of a normally implanted  The external bleeding is not evident, signs of shock not proportional
to the amount of external bleeding. pregnancy test or physician/nurse/midwife confirmation)?
placenta.  Woman who has been pregnant before & states that she is sure she
 Also termed as accidental hemorrhage & ablatio placenta. Marginal (B)
 AKA overt or external bleeding type is pregnant is probably right even if it is not yet confirmed
 Second leading cause of bleeding in the 3rd trimester & occurs in 2. Pregnancy length
1/300 pregnancies.  The placenta separates at the margins & bleeding is external,
usually proportional to the amount of internal bleeding  What is the length of the pregnancy in weeks?
 Occurs when the placenta separate from the inner wall of the 3. Duration
uterus before birth -> oxygen deprivation  May be complete or incomplete depending on the degree of
detachment.  How long did the bleeding episode last? Is it continuing?
4. Intensity
Risk factors  How much bleeding occurred?
 Maternal HPN, PIH, renal dss Management
 Maintain bedrest - LLR  Ask to compare it to a common measure s/a tbsp or cup
 Sudden uterine decompression - multiple pregnancies, 5. Description
polyhydramnios  Careful monitoring - V/S, FHT, LABOR ONSET & PROGRESS, I&O,
oliguria, pain, and bleeding  Was blood mixed w/ amniotic fluid or mucus?
 Advance age, multiparity  Was it bright red (fresh blood) or dark (old blood)?
 Short umbilical cord  Administer fluids thru large-bore needle - plasma or blood; for
faster infusion to replenish fluid loss or shock  Was it accompanied w/ tissue fragments?
 Trauma  Was it odorous?
 Prep for diagnostic exam and explain results to client
6. Frequency
Signs & Symptoms  Provide psychological support
 Steady spotting? Single episode?
 Painful vaginal bleeding = 3 rd trimester  Prep for emergency birth - CS OR NSVD
 How often she change pads
 Rigid board-like and painful abd  Observe for postpartal complications - poorly contracted uterus if
7. Associated symptoms
 Enlarged uterus - due to concealed bleeding there is couvelaire uterus, PPH, DIC (hemorrhage and CVA),
 Cramping, sharp pain, dull pain, presence of contractions
 Tetanic contractions - if in labor w/ absence of alternating prematurity, neonatal distress which cause morbidity and mortality,
 Has she ever had cervical surgery?
contractions and relaxation of uterus hypofibrinogenemia
8. Action
 Signs of shock not proportional to the degree of external bleeding  What was happening when the bleeding started?
BLEEDING DURING PREGNANCY
 What has she done to control the bleeding?
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9. Blood type  Prepare client & family for early intervention of pregnancy
 Does she know this?
 Rh-negative women will need Rh immune globulin to prevent Rh PREMATURE RUPTURE OF MEMBRANES (PPROM)
isoimmunization  Happens beyond 37 weeks of gestation
 Rupture of bag of water before labor started PREGNANCY-INDUCED HYPERTENSION
DISSEMINATED INTRAVASCULAR COAGULATION  This is characterized by 3 symptoms: hypertension, edema &
 It is a rare life-threatening condition. PPROM (Preterm premature rupture of membrane): occurs 37 weeks AOG proteinuria
 Early stages of this condition = blood to clot excessively. SPROM (Spontaneous preterm rupture of membrane): occurs after or  Appears 20-24 weeks AOG
 As a result, blood clots may reduce blood flow & block blood from with onset of labor occurring before 37 weeks  Disappear 6 weeks after delivery
reaching bodily organs. Prolonged rupture of membrane - persists for more than 24 hours and  7-10% of all pregnancies & one of the major causes of maternal &
 As a condition progresses, platelets & clotting factors, the prior to onset of labor neonatal mortality
substances in the blood that are responsible for forming clots are  Cause is unknown
used up. When this happens, the person could experience excessive Complications
bleeding.  Chorioamnionitis - maternal infection; most common Etiology
 Serious condition that can lead to death  Fetal sepsis  Nulliparity w/ extremes of age - <17 yo or >35 yo
 Premature labor  Severe nutritional deficiency - low protein diet & calories
Signs & Symptoms  Cord prolapse  Presence of co-existing conditions -DM , multiple pregnancy,
 Bleeding - depleting platelet Diagnosis chronic hypertension, renal dss
 Presence of blood clots  Sterile speculum examination - direct visualization of fluid from  Generalized vasospasm & arterial vasoconstriction - cause
 Hypotension cervical os; most reliable diagnosis of PROM increased peripheral resistance, decreased blood flow to tissues,
 Easy bruising  Vaginal speculum - pooling amniotic fluid and hypertension
 Rectal or vaginal bleeding  Nitrazine paper - change from yellow to blue = alkaline amniotic  Reduced blood flow to tissues = tissue ischemia and altered organ
 Petechiae fluid is present functioning in kidneys, brain, and uterus
 Ferning test - amniotic fluid w/c is high in sodium content will
Diagnosis assume a ferning pattern when dried on the slide Signs & symptoms
 Blood: CBC, PLT count  Kidneys
 Partial thromboplastin time Signs & symptoms  Triad: Proteinuria; hypoproteinemia; Edema;
 D-dimer test  Passage of fluid thru vagina  Renal vasospasm
 Serum fibrinogen  Determination of alkaline fluid and not acidic urine or vaginal  Decreased perfusion w/c causes glomerular lesions and
 Prothrombin time discharge membrane damage resulting in disturbed function
 Albumin glomerulo…..
Complications - may occur from excessive clotting that happens in the Management  Altered blood osmolarity
early stages of condition and the absence of clotting factors in the later  Bed rest - don’t allow px to ambulate to prevent prolapse of  Fluid shift from intravascular compartment to interstitial
stages umbilical cord spaces = EDEMA
 Blood clot - lack of o2 to other organs  Monitor FHR,V/S & initiation of labor  Angiotensin release = vasospasm & HPN
 Stroke  Labor induction  Brain
 Excessive bleeding w/c leads to death  Administer IV fluids as ordered  Cerebral arteriospasm & edema - causes cerebral hypoxia &
 Administer betamethasone x2 doses as ordered CNS irritability
Management  Antibiotics - as prophylaxis bec mother is at risk for having  Visual disturbances, double vision, blurring & dimness of
 Halt the source of bleeding chorioamnionitis; started after 6 hrs from the time of rupture; esp if vision
 Heparin - anticoagulant; reduce and prevent clotting; may not be there is prolonged rupture of membranes  Hyperreflexia or hyperirritability
adminstered if px is lacking PLTs or bleeding too excessively  Prep for delivery - CS or NSVD  Convulsion and coma
 If sudden DIC = requires hospitalization often in the ICU to correct  Alert for any signs of infections: fever, chills, malaise, and signs of  Uterus
DIC while maintaining organ function labor onset 1. Decreased placental perfusion = SGA
 Blood transfusion - replace missing PLTs  Observe onset, character, amount, color, odor of amniotic fluid 2. Generalized vasoconstriction and arteriospasm
 Plasma transfusions - have the ability to replace the clotting factors  Provide appropriate treatment as ordered 3. Abruptio placenta
that is lacking  W signs of infection - antibiotics Signs Mild Pre-eclampsia Severe Pre-eclampsia
 W/o signs of labor - induction of labor will be delayed HPN 140-170/90-105 mmHg >160/110 on 2 readings taken 6
 Psychological support hrs apart after bed rest
 Explain procedures and findings Proteinuria 1+ or 1 g/day 3+-4+ or 5g/day or more
 Inform progress Edema Generalized; confined Generalized; severe facial
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to face (periorbital) & puffiness, severe swelling of  Seizure precaution
fingers; weekly weight face; excessive weight gain (5  Reduce envi stimuli of room @ near nurse’s station - dim
gain (1 lb/wk) lbs/wk); epigastric pain; cerebral and semi quiet
disturbances  Restrict visitors - 2 px/room
Oliguria Absent Present  Monitor for signs of impending convulsion - severe
IUGR- Absent Present headache in the frontal area, severe epigastric pain, sharp
Intrauterin crying fixed unresponsive eyes, facial twitching,
e growth hyperreflexia
retardation  Have on bedside: airway, urinary catheter set, IV fluids & c. After
Others Hypoproteinemia; emergency drugs  Monitor BP, RR, DTR, I&O, FHT
Hemoconcentration;  Administer anticonvulsant as ordered  Blood pressure = no hypertension or hypotension
Hypernatremia  Urine = oliguria should not happen; make sure to
Eclampsia Pharmacologic Management have >30 cc/hr
 3rd type of PIH 1. Magnesium sulfate - prevent convulsion; decrease BP  Respiratory rate = not go down <12 cpm
 Convulsion and coma: check BP - first nursing action  IM, IV bolus, IV infusion  Patellar reflex = DTR; must be positive; depressed reflex
 Severe headache and epigastric pain may tell incoming convulsion  Concentrated electrolyte that causes pain & irritationto means toxiciity
 First sign of convulsion: rolling of the eye balls the muscles and veins 2. Hydralazine (Apresoline) - could easily drop the blood pressure of client;
 Px are admitted in the labor room near the nurses’ station with dim  Flushing occurs; depresses Respiratory center and Alpha blocker; IVTT; monitor BP
lights and lesser noise with a maximum of 2 patients inside the smooth muscles of respiration 3. Diazepam (Valium) - for convulsion
room. a. Before 4. Diuretics may be rare - monitor BP
 Environmental stimuli could be a factor to have eclampsia  Assess RR (12-20 cpm or more) before giving 1 st dose 5. Blood volume expanders - for shock
 Cerebral edema is acute that a grand mal (tonic-clonic) seizure or  Assess DTR before giving the 2 nd dose - if present and
coma has occurred more then 1+ = 1 st dose did not depress the CNS to toxic HELLP SYNDROME
levels  This is a life-threatening disorder associated with pre-eclampsia.
Management  Check BP  Severe PIH
 Diet: high protein, moderate sodium & supplemental iron  Antidote on stand-by: 10% Calcium Gluconate  Disorder of the liver and blood and is fatal if left untreated
 Protein - increase good osmolarity & prevent fluid shift to - IV bolus = high volume  Symptoms can be difficult to diagnose because they are wide
interstitial spaces  Procainamide hydrochoride or Lidocaine cocktail ranging and vague
 Iron: 30-60 mg/day in 2nd and 3rd trimester until 2 to 3 - minimize pain by numbing the area; needs DO  Less than 1% of pregnancies
months postpartum in lactating mothers b. During  Develops in last trimester of pregnancy but may occur earlier and
 Increase caloric intake by 10% in pregnancy  Loading dose given thru deep IM thru Z track method even present postpartum
 Sodium restriction in pregnancy is harmful bec it can decrease  Deep IM = to evenly distribute meds  Causes of symptoms is unknown
circulating volume and result in fluid and electrolyte  Cocktail = lidocaine + magnesium sulfate to minimize  Hemolysis is the breaking down of blood cells too early and too
imbalance and elimination of vital nutrients irritation and pain rapidly which can lead to anemia.
 Provide a high protein diet with moderate sodium: no total  Given to both buttocks; divide administration
restriction of sodium  Z track method = to prevent seepage of blood; to lock Hemolysis
 Retain fluid with no added salt - to replace losses & reduce meds in muscle; reduces pain; prevents dispersion of  Break down of RBC too soon and too rapidly w/c may result to low
edema medication into the SQ tissue RBC level and anemia (blood doesn’t carry enough oxygen to the
 Promote adequate rest & sleep in LLR - to promote tissue perfusion  Infused IV for 24 hrs to 3 days to a week - monitor for rest of the body)
and induce diuresis; reduce risk of supine hypotension syndrome toxicity q4h or every change of bottle  Diagnosis requires >2 of the ff:
 Reg prenatal care & report danger signs such as visual disturbances,  Abnormal peripheral blood smear (schistocytes, burr cells)
severe persistent headache, and dizziness, irritability, epigastric  Elevated serum bilirubin (≥ 1.2 mg/dL)
pain, and edema  Low serum haptoglobin
 Teach client in monitoring own BP  Significant drop in hemoglobin level unrelated to blood loss
 Monitor I/O strictly - Oliguria: bad; Diuresis: good Elevated Liver Enzymes
 Monitor V/S reg - maternal and fetal  Indicate liver is not functioning properly
 Placed in room near nurse’s station  Inflamed or injured liver cells leak high amount of certain chem inc
 Weigh daily - eval degree & distribution of edema enzymes into the blood
 Used to administer large volume IM injections  AST or ALT ≥ 2x upper limit of normal
 Monitor DTR (first to get lost with CNS depression secondary to  Decreases likelihood of localized irritation
magnesium sulfate toxicity), onset of labor and abruptio placenta  LDH ≥ 2x upper limit of normal
 Done in gluteus medius Low Platelet count
 Administer Magnesium sulfate as ordered
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 Components of blood that help with clotting,  Parity - as parity increases, chance of multiple birth increases race, age, parity & heredity
 when PLT lvls are low = client may develop increased risk of  2 separate ova
excessive bleeding Types
 <100,000/mm3 1. Monozygotic Twins - Identical Dichorionic/Diamniotic twins -2
 develops from single ovum that divides forming identical twins, 1 chorions and each one has their own
Risk Factors amnion, different umbilical cord amnion
 Maternal age greater than 34  Share all one set of traits 1 placenta, 1 chorion. Monochorionic/ Diamnionic -1 chorion
 Multiparity  They usually have 1 amnion except for the umbilical cord. and 2 amnion
 Each fetus has their own umbilical cord, they are of the same Monochorionic / Moniamniotic - same
Signs & Symptoms genotype or appearance & of the same sex. chorion and amnion
 Malaise, N/V  The incidence of monozygotic twin is about 1 in 250 births the Conjoined twins - part of body is joined
 Edema w/ secondary weight gain survival of monozygotic twins is 10% lower than that of dizygotic and does not separate until development
 Epigastric or right upper quadrant pain - due to liver edema twins & congenital defects are more prevalent.
 Dyspnea - if pulmonary edema present 3. Supertwins
 Jaundice a) Diamnionic Monozygotic  common term for rare triplets &
 Signs of dehydration - sunken eyes  Occurs within the first 72 hours after fertilization before the other higher order multiple births
 Edema leading to puffy eyes inner cell mass & chorion is formed such as quadruplets or quintuplets & these babies can be identical,
 Dry mucous membranes  There will be 2 fraternal or a combination of both.
embryos, 2  3 or more on 1 pregnancy
Class 1 Class 2 Class 3 amnions, & 2
Severe Moderate Mild chorions that will Manifestations
Platelets ≤ 50,000/uL 50,000-100,000/uL 100,000-150,000/uL develop.  Positive hx of twinning (w.in family or past pregnancies)
AST or ALT ≥70 IU/L ≥ 70 IU/L ≥40 IU/L  It occurs in 20-30%  Large uterus
LDH ≥600 IU/L ≥600 IU/L ≥600 IU/L of the time.  2 or more FHTs - asynchronous
Incidence of 13% 8% No increased risk  They may be 1  Palpation of 3 or more large parts
bleeding distinct placenta ora  2 fetal outline by UTZ;
** differ on the level of PLT, increase in liver enzymes, lvls of LD, and single-fused  increased maternal weight
chances of bleeding placenta.  Discomforts: edema, varicosities, SOB, increased susceptibility to
 If division occurs 4-8 supine hypotension syndrome
Management days after
 IV fluids given cautiously - edema is manifested that could worsen fertilization, 2 Diagnosis
in increased IV fluids embryos develop  UTZ and palpation
 Treat HPN with separate  High Serial Estriol
 Delivery of fetus may be done earlier if lung maturity is evident amniotic sacs later to
 Delivery (either NSVD or CS) if HELLP syndrome occurs close to 34 be covered by a Complications
wks gestation common chorion. A. Maternal
 Monitor bleeding and shock b) Monochorionic  IDA - most common
Monozygotic  Threatened abortion
MULTIPLE PREGNANCY  If the amnion has already developed approximately eight days  Preterm labor/PROM
 gestation of 2 or more fetuses or carrying of more than 1 fetus after fertilization, division results in two embryos with a  PIH
during the same pregnancy common amniotic sac & common chorion.  Uterine atony after delivery or postpartal hemorrhage
 Hyperemesis gravidarum
Risk Factors 2. Dizygotic Twins - Fraternal  Anxiety and depression
 Rise of Infertility management by assisted reproductive technology,  Exists between the B. Fetal
ovulation induction, or identified causes of triplet pregnancy dizygotic twins is similar  Prematurity - common in LBW
 Advanced maternal age to the relationship that  RDS - leading cause of death in premature infant
 result of delaying pregnancy by choice and infertility which exists between siblings,  Hypoglycemia, hyperbilirubinemia, anemia
lead to major risk to multiple gestation: prematurity and low they may be of the same  Conjoining abnormalities - from incomplete separation in
birth weights or different sex the common organs or parts
 Use of Clomiphene citrate - to increase maturation of ovarian incidence of fraternal  Intrauterine asphyxia
follicle to manage female infertility; side effects: multiple ovulation twins varies with maternal  Birth injuries and stillbirth
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 Cerebral palsy and other neuro impairments  So normally at normal physiology, the baby is going to be
OLIGOHYDRAMNIOS & POLYHYDRAMNIOS swallowing an adequate amount of that amniotic fluid & it is
Medical Management going to go down into the baby's lungs, expand, & put a little
 Early diagnosis - comprehensive prenatal care Movements of amniotic fluid are done in one of 2 ways or both: internal stress on the lungs.
 Frequent monitoring fetal wellbeing, growth, viability - labs, serial 1. Baby swallows amniotic fluid,  And as part of normal pulmonary development without amniotic
ultrasonography,NST, biophysical profile beginning at 30-34 wks  amniotic fluid will move from the amniotic sac into the baby's fluid being swallowed by the baby going into the lungs &
 Nutritional support body expanding the lungs space, causing a little bit of internal stress,
 Non-pregnant kcal: 1800kcal - 2,300kcal  the fluid in the amniotic space will decrease because it's no there is going to be an abnormal pulmonary development that
 Singleton: Non pregnant kcal + 300kcal longer than the amniotic space & out in the baby's body leads to pulmonary hypoplasia
 Multiple: Non Pregnant kcal + 300kcal + 300kcal 2. Baby can urinate  No amniotic fluid = lungs are small= pulmonary hypoplasia.
 Iron: 60-100 mg/day of iron in multifetal (increase from 30-  fluid move from the baby into the amniotic space therefore
60mg for singleton) increasing fluid) Potter Sequence
 Folate:1 gram/day of folate; adequate protein from a variety 1. Pulmonary hypoplasia
of sources may supply adequate amt of folate 2. Oligohydramnios
 Delivery: NSVD or CS 3. Twisted face
 Cervical assessment - continuous fetal monitoring in labor to 4. Twisted skin
provide assessment data for uterine activity and fetal tolerance to 5. Extremity deformities
labor 6. Renal agenesis => decreased urination

Nursing Management **if baby cant urinate, less amniotic fluid goes into the amniotic space or
 Teach client on frequent prenatal care and balance diet and oligohydramnios occurs and you cant swallow fluid and abnormal
 Every 2 weeks in the 2nd trimester lung development occurs which means that you will have pulmonary
 Every week then Twice a week in the last 4 weeks hypoplasia
 Increase calories and iron and vitamin supplementation
 Folic acid is important taken one month prior to and TTE
throughout first 3 months of pregnancy to decrease risk for neural - no amniotic fluid so baby is not cushioned by amniotic fluid and there
tube defects such as spina bifida will be a lot of pressure and tension on the baby from the uterus
 Emphasize importance of frequent rest - LLR
 prompt reporting of danger signs - bleeding, passage of fluid in ISOIMMUNIZATION (RH INCOMPATIBILITY)
vagina, premature contractions  Occurs when a Rh-negative mother carries a fetus with a Rh
 Psychosocial assessment & support referral is needed to social positive blood type
services, postpartum caregivers and lactation support people Polyhydramnios – too much amniotic fluid in the amniotic space  for this situation to occur, the father of the child must either be
 Intranatal:  Anything that prevents the baby from adequately swallowing liquid homozygous or heterozygous Rh-positive
 Strict asepsis - prevent infection will cause the swelling to occur & therefore more fluid will build up  If the father of the child is homozygous, for the factor, 100% of the
 Assistant nurse for each NB is scrubbed, gowned, and gloved in the at the amniotic space causing polyhydramnios. couple’s children will be Rh-positive.
 Cord is clamped after delivery of Baby A  Anything that decreases swallowing, anything that prevents the  If the father is heterozygous, for the trait, then 50% of their
 Label babies as Baby A, B baby from adequately swallowing liquid will cause the swelling to children can be expected to be Rh positive.
 Assist safe delivery of the 2 nd child - optimum time of delivery not occur & therefore more fluid will build up in the amniotic space  Although this is basically a problem that affects the fetus, it causes
of 2 nd child = 5-20 mins causing polyhydramnios. concern & apprehension in a woman during pregnancy that it
 Prevent bleeding:  Developmental abnormalities that cause decreased urination becomes a maternal problem.
 Administer oxytocin after delivery of last baby include any type of bladder outlet obstruction or polycystic kidney  The baby has its own unique blood type because it inherits half of
 Palpate fundus disease (anything that causes the baby not to urinate). its genetic makeup from its father.
 Do not massage until after the uterus contracts and expels  Increasedurination may be due to maternal diabetes, so baby will  The mother &baby’s bloods do not mix but they come in very close
and separates the placenta be big, baby will also have polyuria since baby will have increased contact with each other across the placental membrane.
 Give ordered Methergine -IM glucose also
 Gently massage and elevate fundus for 15-30 mins Rhesus positive:
 Promote bonding & psychological support Oligohydramnios – too little amniotic fluid in the amniotic space  red blood cells have the rhesus antigen O
 Fetuses are more likely to spend more time in the NICU -  Pulmonary hypoplasia occurs if there is no amniotic fluid in the  If you have the rhesus antigen, your body learns to recognize that
complications of prematurity or defects lungs antigen as being part of your body so it does not attack it.
 Encourage verbalization of concerns and anxiety  The baby is sitting in the sac in the womb & outside of it should
have this amniotic fluid. Rhesus negative:
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 no rhesus antigen O in RBC; fetal self , the doctor may shot another RhoGAM at any point
 When you do not have the rhesus antigen & you come in contact during pregnancy
with that antigen, your body thinks that is a pathogen & attack. 3. Abortion - still needs to receive RhoGAM
 If you were transfused with blood that contained the rhesus 4. HYDROPS FETALIS - fetal complication where the baby
antigen & your body did not have the rhesus antigen, then the B becomes edematous and the liver swells due to
cells of your immune system would recognize that as something insufficient albumin
that does not belong to your body & would launch an immune
response & create anti-D antibodies against that rhesus antigen. GERMAN MEASLES/ RUBELLA
 An acute, viral infection caused by a mix of virus.
 This is important in pregnancy because if the mother is Rhpositive,  Maternal infection is mild but fetus is severe.
there is nothing to worry about because the baby can be  Incubation Period: 2-3 weeks
Rh-negative or Rh-positive & she is never going to try & attack the  Communicability happens within 7 days to 5 days until rash appears
Assessment
baby’s blood cells. But if the mom is Rh-negative & the baby is  Teratogenic
Rhpositive, anytime the baby’s blood gets into the mother’s  Anti-D antibody titer (mother)  Transmission: direct and indirect contact
bloodstream, she will create anti-rhesus antibodies.  1 st pregnancy visit  Symptomatic
 Repeated at week 28 of pregnancy if
 results are normal or minimal from
This can happen at sensitizing events; 1 st trimester 2 nd trimester
1. Miscarriage after 12 weeks 1st pregnancy visit
Deafness; Eye defects; CNS defects; Premature labor; IUFD; subtle
2. abdominal trauma - some bleeding inside the placenta & some  No therapy needed if results are still
Cardiac malformation (patent abnormalities present later in life; ;
blood cells have to cross normal
ductus arteriosus) DM; Thyroid problem; Progressive
3. At birth when there is lots of bleeding & mixing of the mother  If the woman’s Antibody Titer is elevated
panencephalitis
& baby’s blood. at the first assessment showing RH
sensitization, the well-being of the
Other anomalies: (1st trimester)
 fetus will be monitored q 2 wks or more (fetal doppler)
This does not have much of an impact at that time because the ● Microcephaly
 Doppler velocity of the fetal middle cerebral artery - technique
mother will just destroy the blood cells that got into her system but ● Mental retardation
to predict when anemia is present or fetal red cells are being
in future pregnancies, the antibodies that the mother has ● Susceptibility to pneumonia
hemolyzed
developed will be able to cross the placental barrier because there ● Enlarged liver
 Anemia - RBC are destroyed faster than they are made
are only very small proteins & they will get into the bloodstream of ● Blood dyscrasia
 Jaundice - build up of the substance in the blood that causes the
the baby & start attacking the baby’s blood cells as the baby’s blood ● Hemolytic anemia
skin to look yellow
cells are hemolyzed or destroyed, that releases chemicals (bilirubin) ● Thrombocytopenia
into the baby’s body.  Swelling of the body - can lead to heart failure or breathing
problem
Assessment Findings
Hemolytic Disease of the Newborn or HDN  Baby look edematous
 Pink maculo-papular rash all over patient - starts on face and
 Bilirubin is responsible for creating jaundice. spreads caudally on 3-5 days
 A slight jaundice in babies is normal which is called a physiological Management
 Slight fever, malaise, nasal congestion
jaundice. 1. Rh (D) antibodies (RhIG)
 Anorexia
 When the bilirubin level gets very high, it can cause significant brain 2. RhoGAM injection
 Posterior auricular & occipital adenopathy
damage & long-term learning difficulties & disabilities.  Use to treat RH incompatibility during pregnancy
 Arthritis/arthralgia
 process of antibodies crossing the placenta into the baby’s  Shot contains antibodies collected from plasma donors that
bloodstream & causing a hemolytic anemia & a severe jaundice stop the immune system from reacting to the baby’s RH
Management
 Prevention: anti-D immunoglobulin positive blood cell
 Rubella Vaccine is given immediate postpartum or 1-3 months
 Keeps the mother and the baby’s blood RH incompatibility
 anti-D antibodies given by an intramuscular (IM) injection at before pregnancy
from causing any possible problems, wherein the blood types
any event where the mother might become sensitized.  to all non-pregnant non-immune women of childbearing age
mix at any point during the pregnancy or delivery
 So anytime the baby’s blood might have gone into the  should avoid pregnancy for at least 1 month/4 weeks after
 Arm or backside
mother’s bloodstream, this injection circulates around the immunization
 Mother & baby may be Rh incompatible = shot of RhoGAM @
blood & destroys any of the baby’s blood or any of the blood  not contraindicated for breastfeeding
26-28 weeks AOG & again at 72 hours after delivery to ensure
cells in the mother than contain the rhesus antigen.  all children should receive MMR at age 15 months old and
future pregnancies are as safe as the first.
 By destroying all of the baby’s blood cells before the mother pregnant non-immune women should receive be immunized
 If the client undergoes Chorionic Villi Sampling or
has an opportunity to launch an immune response, you in the immediate postpartum confinement; never during
Amniocentesis or if the mother experiences bleeding during
prevent the mother becoming sensitized & developing her pregnancy because defects may be delayed for up to 21 days
pregnancy or any trauma , where there could be exposed to
own antibodies against the rhesus antigen.  Supportive treatment
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 Immune serum globulin
 Given to exposed women to prevent aggravation of maternal
symptoms but will not alter fetal infection nor reverse fetal
defects already present
 Immunization - rubella vaccine
 Should avoid pregnancy for 1 month or weeks after
immunization
 All children should receive MMR at age 15 months
 Cornerstone of therapy
 Pregnant non-immune women should be immunized IMMEDIATE
POSTPARTUM
 Never during pregnancy because defects may be delayed for
up to 21 days
 BF not C/I

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NURSING CARE OF THE HIGH-RISK PREGNANT CLIENT DURING LABOR &  Part of their cardinal mechanism that upon complete extension, the
DELIVERY head should be facing downwards
 Symphysis pubis will serve as a joint wherein the head could pivot
COMPONENTS OF LABOR during complete extension
1. Passenger - fetus
a. Fetal malposition Abnormal Position:
b. Fetal malpresentation  fetus occiput is towards the posterior part of the pelvis; but fetus
c. Fetal distress can still position himself correctly to the maternal pelvis allowing a
d. Prolapsed umbilical cord successful vaginal delivery
2. Passageway - birth canal  Occipitoposterior = fetus could be facing upward w/c causes
a. Abnormal size or shape of the pelvis This is the ideal position in the maternal pelvis; vertex should be on the problems during complete extension
b. Cephalopelvic disproportion anterior portion of the maternal pelvis = fetus is facing towards the back =
c. Shoulder dystocia facilitate successful cardinal movements of labor & delivery Risk Factors: Android, anthropoid, or contracted pelvis
3. Powers - force that propels fetus; uterine contractions Occipitoposterior
a. Dystocia Assessment Findings
b. Premature labor  Pressure and pain in the lower back
c. Precipitate labor & birth
d. Uterine prolapsed Management
e. Uterine rupture  Provide back rub
4. Psyche - woman’s & family’s perception of the event  Keep the bladder empty - to allow descent of the fetus
a. Fear & anxiety on labor progress  Provide IV glucose for prolonged labor - to prevent hypoglycemia
 Cesarean delivery
PASSENGER - fetus  Arrest in transverse position
Cephalic Presentatation  Fetal distress
 baby is positioned head down facing the mother’s back where the  Presence of obstruction
chin is tucked to its chest and the back of the head is ready to enter  Induce or Augment labor for possible NSVD
the pelvis If the fetus is about to be delivered, the fetus needs to have a long  Vacuum may be used - to assist delivery
 Most babies settle into this position w/in 32 nd to 36 th week of rotation which means that she needs to rotate 3/8 of the total  Intact BOW - amniotomy may be done
pregnancy circumference of the pelvis = long rotation = successful vaginal delivery  Fully dilated with no signs of obstruction - successful
Short anterior rotation - as it rotates, it gets stuck in transverse position dilatation of 10cm
Risk Factors Nonrotation - does not rotate at all; fetus not positioned for successful  Note that delivery may be complicated by perineal cares or extension
1. GDM position of episiotomy
2. Multiple pregnancy - alter position & lie Short posterior rotation - maintain to posterior part ; facing upright  If there are signs of obstruction or if the FHR is abnormal = fetal
3. Malpositioned fetus during extension distress = CS
4. Immature or preterm  Cervix not fully dilated = oxytocin
 Cervix fully dilated & no descent in expulsive phase - assess for signs of
Fetal Malposition - Occipitoposterior obstruction
 Occurs when the occiput of the fetus, who are in vertex  Fetus could be arrested in transverse position
presentation is rotated so that it is not oriented anteriorly in the  Cervix fully dilated & fetal head is 3/5 palpable above the symphysis
maternal pelvis pubis or the bony prominences of the head is above -2 station =
 Occipitoposterior - most common CESAREAN SECTION

Diamond-shaped = anterior fontanel Fetal Malpresentation - Face &

Triangle-shaped = posterior fontanel Brow Presentation
 Chin serves as a reference
point in describing the
position of the head
 chin anterior position - chin
is anterior in relation to the
Normal Position & Presentation: maternal pelvis;prolonged
 well flexed and occiput should be on the anterior part of the pelvis labor is common; descent in
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delivery of the head by flexion; can still have NSVD (A) ** both could be prevent the fetus to position correctly or to a  Vaginal delivery is possible so woman must not have history
 Chin posterior - chin is directed towards the back portion of the cephalic position of CPD, membranes are intact, amniotic fluid is adequate, no
mother; fully extended head is blocked by sacrum; prevents 6. Pendulous abdomen complicattions s/a fetal growth restriction, uterine bleeding,
descent; labor is arrested; CS 7. Multiple gestation prev CS, fetal abnormality, twin pregnancy, hypertension, and
 Prolonged labor is common fetal death
 Always remember that the face and brow presentation, though it  Breech birth
could be done thru NSVD, vacuum extraction should not be used Assessment  Not that common bec doctors opt to have CS
 FHR - high in the abdomen;  Vaginal breech delivery is done by a skilled healthcare provider w/
Findings: edematous upon delivery esp the lips auscultation; loudest above the safe & feasible conditions
umbilicus; done if any doubt  Could only be done with complete or frank breech
remains after palpation in a  Should have adequate clinical pelvimetry, fetus is not too large, no
vaginal examination prev CS for CPD, and flexed head
 UTZ - confirmatory; clarify the  Examine woman and refer the progress based on CTG
diagnosis and will exclude fetal  If membranes are ruptured = examine woman immediately to
malformation explore cord prolapse
 Cord prolapse and delivery is not imminent = CS
Diagnosis  If there are signs of fetal distress or prolonged labor = cannot have
 Palpation of the lower part of the uterus which is occupied by a soft vaginal breech birth,
Diagnostic: irregular mass and fundal area is firm, smooth, rounded mass that  should not push until the cervix is fully dilated
 Leopolds maneuver is present which bounces between fingers if gently pushed  Full dilatation should be confirmed by vaginal examination
 UTZ - confirmatory; confirm the presentation  Breech birth:
 Internal Examination - examiner will fell the chin instead of the occiput Complication 1. Before labor, position into left sacral posterior
1. Hip dysplasia 2. Descent and internal rotation, legs are being born
Breech presentation 2. Anoxia from cord prolapse - head was not able to snugly fit into the 3. Shoulders turn to present anterior to posterior diameter
 Frequency of breech presentation falls as pregnancy advances cervix 4. Head is born last wherein the external rotation has put the
 30 th week of pregnancy = 15% of the fetuses present as breech 3. Head trauma anterior posterior diameter of the head inline with the
 35 th week of pregnancy = proportion has fallen to 6% 4. Arm or spine fracture anterior posterior diameter of the woman’s pelvis.
 Term pregnancy = 3% breech and most will turn to become cephalic 5. Early rupture of membrane 5. Head should be facing downwards
 Presentation of the fetus is of no clinical importance before the 32nd 6. Meconium staining - does not mean fetal distress; common to breech 6. The head is born in gentle pressure to flex the head fully.
- to 35 th weeks presentation bec of the pressure applied in the rectum or the anus of the 7. By gentle traction to the shoulder, upward and downward.
fetus producing its meconium Lift up the baby’s body then pull it downwards.
8. Additional pressure might be applied by an assistant to the
Frank Breech Position - breech with extended leg Management abdominal wall to ensure head flexion.
Complete Breech Position - breech with flexed legs; hips & knees are  External cephalic version
completely flexed  Procedure that externally rotates the fetus from a breech
Footling Breech Position - single or double footling; both legs could be presentation to a cephalic presentation
dropped into the maternal cervix  If successful - may proceed w/ NSVD and avoid CS
 Fails = CS
 Need anesthesia
 Criteria:
 Make sure that the uterus is not contracting to allow free
moving of the fetus .
 There should also be enough
amniotic fluid.
 Only attempt external version if
Risk Factors: breech presentation is present
1. Gestational age of <40 weeks - could still be managed at or after 37 weeks.
2. Fetal abnormality  Before 37 weeks, a successful
3. Polyhydramnios version is more likely to  Cesarean section
4. Midseptum in the uterus spontaneously revert back to  Successful aversion of a breech into cephalic presentation allows a
5. Tumor growth in the uterus breech presentation woman to avoid CS delivery
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 Ideal management esp : 5. Bleeding  Always an emergency situation bec the pressure of the fetal head
 Double foot 6. PIH against the cord at the pelvic brim leads to cardiac compression and
 Small or malformed pelvis 7. Supine hypotension syndrome decreased oxygenation to the fetus
 Very large fetus  Common after rupture of bag of water so check the vulva after
 Prev CS for CPD Assessment findings:
 Hyperextended or well flexed head  FHT >160 or <120 bpm Risk Factors
 Examples of anatomy call restrains that may restrict fetal movement  Meconium-stained amniotic fluid 1. PROM
into the vertex presentation would include:  Fetal hypermobility 2. Malpresentation
 Extended fetal leg 3. Placenta previa
 Placental implantation Complications: 4. Intrauterine tumors - preventing fetal part to be engaged
 Contracted maternal pelvis  HIE - Hypoxic ischemic encephalopathy 5. Small fetus
 Tumor  Cerebral palsy and other birth injuries 6. CPD - prevent firm engagement
 Certain fetal anomalies such as hydrocephaly and teratoma 7. Polyhydramnios
 Multiple gestation  Teach mother how to count kicks of baby 8. Multiple gestation
 fetus with altered mobility such as fetal neurologic impairments
and short umbilical cord are less likely to move into the vertex Medical Management Assessment Findings
 Vaginal delivery is possible but we need to make sure that the woman:  Cesarean section  Felt upon vaginal examination
 did not have any history of CPD  Often, the only way to stop fetal distress is to deliver the  In rare instances, the cord may be
 membranes are intact baby felt as the presenting part on an
 amniotic fluid is adequate initial vaginal examination during
 no complications such as fetal growth restriction, uterine bleeding, Management labor or can be visualized on
previous cesarean delivery, fetal abnormality, twin pregnancy,  Position in LLR ultrasound if one of these is taken
hypertension, fetal death.  Relieves pressure on the inferior vena cava which increases during labor.
venous return resulting in increased perfusion of placenta and  Cord prolapse is first discovered only after the membranes have
Shoulder presentation fetus ruptured = readily slips down then vagina, thus it is palpable
 Stop the oxytocin drip upon IE.
Risk factors  in some cases fetal distress could be caused by improper use of  Visible at the vulva - cord
 Pendulous abdomen oxytocin, analgesia, or anesthesia  Deceleration of FHR - unusually slow or variable deceleration
 Uterine fibroid tumors  Stop other drugs as well that is causes hyperstimulation  Assess FHR every rupture of membrane - to rule out cord prolapse;
 Congenital abnormality in the uterus  Administer oxygen - 6-7 L/min; per mask whether ROM occurs spontaneously or by amniotomy
 Premature infant  Correct hypotension -
 By elevating the legs, increase IV rate or increase hydration, Management - aimed at relieving pressure on cord to relieve compression
Management provided that the IV fluid is plain and with no oxytocin. and resulting fetal anoxia or decreased oxygenation to fetus
 Delivery thru CS  Turn then mother to her left if it is a case of vena cava  Assess FHR every rupture of membrane - to rule out cord prolapse;
 if the woman is in early labor and the membranes are intact then syndrome whether ROM occurs spontaneously or by amniotomy
attempt for external version could be done  Monitor FHT and heart rate of mother  Place gloved hand into the vagina and elevate fetal head off the cord
 Notify the physician  Position woman in knee-chest or Trendelenburg - to cause the fetal
Fetal Distress  Prepare for emergency CS if indicated head to fall back from the cord
 Emergency pregnancy, labor and delivery complication  Administer oxygen - 10 L/min by face mask to improve oxygenation to
 Baby experiences oxygen deprivation or birth asphyxia the fetus; tocolytic agent may be prescribed to reduce uterine
 May include changes in the: Umbilical Cord Prolapse activity and pressure on the fetus
 baby’s heart rate, could be tachycardic or bradycardic  a loop of umbilical cord  Amnioinfusion
 decreased fetal movement or hypermobility slips down in front of the  Another way to relieve pressure on the cord
 Meconium in the amniotic fluid presenting fetal part.  Isotonic fluid is instilled into the uterine cavity
 decreased fetal muscle tone  may occur at anytime  Primarily used as treatment to correct FHR changes caused
after the membranes by umbilical cord compression indicated by variable deceleration
Risk factors rupture if the presenting seen on CTG
1. Dystocia fetal part is not fitted  Do not push back the cord into the vagina
2. Cord coil or compression firmly into the cervix.  If the cord has prolapsed to the extent that it is exposed to
3. Improper use of oxytocin  The incidence is about 0.5% of cephalic birth but can rise as 10% or room air,drying will begin which leads to constriction and
4. Co-existing conditions of the mother higher with breech or transverse lies atrophy of the umbilical cord
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 Doing so adds compression by causing knotting or kinking  Longer/wider from front to back than android  High station or floating - even after significant amounts of contraction;
 Cover any exposed cord with gauze wet with sterile saline to prevent  Narrower than gynecoid fetal descent thru birth canal may be difficult; IE - if the station
drying  Some may be able to have NSVD but labor lasts longer would maintain w/in the negative part or it does not totally descent
 Cesarean section 4. Platypelloid even after strong contractions = CPD
 Done if the cervical dilatation is complete at the point where  make a vaginal birth difficult because the baby may having trouble  Prolonged and arrest of labor - Can result into oxygen deprivation
the cord prolapse occurred passing through the pelvic inlet.  Signs of fetal distress
 Birth method of choice = upward pressure on the presenting  need to have a Cesarean section.
part applied by a practitioner’s hand in the woman’s vagina Diagnosis
 History of vaginal delivery rules out
PASSAGEWAY  Pelvimetry
 Birth canal  Diagnosed if mother is a repeater of CS due to CPD
 Labor may be prolonged if the
mother’s pelvis is too small for the Complication
baby to pass thru or the pelvis is in  Hyperstimulation of oxytocin
an abnormal shape  One of the major problems of
CPD is that physicians may react
Risk factors by administering Pitocin or
1. Bony pelvis oxytocin in an effort to speed up
 Contracted - due to malnutrition delivery in regards to trial of
 Deformed - due to trauma or polio Cephalopelvic Disproportion (CPD) labor. Too much of this drug can
2. Soft tissue  One of the most common cause excessive and traumatic
 Tumour in the pelvis - or other physical obstruction in the problems of the passageway contractions which can cause
pelvis  there is a size mismatch between HYPERSTIMULATION
 Viral infection in the uterus or abdomen the mother’s pelvis and fetal head.  Prolonged labor - many doctors allowed labor to progress for too long,
 Scars  baby’s head is proportionally too labor is a trying time for the baby and if it is prolonged - oxygen
large of the mother’s pelvis is too deprivation injuries may occur; may lead to HIE, cerebral palsy,
small to easily allow the baby to fit developmental delays;
through the vaginal opening.  Trauma from continued labor may result to serious intracranial
 make the vaginal delivery hemorrhages
dangerous or impossible  Shoulder dystocia
 If an attempted vaginal delivery is unsuccessful, doctors should move  Shoulder dystocia injury - Erb’s palsy & Klumpke’s palsy
on to  More likely to happen if there is CPD
 Cesarean section. If they fail to do this, prolonged or obstructed labor  Umbilical cord compression
from CPD may result in birth injuries such as: Hypoxic Ischemic  when there is a decreased room in the uterus either because
Encepalopathy or HIE or Cerebral Palsy there is a large baby or small maternal pelvis.
 Common reason for CS  Oxygen deprivation may occur due to a trapped umbilical cord
Pelvimetry or Ultrasound
 Used to compare the size of the fetus to the woman’s pelvic capacity Risk Factors Management
 Used to identify the type of pelvis one has 1. Infertility treatment  True CPD cannot always be diagnosed before the beginning of labor, if
2. Maternal obesity medical professionals believe that they may be dealing with a case of
Types of Pelvis 3. Previous CS delivery CPD, but aren’t entirely sure, they may still attempt a VAGINAL
1. Gynecoid 4. Polyhydramnios DELIVERY.
 Ideal passage for childbirth 5. Gestational diabetes - result to macrosomic babies  Scheduled CS - Severe + diagnosed early = planned CS or scheduled CS
 Most favorable pelvis for vaginal birth 6. Postmaturity  Emergent CS after trial of labor
 Wide open shape = plenty of room for baby during delivery 7. Multiparity  So there will a TRIAL OF LABOR before warranting or
2. Android 8. Advanced maternal age choosing CS section. However, they should be prepared or quickly
 narrower shape of the android pelvis can make labor difficult 9. Short stature move into an emergency C Section or other interventions.
 baby might move more slowly through the birth canal. 10. Transverse diagonal measurement < 9.5 cm  Treatment for CPD varies for severity and when it is diagnosed
 may require a C section 11. History of childhood calcium deficiency or rickets  Symphysiotomy - surgical division of pubic cartilage or an emergencyC
3. Anthropoid section after trial of labor
 Elongated shape Assessment
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 Continued attempt to deliver the baby vaginally - trauma and  Injuries to baby’s shoulder, arms, or hands fetal arm until the forearm may be gripped and swept across the fetal
permanent injury of the baby  Vaginal or cervical tears - tearing of the mother’s tissues such as chest, delivering the posterior arm and shoulder.
 Can perform Trial of Labor esp if mother had CS in first pregnancy and cervix, rectum, or vagina
delivery and mother should be closely monitored  Cord compression
 C/I: TOLAC and NSVD = scheduled CS  Fractured clavicle of newborn POWER
 Brachial plexus injury - due to its compression Contraction phase
 consists of a descending gradient
Shoulder Dystocia Management  the wave begins in the fundus wherein there is the greatest number of
 baby’s head passes through the birth canal and their shoulder H-E-L-P-E-R-R myometrial cells then moves downwards through the corpus of the
becomes stuck during labor  guide for treating shoulder dystocia uterus.
 an obstruction during the delivery after the fetal head has extended  doesn’t have to be performed on the order listed to be effective  Intensity of the contraction diminishes from fundus to cervix.
but the shoulders are stuck. as long as all criteria are met  That’s why when you do your labor watch your hands should be
 prevents the doctor from fully delivering the baby and can extend  There are other maneuvers placed on the fundal area to feel the utmost contractions.
the length of time for delivery. depending on the doctor’s
 If this occurs the doctor will have to use extra interventions to help experience and mothers Retraction phase
the baby shoulder move through, so that the baby can be delivered preferred position  which is throughout the labor the upper uterine segment is more
 considered as medical emergency, the doctor must work quickly to  Managed by a lot of people active, contracting more
prevent complications related to this 1. Call for Help intensely and for a
 Not common bec once the head is delivered the shoulder will  doctor should ask for help longer time than the
follow such as assistance from other lower uterine segment
 Dystocia = difficulty in delivering; many reasons and it can come doctors and nurses  second part of the
from passenger, passageway and power 2. Evaluate for Episiotomy contraction
Episiotomy- an incision or cut in the perineum; does not solve the  after the muscles has
entire concern for should dystocia contracted it retracts as
Risk Factors 3. Legs: McRoberts Maneuver it relaxes by pulling up the cervix and lower uterine segment.
1. GDM  doctor asks the patient to pull her legs towards the  The upper uterine segment becomes thicker in time, while the
2. History of macrosomic baby - Large birth weight or macrosomia stomach/chest more passive lower segment become thinner.
3. History of shoulder dystocia  helps to flatten and rotate the pelvis which helps the baby pass  The synchronous nature of contractions is necessary for efficient
4. Labor induced through more easily dilatation and effacement of the cervix.
5. Obesity 4. External Pressure - suprapubic pressure  Women who are dehydrated frequently experience preterm labor
6. Post-term - giving birth after due date  pressure on a certain area on the pelvis to encourage the that can be stop by hydration.
7. Having an operative vaginal birth - uses forceps or vacuum to guide baby’s shoulder to rotate to an oblique position  Normal uterine contractions are like waves composed of:
baby thru birth canal 5. Enter: rotational maneuvers ■ Increment -the building of or ascending
8. Multiple gestation  this means helping to rotate the baby’s shoulders to where portion.
9. there are other women who have shoulder dystocia without having any they can pass through more easily ■ Acme - peak.
risk factors  internal rotation ( another term ) ■ Decrement - coming down or descending
 pressing the suprapubic downwards to facilitate the portion
Assessment shoulders to turn internally to an oblique position  A normal or an ideal contraction: maximum duration of 80 secs.
 Turtle sign - crowning but retracts during contractions 6. Remove the posterior arm from the birth canal And with a minimum relaxation of 2 mins.
 art of the baby’s head coming  If the doctor can free one of the baby’s arm from the birth  Any alteration with power may be brought about the OB score or
out of the birth canal, but the canal this makes it easier for the baby’s shoulder to pass through OB history of a pregnant women
rest of the baby isn’t able to be the birth canal
delivered 7. Roll the patient to her hands and knees Risk Factors
 fetal head first come out of the  this movement can help the baby to pass more easily 1. Primigravida
body but will then go back into through the birth canal 2. Pelvic bone contraction
the birth canal  ask mother to get on her hands and knees 3. Posterior fetal position or extension of fetal head
 Prolonged second stage of labor - due to obstruction 4. Failure of uterine muscle to contract
 Arrest of descent By passing one hand into 5. Nonripe cervix
the vagina along the 6. Full rectum or bladder
Complications posterior arm, the 7. Exhaustion from labor
 Hemorrhage - excessive bleeding in the mother practitioner may flex the 8. Inappropriate use of analgesia
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 if bowel or bladder distention prevents descent or firm  If deceleration in the fetal heart rate or FHR or an abnormally
Dystocia engagement long first stage of labor or lack of progress with pushing occurs,
 Difficult labor  pain relievers such as sedatives should be given if the mother cesarean birth may be necessary.
 prolonged difficult labor and/or delivery because of problems with the is greater then 3-4 cm cervical dilated.  Both the woman and her support person need to understand
factors of labor  may occur in a uterus that is overstretched by multiple that although the contractions are strong, they are ineffective or
gestation, a larger than usual single fetus, hydramnios or in a not achieving cervical dilatation.
Etiology uterus that is lack from a grand multiparity.
1. Hypotonic uterine contractions  not exceedingly painful because of their lack of intensity. Hypotonic uterine Hypertonic uterine inertia
2. Hypertonic uterine contractions  Keep in mind that however that a strength of a contraction is inertia
3. Dysfunctional labor subjective symptom, some women may interpret this Onset Late onset; active phase Early onset;latent phase
4. Pathologic retraction ring contraction as very painful. Contractions Weak, painless Strong, painful
 Aka Bandl’s ring  increase the length of labor because more of them are Tension not synch Uncoordinated, increased
 Appears during the 2 nd stage of labor necessary to achieve cervical dilatation. contractions but ineffective
 Indentation across the abdomen due to excessive retraction of the  can cause uterus to not contract as effectively during the post in bringing further
upper uterine segment partal period because of exhaustion increasing a woman’s dilatation
 Upper part has thicker myometrium chest for post partal hemorrhage Causes Overdistention, Primigravidity, young age,
 Passive area tends to be longer and taller  In the first hour after birth following a labor of hypotonic advanced age, increased injudicious use of oxytocin
contractions, palpate the uterus and assess lochia every 15 parity, contractures,
mins. to ensure that post partal contractions are not also fetal malposition,
hypotonic and therefore inadequate to halt bleeding. analgesia/anesthesia
Treatment Enema, walking, Sedation
Third CTG strip - hypertonic uterine inertia amniotomy, oxytocin
Hypertonic contractions
 marked by an increase in resting tone to more than 15 Stage of Labor Dysfunction Nullipara Multipara
millimeters mercury Prolonged 20 hours and >14 hrs
 intensity of the contraction maybe no stronger than that
Latent Phase beyond
associated with hypotonic contractions.
Protracted 1.2 cm/hr 1.5 cm/hr
 tend to occurs frequently and are most commonly seen in the
Active Phase
latent phase of labor
1 st Stage Prolonged >3 hrs >1 hr
 occurs because the muscle fibers of the myometrium do not
Deceleration
repolarize or relax after a contraction thereby wiping it clean to
Phase
accept a new pacemaker stimulus
 may occur because more than one pacemaker is stimulating Secondary
contractions = they tend to be more painful than usual because Arrest of > 2 hrs
the myometrium becomes tender from constant lack of Dilatation
relaxation and the anoxia of uterine cells that results. Prolong <1.0 cm/hr <2.0 cm/hr
 woman may become frustrated or disappointed with her 2 nd stage Descent
breathing exercises for childbirth because such technique are Arrest of 2 hr 1 hr
ineffective with the type of contraction Descent
 Even in relaxation, pain is strong enough
 danger of hypertonic contractions = lack of relaxation 1 st Stage
First CTG Strip - ideal uterine activity during an active labor
between contractions may not allow optimal uterine artery 1. Prolonged latent phase
filling this could lead to fetal anoxia early in the latent phase of  occurs if the cervix is not ripe at the beginning of labor
Second CTG strip :
labor.  may occur if there is excessive use of analgesia early in labor
Hypotonic Uterine inertia  uterus is in a hypertonic state;
 most opt to occur during the active phase of labor,  Any woman who is pain sense is out of proportion to the
equality of her contractions should have both a uterine and fetal  Relaxation between contractions is inadequate and
 the resting tone of the uterus remains less than 10mmHg and contractions are only mild, therefore ineffective
the strength of contractions does not rise above 25 mmHg external monitor applied for at least 15 minutes to ensure that
the resting phase of the contraction is adequate and that the  One segment of the uterus may be contracting with more force
 may occur after the administration of analgesia especially if than the other segment
the cervix is not dilated to 3-4 cm fetal pattern is not showing late deceleration.
 Very slow contractions and it is note effective in further
cervical effacement
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 Management: helping the uterus to rest, provide adequate  Prior to the onset of labor, the junction between the lower and the  Maternal infection -leading cause; Illness or disease such as renal or
fluid for hydration and pain relief with a drug such as morphine upper uterine segment is slightly thickened ring. cardiovascular diseases and diabetes mellitus may be included
sulfate.  NORMAL: lower part of the uterus  PROM
2. Protracted Active Phase  ABNORMAL: apparent in the upper part of the uterus.  Bleeding - uterine abnormalities or overdistention
 Very slow progress  In abnormal and obstructed labors, after the cervix has reached full  Incompetent cervix
 usually associated with fetal malposition or CPD, although it may dilatation further contractions cause the upper uterine segment  History of preterm labor - spontaneous or induced abortion,
reflect ineffective myometrial activity. muscle fibers to shorten so the actively contracting upper segment preeclampsia, short interval of <1yr and between pregnancies
 prolong if cervical dilatation does not occur atleast becomes thicker and shorter.  Trauma, poor nutrition - due to low socioeconomic status, no
 1.2cm/hr = nullipara  The ridge of the pathologic ring of the bandl’s can be felt or seen prenatal care, lack of childbirth experience
 1.5 cm/hr in multipara rising as far as high up the umbilicus so upon assessment there  Extremes of age - decreased weight and less height
 if the active phase last longer than: could be the retraction ring inspected along the umbilicus level.  Excessive fatigue - lack of rest
 12 hrs in primigravida  The lower segment becomes stretched and thinner and if neglected  Smoking
 6 hrs in multigravida may lead to uterine rupture.  Emotional stress
 If the cause of delay is malposition or CPD = cesarean brith  Major pathology behind obstructed labor a circular groove 2. Fetal factors
3. Prolonged deceleration phase encircling the uterus is formed between the active upper segment  Multiple pregnancy
 If it most often results from abnormal head position and the distended lower segment.  Infections
 cesarean birth is frequently required  Due to pronounce retraction there is fetal jeopardy or even death.  Polyhydramnios
 Mvmt of fetus from negative station to 0 to positive will take time  Congenital adrenal hyperplasia
even if there is dilatation and contractions has been very strong  Fetal malformations
4. Secondary arrest of dilatation 3. Placental factors
 occurred if there is no progress in cervical dilatation for longer than  Placental separation
2 hrs,  Placental disorders
 CS birth is necessary
 Mother has been on 4 cm for more than 2 hrs or stuck in 5 cm for Complications
more than 2 hours  Prematurity
 Fetal death
2 nd stage - stage wherein fetus is being delivered  SGA/ IUGR
1. Prolong descent
 occurs if the rate of descent is less than 1.0 cm in nullipara and less Management
than 2 cm/hr for multi  Hospitalization to prevent premature delivery
 It can be suspected if the second stage lasts for than 2 hrs in a  Bed rest on LLR
multipara  Hydration - oral and parenteral route
 Fetus should be already crowning but descent and cervical opening  Monitor:
is very slow a. Contractions - q1-2 hrs to determine increasing/decreasing
2. Arrest of descent contractions
 no descent has occurred for 2 hrs nullipara and 1 hr in multipara b. V/S - major drugs employed can alter them
 10 cm but still not descending Hypertonic Uterine Contractions c. I/O
 There might be cord coil if everything is fine and there is still no Management d. Signs of infection
descent  Morphine sulfate or amyl nitrate - to alleviate pain e. Cardiac & respiratory status - for distress signs
 Failure of descent occurs when expected descent of fetus does not  Tocolytic agent - to halt contraction f. Cervical dilatation & effacement
begin or engagement or movement beyond 0 station does not  CS delivery g. Fetal well-being
occur h. Edema - pulmonary edema is a possible complication of tocolytics;
 if most likely the cause is CPD, cesarean birth is necessary Hypotonic Management early signs
 No contraindication to vaginal birth, oxytocin may be used  Administer oxytocin  Promote physical & emotional comfort - keep client informed of the
progress
Pathologic retraction ring ( Bandl’s ring) Preterm Labor  Administer Tocolytics(e.g. MgSo4, Terbutaline & Ritrodine) - to arrest
 Causes dystocia - A labor that occurs after the 20th week and before 37th week of labor by causing relaxation of the uterus; Toco - contractions; lytic -
 abnormal junction between the two segments of the uterus which gestation to stop or hold; to stop contraction; cannot administer if BOW has
is a late sign associated with obstructed labor. ruptured and dilatation and effacement is inevitable or very wide
 appears during the second stage of labor Risk Factors that fetus can already go down
1. Maternal factors Contraindications to arresting labor:
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 Advanced pregnancy not readily distensible and hypotonic contractions which can cause ● ensuring there is no pulsation between the two ties to prevent
 Ruptured BOW - prolonged rupture = higher risk for infection hemorrhage especially postpartum) transfusing newborn blood to the outside leading to
and mother could complicate w/ chorioamnionitis  Fetal - hypoxia, anoxia, sepsis, intracranial hemorrhage hemorrhage and shock.
 Maternal diseases  Allow placenta to separate naturally.
 Fetal distress Assessment findings: ● Wrap placenta, cord and baby together.
 Rh Isoimmunization and other fetal problems  Tetanic-like contractions ● Have the fetal side near to newborn.
 Administer corticosteroid (Betamethasone)  Rapid labor and delivery ● Place infant on mother’s abdomen or better encourage mother
 to enhance maturation of fetal lungs by stimulating the  Nullipara - 5 cm/hr to breastfeed to induce uterine contractions and for
production of surfactant when there are contraindication to  Multipara - 10 cm/hr reassurance that all is well.
arrest preterm labor.  Impending delivery ● institute measure as prescribes in the 3rd and 4th stage of
 Administer the ordered drugs according to protocol.  Desire to push labor.
 Assess effect of drugs on labor and fetus and monitor side  Strong contractions ● Handle delivery gently to prevent injury to the mother and
effects of drugs  Rupture membranes baby
 Surfactant - prevent lung collapse and help them breathe  Heavy bloody show  Perform Unang Yakap.
when they cry outside intrauterine  Bulging rectum
 Routine mgmt for <37 weeks labor  Severe anxiety Treatment
 IM  Episiotomy
 Client may be discharged once contractions have stopped and Management  Facilitate delivery
maternal and fetal conditions stabilized.  Never leave client.
 Monitor FHT q15mins - to detect the stress from fetal hypoxia Uterine Rupture
Health Teachings - to prevent recurrent preterm labor secondary to tetanic contractions  because of the stress of labor with extrusion of uterine content into
1. Maintain bed rest. - LLR  Provide emotional support. - by reassuring that you will stay. Explain the abdominal cavity.
2. Well-balanced diet: high in iron, vitamins, and important minerals precipitate labor in simple terms. Inform the client of what is  common among women
3. Continuation of oral medications as ordered happening. Provide care until the physician or help arrives. Assist who had history if
4. Frequent prenatal visits every week. the client in retaining a sense of control. Cesarean section and
5. Activity restrictions  Assist with delivery - never hold baby back. Put on sterile gloves if it happens along the
6. Chronic illnesses should be monitored while acute cases should be possible and if there is still time. incision of the previous
treated immediately.  Instruct client to pant and not to push. CS delivery.
7. Teach client on the observable signs and symptoms of preterm  Rupture the membranes if intact.  When it ruptures, the
labor and importance of prompt reporting to the physician when 1. gently flip the cord over the head with free hand if the cord is content of pregnancy
present. draped around the neck. may disperse
8. Establish psychological support 2. Use gentle pressure to fetal head upward toward the vagina to throughout the
prevent damage or injury to fetal head and vaginal laceration abdominal cavity
Precipitate Labor  Deliver head in between contractions.
 Last to 2-3 hours or less; very inevitable to stop it and reach hospital ● shoulders are usually born spontaneously after external Risk Factors
to deliver NB rotation. 1. Previous CS Scar - common cause
 Primigravida can also experience this ● If not, use gentle downward pressure to move anterior or contributory factor; uterus is
Risk Factors shoulder under symphysis pubis then use upward pressure for very weak and cannot sustain
1. Multiparity - most common and most important the delivery of posterior shoulder. pressure from contraction
2. Trauma ● Right after the head is delivered and before the shoulders are 2. Improper use of oxytocin
3. Large pelvis and lax soft tissues out, suction the mouth and nose using bulb syringe if available 3. Overdistention
4. Small fetus and if not, use towel to wipe blood and ,mucus from mouth 4. Strong contractions with
5. Labor induction - by oxytocin and ROM and nose. nonprogressive labor
6. Severe emotional stress  Support the fetal body during expulsion. 5. Abnormal presentation
7. History of precipitate labor - instruct mother to go to hospital if in term  Perform cord care. 6. Trauma
or experiencing signs of labor; more pregnancy = faster delivery ● If materials are available, clamp cord into places, and cut 7. Injudicious obstetrics -
between with the knife or scissors. application of forceps when the
Complications ● If there is no available instruments for cord clumping and cervix is not fully dilated, Second stage of labor, fundal pressure and
 Maternal - laceration, hemorrhage (secondary to premature cutting, just double tie using the cleanest possible piece of forced delivery of fetus with abnormality such as hydrocephalus
separation of placenta), infection, uterine rupture (if birth canal is cloth or string 8. Ill-advised podalic version
9. Multiple gestation
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 Normal placenta detached from the uterus and exits from the vagina  Resume oxytocin after placing the uterus back. - to trigger
Assessment Findings around half an hour after the baby is delivered. contractions and stop the uterus to inverting again
 Sudden acute abd pain and tenderness  placenta remains attached and its exit pulls the uterus inside out.  oxytocin should be administered after placing the uterus
 Cessation of contractions & FHT  In most cases, the doctor can manually detach the placenta and push back, and should not be given before or during the replacement of
● presenting part no longer felt through cervix. the uterus back into position. the uterus.
● A feeling in the mother that something happened inside her,  Occasionally, abdominal surgery is required to reposition the uterus.  Close monitoring in intensive care for few days may be
signs of external bleeding, signs of shock and presence of  Could cause severe bleeding necessary.
predisposing factors  Happens during placental delivery esp if the cord is too short wherein  Blood transfusion
 Shock - hypovolemic shock can happen inig bira kay ma apil ang uterus = bleeding and may lead to shock  Emergency hysterectomy. - surgical removal of the uterus.
 Antibiotics - to reduce risk of infection
Complications Risk Factors  Primary goal: REPOSITION UTERUS BACK INTO PLACE
 Shock 1. Long labor 1. Stop oxytocin - mugahi ang uterus nya dili mubalik sa orig; have to
 Maternal and fetal mortality 2. Use of muscle relaxants such as make uterus flaccid
 Infection - from traumatized tissues magnesium sulfate during labor 2. Push back uterus using fist and give oxytocin to statrt contractions
 Hyperstimulation esp if there is improper use of oxytocin 3. Short umbilical cord and stop bleeding
4. Pulling too hard of the umbilical
Management cord especially if it’s attached to
 Laparotomy - to deliver the fetus the fundus. - to hasten the
 Hysterectomy - for complete rupture although in most cases, the delivery of the placenta
uterus may be sutured and left in. 5. Placenta accreta - placenta had
 Blood transfusion and plasma transfusion invaded too deeply to the uterine
 IV fluid replacement wall
 Antibiotics 6. Presence of congenital abnormalities or weaknesses of the uterus
 Stay with the client and call for assistance. - if uterine rupture is
suspected There are different kind or uterine inversion is grade by its severity
 Position - TRENDELENBURG include: This is the manual replacing of the uterus, so using the glove hand of
POSITION; considered as 1. Incomplete inversion/First degree inversion – when the top of the the practitioner it will pushed back in to its original position in
shock position; elevate uterus or fundus has collapsed but the uterus hasn’t come through the making a fist to apply pressure maintaining its original position,
body so blood will perfuse cervix make sure not to administer oxytocin or any oxytocin drugs during
to brain 2. Complete/ second degree inversion – uterus is inside out and coming this process and it should be given after repositioning the uterus.
 Chest compression can also be out through the cervix
done to keep heart pumping 3. Prolapsed inversion – the fundus of the uterus is coming out of the
 Provision of warmth - notify physician and support person vagina
Amniotic Fluid Embolism
 Prompt IV infusion 4. Fourth degree inversion / total inversion – both uterus and vagina
 escape of amniotic fluid into the maternal circulation through the
 Prepare for immediate surgery protrude inside out. This occurs more commonly in cases of cancer than
placental site and into the pulmonary arterioles or veins and can
 Provide psychological support. child birth.
obstruct and circulation can stop and also heart so may go in arrest
 Risk for bleeding so should be treated same as shock patients
or shock
 Anxiety, lightheadedness or confusion, tachycardia, Management
 common among premature or normal rupture of membranes when
tachypnea, hypotension  Treatment options vary depending on individual circumstances and
there is amniotic fluid embolism starts from the moment the bag of
 Anaphylactic - severe allergic shock the preference of the practitioner but could also include
water rupture, abruptio placenta, and difficult labor,
 Hypovolemic shock, spinal cor dompression can cause shock  Attempts to reinsert the uterus by hand
 this is rare but usually fatal.
 ALWAYS PRIORITIZE THE VITAL ORGANS ESP THE BRAIN  administration of the drug to soften the uterus during reinsertion,  Mortality in the first hour in 25% of pregnant women with amniotic
 If there is a few oxygen perfusion in brain, the brain will  Administer IV fluid replacement esp if bleeding occurs fluid embolism is usually fatal for both the mother and baby, and
deteriorate and will not recuperate and heal anymore  Flushing the vagina with saline water so that the water pressure
this is considered an obstetric emergency.
 Long time of hypoxia or poor oxygenation in the blood = poor inflates the uterus and props it back into position
oxygenation to brain = brain cells die = never regenerate  Manual reinsertion of the uterus while the woman is under general
Assessment Findings
again anesthesia
 Acute dyspnea - respiratory distress
 Abdominal surgery - to reposition the uterus if all other attempts to
 Cyanosis
reinsert have failed
 Sudden chest pain
Uterine Inversion  Stop oxytocin and replace uterus manually.
 Pulmonary shock & edema
 It is the potentially life threatening complication of child birth.
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 Shock - circulatory collapse as a sign of shock Criteria  Maternal exhaustion
 DIC - secondary bleeding  Fully dilated  Medical diseases
 Ruptured BOW  Ineffective expulsive effort or poor progress
 Engaged head
Management  Empty bowel & bladder
 Cardiorespiratory support - treatment of choice; CPR  No CPD
 Oxygenation  Episiotomy Criteria
 Hydration - by administration by IV fluid and plasma, full blood  Anesthesia  Fully dilated - and if the doctor attempts vacuum extraction that it is
fibrinogen transfusion, monitoring fluid I&O, digitalis for feeling not fully dilated there is a significant chance of injury or tearing of
cardiac function Complications cervix, Cervical injury requires surgical repair and may lead to problem
 Heparin  Facial paralysis - trauma to facial nerve of NB and cause temporary in future pregnancies.
 Deliver: forceps- if the cervix is fully dilated paralysis; half of the face is crying while other half has flat affect or  exact position of the baby’s head must be known and the vacuum
vaginal if open and dilating well poker face should never be placed on the baby’s face or brow. The ideal position
 Continue monitoring of mother and fetus is very vital  Lacerations, Hemorrhage of the vacuum cup is directly over the midline on top of the baby’s
 Uterine rupture head.
In the institution in the measures to support life:  Uterine prolapse  Ruptured BOW
 Cystocele, rectocele - The membrane should be also ruptured to apply the vacuum
 Facial paralysis of the cup to the baby’s head; the amniotic membranes must be
1. place the mother on shock position as
newborn - Bell’s palsy ruptured. This usually occurs well before vacuum extraction is
indicated which is Trendelenburg
 Intracranial hemorrhage considered.
position and also turn the mother
 Skull fracture  Engaged head
towards the left to facilitate the
 Increase perinatal morbidity and ● Vacuum delivery is less likely to succeed if the baby is facing
perfusion of the blood towards the
mortality straight up and when the client is lying on her back.
fetus,
 Brain damage ● The baby’s head must be engaged within the birth canal.
2. oxygenate promptly,
 Tissue trauma ● The position of the baby’s head in the birth canal is measured
3. Maintain IV fluids, and blood transfusion,
 Cord compression in relation to the narrowest point of the child birth canal.
4. provide the administered drugs,
● The baby should be in the lower position.
5. inform family of the woman’s conditions,
2 types of forceps delivery ● Before vacuum extraction is attempted the top of the baby’s
6. provide support,
1. Low or Outlet Forceps Delivery- head is even with the ischial spine preferably the baby’s head
7. transfer to ICU when stabilized for close monitoring and intensive care
application of forceps on the fetal head has descended 1 to 2 cm below the spine. So the chances for
which is on the perineal floor the success of vacuum delivery increase. It also increases when
 HIE - NB head stuck in secluded portion in vagina so there will be 2. Mid Forceps Delivery - Wherein the the baby’s head can be seen at the vaginal opening during
damage in brain and then there will be disabilities that will fetal head is at the level of ischial spines. pushing
develop  Empty bowel & bladder
 No CPD
OPERATIVE OBSTETRICS Vacuum Extraction ● The baby should snugly fit to the birth canal there should be no
 procedures done to manage complications in labor and delivery  Vacuum-assisted Delivery CPD.
 procedure sometime done during ● There are times when the baby is too big or the birth canal or
Forceps Delivery the course of vaginal child the birth canal is too small for a successful delivery, attempting
 using obstetrics instruments such as forceps which consist of the blade, birth. a vacuum extraction in this situation will not all be unsuccessful,
shank, handle, and a lock  health care provider applies the but may result in complications.
vacuum which is a soft or rigid  Episiotomy - support perineum
Indications cup with a handle and a  Anesthesia (lesser than forceps delivery)- used together w/ episiotomy
 Second stage of labor – fetal distress & shorten the labor vacuum pump to a baby’s head  pregnancy must be termed or near term. The risk of vacuum extraction
 Abnormal presentation or arrested descent to help guide the baby out of the birth canal. is increased in premature infants. Therefore, it should not be
 Preterm labor  typically done during a contraction while the mother pushes. performed before 34 weeks in pregnancy.; forcepts can be used to
 to protect fetal head from injuries assist preterm infants
 Maternal exhaustion Indications:
 Medical diseases  Prolonged second stage of labor - fetal distress & shortened labor
 Ineffective expulsive effort or poor progress  Abnormal presentation or arrested descent Risks
 Preterm labor - to protect fetal head from injuries  Pain in the perineum
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 Vaginal tears  Vaginal infection: Herpes  Inhalation is used and then after the inhalation then the mother
 Lower genital tract tears needs to be intubated for continuous sedation
 Short term difficulty in urinating or emptying the bladder which could  Mother is sedated and medications are inhaled and will lose
be temporary Classical way (look like a vertical line from below the umbilicus down to consciousness
 Dysuria the hypogastric area) ; on emergency cases bec there is faster approach to  Only in medical emergencies and
 (Short term or long term) Temporary urinary or fecal incontinence fetus; done for placenta previa so there will be no trauma to the placenta not all the time
 Fetal scalp wounds
 High risk of getting the baby’s shoulder stuck after the baby’s head has
Low transverse incision (done transversely on the lower segment of the
been delivered (Shoulder dystocia)
uterus; most common; PFANNENSTIEL; faster healing; lesser blood loss
 Skull fracture Epidural catheter
 Bleeding within the skull  inserted into the epidural space
 Serious infant injuries after vacuum extractions are rare 1. Regional Anesthesia and part of the catheter is placed
 Caput formation - temporary ➔ Regional anesthetics, such as safe and it should be taped for
Epidurals and Spinal blocks, numb security (yellow rectangle). And
the area from the waist down and then on this yellow part here
allow the woman to remain awake (yellow circle), this is where the
Cesarean Section
during the surgery. doctor would administer the
 scheduled by the doctor in advanced by the due date or it may
a. Epidural medication on a regular period for continuous anesthesia
become necessary during labor because of emergency
 catheter or an epidural
catheter is inserted into the Management
1. Scheduled elective CS
epidural space, providing 1. Pre-operative- we need to follow reg prep for abd or pelvic surgery
➔ Common among women who has history of CPD, known to
continuous administration of such as:
have a transverse lie or pregnant client who have breech
the medication.  Deep breathing
presentation
 fine tube is inserted to a woman’s back, into a space  Incentive Spirometry
➔ Full breech - normal for it to have meconium staining due to
between the spinal cord and its outer membrane.  Turning
pressure in rectum
 The anesthesia medication moves through the tube into  Ambulation
2. Emergent CS
the woman’s back, and the flow of the medication can be  Informed consent
➔ Common in women who have undergone trial of labor or who
controlled.  GI Prep - NPO -post midnight
have tried labor however have encountered problem during
 usually maintained hours after or hours during 2. Intra-operative
the 1st stage of labor with fetal complications or distress
postpartum.  Skin preparation - to prevent infections
 Immediate effect but for a short while  Assist birth of infant
➔ Reason why DR is connected to OR  Done if doctor cannot estimate when the procedure will  Newborn care
be done 3. Post-operative
Indications: b. Spinal  Ensure patent airway, prevent respiratory obstruction, and equip
 Prolonged labor- it happens when a primigravida is in labor for  directed once into the spinal space the postpartal recovery room with suction and oxygen. If under
20 hours or more or 14 hours or more for mothers who have  anesthesia medication is injected in one single dose, intoa anesthesia, position the patient on her side, to promote drainage of
given birth before. Also for baby’s who are too large for birth, part of a woman’s spinal column. secretions.
slow cervical thinning, and carrying multiple babies which can  For this medication given can give a longer effect  Turn and assist with deep breathing every 2 hours
cause prolonged labor. compared to epidural anesthesia.  Monitor V/S q5 mins until stable, q15 mins for 1 hour and q 30 mins
 Abnormal positioning - does not follow ideal position  The pain relieving effects of a spinal block are almost until discharge to the post partal floor & I/O observe urine for
 Fetal distress; Birth defects - to reduce delivery complications instant and they last about 1-2 hours, after the injection, bloody tinge which is a danger sign of trauma to the bladder during
 History of CS - about 90% can deliver vaginally for next birth; which could cover the whole procedure of c-section. surgery
mothers who cannot perform VBAC needs to have repeat CS  No catheter and longer; used if doctor is sure that they will  Monitor uterine fundus - the fundus must be palpated by placing a
 Chronic health condition - heart dss or GDM; to prevent any be done in an hour hand to support the incision, but do not tamper with the abdominal
danger caused by NSVD  Maintain mother flat on bed after delivery dressing; ensure that it is firm
 Cord prolapse; CPD  Spinal headache - one of the complications; can cause  Regularly check dressing and perineal pad q 15 mins for at least 2
 Placental issues - dizziness hours. Do pad count or weigh pad if feasible
LOW LYING OR 2. General Anesthesia  Maintain fluid & electrolyte balance
PLACENTA  puts the woman to sleep and is  Give fluids after passage of flatus which is requirement for oral
ABRUPTIO frequently used for emergency intake and early resumptions of solids
 Multiple pregnancy CS such as cord prolapse.

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 Provide assistance during mother/father-infant interaction;  fear and anxiety
emotional support; promote bonding; be present during the entire Trial of Labor  A woman who is relaxed, aware of, and participates in the birth
initial BF time  A number of women would like to perform TOLAC or trial of labor process, usually has a shorter or less intense labor.
 Administer medications as ordered: after Cesarean Section. It is often those successful which can lead to  Other factors that affects psychological response of the mother
● Oxytocin - to ensure a firm fundus VBAC or vaginal birth after Cesarean Section. would include: childbirth preparation process or attending to
● Analgesics - to relieve post-operative pain  provide a shorter recovery period for the woman and could also prenatal classes.
● Antibiotics - prevent puerperal sepsis lead to lower health risk such as bleeding, infection and death.  This is considered to be a viable tranquilizer during the birth
 Encourage exercises process, which leads to decreased need for analgesics in
 Assess for complications such hemorrhage, infection and leg Trial of Labor after Cesarean Section labor.
thrombophlebitis ❖Indications:  support system
 Assist in regular repositioning of patient in bed with passive and  Low transverse incision or side-to-side incision in the  The husband’s presence in the labor and delivery unit, can
active leg exercises. uterus used for all CS birth provide emotional support which could lead to less anxiety,
 Assess for danger signs such as local redness, warm to touch  Client should not have health problems that would prevent less emotional tension and less pain perception.
swelling and pain. VBAC.  The attending nurse should provide a caring and supporting
 Evaluate using Homan’s sign or calf pain upon dorsiflexion of the leg  Normal position and presentation environment as well, by respecting the client and family’s
❖Contraindications: needs and attitude = therapeutic communication.
Exercise Time to Start  Classical incision  previous experiences could facilitate good psychological response
Foot & leg exercise As soon as possible, especially after  History of uterine rupture & surgeries. to labor and delivery.
epidural anesthesia, as peripheral  Previous delivery within 18 months.  Anticipation of pain can increase emotional tension, which could
circulation is sluggish – - risk for  History of 2 or more CS increase the pain perception.
DVT.  Pre-eclampsia; Post-term  Even though perception of childbirth pain is greatly influenced by a
Abdominal tightening, pelvic Can be practiced gently after 24 lot of psychosocial factors, there is a physiologic basis for
tilting/rocking, knee rolling hours. Management discomfort during labor as well.
➔ Monitor FHT & uterine contractions frequently.
Pelvic floor exercise, curl-ups, hip After 4-5 days when woman is ➔ Urge woman to empty the bladder every 2 hours so her urinary
hitching more comfortable. bladder is as empty as possible, allowing the fetal head to use
Strenuous keep-fit exercises, 10 – 12 wks. After surgery and only as much space as possible.
aerobics, competitive sports after ensuring that pelvic floor ➔ If after a definite period, 6-12 hours, adequate progress in
muscles are functioning effectively. labor cannot be documented, or if at any time fetal distress
occurs, the tolac will be discontinued and the woman will be
Rationale scheduled for Cesarean birth.
1. Foot & leg exercises - to improve circulation, reduce edema and ➔ It is also important to emphasize, but do not overstress, that it
prevent DVT. is best for their baby to be born vaginally.
➔ If the tolac fails and Cesarean birth is scheduled, provide an
2. Abdominal tightening, pelvic tilting/rocking, knee rolling - to explanation as to why Cesarean birth is necessary and why it
ease backache and flatulence, abdominal tightening tones, has become the best route for the birth of their baby
deep transverse muscles, which are the main support of the ➔ Provide psychological support.
spine and will help prevent backache in the future
PSYCHE
3. Pelvic floor exercises, curl-ups, hip hitching - to prevent stress  A pregnant woman’s general behavior and influences upon her also
incontinence affect labor progress.
 factors that make labor a meaningful positive or negative event
4. Strenuous keep-fit exercises, aerobics, competitive sports - to were identified
keep fit and help regain strength  cultural influences integrating maternal attitudes,
 how a particular society views childbirth,
 Always remember that the exercises  expectation and goals for the labor process whether realistic,
double leg lift and sit-ups should never be achievable or otherwise
performed. Avoid lifting, if inevitable keep  feedback from other people participating in the birth
the object as light as possible, and closer process.
to the body, bend knees and straighten  Pregnant women’s psychological responses to uterine
back. contractions
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NURSING CARE OF THE HIGH RISK POSTPARTAL CLIENT  Copious vaginal bleeding 2 nd degree
 Soft, boggy, non-palpable uterus - uterine atony  Skin and muscle of perineum; might extend deep into the vagina
Postpartal Hemorrhage  Incomplete placenta  Require stitches; heal w/in few weeks
 Excessive bleeding that reaches about 500mL or more  Obvious lacerations
 Can happen anytime after delivery up to 6 weeks  Bleeding from the wound
3 rd degree
A very crucial part of our assessment to check for vaginal discharges. We  Extend into muscle w/c surrounds anus or anal sphincter
always need to remember the different lochia that is expected  Sometimes require repair w/ anesthesia in an OR rather than DR
postpartum. Any deviation from the inclusion days wherein the lochia is  Longer than few weeks to heal
prominent would mean there could be possibly postpartum bleeding.  Complications: stool leakage and painful intercourse
0-4 days Bright red, heavy like a period, small/medium clots
5-8 days Red/pink, less bleeding, heavier when active, small clots 4 th degree
9-14 days Pink/brown, minimal loss, no clots  Most severe; extends thru anal sphincter into the mucous membranes
3-4 weeks White/cream, blood changes to discharge, no clots that lies the rectum
Do’s Use large and soft sanitary pads  Requires repair w/ anesthesia inside OR
Don’t’s Use tampons, use same pad for over 4 hrs to prevent  Lead to PP bleeding esp if it is not dealt immediately
infection
Early or Primary Postpartal Hemorrhage Management
 3rd stage of labor up to 24 hrs postpartum  Stay with client
 There should be no prominent blood clots or heavy bleeding
 Uterine atony - most common cause of postpartal bleeding  Fundal massage until firm
present which could mean postpartum bleeding.
Late or Secondary Postpartal Hemorrhage
 Deviation in lochia: blood clots on 10 days may be a sign for PP - 1 st nursing action to uterine atony; not too long bec this can
 After 24 hrs until 6 th week postpartum exhaust the muscles and have rebound contractions
bleeding -> assess for shock (lightheadedness, confusion)
 Usually caused by infection  Expel clots - avoid overmassaging as it can tire the muscles causing
relaxation
Risk Factors  Provide oxytocic drugs. (e.g. oxytocin, methergine, carboprost)
1. Uterine atony  Apply ice pack over hypogastric area & perineum. - reduce swelling and
2. Over distention brought about by multiple pregnancy reduces pain & bleeding
3. Diabetic pregnancy  Promote bladder emptying. - to keep the uterus contracted; let mother
4. Polyhydramnios void on her own if capable; use straight catheterization if not capable
5. Effect of anesthesia - General anesthesia that causes uterus to be  Initiate early breastfeeding. - perform nipple stimulation to stimulate
atonic oxytocin secretion by the posterior pituitary gland
6. Multiparity  Check v/s and fundus q15 mins
7. Precipitate labor - brings excessive contraction in less than 1 hr causing  Keep all pads and linens to assess the volume of blood loss
uterine muscle an insufficient opportunity in strength to contract  Assess & estimate blood loss frequently.
8. Prolonged difficult labor resulting in uterine inertia.  Notify the physician. - for repair of lacerations and retained
9. Placenta previa which is the lower uterine segment that is not membranes; or D&C
contractile as the upper fundal portion  Maintain asepsis - hemorrhage predisposes the mother to infection
10. Abruptio placenta wherein it could cause Couvelaire uterus and  Monitor I&O
prevent normal uterine contractility.  Fluid and blood replacement and oxygen administration
11. Incomplete placental separation which causes inefficient contraction Four degrees of vaginal tears:  Be alert for blood reactions
and retraction  Occurs when the baby’s head is coming thru the vaginal opening  Provide psychological support. - explain test procedures to help deal
12. Lacerations - operative obstetrics such as forceps for management of and is too large for the vagina to stretch around or the head is in w/ anxiety
the second stage of labor, precipitate labor, and large fetus, and abnormal normal size but the vagina but the vagina doesn’t stretch easily  Increase iron diet and to adhere to follow-up care schedule
position  Kinds of tears are relatively common
13. Retained placental fragments - caused by injudicious 3 rd stage of labor Puerperial Infection
and adherent placenta which may cause some membranes to be retained;  Any infection of the reproductive organs that occurs between the
1 st degree
subinvolution first 6 weeks after child birth or 1st week after abortion.
 Involves only the perineal skin (skin between the vaginal opening and
14. Large size of the fetus  Usually localized in the endometrium causing endometritis.
rectum) and tissue directly beneath the skin
15. Incomplete placenta\Bleeding from the wounds  Postpartum infections are the leading cause of nosocomial infection
 Manifest: pain or stinging directly beneath the skin during urination
 Might or might not require stitches; typically heal within a few weeks and maternal morbidity and mortality.
Assessment
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 Kind of infection would vary depending on the area where infection  Obesity  Promote drainage or secretions
is present or its manifestation: fallopian tube, ovaries, within uterus,  DM  Position: Fowler’s or semi-fowler’s
within cervix which could result to cervicitis  Immunocompromised - HIV, chorioamnionitis, long-term steroids (oral  Teach regarding perineal hygiene
or IV), poor prenatal care  Handwashing before and after touching the perineum
Criteria  Previous CS delivery  Front to back removal of sanitary napkins
 Fever on any 2 days of the first 10 days postpartum, excluding the  Lack of cautionary antibiotics or preincision anitmicrobial care  Frequent changing of napkins
first 24 hours after delivery which is more or less due to  Long labor or surgery  Diet modification - nutritious, high calorie, high protein, and high
dehydration  Excessive blood loss during delivery or surgery iron
Etiology  Promote comfort
 Bacterial - both aerobic and anaerobic (Streptococci; most common)  Positioning
 E. Coli Signs & Symptoms  Make sure that the client doesn't feel cold, use heat or cold as
 Abd pain indicated to relieve localized pain
Risk Factors  Redness & swelling in the incision site  Prevent or relieved common discomforts of the puerperium
 Prolonged labor that lasts more than 18 hours  Pus Drainage & pain on incision site  Find a restful environment
 Route of delivery: CS over NSVD - single most significant risk of  Foul-smelling discharges
postpartum infection is 20x greater in CS than in NSVD due to  Bleeding that soaks the dressing or that contains blood clots Evaluation of Episiotomy Healing
colonization of immunity  Fever, painful urination REEDDA
 Frequent IE - procedures in prolonged labor with frequent vaginal  Leg pain or swelling  instrument designed to measure the healing process of the
examination perineum following an episiotomy and/or laceration during
 Internal fetal monitoring Assessment Findings childbirth
 Prolonged delivery after ROM - > 24 hours  Fever, chills, tachycardia  Can be implied to any incision
 Positive amniotic fluid culture - Escherichia coli and Klebsiella form  Changes in lochia color, amount, odor, and consistency  Each part of the REEDDA should be assessed accurately and
amniotic fluid culture  Painful/uterine fundus regularly for the medical health team to monitor the involution or
 History of infection - UTI and STD  Subinvolution the recovery of the woman’s postpartum
 Prenatal factors - obesity, anemia, and malnutrition  Delayed uterine involution R - redness
 Body malaise, anorexia, headache, dysuria E - Edema
 Burning sensation on urination E - Ecchymosis - bruises
 Costovertebral tenderness D - Discharges
D - Drainage
Management A - approximation of wound edges - edges of the wound fit snugly
 Antibiotics
 1 st line treatment for puerperial sepsis Endometritis
 Prevention in early treatment of anemia in pregnancy  inflammation of the uterus lining = endometrium
 Start with ordered antibiotics immediately after appropriate  usually due to an infection during postpartum
specimen is obtained  usually not life threatening but it is important to get it treated as soon
 Broad spectrum antibiotics directed at multiple organism as possible
often are administered  Generally goes away with antibiotics
Take note:  Adequate treatment of dystocia and PROM with antibiotics  Occurs together with the inflammation of the cervix (cervicitis)
❖The bacteria could be coming from the vagina and it goes up the uterus  Maintain bedrest and islotae mother from the NB  This condition may or may not cause symptoms
and it could affect the fallopian tube and lastly, the ovaries.  Strict asespsis in handling labor and delivery
 Prevention of lacerations as much as possible Signs & Symptoms
Postpartum fever:  Administer analgesics as ordered  Abdominal swelling
1. Dehydration  Good management of 3 rd stage to prevent retention of membranes  Abnormal vaginal bleeding and discharges
2. Breast engorgement  IV fluids containing calories and electrolytes in CS when  Pelvic pain or in lower abd area and rectal area
3. Postpartum sepsis appropriate  Constipation
 Standard precaution & careful handwashing  Discomfort during bowel movements
Wound Infection  Hygiene and proper attire of personnel is important and  Fever
 May happen on incisions done after CS or on episiotomies with personnel with s/s should be assigned to render direct care  fatigue
NSVD  Monitor v/s and I/o
 Increase oral fluids - force fluids up to 3000-4000 ml
Risk Factors  If not C/I, encourage frequent voiding
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Etiology
 Infection from the uterine cavity or the placental site into the pelvic
and femoral vein
Thrombophlebitis  Circulatory stasis esp if mother tends to be bed ridden or stays
 Inflammation of the vain resulting in vascular occlusion of vessels, non-ambulatory PP
Urinary Tract Infection
pelvis, or lower extremities  Hypercoagulability - increase post delivery coagulability of blood from
 Pelvic floor muscles help in keeping the urethra closed so that the
 Thrombophlebitis is caused by infection from the uterine cavity or progesterone effect
urine does not leak.
the placental site into the pelvic and femoral veins.  Trauma of childbirth
 During labor, these muscles go into an overdrive along with the
 It can also be caused by circulatory stasis (especially if the mother  Lack of activity
ligaments, nerves and muscles of the lower abdomen.
tends to be bedridden or stays nonambulatory postpartum  Clot formation in pelvic veins following by CS
 Excessive wear and tear during delivery can lead to injury and
 Increased postpartum delivery coagulability of blood, progesterone  Clot formation if calf of leg due to poor circulation
trauma to this set of muscles and ligaments. These might
effect, trauma of childbirth, lack of activity, clot formation of pelvic
subsequently fail to do their job as they did pre-labor.
veins following cs and clot formation in calf of legs due to poor Risk Factors
 Pregnancy might also cause the bladder to lose its tone, making it
difficult for women to empty their bladder. Urine is more
circulation  Bedrest or prolonged immobility
susceptible to flow back to the ureters and the longer the urine  CS - operative delivery
stays in the urinary tract, the higher the chances of bacteria to
Superficial Thrombophlebitis  Multiparity & advanced age over 30 yo
 Common from 4-10 days PP  Obesity
multiply, hence, higher vulnerability to infection.
 Mild fever or slight pyrexia  Estrogen therapy - for suppression of lactation
 If the woman is in pain after delivery or does not void due to
 Tender varicose vein; Swelling; Hardness; Redness  History of thrombophlebitis
activity restrictions then the mother could suffer from UTI
postpartum
Deep Vein Thrombosis Complication
 Manifest during the 1st 2 weeks after delivery  Pulmonary embolism - most common; passage of thrombus usually
Signs & Symptoms  Calf pain/Positive Homan’s sign originating in one of the uterine or other pelvic veins into one of
 Pelvic & abd pain  Edema and swelling of the leg 2-3 cm larger than the non-affected the lungs where it disrupts circulation of blood causing embolism
 Inflamed bladder and urethra leg and death
 Strong urge to urinate but only urinates a few drops  Pain, fever & chills
 Dysuria, polyuria Management
 Foul odor urine Assessment findings  Early ambulation - preventive measure
 Chills, fever & fatigue, body pain  Mild fever  Avoid pressure behind the knees - avoid crossing of the legs and
 Burning sensation while urinating  Tender varicose vein constricting garters
 Generalized body pain  Swelling, hardness, redness  Maintain bedrest
 Positive Homan’s sign  If using bed cradle to support linens and beddings by elevating the
 Edema affected leg or hip, apply heat or warm compress for 15-20 minutes;
 Fever & chills use support bandage or stockings
 administer antibiotics or anticoagulants as ordered
 Heparin - most commonly used anticoaglulant
 Analgesia except for aspirin - for pain; aspirin alters clotting and causes
bleeding
 Do not massage the affected area - legs; to prevent clot dislodgement
and pulmonary embolism
 Allow client to express feelings and fears; provide support

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 Monitor for signs of complications or pulmonary embolism. Such as  is gradual and may occur 2 weeks postpartum and may last up to 3 - no audible heartbeat or if cardiac rate is below 80 bpm
sign of small pulmonary embolism to 6 months with incidence of at least 1 out of 10 postpartum  closed chest massage should be started
 sudden intense chest pain, women  a combination of lung ventilation at a rate of 30 times
 marked distress, per minute should be continued
 severe dyspnea, Acute Postpartum Psychosis  interchange of cardiac massage at a ratio of 1:5.
 pallor or cyanosis,  has low incidence, it is divided into depressed and manic types  need to monitor transcutaneous oxygen or pulse
 hemoptysis, Syncope,  Symptoms typically begin 2-3 days after delivery. oximeter to evaluate respiratory function in cardiac
 apprehension,irregular thready pulse,  The period of highest risk for developing postpartum psychosis is efficiency
 diaphoresis, signs of shock, sudden collapse. within the first month after delivery 3. Maintenance of fluid and electrolyte balance
 If the client is undergoing heparin therapy, it is important to - After initial resuscitation attempts
monitor the client for signs of bleeding and make sure to have Risk Factors  hypoglycemia may result from the effort of the
Protamine sulfate which is an antidote for heparin  Mental illness - prior newborn expended to begin breathing.
 Stress - stresses of pregnancy or delivery, physical health problems, - Dehydration may result from increased insensible water loss from
Postpartal Psychologic Maladaptation stresses of near responsibility of parenthood, separation of maternal rapid respiration.
 Postpartum period is a demanding period characterized by and neonatal problems - Fluids such as Lactated Ringers or Ringer Lactate or 5% dextrose in
overwhelming biological, physical, social and emotional changes  Physical problems water
 It requires significant personal and interpersonal adaptation  Social factors - lack of support system, low socioeconomic status,  to maintain fluid and electrolyte level
especially in case of primigravida disturbed family relationship, surfacing of deep feelings about female  Electrolytes sodium and potassium and glucose are
 Pregnant women and their families have lots of aspirations from myth and concepts added as necessary depending on the electrolyte
the postpartum period which is colored by the joyful arrival of the analysis.
new baby. Management - fluid demand or fluid administration must be carefully maintained
 Unfortunately, women in the postpartum period can be vulnerable  Execute early recognition of the problem because of high fluid intake can lead to heart failure.
through a range of psychiatric disorders like postpartum blues,  Explore potential resources that the client and family might use to - Using also radiant warmer, increases water loss from convection
depression and psychosis. reduce the stress of parenthood and
 Perinatal mental illness is largely under diagnosed and can have far  Maintain contact with infant - radiation.
reaching ramifications for both the mother and the infant.  Support positive parenting behaviors - give feedback as much as  Newborn on warmer therefore, will require more fluid
 Early screening diagnosis and management are very important and possible than one who were placed in double walled
must be considered as mandatory part of postpartum care  Administer psychotropic medications as ordered incubators
 Offer positive feedback to improve self-esteem 4. Control of body temperature
Postpartum Postpartum Postpartum Psychosis  Refer to other health team members or agency to improve the - Any high risk infant may have difficulty maintaining normal
Blues Depression resources of the client or the family temperature in addition to stress from an illness or immaturity
Manifestations Fluctuating Depressed Depressed and manic,  Prognosis of postpartal maladaptation is good but may recur after an infant’s body is often exposed during procedures such as
mood, mood, Delusions/hallucinations subsequent pregnancies and recurrence may happen with chances of resuscitation and blood drawing.
sadness, feeling of 33-51% - It is important to keep newborn in a neutral temperature
crying loss environment, so one that is neither too hot or too cold, as
Onset Within 2 2 weeks PP 2-3 days PP up to 1 WEEK 5: NURSING CARE OF THE HIGH-RISK NEWBORN doing so places less demand on infant to maintain a minimal
weeks PP up to 3-6 month Priorities in the First Days of Life metabolic rate necessary for effective body functioning.
months 1. Initiation and maintenance of respirations - To prevent newborn from becoming chilled after birth:
Etiology Hormonal Lack of Reactivation of psyche - establish the airway and maintain respiration, a.wipe infant dry
changes support disorder - most deaths occurring during the 1st 48 hours after birth result b. cover the head with a cup and
from newborn’s inability to establish or maintain adequate c.place him/her immediately under a prewarmed radiant
Postpartum Blues respiration. warmer or warm incubator
 also known as baby blues and maternity blues - An infant who has difficulty accomplishing effective respiratory d. establish skin to skin contact against the baby's skin to
 More on hormonal actions in the 1st hour of life and yet survive many experience the mother’s skin to establish thermoregulation
 it is a very common but self limited condition that begins shortly residual neurologic dysfunction because of cerebral hypoxia,
after childbirth and can present with a variety of symptoms such as we need to be prompt and thorough care is necessary for
mood swings, irritability and tearfulness effective intervention 5. Intake of adequate nourishment
 Mothers may experience negative mood symptoms mixed with 2. Establishment of extrauterine circulation - An infant who experience severe asphyxia at birth usually receive
intense periods of joy - lack of cardiac functions may be present concurrently or may intravenous fluid so they do not become exhausted by sucking
develop if respiratory function cannot be quickly initiated and
Postpartum Depression maintained
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- there are times that because of the temporary reduction in oxygen - Healthcare personnel with an infection has a professional and - For example : birth defects, seizures, cerebral palsy, mental delays,
of the bowel, this will result to NECROTIZING ENTEROCOLITIS moral obligation to refrain from caring for newborns. permanent brain damage or even death to the baby
 this is a condition in the bowel that we need to 8. Establishment of an infant-parent relationship
prevent intake of fluids through the bowel - Be sure of parents of high-risk newborns are kept informed of what Primary Apnea
- If the infant’s respiratory rate remains rapid, and NEC has been is happening during resuscitation at birth. - when an infant is deprived of oxygen, initially, rapid breathing
ruled out, gavage feeding may be introduced - They should be able to visit the special nursing unit to which the occurs.
- preterm infant should be breastfeed if possible. child is admitted as often as they choose. - If the asphyxia continues:
- If it is not possible then mother can express her breastmilk and use - We need to inform them that they have to wash their hands, gown  the respiratory movements cease
those milk to initiate feeding. and hold and touch their child. This helps to make the child’s  heart rate begins to fall,
- We need to increase the feeding according to its demand and birth more real to them  neuromuscular tone ceases
caloric needs - Should the child not survive with the illness, this interaction can - in order to counter primary apnea we need to:
6. Establishment of waste elimination help make the death more real.  Tactile stimulation and exposure to O2 will induce
- most immature infant - Only the birth and death seem real can help parents begin to work respiration
 void within 24 hours of birth, through their feelings and help the parents begin truly accept
 they may void later than term newborn because due this event. Secondary apnea
to all the procedures that may be necessary for - All parents handle newborn babies tentatively until they have - if asphyxia continues, baby develops:
resuscitation, their blood pressure may not be claimed them or have become better acquainted.  deep gasping response
adequate to optimally supply their kidneys, - urge parents to spend time with the infant in the intensive care or  Heart rate continues to fall ( there will be significant
 so carefully we need to document any voiding that nursery as the infant improves and is able to begin interacting bradycardia)
occur during resuscitation, this is a proof that with them  BP begins to fall.
hypotension is improving and the kidneys are being - Be sure they have access to healthcare personnel after discharge to  unresponsive to stimulation
perfused. help them care confidently to the child at home  will not spontaneously resume respiration unless PPV
 may pass stool late than term infants, because 9. Institution of developmental care (positive pressure ventilation) is initiated
meconium has not yet reached the end of the - Most high risk infants experience catch up growth once they
intestine by birth. stabilize from the trauma of birth or whatever caused them to Nursing Intervention
7. Prevention of infection classified as high risk. 1. From the time the baby is delivered, we get the apgar score
- Contracting an infection could drastically complicate a high risk - They quickly move to playing with age appropriate toys, some right away, as soon as we observe the apgar score is very poor,
newborn ability to adjust in the extrauterine life. parents needs support before and after their infant are  nasal flaring , bluish discoloration of the body and the
- Infection, like chilling, increase metabolic demand, which stress the discharged at home to begin and view them well and capable
absence of cry.
of doing all the things they are now capable of doing
baby out.  Within the 2 minute period we need to resuscitate right
- Remember that newborns have immature immune system so they - anticipatory guidance help them to be ready for next
away.
are prone to infection. developmental steps.
2. Fetal Resuscitation
- Infection stresses the immature immune system and already stress a. Establish an airway (establish a patent airway)
defense mechanism of a high risk newborn BIRTH ASPHYXIA
- Make sure there is no obstruction, we need to clear off all the
- the baby can be exposed to an infection through prenatal, - condition in which the baby does not receive or get enough oxygen.
secretions from the mouth and nose to help expand the lungs,
perinatal, or even postnatal causes. - With that deprivation of oxygen this can lead to brain suffering to
with the patent airway we are also helping the baby to breathe
- So some instances, such as preterm or premature rupture of the baby and in prolonged period this can also cause death to
and initiate breathing thus by this the lungs will expand.
membrane the baby.
b. Expand the lungs
 infection that places an infant in an high risk - This can occur before delivery, or before labor, during and after
c. Initiate and maintain effective ventilation
category. delivery.
- If the baby has no effort in beathing, we have to do positive
- Others also from viruses that affect infant in the utero. - perinatal asphyxia or neonatal asphyxia
pressure ventilation.
 Cytomegalovirus, toxoplasmosis virus. - insult to the fetus or newborn due to lack of oxygen or lack of
- We have to initiate and maintain effective ventilation.
 Infant with either of these infection may have born perfusion to various organs
with congenital anomalies from the virus invasion. - The problem of birth asphyxia is deprivation of oxygen, with this
> Nursing management:
- AGAIN, infant has low immune system and we need to be very the cell cannot sustain that status.
Stimulate the newborn
careful to prevent an infant in contacting infections.  This builds up waste products, acids to the cell causing
- tactile stimulation or stimulate the newborn by drying the baby,
- All persons coming in or in contact with infant must observe good temporary damage, could also be permanent
touching the baby. We need to wake up the baby.
handwashing technique and standard precautions to reduce damage to the brain of the baby
Suction
the risk of infection transmission. - In prolonged periods, this damage can cause lifelong disabilities to
- the baby is covered with secretions so we need to suction those
the baby.
secretions and remember that this baby is asphyxiated we

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have to clear off everything that blocks the airway. (clear - Gain access to lungs to give oxygen
mouth and nose) - Anticipate that the tube is connected to the oxygen and that the
Sniffing position oxygen should be readily available and it should be warmed
- ideal position in performing intubation. and humidified.
- the head of the baby is extended and the neck of the baby is flexed - Also, we have to make sure that the O2 sat established or good O2
saturation.
- We have to hook the baby to a O2 saturation instrument
- Continuously monitor or auscultate the heartbeat of the baby and
anticipate that after the insertion of the endotracheal tube, a
chest x-ray will be ordered to ensure proper placing of the Pulse Oximeter
endotracheal tube. - May be able to detect the heart rate of the baby as well as the O2
Oral Gastric Tube (OGT) saturation.
- Inserted after the airway management for feeding.
- And we expect that the distress that baby is facing, the baby will With the stress that the baby is facing during resuscitation, it is expected
have a problem in thermoregulation so we have to set up a that infants will have problems in thermoregulation. As mentioned, we
1. Simple head extension have to prepare radiant warmer or machine that can help regulate the
radiant warmer and the baby will as well go to hypoglycemia
o extend the head. temperature of the baby. One of that
so we have to monitor for the capillary blood glucose level
o no shoulder roll or headrest for babies is:
2. make sure that the glabella (the part between the brows of the Radiant warmer
baby) and the chin are horizontally aligned. - A standee wherein there’s a probe that is attached to the baby to
3. Make sure that the neck should be open. continuously monitor the temperature of the baby.
4. External Auditory Meatus of the ear and the sternal notch are
horizontally aligned Isolette or incubator
Attach to pulse oximeter - serves a good thermoregulating machine, help in thermoregulation
- In order to monitor the O2 saturation on the temperature of the baby
APGAR scoring
- continues to do this until the baby will have a good score
Airway management
- these are sets of maneuver or medical procedures that is Altered gestational age/Fetal growth abnormalities
performed to prevent and relieve airway obstruction. This  Term infants
ensures an open pathway of gas exchange between the px/s APGAR Score
 Preterm infants
lungs and atmosphere - taken 1 min and 5 min after birth.
 Post term infants
- Newborns are observed and rated according to its APGAR.
 AGA (appropriate gestational age)
Fetal Resuscitation - An APGAR Score standardized infant assessment at birth and

➔ APGAR Score
SGA (small for gestational age)
- serves as a baseline for future evaluation.

➔ Airway management - heart rate, respiratory effort, muscle tone, reflex and irritability, LGA (large for gestational age

➔ OGT - and color of the infant.

➔ Radiant warmer - Each rated as 0, 1 and 2.
➔ Hypoglycemia
- The 5 scores are then added
- newborn that has a total score of below 4 is in serious danger and
In the event that the baby does not respond to any of the stimulation
needs resuscitation;
being performed by the doctors or the nurses, you need to anticipate and
- a score of 4-6 means the infant’s condition is guarded and the baby
be ready that the doctor will have to do the fetal resuscitation or the
may need clearing of airway and supplemental oxygen;
airway management.
- a score of 7-10 is considered good, indicating that the infant’s score
is high as 70%-90% to all infants at 1-5 mins afterbirth.
Instrument:

Laryngoscope
- a light can be found at the end of the tip which serves as a guide
and helps the doctor in viewing the part where the
endotracheal tube is inserted so that we can establish a patent
airway.
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- deviation in expected fetal growth pattern, caused by multiple o One risk of having large amount of oxygen is
adverse conditions pulmonary edema and retinopathy of
- not all IUGR infants are SGA. prematurity
- Failure to achieve potential size. ● Monitor intake and output
- These babies (IUGR baby) are considered pathologic - in preterm infant, intake and output is very strict
- we need to be very accurate in getting the I&O of the baby.
PRETERM INFANT o I&O monitoring should be every 2 hours in absolute figures.
- is usually defined as a live born infant, born before 37 weeks ● Feeding schedule
gestation - feeding of the preterm infant.
- less than 2,500 grams and about 5 lbs/8oz - If the baby is born <28 weeks
- Ballard scoring o nutritional need of the baby can be addressed
 we get the physical and neurologic score in order to through intravenous fluid.
determine if the baby is term, preterm or post term - If the baby is born 28-32 weeks
o inserted with OGT (Orogastric tube) where
Clinical Manifestation feeding can be done.
- 32-34 weeks
on the bottom, you will see week of gestation and on the right side, you Size o feeding can be introduced through cup feeding
will see weight in grams. This chart will be used to assume or will show - comparison of the person’s palm and the size of the baby. - 34 weeks and above
that the baby’s growth is appropriate or if it’s showing an appropriate sign - The preterm infant is very small, almost the same size as the palm o the baby can now have breastfeeding as long as
by its gestational age. Constantly the baby is monitored through of an individual. it is tolerated.
ultrasound during intra uterine life. One of the data that is Disproportionate large head - Feeding may be safely delayed until an infant has stabilized his/her
collected in the utz is the estimated weight. By the estimated weight, you - the head is bigger than the body of the baby respiratory effort from birth.
can also get the AOG so you can also monitor the weight of the baby if it’s Ruddy skin - Preterm infant may be feed by total parenteral nutrition until they
appropriate. - skin is generally ruddy because the infant has little subcutaneous are stable enough for other means (OGT, cup feeding and
 If the baby falls below the 10th percentile (the curve line, niya underneath it breastfeeding)
below ana (second line)) = small for gestational age - veins are easily noticeable. - Caloric need
 if the baby’s weight is above the 90%, then the baby is Large acrocyanosis o Preterm infant : 115-140 calories per kilogram of body
expected to be large for gestational age. - high degree of acrocyanosis may be present weight per day.
 If in between, then the baby is appropriate for its gestational Extensive lanugo o Term infant : 100-110 calories per kilogram of body
- the lanugo will usually cover from the back, forearm of the baby, weight per day
age
forehead of the baby and the sides of the face of the baby. - Protein requirement :
Few or no creases on soles of feet o Preterm: 3-3.5 grams per kilogram of body weight
Classification of Size:
- the sole and the palms of the baby would feel very smooth and soft o Term: 2-2.5 grams per kilogram of body weight
SGA
because of the little to no creases on this type of baby - A preterm infant has a small stomach capacity, this baby can't take
- small for gestational age-weight below 10th percentile.
a large feeding so feeding schedule would be more frequent
- Note not all SGA are the same with IUGR.
Nursing management: with smaller amount.
- Can be a small baby and can have a normal growth.
- Usually if we deal with preterm labor our goal would be to hold - Feeding may be as small as 1 or 2 mL every 2-3 hrs
- One good example is that when parents are small, you will expect
that the baby will also be small, as long as there are no growth the pregnancy so that the baby will be able to survive in the
extrauterine life ●Thermoregulation:
restrictions in the intrauterine
AGA ● Emergency CS - preterm infant’s skin has less fat so they are prone to heat loss.
- weight between 10 and 90th percentiles - if incase the baby will go into distress. Preterm infants are monitored closely for the temperature and
- (between 5lb 12 oz (2.5kg) and 8 lb 12 oz (4 kg) - In preterms, a lack of lung surfactant makes them extremely they should be placed under radiant warmer.
vulnerable to respiratory distress syndrome.
LGA o Surfactant will be produced at 34 weeks INTRAUTERINE GROWTH RESTRICTION (IUGR)
- weight above 90th percentile gestation - IUGR babies are babies who fail to achieve potential size
o Before the 34 week gestation and the baby will - Growth curve: these babies falls below the tenth percentile
be delivered early, the baby will be attached
to supplemental oxygen so this baby will be Causes for IUGR: maternal and placental
IUGR (intrauterine growth retardation/restriction) bombarded with oxygen. 1. Maternal:
o substance abused mother
o mother who’s taking medications
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o mother with medical condition like diabetes mellitus and - Commonly nurses, midwifes, an obstetrician would recommend - also termed macrosomia
hypertension inducing labor at 2 weeks postterm to avoid post mature birth, - if the birth rate is above the 90th percentile on an intrauterine
o Mother is exposed to TORCH infection however when gestational age is miscalculated or for some growth chart for that gestational age.
2. Placental causes: other reason labor is not induced until 43 weeks of pregnancy, - appears deceptively healthy at birth because of the weight, but a
o Insufficiency in the placenta – placenta was not able to or after the pregnancy may result in a post-term infant. gestational age examination often reveals immature
penetrate well, poor perfusion to the placenta can lead to - Infants who stay in utero past 42 weeks are at special risk because a development.
intrauterine growth restriction placenta appears to function effectively for only 40 weeks. - It is important that LGA infants be identified immediately so they
- After that time, it seems to lose its ability to carry nutrients can be given care appropriate to their gestational age rather
Difference between IUGR and SGA (small for gestational age) effectively to the fetus, and fetus who remains to the uterus than being treated as term newborns.
IUGR - has a pathologic cause with a failing placenta may die or develop postterm syndrome.
SGA - no pathologic cause Postterm Syndrome Etiology:
- Infants with this syndrome demonstrate many of the characteristics 1. Infants who are LGA have been subjected to an overproduction
Clinical Manifestation of IUGR of the SGA infant: of nutrients and growth hormone in utero.
- Infant has an overall wasted appearance o dry, cracked, almost leather-like skin from lack of fluid 2. This happens most often to infants of women who are obese
- Poor skin turgor and an absence of vernix caseosa. or who have diabetes mellitus.
- appears to have a large head because the rest of the body is so o They may be SGA or light weight due to weight loss o Extreme macrosomia in fetuses of diabetic
small. that occur due to poor placental function mothers whose symptoms are poorly
- Skull sutures may be widely separated from lack of normal bone o amount of amniotic fluid surrounding them may be controlled
growth. less at birth than usual at new and it may be o Fetus exposed to high glucose level
- Hair is dull and luster less. meconium stained. 3. Multiparous women may also have large babies because with
- Abdomen may be sunken - Fingernails have gone well beyond the end of the fingertips, each succeeding pregnancy babies tend to grow larger.
- cord often appears dry and may be stained with yellow because they are older than a term infant, 4. Beckwith-Wiedemann syndrome, a rare condition
- Small liver - which may cause difficulty regulating glucose, protein - demonstrate alertness much more like a two week old baby than a  characterized by general body overgrowth
and bilirubin level after birth newborn. 5. congenital anomalies, such as omphalocele, may also be a
- Blood studies for IUGR babies - At birth, the postterm baby is likely to have difficulty establishing cause.
 High HCT: lesser amount of plasma in proportion to respirations, especially if meconium aspiration occurred.
the level of RBC present due to the lack of fluid - In the first hour of life Hypoglycemia may develop Assessment:
present in the intrautero. o because the fetus may use stores of glycogen for nutrition or - If a fetus is suspected of being LGA when a woman's uterus appears
 Polycythemia nourishment in the last week of intrauterine life. to be unusually large for the date of pregnancy. Abdominal size
o increase in the total number of RBC is due to a - Subcutaneous fat level may also be low, having been used in the can be deceptive, however. Because a fetus lies in the flexed
state of anoxia during the intrauterine life utero. fetal position, he or she does not occupy significantly more
o causes increased blood viscosity that puts extra o loss of fat can make temperature regulation difficult, making space at 10lb than at 7lb.
effort in the infant’s heart because it is more it important to prevent a postterm infant from becoming - If an infant's large size was not detected during pregnancy, it may
difficult to effectively circulate thick blood chilled at birth or during transport. be first recognized during labor when the baby appears too
o Extreme: vessels may actually become black and - Polycythemia may have developed from decreased oxygenation in large to descent through the pelvic rim. If this happens as a
thrombus formation can result. the final weeks. cesarean birth may be necessary because shoulder dystocia
- Acrocyanosis o The hematocrit may be elevated because polycythemia and (The wide fetal shoulders cannot pass; or need significant
 blueness of the hand and feet dehydration have lowered the circulating plasma level. manipulation to pass through the outlet of the pelvis) would
 prolonged and persistent and more marked than Nursing Management: halt vaginal birth at that point.
usual. - Make certain a woman spends enough time with her newborn to
- Hypoglycemia assure herself that although birth did not occur at the Complications:
 one of the most common problem in IUGR ) predicted time the baby should do well with appropriate - After birth LGA infants may show immature reflexes and low
 due to decrease glycogen stores intervention to control possible hypoglycemia or meconium scores in gestational age examinations in relation to their size.
 need intravenous glucose to sustain blood sugar until aspiration - Babies may have extensive bruising or a birth injury such as a
they are able to suck vigorously enough to take - all postterm infants need follow-up care until at least school age to broken clavicle or Erb-Duchenne paralysis from trauma to the
sufficient oral feeding track their developmental abilities because the lack of cervical nerves they were stressed in order for the wide
nutrients and oxygen in utero may have left them with shoulders to be born vaginally.
neurologic symptoms that will not become apparent until they - Caput succedaneum
attempt fine motor tasks o appeared in a large LGA baby because of the
POSTTERM INFANT pressure.
- born after the 42 week of a pregnancy. LARGE-FOR-GESTATIONAL-AGE (LGA)
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o There is extensive or more pressure than usual  this results in decreased lung compliance and unstable on the alveolar surface thus leads to severe
during birth. alveoli. acidosis.
o With pressure it forms edema to the loose - Surfactant - are produced normally until the 34th week of gestation - Proteinaceous debris leaks into the membrane thus
connective tissue wherein there is buildup of  Decreases the surface tension acidosis causes vasoconstriction and decreased
fluids in the connective tissue and extends  To promote lung expansion during inspiration pulmonary perfusion from vasoconstriction further
across the numbers of sutures  To prevent alveolar collapse and loss of lung limits the surfactant production.
o disappears within 24 hours volume at the end of expiration 4. Surfactant Deficiency
- Cephalohematoma  Facilitates recruitment of collapsed alveoli - with decreased surfactant production, the ability to
o ruptures of blood vessels in the subperiosteal layer, a - Incidence: stop alveoli from collapsing with each expiration
buildup of blood under the periosteum.  60-80% of babies born at 28 weeks - are very becomes impaired.
o Build up does not pass through sutures; one location susceptible to developing this complication - This vicious cycle continues until oxygen-carbon
only (RDS) dioxide exchange in the alveoli is no longer
o Disappears 2-3 days  15-30% of babies born 32-36 weeks - are also adequate to sustain life without the ventilator or
- Molding susceptible to having Respiratory Distress eventually this will lead to respiratory failure and
o Takes places on fetal skull; changes in the shape of the Syndrome death.
skull of the baby in order to pass through the birth  Rarely in those above 37 weeks - Debris collected impairs the function of the already
canal Etiology: little surfactant
- Rebound hypoglycemia - Prematurity
 LGA infants also need to be carefully assessed for - Meconium aspiration syndrome - due to poor or decreased blood Signs and Symptoms:
hypoglycemia in the early hours of life because perfusion to the lungs o Expiratory grunting
large infants require large amounts of nutritional - Pneumonia - due to closure of the glottis that creates a prolonged
stores to sustain their weight. expiratory time
 If the mother had diabetes that was poorly controlled Increased incidence of RDS in preterm babies: o Nasal flaring
(the cause of the large size), the infant would have Term Babies - have storage pool of approximately 100 mg/kg of o Central cyanosis in room air
had an increased blood glucose level in the utero to surfactant at birth o Tachypnea
match the mother's glucose level; this caused the Preterm Babies - have a storage pool of approximately 4-5 mg/kg - more than 60 respirations per minute
infant to produce elevated levels of insulin to surfactant at birth o Substernal and subcostal retractions
counter hyperglycemic environment
 After birth, these increased insulin levels will continue Pathophysiology of Respiratory Distress Syndrome Diagnosis:
for up to 24 hours of life, possibly causing rebound 1. Breathing o Chest x-ray
hypoglycemia - is compromised in this condition due to high pressure, - will reveal a diffused pattern of radioptic areas that
it’s required to fill the lungs with air for the first looks like a ground glass or haziness
Nursing Management: time to overcome the pressure of lung fluid. o ABG (Arterial Blood Gas)
- Breastfeed the baby immediately - If alveoli collapse with each inspiration, as to what - or blood gas studies are taken from an umbilical vessel
happens when surfactant is deficient. catheter which will reveal respiratory acidosis
RESPIRATORY DISTRESS SYNDROME (RDS) - Forceful inspiration are still required to inflate them
- Also called hyaline membrane disease that is why there is repetitive reopening and Therapeutic Management:
- Most common cause of respiratory distress in preterm infants. overdistension in the absence or little surfactant o Surfactant
- infants of diabetic mothers, infants born by cesarean birth or those causes the Lung damage - From an endotracheal tube at birth for infants at risk
for any reason who have decreased blood perfusion of the - Shear stress in the alveoli and terminal bronchioles because of low gestational age
lungs, such as newborns with meconium aspiration. due to repetitive reopening of collapsed alveoli and - Synthetic surfactant
- The pathologic features of RDS is a hyaline like (fibrous) membrane overdistension of the open alveoli  is sprayed into the lungs by a syringe or
formed from an exudate of an infant's blood that begins to line 2. Lung Damage through endotracheal tube at birth
the terminal bronchioles, alveolar ducts, and alveoli. - poor oxygen exchange leads to tissue hypoxia which while the infant is positioned with the
 This membrane prevents the exchange of oxygen and causes the release of lactic acid head held upright and then tilted
carbon dioxide at the alveolar-capillary membrane, - forces damage to the fragile lung architecture downwards
interfering with effective oxygenation. 3. Hyaline Deposits - It is important that the infant’s airway is not suctioned
 The cause of RDS is the low level or absence of - this lactic acid combines with carbon dioxide level for a long period as possible after administration to
surfactant, the phospholipid that normally lines the resulting from the formation of hyaline membrane avoid suctioning the drug away
alveoli and reduces surface tension to keep the o Oxygen Administration
alveoli from collapsing on expiration
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- Is necessary to maintain correction of PO2 and pH  steroids appears to quicken the formation of
levels lecithin, so it may be possible to prevent RDS Therapeutic Management:
- Continuous Positive Airway Pressure (CPAP) or assisted in infants by administering to injections of o Infant should be suctioned with bulb syringe or catheter while
ventilation with Positive and Expiratory Pressure glucocorticosteroids such betamethasone to at the perineum before the birth of the shoulder to avoid
(PEP) will exert pressure on the alveoli at the end of the mother at 12 & 24 hours during this time; aspiration
expiratory, and keep the alveoli from collapsing  most effective when given between 24-34 o There is still dispute as to whether all infants with meconium
- Greatly improves oxygen exchange weeks of pregnancy stained fluids needs intubation.
- Complications: Retinopathy of prematurity  there is still a warning that preterm birth is o Those with severe staining are intubated and meconium is
o Airway Management imminent hours before birth suctioned in the trachea and bronchi
- need to attach the baby to endotracheal tube and  steroids does not take effect before 24 hours or o Amnioinfusion - can be used to dilute the amount of
attach to a ventilator 48 hours so some labor and birth will progress meconium in the amniotic fluid and reduces the risk of
o Extracorporeal Membrane Oxygenation (ECMO) too rapidly for this preventive measure to be aspiration
- First developed as means of oxygenating blood during effective o CS – after deeply meconium stained, amniotic fluid becomes
cardiac surgery evident during labor
- currently used and has expanded to management of MECONIUM ASPIRATION SYNDROME o Oxygen administration and assisted ventilation
chronic severe hypoxemia in newborns with - Meconium is present in the fetal bowel as early as 10 - do not administer oxygen under pressure or bag and
illnesses such as meconium aspiration, RDS, weeks gestation mask until infant has been intubated and suctioned
pneumonia, diaphragmatic hernia - An infant with hypoxia in utero experiences vagal so that the pressure of oxygen does not drive small
- Also used for near-drowning victims or infants with reflex relaxation of the rectal sphincter which then clogs of meconium further down into the lungs
severe lung infections release meconium into the amniotic fluid which worsens the irritation and obstruction
- Blood is removed from the baby by gravity using a - Babies born through breech presentation may expel o Antibiotic therapy – to slow development of pneumonia as a
venous catheter, advanced into the right atrium of meconium into amniotic fluid from pressure of the secondary problem
the heart then the blood circulates from the buttocks o Pharmacologic
catheter to the ECMO machine where it is - Green to greenish black amniotic fluid due to staining o if lung noncompliance is poor, surfactant may be administered
oxygenated rewarmed so it is then returned to the - Meconium staining occurs in 10-12% of pregnancy o Maintain a temperature-neutral environment to prevent the
infant’s aortic arch by a catheter advanced through - Does not tend to occur in extremely low birth weight infant from having to increase metabolic oxygen demands
the carotid artery infants because the meconium has not passed deep o Chest physiotherapy
- Used for 4-7 days enough in the bowel for it to be at the rectal - with clapping and vibration may be helpful to
- Has many potential complications such as intracranial sphincter encourage removal of remnants of meconium from
hemorrhage possibly from the anticoagulants; - May aspirate meconium in utero or within the first the lungs
anticoagulant therapy is necessary to prevent breath after birth o Extracorporeal Membrane Oxygenation (ECMO) - to ensure
thromboembolism - Cause severe respiratory distress in 3 ways: adequate oxygenation
- Constant nursing care is required for a child receiving  Inflammation of bronchioles
ECMO to ensure that the child’s blood volume because it is a foreign substance Complication
remains adequate  Blockage of small bronchioles by o If lung noncompliance continues, this may necessitate high
- Bleeding should not occur and adequate oxygen is mechanical plugging inspiratory pressure
supplied to body tissue  Decrease in surfactant production - This causes pneumothorax or pneumomediastinum
Prevention which leads to lung cell trauma (air in chest cavity)
o Rarely occurs in term indants - Overall, this causes hypoxemia, carbon dioxide - Observe infant closely for signs of trapping air in the
o Dating a pregnancy by sonogram retention, intrapulmonary and extrapulmonary alveoli because the alveoli can expand only so far
o Documenting the level of lecithin in surfactant shunting and then will rupture, sending air into the pleural
 obtained from amniotic fluid exceeds that of - Secondary infection of injured tissue may lead to space (pneumothorax)
sphingomyelin by 2:1 pneumonia o Ductus arteriosus remains open and this can occur because of
 important ways to certain an infant born by - Infant with meconium stained amniotic fluid will have increased pulmonary resistance which causes blood to shunt
cesarean birth or has labor induced is mature difficulty establishing respiration at birth from the pulmonary artery into the aorta and compromising
enough that RDS is not like to occur Signs and Symptoms: cardiac efficiency and increasing hypoxia
o Using tocolytic agents such as magnesium sulfate or o Low APGAR score - because almost immediately, tachypnea, - To detect this, observe and infant closely for signs of
terbutaline retractions and cyanosis occurs heart failure such as increased heart rate or
 can help prevent preterm birth for a few days o Retractions respiratory distress
because o Barrel chest
o X-ray - bilateral coarse infiltrates
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 Sleeping Prone Blood group
- Typically, infants are well nourished Mother Rh negative O
- Parents may report an infant may have slight head Fetus Rh positive A or B
cold after being put to bed or for a nap. Infant is Pregnancy Usually second Usually first
found dead a few hours later. affected More antibody circulating
- Infants who die this way do not appear to make any to destroy new baby’s
sound as they die: indicates death due to blood
Laryngospasm Severity Severe Mild
- Many infants are found with blood-flecked sputum or Blood smear Erythroblastosis Spherocytosis
vomitus in their mouth or in their bedclothes DCT Strongly positive Weakly positive or
- autopsy often reveals petechiae in the lungs and mild negative
inflammation and congestion in the respiratory
tract Etiology: incompatible RH and ABO
- these symptoms are not severe enough to cause
sudden death Signs & Symptoms:
Diagnosis o Coombs Test
- diagnosis of Exclusion (rule out all other cause) - Positive Direct Coombs tes: detecting antibodies on
- Autopsy should be performed the fetal erythrocytes in cord blood by
Risk Factors: percutaneous umbilical blood sampling at birth
- For the baby: - indirect: Rh incompatibility: rising anti-Rh titer or
o How they sleep antibody in the mother during pregnancy
o Male neonate (more prone to develop SIDS) o Enlarged liver & spleen
o 2-4 months - due to the attempts to destroy blood cells
o Formula feeding o Edema
o Premature baby and underweight - If the number of RBC has significantly decreased, the
o Low birth weight blood in the vascular circulation may be hypotonic
- For the mother: to interstitial fluid.
^Meconium Aspirator o Little to no prenatal care
- attached to a suction machine, in another side it is - Fluid will shift from lower to higher isotonic pressure
o Teen mother by osmosis
attached to an endotracheal tube (where deep o Smoking during pregnancy
suctioning is performed and is Inserted through the - May be extreme
o Drinks Alcohol(Addtn’l:) o Severe anemia
trachea and bronchi) o Closely spaced pregnancies
- Deep suctioning done so that meconium stained - can result in heart failure
o Tween Native-American Infants - heart has to beat fast to push dilute blood forward
amniotic fluid will be aspirated o Alaskan-Native Infants o Hydrops fetalis - is an old term for appearance severely
o Economically disadvantaged black Infants involved infant at birth
SUDDEN INFANT DEATH SYNDROME (SIDS) o Narcotic-dependent mothers
- Crib Death (other term for SIDS): - Hydrops refers to edema
- Sudden, unexplainable death during 1st year of Life - Fetalis refers to the lethal state
How to prevent: - Pathologic accumulation of at least two or more
Etiology: 1. Use of firm sleep surface
- unknown cavities with a collection of fluid in the fetus
2. Breastfeeding o Pathologic jaundice
- postulated theories in addition to prolonged and 3. Room sharing without bed sharing
unexplained apnea - occurring within the first 24 hours of life; will begin
4. Routine immunization indicating in both ABO & Rh incompatibility that a
- Others include: 5. Consideration of using a pacifier
 Viral or Respiratory Ptyalism Infection 6. Avoidance of soft bedding, overheating, and exposure to
hemolytic process is at work
 Pulmonary Edema - This is due to a RBC has been destroyed & indirect
tobacco,smoke, alcohol, and illicit drugs bilirubin has been released.
 Brainstem abnormalities, Neurotransmitter 7. Supine position
deficiencies - Indirect bilirubin - a fat soluble that cannot be
 Heart Rate Abnormalities excreted in the body
ABO/RH INCOMPATIBILITY - Under usual circumstances, the liver enzyme
 Distorted Familial Breathing Pattern Rh Hemolytic Disease of ABO Hemolytic Disease glucoronyl transferase converts indirect bilirubin to
 Decreased Arousal Response Newborn of Newborn direct bilirubin
 Possible Lack of Surfactant in the alveoli Frequency less common More common
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- Direct bilirubin – mater-soluble and combines with bile  as the antibody to A & B cells are naturally occurring antibodies  Scheduled for phototherapy when the
for excretion from the body through feces or are present from birth in individuals whose red blood cells total serum bilirubin rises to 15 mg/dL at
- In preterm infants or those with extreme hemolysis, lack this antigen 24-48 hours of age
the liver cannot convert all of the indirect bilirubin  These antibodies are of large class and does not cross the - Preterm newborns:
produced into direct bilirubin fast enough, so placental barrier (this refers to Immunoglobulin M or IgM)  Treatment begun at levels as low as 10-12
jaundice occurs  An infant with ABO incompatibility is not born anemic mg/dL
compared to RH sensitized child o Exchange transfusion
o Hypoglycemia  Hemolysis of blood begins with birth when the blood and - Use of intensive phototherapy in conjunction with
- infant needs to use glucose stores to maintain antibodies are exchanged during the mixing of maternal-fetal hydration and close monitoring of serum bilirubin
metabolism in the presence of anemia which causes blood as the placenta is loosen. levels has greatly reduced the need for exchange
progressive hypoglycemia, compounding the initial  Destruction of RBC may continue up to 2 weeks of age. transfusions
problem  Preterms do not seem to be affected by ABO incompatibility - Preferred method for neonatal jaundice
o A decrease in hemoglobin during the first week of life to a level  this may be because of the receptor site for anti- A & - Despite all of these have been exhausted and still the
less than that of the cord blood is a later indication of blood anti- B antibody which does not appear to the RBC bilirubin level continues to rise, exchange
loss or hemolysis until late in fetal life). transfusion may be necessary
o Green stool o Even in mature newborn, the direct Coomb’s test may be only - Before transfusion procedure, the baby’s stored milk is
- because of excessive bilirubin being excreted as the weakly positive because of few anti-A & anti-B sites present aspirated to minimize risk of aspiration from
result of phototherapy o Reticulocyte count manipulation
o Dark urine  Immature or newly formed red blood cells - Umbilical vein is catheterized as the site for
- because of urobilinogen formation when exposed to  Usually elevated as the infant attempts to replace transfusion
photo therapy destroyed cells - Alternating withdrawing small amounts of infant blood
of about 2-10 ml and replacing it with equal amount
A baby can suffer RH incompatibility: mother is RH - & baby is RH + Nursing Management: - all may be IMMEDIATE measures to reduce of donors blood;
 Example: The mother is RH - & baby is RH + in which the RH bilirubin levels of infants affected with Rh or ABO Incompatibility - Blood is exchanged slowly to prevent alternating
positive contains the D antigen. o Early breastfeeding hypovolemia and hypervolemia
 Introduction of the fetal blood cells causes - Bilirubin is removed from the body by being excreted - A lengthy procedure of about 1-3 hours
sensitization to occur and the mother begins to through the feces - Automatic pumps are helpful to perform the
form antibodies against that D antigen. - The sooner the bowel elimination begins, the sooner exhausting repetitive ritual
 Most form in the mother’s blood stream in the first 72 bilirubin removal begins - At the end of the procedure, using the last specimen of
hrs. after birth because there is an active exchange - Stimulates bowel peristalsis the blood are withdrawn, hematocrit, bilirubin,
of fetal-maternal circulation or blood as placental o Phototherapy electrolyte (esp calcium, glucose) are determined
villi loosens and placenta is delivered. - Fetus’s liver processes little bilirubin in utero because and blood culture is also taken
 After the sensitization, during the 2nd pregnancy, the mother’s circulation does this for the fetus - May need to be repeated because additional
there will be a high level of antibody D circulating - Exposure to light is believed to trigger the liver to unconjugated bilirubin from the tissue moves into
the mother’s blood stream in which this will act to assume this function the circulation after initial exchange
destroy the fetal blood cells early in pregnancy, if - Additional light supplied by phototherapy appears to o Erythropoietin
the new fetus is RH POSITIVE. speed the conversion of unconjugated (fat-soluble)
Nursing Considerations:
into conjugated (water-soluble) bilirubin
ABO incompatibility: the mother is Type O & the baby is either Type A, B, o Protect eyes and genitalia
- Exposes the infant to continuous specialized light
or AB - Put on eye patches to avoid damage on the retina and
- quartz halogen, cool white daylight or blue fluorescent
 More common light at 12-30 inches above the bassinet or
genital patches
 Theoretically, there is no connection between fetal & maternal incubator - Monitor the baby to see if the eye patch is properly in
circulations (no fetal blood cells can enter into the maternal - special fiber optic lights system incorporated into the place to avoid suffocation
circulation) fiber optic blanket also have been developed and is - Prolonged exposure to bright light causes damage to
 In actuality, occasional placental villi breaks and a drop or two deal for home care (biliblanket) retina
of fetal blood, enters the maternal circulation (this is where the - infant is undressed except for a diaper to protect the o Frequently feed
problem begins) ovaries or testes so as much skin surface is exposed - Remove from under the light for feeding so that he or
 Infants with Type B blood have the most serious cases. as possible she continues to have interaction with the mother
 Hemolysis can become a problem with the first pregnancy in - Term newborns: - in addition to supplemental feeding, formula may be
which there is an ABO incompatibility recommended to prevent dehydration
o Promote mother and child interaction
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- Removal of the eye patches while the infant is with the virus and a number of infants will develop liver - For Ophthalmia neonatorum
mother, this gives an infant a period of visual cancer later in life. o Bath baby immediately (HBsAg+ mother)
stimulation and other way this can also promote - To reduce the possibility of HBsAG being spread to - Bath immediately to remove the secretions and blood
mother and infant interaction newborns nowadays, infants are routinely from the baby
o Thermoregulation vaccinated at birth o HBIG + HBV
- Monitor the temperature because exposure to - If the mother is identified as a HBsAG positive, the - Babies are given vaccines and immune serum globulin
phototherapy can have a radiation, convection,heat infant is also administered immune serum globulin for protection
loss and transfer of heat within 12 hours of birth to decrease the possibility o Acyclovir (Herpes simplex)
- The temperature can be very crucial so that's why we of infection - For herpes simplex, Acyclovir is given
need to make sure that the baby’s ❑ Generalized Herpes Virus Infection o Antenatal prevention
thermoregulation is established - Herpes simplex virus type 2 infection is the most - Follow antenatal management in order not to transfer
- Assess skin turgor and intake and output to ensure prevalent among women with multiple sexual the infection to the baby
dehydration is not occurring from the warm partners
environment It can be contracted by a fetus across the placenta if INFANT OF MOTHER WITH DIABETES MELLITUS
the mother has active or primary infection during - An infant of a woman who has diabetes mellitus whose
ACQUIRED MATERNAL INFECTION pregnancy illness was poorly controlled during pregnancy is
- Newborns are susceptible to infection at birth because - Often, the virus can be contracted from vaginal typically longer and weighs more than other babies
of their ability to produce antibody is immature secretions of a mother who has active herpetic (macrosomia).
- Many infections in newborns: Toxoplasmosis rubella, vulvovaginitis at the time of birth. - The baby also has a greater chance of having a
syphilis, cytomegalovirus infection which are spread ❑ HIV Infection congenital anomaly such as a cardiac anomaly, as if
some to fetus across the placenta in utero. - Human immunodeficiency virus infection and hyperglycemia is teratogenic to a rapidly growing
- Other infections are contracted from exposure to acquired immunodeficiency syndrome or AIDS can fetus.
vaginal secretions at birth. be caused by placental transfer or direct contact - Caudal regression syndrome
❑ Group B Beta-Hemolytic Streptococcal Infection (GBS) with maternal blood during birth o hypoplasia of the lower extremities
- The major cause of infection in newborn. o syndrome that occurs almost exclusively
This is a gram-positive bacterium and is naturally an Diagnosis in such infants.
inhabitant of female genital tract o Blood culture Signs & Symptoms
- It may be spread from baby to baby if good hand washing o Cushingoid or fat and puffy appearance
technique is not used in handling newborns. Signs & Symptoms o Lethargic or limp in the first few days of life as a result of
- If a mother is found to be positive with GBS during late - Symptoms would commonly manifest as hyperglycemia
pregnancy, ampicillin administration is given pneumonia-like symptoms. o Macrosomia
intravenously at 28 weeks and again during labor to help - Early signs of pneumonia become apparent within the - Results from overstimulation of pituitary growth hormone
reduce the possibility of newborn exposure. first day of life as well as tachypnea, apnea, and and extra fat deposits created by high levels of insulin
❑ Ophthalmia Neonatorum signs of shock: during pregnancy.
- eye infection that occurs at birth during the first o decreased urine output o Severe hypoglycemia
month o extreme paleness - Immediately after birth, the infant tends to be
- most common causative organism is Neisseria o hypotonia- muscles are relaxed. hyperglycemic because the mother was at least
gonorrhoeae and Chlamydia trachomatis. o Hypothermia Hypotonia Tachypnea, slightly hyperglycemic during pregnancy and excess
- An infant contracted an organism during birth from paleness glucose transfused across the placenta during
vaginal secretion MANAGEMENT pregnancy
- Neisseria gonorrhoeae infection is an extreme serious o Prophylaxis - Tthe fetal pancreas responds to this high glucose level
form of conjunctivitis because if left untreated, the - Some of the causative agents of this infection is caused with islet cell hypertrophy, resulting in matching
infection progresses to corneal ulceration and by gram-positive bacteria so that's why the babies high insulin levels.
destruction and resulting to opacity of the cornea are covered with antibiotic therapy known as - After birth, as an infant’s glucose level begins to fall
and severe vision impairment. prophylaxis. because the mother’s circulation is no longer
❑ Hepatitis B Virus o Standard and contact infection precautions supplying glucose, the overproduction of insulin will
- This can be transmitted to the newborn through - Is observed in order not to transfer or spread the cause the development of severe hypoglycemia.
contact with infected vaginal blood at birth when viruses from one baby to another. - Hypoglycemia: <45 mg/dL
the mother is positive for the virus - Wear a mask, gloves, gowns in order to stop the chain o Hypocalcemia
- A destructive illness accounts for 70-90% of infected of infection.
infants because they become chronic carriers of the o Eye irrigation
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- parathyroid hormone levels are lower in these infants  Possible hyperreflexia and clonus - Alcohol crosses the placenta in the same concentration as is
because of hypomagnesemia from excessive renal (neuromuscular irritability) present in the maternal bloodstream.
losses of magnesium.  Convulsions - This results in fetal alcohol exposure and fetal alcohol syndrome.
o Hyperbilirubinemia  Tachypnea (rapid respirations), possibly - syndrome appears in about 2 per 1000 newborns and is often more
- may occur in these infants because, if immature, they so severe that it leads to difficult to document than recreational drug exposure. Because
cannot effectively clear bilirubin from their system. hyperventilation and alkalosis it is unknown if there is a safe threshold of alcohol ingestion
 Vomiting and diarrhea, leading to large during pregnancy, all pregnant women are advised to avoid
NSG. CONSIDERATIONS: fluid losses and secondary dehydration alcohol intake to prevent any teratogenic effects on their
o Early feeding - Specific neonatal abstinence scoring tools may be used newborn.
- In a newborn, hypoglycemia is defined as a serum to quantify and assess an infant’s status. - The newborn with fetal alcohol syndrome has several possible
glucose level of less than 45 mg/dL. - In newborns experiencing opiate withdrawal, signs problems at birth.
- To avoid a serum glucose level from falling this low, usually begin 24 to 48 hours after birth, but in some - Characteristics that mark the syndrome include:
infants of diabetic women are fed early with infants they may not appear for up to 10 days. o prenatal and postnatal growth restriction
formula or administered a continuous infusion of - Generally signs last approximately 2 weeks, but mild o central nervous system involvement such
glucose. signs may appear for up to 6 months. as cognitive challenge,
- It is important the infant not be given only a bolus of o microcephaly
glucose; otherwise, rebound hypoglycemia ❖ NSG. CONSIDERATIONS: o cerebral palsy
(accentuating the problem) may occur.  Remove excessive stimuli o distinctive facial feature of a short
o Monitor bowel movement - Infants of drug-dependent women usually seem most palpebral fissure and thin upper lip.
- Some infants of diabetic women have a smaller-than comfortable when firmly swaddled.
usual left colon, apparently another effect of - Keep them in an environment free from excessive stimuli (a
intrauterine hyperglycemia, which limits the small isolation nursery, not a large, noisy one).
amount of oral feedings they can take in their first - Some quiet best if the room is darkened.
days of life.  Many infants of heroine addicted women suck vigorously and
- Signs of an inadequate colon continuously and seem to find comfort and quiet if given a
o vomiting or abdominal distention after pacifier.
the first few feedings.  Infants of methadone- and cocaine-addicted women may have
- Careful monitoring for normal bowel movements is extremely poor sucking ability and may have difficulty
important achieving sufficient fluid intake unless gavage fed (gavage
feeding).
INFANT OF A DRUG-DEPENDENT MOTHER  Specific therapy for an infant is individualized according to the  Eyes
- Infants of drug-dependent women tend to be SGA nature and severity of the signs. o small palpebral fissures, low nasal bridge, epicanthal
(small for gestational age).  Maintenance of electrolyte and fluid balance is essential. folds.
 If an infant has vomiting or diarrhea, intravenous  Between the nose and the mouth
Signs & Symptoms administration of fluid may be indicated.
NAS (Neonatal Abstinence Syndrome) o supposed to be there’s a fold there
 Avoid breastfeed with narcotic-use mothers. o in fetal alcohol syndrome, there is smooth philtrum.
- Exposure to illicit or prescription drug
- Passes via placenta to baby
- An infant should not be breastfed to avoid passing narcotics  Upper lip is also thin
- Dependency to drug (mom and baby)
in breast milk to the child.  Micrognathia
 Once an infant has been identified as having been exposed to o condition in which the jaw is lower or undersized.
- If the woman is dependent on a drug, an infant will
show withdrawal symptoms (neonatal abstinence
drugs in utero, the mother needs treatment for withdrawal  Minor ear anomalies.
syndrome) shortly after birth. These include such
symptoms and follow-up care as much as the infant.  During the neonatal period, an infant may be tremulous,
 In addition, evaluation is necessary to determine before fidgety, and irritable and may demonstrate a weak sucking
signs as:
discharge, whether an environment that allowed for drug reflex.
 Irritability
 Disturbed sleep pattern
abuse, will be safe for an infant at home.  Sleep disturbances are common, with the baby tending to be
 Infants who are exposed to drugs in utero may have long term either always awake or always asleep, depending on the
 Constant movement, possibly leading to
neurologic problems. mother’s alcohol level close to birth.
abrasions on the elbows, knees, or nose
 Tremors  Most serious long-term effect is cognitive challenge.
 Frequent sneezing
INFANT WITH FETAL ALCOHOL EXPOSURE  Behavior problems such as hyperactivity may occur in school
 Shrill, high-pitched cry age children.
S/S: FASD (Fetal Alcohol Spectrum Disorder)  Growth deficiencies may remain throughout life.
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 An infant needs follow-up so any future problems can be  Length, regularity, and frequency of menstrual periods
discovered. FEMALE – 35%  Amount of flow
 The mother needs follow-up to see if she can reduce her Anovulation  Any difficulties experienced, such as dysmenorrhea or
alcohol intake for better overall health. - Faulty or inadequate production of ova problems of ova premenstrual dysphoric disorder (PDD)
WEEK 5 - transport through the fallopian tubes to the uterus, uterine factors  History of contraceptive use
The inability to conceive a child or sustain a pregnancy to birth that affects such as tumors or poor endometrial development, and cervical  History of any previous pregnancies or abortions
as many as 14% of couples who desire children. Couples exploring fertility and vaginal factors that immobilize spermatozoa. o A minimum history for the man should include:
testing come in all different types: many are married couples who are  General health
having trouble conceiving; some are couples who have plans to marry and BOTH – 20%  Nutrition
wonder if they will have trouble conceiving; some desire to remain single Environmental factors  Alcohol, drug, or tobacco use
or partner with someone of their own sex and bear a child, through an - Exposure to radiation or chemicals  Congenital health problems such as hypospadias or
assisted fertility method; some are gay or lesbian. When a couple first Drugs cryptorchidism
pursues fertility counseling, they usually have fears and anxieties not only - Drug users or prolonged maintenance of a drug that can lead to  Illnesses such as mumps orchitis, urinary tract
about their inability to conceive but also about what this condition will infertility
infection, or sexually transmitted diseases
Diet/Exercise
mean to their future lifestyle and family.  Radiation to his testes because of childhood cancer or
- Heavy exercises or faulty eating habits can also lead to infertility
another cause
SUBFERTILITY or INFERTILITY  Operations such as surgical repair of a hernia, which
- exist when a pregnancy has not occurred after at least 1 year UNEXPLAINED – 10%
could have resulted in a blood compromise to the
- inability to conceive a child or sustain a pregnancy to birth after at testes.
Assessment & Evaluation of Infertility:
least 1 year of unprotected sex  Current illnesses, particularly endocrine illnesses or
Primary Subfertility o Health history and perform physical assessment
low grade infections
o Nurses often assume the responsibility for initial history taking
- There is no history of conception, which means that there  Past and current occupation and work habits
has been no previous conception at all. with a subfertile couple. Because of the wide variety of factors
that may be responsible for subfertility.  Sexual practices such as the frequency of coitus and
Secondary Subfertility masturbation, failure to achieve ejaculation,
- There has been a previous viable pregnancy but the couple is o Most couples assume that subfertility is the woman’s problem.
Many women, even after careful explanation that the problem premature ejaculation, coital positions used, and
unable to conceive at present. use of lubricants
is their male partner and not theirs, continue to show low
self-esteem, as if the fault did rest with them. For a thorough  Past contraceptive measures, and existence of any
Sterility - the inability to conceive because of a known condition, such as children produced from a previous relationship.
the absence of a uterus. women’s health history, ask about:
 Current or past reproductive tract problems, such as o For both, nurses have to check into the lifestyle, use of
infections contraception, STDs, smoking practices, exercises and the type of
CAUSES OF INFERTILITY occupation.
Male – 35%  Overall health, emphasizing endocrine problems such as
Pretesticular galactorrhea (breast nipple secretions) or symptoms of
thyroid dysfunction Diagnosis:
- concerning extragonadal endocrine, such as those originating o To determine and diagnose problems of infertility, the couple or an
in the hypothalamus, pituitary or adrenals, in which these  Abdominal or pelvic operations that could have
individual has to undergo a series of diagnostic tests and procedures.
affect spermatogenesis (production of sperm cells). compromised blood flow to pelvic organs
o In male infertility, problems in spermatogenesis, or inadequate
- Pretesticular in other words are problems concerning the  Past history of a childhood cancer treated with radiation
sperm count are determined by the diagnostic test semen analysis.
amount of sperm or low sperm count. that might have reduced ovarian function
 after 2 to 4 days of sexual abstinence, the man ejaculates by
Testicular  The use of douches or intravaginal medications or sprays
masturbation into a clean, dry specimen jar.
- These are primary defects in the testis. that could interfere with vaginal pH
 The number of sperm in the specimen are counted and then
- concerns the shape and morphology of the sperm.  Exposure to occupational hazards such as x-rays or toxic
examined under a microscope within 1 hour, then their
Post-testicular substances
appearance and motility are noted.
- These are factors affecting the ability of the sperm to travel from o Nutrition including an adequate source of folic acid and
 An average ejaculation should produce 2.5 to 5.0 mL of semen
the site of production, the testicle, to leave the body in avoidance of trans-fats.
and should contain a minimum of 20 million spermatozoa per
ejaculation. So it is more on the problem of sperm motility or o If she can detect ovulation through such symptoms as
milliliter of fluid
the movement of sperm. Such as those problems that develop  breast tenderness
 the average normal sperm count is 50 to 200 million per
due to autoimmunity which immobilizes sperms.  mid cycle “wetness,”
milliliter
- Another could be problems in the ejaculation or deposition  lower abdominal pain (mittelschmerz).
 In this procedure, the male should be instructed that a repeat
preventing spermatozoa from being placed close enough to a o Also obtain a menstrual history including:
is done after 2 or 3 months, because spermatogenesis is an
woman’s cervix to allow ready penetration and fertilization.  Age of menarche

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ongoing process, and 30 to 90 days is needed for new sperm to - plots this daily temperature on a monthly graph, noticing conditions - start with the induction of a paracervical block or anesthesia, then a
reach maturity. that might affect her temperature (e.g., colds, other infections, thin probe and biopsy forceps are introduced through the
sleeplessness). cervix.
Male Infertility Factors - At the time of ovulation, the basal temperature can be seen to dip - may experience mild to moderate discomfort from the
Erectile dysfunction or impotence slightly (about 0.5° F); it then rises to a level no higher than maneuvering of the instruments.
- Sperm transport disorder normal body temperature. - moment of sharp pain as the biopsy specimen is taken from the
- inability to achieve erection - Towards the end of the cycle, during the 24th day, her temperature anterior or posterior uterine wall.
- primary if the man has never been able to achieve erection and begins to decline, indicating that progesterone levels are - Possible complications
ejaculation falling, and that she did not conceive. o Pain
- secondary if the man has been able to achieve ejaculation in the o excessive bleeding
past but now has difficulty. Tubal patency. o infection
- Solutions to the problem can include psychological or sexual - Both ultrasound and x-ray imaging can be used to determine the o uterine perforation.
counseling patency of fallopian tubes and assess the depth and - Contraindicated:
- use of a drug such as sildenafil (Viagra). consistency of the endometrial lining. o if pregnancy is suspected (although the chance that it
Premature ejaculation - Nurses need to assess the tubal patency to determine tubal would interfere with a pregnancy is probably less
- ejaculation before penetration transport problems. than 10%)
- another factor that may interfere with the proper deposition of - Difficulty with tubal transport usually occurs because scarring has o infection such as acute PID or cervicitis is present.
sperm. developed in the fallopian tubes. - Caution a woman that she might notice a small amount of vaginal
- another problem often attributed to psychological causes.  This typically is caused by chronic salpingitis (chronic spotting after the procedure.
- Adolescents may experience it until they become more experienced pelvic inflammatory disease). - For follow-up, she needs to call her primary care
in sexual techniques.  It can result from a ruptured appendix or from Insertion of dye for a hysterosalpingogram.
abdominal surgery involving infection that spreadto - The contrast dye outlines the uterus and fallopian tubes on
Female Infertility Factors the fallopian tubes and left adhesion formation in radiographs to demonstrate patency.
- monitor and check for the production of ova. the tubes. - If she develops a temperature greater than 101° F, has a large
Anovulation Sonohysterography amount of bleeding, or passes clots.
- absence of ovulation - is an ultrasound technique designed for inspecting the uterus and - She also needs to call the health care agency when she has her next
- the most common cause of subfertility in women fallopian tube. menstrual flow. This helps “date” the endometrium and the
- may occur from a genetic abnormality such as Turner’s syndrome - The uterus is filled with sterile saline, introduced through a narrow accuracy of the analysis.
(hypogonadism) in which there are no ovaries to produce ova. catheter inserted into the uterine cervix.
- It may result from a hormonal imbalance caused by a condition - A transvaginal ultrasound transducer is then inserted into the Management:
such as hypothyroidism that interferes with vagina to inspect the uterus for abnormalities such as septal Pharmacologic:
hypothalamus-pituitary-ovarian interaction. deviation or the presence of a myoma and assess the patency  Sildenafil (Viagra)
- Ovarian tumors may also produce anovulation because of feedback of the fallopian tube. - This drug is used to treat male’s sexual function problems,
stimulation on the pituitary, thus ova is not produced. - Because this is a minimally invasive technique, it can be done atany like impotence or erectile dysfunction disorder.
- Chronic or excessive exposure to x-rays or radioactive substances, time during the menstrual cycle. - This is in combination with sexual stimulation.
general ill health, poor diet, and stress may all contribute to Transvaginal Hydrolaparoscopy - It works by increasing the blood flow to the penis, to help a
poor ovarian function. - allows direct visualization of female peritoneal cavity. man get and keep an erection.
- The most frequent cause, however, is naturally occurring variations - Trocar: passed through the vagina, into the pouch of douglas,
in ovulatory patterns or polycystic ovary syndrome and an optic scope is placed through the trocar sleeve, allowing Dapoxetine
 a condition in which the ovaries produce excess close examination to the uterus, ovaries, fallopian tube, and - A selective serotonin reuptake inhibitor (SSRI) which is specially
testosterone, lowering FSH and LH levels. peritoneum. developed for treatment of premature ejaculation.
- no abdominal incision is required. - This increases the time to ejaculate and can improve the control of
Ovulation monitoring - can be accomplished in the office setting. ejaculation.
- least costly way to determine a woman’s ovulation pattern. - It starts to work very quickly so it is taken when you anticipate
- Patient is asked to record her basal body temperature (BBT) for at Uterine endometrial biopsy having sex, rather than taking it everyday.
least 4 months (according sa book; 1 month gi ingon ni Miss so - may be used as a test for ovulation or to reveal an endometrial - You have to take it 1-2 hours before an individual will engage in
dili ko sure). problem such as a luteal phase defect. sexual activity.
- To determine this, a woman takes her temperature each morning, - Endometrial biopsies are done 2 or 3 days before an expected Hormone Therapy
before getting out of bed or engaging in any activity, eating, or menstrual flow (day 25 or 26 of a typical 28-day menstrual - For couples who are unable to have children, this treatment can
drinking, using a special BBT or tympanic thermometer cycle) increase the chance of pregnancy.

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- In many cases, inability to have children can be attributed to Canalization of fallopian tube the rate of conception may be lower from this source, there
hormonal imbalance. - This is a nonsurgical procedure to clear the blockage in the fallopian appears to be no increase in the incidence of congenital
- Although hormonal imbalance can be present in both men and tube and this is performed through a speculum placed in the anomalies in children conceived by this method. An advantage
women, hormone treatment is usually performed in women. vagina, and a small plastic tube is inserted into the cervix tothe of cryopreserved sperm is that it can be used even after years
- Hormone treatment, in women, aims to promote egg maturation uterus. of storage.
and triggers ovulation. - Then a liquid contrast agent is injected through a catheter and - Some couples have religious or ethical beliefs that prohibit them
- So this increases thelikelihood of successful fertilization examine the uterine cavity on a nearby monitor using an x-ray from using artificial insemination. Some states have specific
- Clomiphene citrate or clomid. camera. laws regarding inheritance, child support, and responsibility
 This is an oral medication that is often used to treat - If blockage is determined, and it is located on one or both fallopian concerning children conceived by artificial insemination
certain types of women infertility. tubes, thread a small catheter through the first catheter and - takes an average of 6 months to achieve conception, it may be
 Clomid works by making the body think that your then into the fallopian tube to clear the blockage. discouraging process for couples to have to wait this long to
estrogen levels are lower than they are, which Adhesiolysis see results.
causes the pituitary gland to increase secretion of - Adhesions can form from any type of trauma to the abdomen.
FSH (follicle stimulating hormone) and LH - However, they’re most commonly a side effect of abdominal Preparations
(luteinizing hormone). surgery. - a woman must record her Basal Body Temperature (BBT)
 High levels of FSH stimulate the ovary to produce an - this is the removal of adhesions in any part of the abdominal cavity. - assess her cervical mucus
egg cell or multiple follicles that would develop and - Infertility adhesion can cause female reproductive organ problems - use an ovulation predictor kit to predict her likely day or
release during ovulation, while high levels of LH by obstructing ovaries or fallopian tubes. involution.
stimulate ovulation. - They can also be a cause of painful intercourse for some people. - On the day after involution, the selected sperm are instilled into the
Letrozole - So if a doctor suspects adhesions are causing the reproductive cervix using a device similar to a cervical cap or diaphragm, or
- is a medication that has been used in women with breast cancer. issue, they may recommend surgery to remove them. they are injected directly into the unterus using a flexible
- It is sold under the trade name femara. - a laparoscope is a long thin tube that contains a camera and light catheter.
- belongs to a class of medication known as aromatase inhibitor. is inserted into an incision which helps the surgeon find the
- Aromatase adhesion to remove them. Therapeutic Donor Insemination
 an enzyme that is responsible for the production of - the donors are volunteers who have no history of disease or no
estrogen in the body. Artificial Insemination family history of possible inheritable disorder.
- It works by inhibiting aromatase, thereby suppressing estrogen - the instillation of sperm into the female reproductive tract to aid - The blood type, or atleast the Rh factor, can be matched with the
production. conception. woman’s to prevent incompatibility. S
Clomiphene citrate - sperm is instilled into the cervix (Intracervical insemination) or - perm from sperm banks can be selected according to the desired
- blocks estrogen receptors. directly into the uterus (intrauterine insemination). physical or mental characteristics.
- In both cases, the result is that the pituitary gland produces more - husband’s sperm (artificial insemination by husband) or donor
hormone needed to stimulate the ovaries. sperm (artificial insemination by donor or therapeutic donor
- These hormones, FSH and LH, can cause the development of insemination) can be used.
ovulation in women who are anovulatory or increase the - used if the man has an adequate sperm count or a woman has a IN VITRO FERTILIZATION
number of eggs developing in the ovaries of women who vaginal or cervical factor that interferes with sperm motility. - one or more mature oocytes are removed from a woman’s ovary by
already ovulates. - Donor insemination can be used if a man has a known genetic laparoscopy and fertilized by exposure to sperm under
Bromocriptine disorder that he does not want transmitted to children or if a laboratory conditions outside a woman’s body.
- belongs to the group of medicine also known as ergot alkaloids. woman has no male partner. - About 40 hours after fertilization, the laboratory grown fertilized
- It blocks the release of a hormone called prolactin from the - It is a useful procedure for men who, feeling their family was ova are inserted into a woman’s uterus, where ideally one or
pituitary gland. complete, underwent a vasectomy but now wish to have more of them will implant and grown
 Prolactin affects the menstrual cycle and milk children. - most often used for couples who have not been able to conceived
production. - In the past, men who underwent chemotherapy or radiation for because a woman has blocked or damaged fallopian tube .
- used to treat certain menstrual problems like amenorrhea in testicular cancer had to accept being child free afterward as - It is also used when a man has oligospermia ( very low sperm
women and stop milk production in some men and women they were no longer able to produce sperm. count).
who have abnormal milk leakage - Today, sperm can be cryopreserved (frozen) in a sperm bank before - may be useful to help couples when an absence of cervical
- also used to treat infertility in both men and women that occurs radiation or chemotherapy and then used for insemination mucus prevents sperm from travelling to or entering the
because the body is making too much prolactin. afterward cervix, or antisperm antibodies cause immobilization of sperm
Antibiotic therapy - Cryopreserved sperm – sperm placed in a sperm bank before - couples who have unexplained infertility of long duration may be
- given if underlying cause is brought about by infection, such as in radiation or chemotherapy helped by IVF
pelvic inflammatory diseases. - Disadvantage of using frozen sperm is that it tends to have slower - A donor ovum, rather than a woman’s own ovum, also can be used
motility than unfrozen specimens/sperm. However, although for a woman who does not ovulate (genetic disorder) or carries
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a sex linked disease that she does not want to pass on to her 3. Reinforce options on alternative childbirth techniques. image and imperfections. A positive self image can
children (these are the indications). Surrogate mothers, adoption, child free living boost our physical, mental, social, spiritual well
- Before the procedure, a woman is given an ovulation-stimulating - Surrogate mothers – is a woman who agrees to carry being
agent such as Clomiphene citrate (Clomid) . a pregnancy to term for a infertile couple
- Beginning about the 10 th day of the menstrual cycle, the ovaries - Adoption – once a ready alternative for infertile SEXUAL DYSFUNCTION
are examined daily by ultrasound to assess the number and couple - This can happen at any phase of sexual response cycle,
size of developing ovarian follicles. - Child-Free Living – is an alternative lifestyle available and it prevents an individual from experiencing
- When a follicle appears to be mature, a woman is given an injection for both fertile and infertile couple couples who satisfaction from sexual activity
of hCG, which causes ovulation in 38-42 hours. have been through rigors and frustrations of 1. Desire disorders
- In the harvesting procedure, a needle is introduced intravaginally, subfertility testing and unsuccessful treatment - lack of sexual desire or interest in sex
guided by ultrasound and the oocyte is aspirated from its regimens, child free living may emerge as the option - the decrease in the sexual desire can also be the effect
follicle. they finally wish to pursue. of the medicine or chronic disease such as peptic
 Many oocyte may ripen at once and perhaps as many - ADVANTAGE: ulcer or chronic pulmonary disorder that causes
as 3 to 12 can be removed.  Pursue careers frequent pain and discomfort.
 The oocyte are incubated for atleast 8 hours to ensure  Travel more - This may interfere with the man and women’s overall
viability. In the meantime, the husband or donor  More time for hobbies wellbeing and interest in sexual activity
supplies fresh semen specimen.  May continue their education 2. Arousal Disorders
 The sperm cells and oocyte are mixed and allowed to - inability to become physically aroused or excited
incubate in a growth medium. during sexual activity.
- After sterilization of the chosen oocyte occurs, the zygotes formed CLIENT EDUCATION: - can be caused by physical or psychological factor or
almost immediately begin to divide and grow. By 40 hours after 1. Provide information of the different tests and procedures and both. Needs careful assessment to help clarify the
fertilization, they will have undergone their first cell division. possible outcomes. cause of the problem
The fertilized eggs are then examined if it is normal, it is 2. Self care awareness regarding fertility: 3. Orgasm disorders
transferred back to the uterine cavity through the cervix by - Avoid douching - delay of absence of orgasm
means of urinary catheter.  can alter the pH of vaginal secretion - the failure of women to achieve orgasm can be a result
- In some instances, progesterone may be given to a woman if it is of poor sexual technique, or concentrating too hard
- Promote retention of sperm after coitus
believed that she will not produce enough on her own to on achievement or negative attitude toward sexual
 right positioning
support implantation. relationships.
- Maximize the potential for fertilization
- Once a pregnancy has been successfully established, a woman’s - Treatment is aimed to relieve the underlying cause and
 monitoring of ovulation and right timing
prenatal care is the same as that for any pregnancy. it may include instruction and counseling for the
of coitus
- Nursing Consideration: couple about sexual feelings and needs. Like the
- Avoid anxiety and stress
 supply support and counseling to sustain the couple - Maintain adequate nutrition
arousal disorder, disorder of orgasm occurs in both
through this process men and women
3. Empowering realistic expectations
 needs emphatic support from the health care - most of the infertility interventions has advantages
4. Pain disorders
providers through this difficult times. - pain during intercourse (DYSPAREUNIA)
and disadvantages and not all of the outcomes
- because the reproductive system has sensitive nerve
favors the couple’s desires. Help them set realistic
NURSING MANAGEMENT – INFERTILITY (SUBFERTILIITY) goals to prevent devastation
supply when pain occurs in response to sexual
1. Educate couples on the variety of test activities it can be acute or severe and impairs a
4. Provide emotional support
- As we all know couples have to undergo a diagnostic person’s ability to enjoy this segment of life
- With all of the anxiety and stress they are going
testing procedures in order to determine problems - Example of a condition under pain disorder:
through, we uplift them, offer genuine
of infertility. Prior to availing those test, we need to a) Vaginismus
encouragement, reassurance and compassion.
inform this couple how these procedures are being o involuntary contraction of muscles at the outlet
5. Create or refer to support groups
perfomed and what is expected of that. of vagina when coitus is attempted.
- couple with infertility are described to extremely
2. Allow couples to express thoughts on subfertility of sterility o This muscle contraction prohibits penile
isolating, they may feel like they are the only couple
- Infertility causes anxiety and emotional stress to penetration.
going through this. To help them, let them talk to
individual or couple o This can occur in women who have been raped
others who are in similar situation
 listen to them, express their concerns, let 6. Promote a positive self image
and also a result of early learning pattern in
them ventilate their feelings and anxiety. which sexual relations are viewed as bad and
- we help them recognize their own assets and potential
This way it relieves tension and air out sinful.
while being realistic liabilities and limitation.
feeling of frustrations and o In other sexual problems, psychological
Negative self image focuses on faults, distorting
disappointments, counseling is needed to reduce this response
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b.) Vestibulitis ● Counseling, behavior modification o This type of vaginitis seems to be linked to sexual
o inflammation of the vestibule. ● Sildenafil (viagra) intercourse especially if a person has multiple
o This condition occurs due to endometriosis or - Problems of impotence sexual partners or a new sex partner. It also occurs
abnormal placement of endometrial tissue, - It can be prescribed to this individual to correct some sexual in women who aren’t sexually active.
vaginal infection, hormonal changes that dysfunction. - Trichomoniasis
occurs with menopause and causes vaginal ● Mechanical aids - Such as vaginal vacuum, these are mechanical o this common sexually transmitted infection is caused by a
drying. aids in helping relieve pain during sexual intercourse and maybe microscopic one celled parasite called Trichomonas
o A psychological condition may be present, penile implant. vaginalis
treatment is aimed at the underlying cause, ● Psychotherapy o Trichonomas vaginalis: this organism spread through
encouraging open communication between sexual intercourse with some who have the infection. In
the sexual partners is necessary Nursing Considerations: men, the organism usually infects the urinary tract that
5. Premature Ejaculation  Educate on preventing sexual dysfunction. often causes no symptoms.
o ejaculation before penile-vaginal contact  How to prevent: We need to understand the underlying cause o In women, trichomoniasis usually infects the vagina and
o this term is also used to mean ejaculation then we can be able to help them abstain or prevent from might cause symptoms also increases a woman’s risk of
before the sexual partner achieved having sexual dysfunction. getting sexually transmitted infection.
satisfaction.  Diet modification
o This can be unsatisfactory and frustrating to - Obesity could be a cause in sexual dysfunction. A diabetic Atrophic Vaginitis
both partners. individual can also experience sexual dysfunction. - Thinning tissues and less moisture due to menopause, estrogen
o Other reasons suggest: doubt of muscularity and ● Control health if comorbidities are present. S/S:
fear of impregnating the woman, which - Health conditions like chronic conditions. We need to inform - Discharges - changes in the color, odor and amount of
prevents the men from sustaining an erection. them that they need to see a doctor to have a discharges from the vagina
o Sexual counseling to both partners may be maintenance medication so that they may be able to do - Redness, swelling, itching, pain during intercourse
helpful to reduce stress in alleviating the some of the activities that they wanted to do, especially - Odor
problem activities for couples. - Dysuria – painful urination
6. Persistent Sexual Arousal Syndrome – excessive sexual INFECTIONS - Light vaginal bleeding or spotting
arousal in the absence of desire.
- Pain or bleeding upon sex
VAGINITIS
Etiology: - is an inflammation of the vagina that can result in discharges, Nursing Considerations
o Urologic problem itching and pain. - Explain complete course of antibiotic therapy
o Chronic conditions - Such as pulmonary disease - The cause is usually a change in the normal balance of the vaginal o To prevent resistance to the drug
o Peptic ulcer can also lead to sexual dysfunction. bacteria or an infection - Avoid douching
o For example, pulmonary disease, if an individualhas chronic - Reduced estrogen level after menopause and some skin disorders - Avoid irritants such as scented products, tampons, pads, douching
pulmonary disease he/she has the tendency to cannot can also cause vaginitis into the vagina
perform, maybe the individual will experience difficulty in
- Rinse soap from the outer genital area after a shower and dry the
breathing. He/She will be deprived of air so the individual Etiology area well to prevent irritation. Do not use harsh soaps such as
cannot reach or an individual has a sexual disorder. - Yeast infection – antibiotics, hormone therapy, diabetes those with deodorant and antibacterial action or bubble bath
o Example: A diabetic individual has decreased libido because o occurs when there are overgrowth of fungal organism, - Avoid tampons. Regularly change sanitary pads.
of the hormone and overweight individuals can also be usually caused by candida albicans in the vagina - Protected sex
one of the etiology of sexual dysfunction. o Candida albicans - also causes infection in other moist o the use of latex condom. Both male and female,
o Hormonal imbalance areas of the body such as in the mouth in the form latex condom may help you avoid infections
o Alcohol and drugs of oral thrush, skin folds and nail beds. The fungus spread by sexual contact
o Nerve damage can also cause diaper rash.
o Psychological in origin - Bacterial vaginosis– STI
o The common cause of vaginitis results from a change
Signs and Symptoms: of the normal bacteria found in the vagina.
● Lack of sexual desire - Lack of interest into coitus o The overgrowth of one of the several organisms PELVIC INFLAMMATORY DISEASE (PID)
● Difficulty in arousal - Problems like erectile dysfunction or usually bacteria normally found in the vagina like - Infection of the female reproductive organs spreading from the
impotence lactobacilli are outnumbered by other bacteria such vagina to the uterus, fallopian tubes or ovaries
● Pain during intercourse as anaerobes - This is an ascending infection in the upper genital tract caused by
o If anaerobic bacteria becomes too numerous they poly microbial organisms
Management: accept the balance causing bacterial vaginosis.
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- This may include infection of any of the following anatomical o pills.
structures: endometrium, oviduct, ovary, uterine wall, uterine o The use of condom every time an individual engage into sex
serosa, broad ligaments and the pelvic peritoneum. with a new partner protects STI. Etiology
- Avoid douching - Current STI – less common in men
Etiology o Douching upsets the balance of bacteria in the vagina. - STI (chlamydia or gonorrhea)
- STDs – gonorrhea & chlamydia TTT o More likely in younger men under 35 years old
o Many types of bacteria can cause PID but gonorrhea - Antibiotics – same with partner - Groin injury – epididymitis
and chlamydia are the most common one. - Temporary abstinence o Undergone surgery to the groin, prostate and bladder
o These bacteria are usually acquired during S/S
unprotected sex. Less commonly, bacteria can enter PROSTATITIS - Swollen, red or warm scrotum
the reproductive tract anytime. - This is an inflammation or swelling of the prostate gland. - Testicle pain and tenderness
- Childbirth, miscarriage, and abortion - It can be very painful and distressing but will often get better - Dysuria – pain upon urination
o The normal value created by the cervix is disturbed. eventually. - Discharge from the penis
o This can happen during menstruation and childbirth,or - Can come at any age but usually between the age 30-50 years old. - Pain or discomfort in the lower abdomen or pelvis
miscarriage or abortion. - Prostate - Blood in the semen
o Rarely bacteria can also enter the reproductive tract  a small gland that lies between the penis and the - Fever – typical sign of infection
during the insertion of IUD, a form of long term bladder. Treatment
birth control or any medical procedure that involves  It produces fluid that mixes with sperm to create - Antibiotics
inserting instruments to the uterus. semen. Nursing Considerations
Risk Factors S/S - Lie down with elevated scrotum
- Sexually active, more than one sexual partner - Dysuria, nocturia, hematuria - Cold packs over scrotum (hypogastric area) to relieve pain and
o Women younger than 25 years old having multiple sexual o Pain when peeing discomfort
partners or being in a sexual relationship with a person o There is frequency, urgency or the need to pee particularly at - Avoid lifting heavy objects
who has more than one sexual partner. night or stop-start peeing. - Abstinence
- Unprotected sex - Pain in the abdomen, groin, or lower back or lower abdomen - Avoid alcohol, caffeine, spicy and acidic foods that irritate the
o Sex without condom - Pain in the area between the scrotum and rectum bladder
- Douching regularly - Enlargement or tenderness of the prostate on rectal examination - Encourage increase in water intake
o Upset the balance of good versus harmful bacteria in the - Pain or discomfort of the penis or testicles
vagina - Painful ejaculation INFANTS
- History of PID or STD - Fever – sign of infection Phimosis
S/S: - Symptoms can have a significant impact on the quality of life but in - The inability to retract the foreskin from the glans of the penis.
- Pain in your lower abdomen and pelvis most cases they gradually improve every time and with - Can occur naturally or be the result of scarring
- Heavy vaginal discharge with an unpleasant odor treatment - Young boys may not need treatment, unless it makes urination
- Abnormal uterine bleeding, especially during or after intercourse or - Sexual problem could also be present such as erectile dysfunction, difficult or causes other symptoms.
between menstrual cycles pain when ejaculating or pelvic pain after sex - Tight foreskin is common in baby boys who are not circumcised
- Pain or bleeding during intercourse (usually stops by 3-years-old)
- Fever, sometimes with chills
- Painful or difficult urination Balanitis
Diagnosis - Inflammation of the phimotic foreskin (glans/head of the penis).
- Pap smear (Papanicolaou smear) - Due to infection or other causes.
- Culture & sensitivity testing – of vaginal secretion - Can be uncomfortable and sometimes painful but is not usually
- UTZ serious.
Nursing Considerations - Relieved with topical medication
- Encourage to practice safe sex and use of contraception
o The use of condoms every time an individual engage into sex EPIDIDYMITIS Nursing Considerations:
and the limitation of numbers of partner and ask about - Where a tube or the epididymis at the back of the testicle becomes - Encourage proper
potential partner sexual history. swollen and painful. hygiene.
o The use of birth control pills do not protect against the - It is often caused by an infection and is usually treated with - Instruct not to forcibly
development of PID. antibiotics. retract the skin.
o Using barrier methods such as condoms helps to reduce the - If the testicles is also affected, if maybe called epididymo-orchitis
risk even if you are taking birth control
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o Paraphimosis may occur. Pharmacological Management:
o A urologic emergency in which the retracted foreskin of an o Anticholinergic (Oxybutynin)
uncircumcised male cannot be returned back to its - Used to treat bladder spasm
normal anatomical position; recognize condition Treatment:
promptly, can lead to gangrene and amputation of the o Surgical correction: 6-12 months of age
glans penis. o Testosterone (pre-op)
- To increase the size of the penis
Treatment: o Goal: To improve the physical appearance, to be able to void in
- Steroid cream a standing position and sexually adequate organ.
- Circumcision
Bladder Exstrophy
- Severe defect involving the musculoskeletal system and
- Failure of one or both testes to design through the inguinal canal
urinary, reproductive and intestinal in some cases.
into the scrotum.
- Congenital abnormality that occurs whenever the skin over
- Another term for this is undescended testicle.
the lower abdomen does not form properly—the bladder
- Usually one testicle is affected but about 10% of the time, both
is open and exposed on the outside of the abdomen.
testicles are undescended.
- “Exstrophy” = turned inside out
- Undescended testicle
Epispadias
 uncommon in general but common among babies born
- Failure of urethra to close; opening at the dorsal of the
prematurely
penis.
 moves into proper position on its own within the first
- The urethra does not form properly.
few months of life.
- So all boys with bladder exstrophy also have
 If your son has undescended testes that doesn’t
(Left: Phimosis; Right: Normal Retracted Foreskin) epispadias, but it can occur on its own.
Nursing Considerations: correct itself, then surgery can relocate the testicle
o Clamp cord with soft umbilical tape or silk suture. into the scrotum.
Hypospadias Sign & Symptoms
- Abnormal ventral placement of urethral opening on the underside o Parental support
Treatment: - Absence of testes in the scrotum.
of the penis.
o Surgery  Testicle formed in the abdomen during fetal
- Birth defect or congenital condition in which the opening of the development.
urethra is on the underside instead of at the tip.  During the last couple of months of normal fetal
- Urethra: Tube through which urine drains from the bladder and exit development, the testicle gradually descends from
to the body. the abdomen through a tube-like passageway in the
- Common and does not cause difficulty caring for this infant. groin or inguinal cavity into the scrotum.
- Surgery usually restores the normal appearance of the child’s penis. - Acquired undescended testes
- Retractile testes on warm baths
Signs and Symptoms:
o Opening of the urethra other than the tip of the penis Treatment
o Chordee - Downwards curvature of the penis - Spontaneous descend within 6 months of life
o Hooded appearance of the penis (only the top half of the penis - Surgery 12-18 months of life
is covered by foreskin) - Orchiopexy
o Normal (spraying?) during urination  a procedure to move testicle that has not descended
Nursing Considerations: or moved down to its proper place in the scrotum.
o No circumcision  Done 6-24 months of life
o Catheter care (in surgery) Nursing Consideration
(How Bladder Exstrophy looks like with Epispadias: Male)
o Urinary diversion - Pain management
Cryptorchidism
o Position drainage bag at lower level to facilitate continuous - Keep post-op site free from stool and urine. Take note of the
flow of urine. anatomical position of the site and the possibility of
o Avoid tub baths, straddle toys, sandboxes, swimming and contaminating urine
rough activities. - Avoid rough sports and straddling
o Encourage quiet play after the first few weeks of surgery. Avoid - Teach child TSE starting puberty
contact sports while the catheter is in place.

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Hydrocele - Most varicocele develop overtime or most varicocele is easy to o Changes in the size, shape or appearance of a breast
- Presence of peritoneal fluid in the scrotum between the parietal diagnose and may not need treatment particularly during physical and breast examination
and visceral layers of the tunica vaginalis. - If it causes symptoms is often can be repaired surgically o Changes to the skin over the breast, such as dimpling
- Most common painless scrotal swelling in children. o A newly inverted nipple
- Swelling in scrotum that occurs when fluid collects in the thin sheet o Peeling, scaling, crusting or flaking of the pigmented area of
surrounding the testicle. the skin surrounding the nipple (areole) or breast skin
- Common in newborns and usually disappear without treatment by o Redness or pitting of the skin over your breast like the skin of
age 1. Other boys and adult men can develop hydrocele due to an orange
inflammation or injury within the scrotum. Treatment:
- Is not usually painful or harmful and might not need any treatment o Lumpectomy
- A surgery to remove cancer or other abnormal tissue from
2 types of hydrocele the breast.
Signs and Symptoms:
o Communicating Hydrocele - Also called breast conserving surgery or wide location
o Rarely it might cause pain (sharp to dull discomfort).
- Open process vaginalis incision because only portion of the breast is removed.
- There is increased pain when standing or physical exertion
- Has an opening into the abdominal cavity. - During lumpectomy, a small amount of tissue around the
over long periods. It worsened over the course of the day
- The opening allows abdominal fluid to pass into the scrotum. lump is taken to help ensure that all cancer or other
and relieved when the person lay down on his back. This
- If the communicating hydrocele does not go away on its own, abnormal tissue is removed.
causes impaired infertility.
and is not treated, it can lead to an inguinal hernia. o Mastectomy
o Physical Appearance:
o Noncommunicating - A surgery to remove all breast tissues from a breast as a way
- Wormlike mass above the testes
- Less serious to treat or prevent breast cancer.
- Decrease testes
- Usually remains the same size or has a very slow growth. - With those early stages of cancer mastectomy, maybe one
- Decrease dihydrotestosterone
- No connection with peritoneum or due to secondary to treatment option.
Treatment:
trauma, infection, torsion. o Chemotherapy
- Varicocelectomy
- Drug treatment that uses powerful chemicals to kill
 surgery performed to remove those enlarged
fast growing cells in the body.
veins and it is done to restore proper blood
- Is most often used to treat cancer, since cancer cells
flow to the reproductive organ.
grow and multiply more quickly than most cells in
ADULT WOMEN
the body.
Breast Cancer
- Many different chemotherapeutic drugs are available,
- Cancer that forms into the cells of the breast , after skin cancer
chemotherapy drugs can be used alone or in
breast cancer is the most common diagnosis in women.
combination to treat a wide variety of cancer.
- Occurs both in men and women, but far more common in women.
o Radiation Therapy
- Survival rates have increased and the number of deaths associated
A type of cancer treatment that uses a beam of
Treatment with this disease is steadily declining.
intense energy to kill cancer cells.
Surgery - for communicating hydrocele, this is corrected within 1 year - Largely due to factors such as early detection, new personalized
- Most often used x-rays but proton or other types of
approach to treatment and better understanding of the
energy can be used.
Nursing Consideration disease.
- Most often refers to external beam radiation therapy.
- Swelling and discoloration are temporary - Damages cells by destroying genetic material that
- Change dressing everyday and bathe after 3 days controls how cells grow and divide. While both
- Avoid straddle toys for 2-4 weeks health and cancerous cells are damaged by
radiation therapy.
ADOLESCENTS - The goal is to destroy as few normal cells, healthy cells
Varicocele as possible. Normal cells can often repair much of
- Elongation, dilation and tortuosity of the veins of the spermatic the damage caused by radiation.
cord or rather this is an enlargement of the vein within the
loose bag of skin that holds the testicle or the scrotum. Nursing Considerations:
- Similar to varicose vein that you may seen in the legs ● Chemotherapy support
- Common cause of low sperm production and decrease sperm - Helps aids in the overall health and well-being of an individual. So
quality which can cause infertility Signs and Symptoms: support from family, friends and healthcare providers has
- Can cause testicle to fail to develop normally or shrink o A breast lump or thickening that feels different from the value to participate as to deal with the disease and treatment.
surrounding tissue ● Hydration
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- Providing adequate hydration can counter the effect of dehydration - uses soundwaves to produce image of the breast and
for significant planned visits to cancer clinics, proper hydration often performed with mammogram; better use for
of the patient. younger women; can help the doctor distinguish
● Address body image concerns. fluid filled cyst and solid mass
- The body image concerns in women have been attributed to loss of Treatment
breast from surgery, this result scarring, physical changes o Fine-needle aspiration
resulting from adjuvant treatment. o Surgical incision Treatment
- All of which have an impact on overall quality of life particularly o Monitoring to detect changes in the size (can shrink or
body image perception. Fibroadenoma of the Breast disappear on their own)
- Solid, non cancerous breast lumps that occur most o Biopsy - to evaluate the lump
Fibrocystic Breast often in women between the ages of 15 and 35. o Surgery - to remove the lump
- Nodular or glandular breast tissue or - Hormonal in nature. - Lumpectomy
these are composed of tissues - Cause is unknown - Cryoablation
that feel lumpy or ropelike in - Occurs more often during the reproductive years Nursing Consideration
texture. - Becomes bigger during pregnancy or hormone therapy o Instruct to wear firm support bra
- More than half of women experienced - May shrink after menopause o Avoid caffeine and fats
fibrocystic breast changes atsome S/S: o Warm pack for discomfort
point of their life. o Firm, smooth, rubbery or hard and has a well-defined shaped
- In fact medical professionals have stopped using the term lump Dysmenorrhea
fibrocystic breast disease and now simply refer to fibrocystic o Painless, moveable - Pain at the suprapubic area or lower abdomen during or shortly
breast. o Complex fibroadenomas after menstruation
- Fibrocystic breast changes because having fibrocystic breast is not - this contains changes such as an overgrowth of cells or Two Types
really a disease. hyperplasia that can grow rapidly; diagnosed after Primary dysmenorrhea
- Breast changes categorized as fibrocystic are considered normal. reviewing the tissue from a biopsy - due to prostaglandin
- Although many women with fibrocystic breasts do not have o Juvenile fibroadenomas - release. 8-48 hrs.
symptoms, some women experience breast pain, tenderness - most common; found in adolescent girls (10-18 y.o.). It - Occurs at menarche and continues throughout life
and lumpiness especially in the upper outer area of the breast. can grow large but shrinks overtime and some may - Commonly first 3 to 5 years after menarche or after ovulation is
- Breast symptoms tend to be most bothersome just before disappear established
menstruation. Simple self-are measures can relieve discomfort o Giant fibroadenomas - Usually life-long
associated with fibrocystic breasts. - can grow larger than 2 in. or 5 cm; might need to - Can cause frequent and severe menstrual cramping for s evere and
Etiology: remove because they can press on or replace other abnormal uterine contraction
o Related to estrogen breast tissue Secondary dysmenorrhea
o Phyllodes tumor - due to pathologic condition.
Signs and Symptoms: - usually benign; some can become cancerous or - Dull pain that radiates to buttocks and thighs
o Breast lumps with fluctuation size especially during or nearing malignant. - Usually starts later in life which may be because of another medical
menstruation - Doctors recommend removing the tumor condition such as PID and endometriosis
o Generalized breast pain or tenderness Risk Factors:
o Green or dark brown nonbloody nipple (secretion is present) o Obese, Smoking
o Monthly increase in breast pain or lumpiness from mid cycle - Drinking alcohol during period tends to prolong
(ovulation) to menstruation menstrual pain
o Early menarche (before the age of 11), nulliparity
Diagnosis: Nursing Considerations:
o Clinical & self-breast exam o Heating pad or hot baths
- the doctor checks the breast and lump modules by the o Massage on lower back to relieve cramping
lower neck and underarm areas; if normal breast o Yoga, acupuncture, aromatherapy
changes = no need for additional tests o TENS or transcutaneous electrical nerve stimulation
o Mammogram o Diet modifications: low salt and sugar
- 45 yrs & above; to take annually. Focuses on a specific o NSAIDS or Nonsteroidal Anti-Inflammatory Drugs
area of concern in the breast. Fine-needle aspiration
o Ultrasound - May collapse the cyst and Imperforated Hymen
resolve the discomfort - Most females are born with hymen.
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- hymen Premenstrual Dysphoric Disorder (PMDD)
 thin membrane that stretches across the vagina. - Significant physical and behavioral symptoms that interfere with
It generally has a ring-like appearance with a daily living.
small opening. Signs and Symptoms:
 There is no real medical purpose for the hymen o Irritability or anger that may affect other people
although some think it may have evolved over o Feeling of sadness or despair
time to help protect vagina from infection. o Thoughts of suicide, Feeling out of control
 Most girls have a small crescent or o Feeling of tension or anxiety, panic attacks, mood swings or
donut-shaped opening in their hymen. crying
 This opening allows for access to the vagina and o Often lack of interest in daily activities and relationships
approximately 1 in 1,000 girls are born with o Trouble thinking or focusing
what is called imperforate hymen. Treatment: o Tiredness or low energy
- Imperforate hymen is a hymen in which no opening to the vagina is o Hymenotomy o Food craving or binge eating and insomnia
present. o Surgically cut away part of the hymen using a scalpel or laser o Bloating, breast tenderness, headache and joint or muscle pain
- Many girls will not even be aware that they have an imperforate Causes:
Nursing Considerations:
hymen until they begin their menstrual period and experience Unknown, but there are some factors that may contribute:
o NSAIDS, antibiotics as ordered
complications due to blood pooling in the vagina. o Cyclic change in hormones or hormonal fluctuation
o Dilator-application
Signs and Symptoms:  Disappears in pregnancy and menopause
o Abdominal pain and swelling which often come and go each o Chemical change in the brain
month  Neurotransmitters: serotonin. This is
o Back pain thought to play a crucial role in mood
o Lack of a menstrual cycle despite having other signs of sexual state. With the fluctuation of serotonin,
Premenstrual Syndrome
maturity (developing breast and pubic hair) this could trigger PMS symptoms.
- 3 of every 4 menstruating women have experienced
o Dysuria and unable to void  Insufficient amounts of serotonin may
premenstrual syndrome.
Diagnosis: contribute to premenstrual depression
- Symptoms may occur in predictable patterns but the
o Gynecologic exam as well as fatigue, food cravings and
physical and emotional changes women experience
o Vaginal or Pelvic Ultrasound sleep problems.
with PMS may vary from just slightly noticeable to
- Rule out transverse vaginal septum or mass o Depression
all the way to intense.
- Imperforate hymen diagnosed in girls younger than 10 years  Some women with severe premenstrual
- We do not let this problem control our life.
old are often found by chance. syndrome have undiagnosed depression
- Treatment and lifestyle adjustment can help reduce or
- In some cases, doctors may suspect an imperforate hymen although depression alone does not
manage the signs and symptoms of premenstrual
following a routine newborn check. So if the doctor cause all the symptoms.
syndrome. Signs and symptoms could be
suspects an imperforate hymen, they can order vaginal or Treatment:
behavioral, physical, or emotional.
pelvic ultrasound. o Advise women to have regular exercise and enough
Signs and Symptoms:
- Can also be mistaken for other pelvic conditions such as sleep
o Abdominal bloating
transverse vaginal septum. o Avoid smoking, limit sugar, salt, alcohol and caffeine.
o Pelvic fullness
 This is a thick mass blocking the vagina and o Joint muscle pain
o Yoga, acupuncture, hypnosis, massage
ultrasound can help confirm the diagnosis. o Stress reduction techniques
o Breast tenderness
Different Types of Hymen: o NSAIDs
o Weight gain due to fluid retention
1. Normal o Premenstrual cravings or appetite changes
2. Imperforate Menopausal Syndrome
o Headache, fatigue
3. Microperforate o Constipation, Diarrhea - The stage of life after you have not had a period for 12 months or
4. Cribriform o Alcohol Intolerance, Acne flares longer.
5. Septate o Depression, crying spells, irritability, panic attacks, anger - This is the time that marks the end of the menstrual cycle.
(mood swings) - It is diagnosed after 12 months without a menstrual period.
o Insomnia, social withdrawal, change in libido, poor - This can happen to women in their 40s or 50s, but the average age
concentration is 51.
Generally, these will disappear 4 days after the start of the - A natural, biological process but the physical symptoms such as hot
menstruation. flashes, emotional symptoms of menopause may disrupt sleep,
lower the energy, or affect emotional health.
Etiology:
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o Decline of hormones - Prevent osteoporosis - The compressed urethra, a possibility of stasis of urine in the
o Hysterectomy bladder.
o Chemotherapy and radiation Nursing Considerations: (Key focus is more on a symptomatic approach) - The severity of symptoms in people who have prostate gland
o Primary ovarian insufficiency o Dress lightly enlargement varies, but they tend to gradually worsen over
- Is said to be genetic - To counter the effects of hot flashes time.
Signs and Symptoms: o Increase cold fluids. Minimize hot beverages, spicy foods, Signs and Symptoms:
o Irregular periods smoking, alcohol, stress, hot weather, and warm room o Frequent or urgent need to urinate
o Vaginal dryness o Use water-based vaginal lubricants o Increased frequency of urination at night (nocturia)
o Hot flashes - For vaginal dryness o Difficulty starting urination
o Chills o Sleep and exercise o Weak urine stream or a stream that stops and starts
o Night sweats o Kegel exercises o Dribbling at the end of urination
o Sleep problems - For the muscle tone in the lower pelvic area o Inability to completely empty the bladder
o Mood changes o The less common signs or symptoms
o Weight gain and slowed metabolism MEN - urinary tract infections
o Thinning hair and dry skin Benign Prostatic Hyperplasia (BPH) - inability to urinate
o Loss of breast fullness - Also called prostate gland - blood in the urine.
enlargement
- Common condition in men as The size of the prostate doesn’t necessarily determine the severity
they get older of the symptoms. Some men with only slightly enlarged prostate
- An enlarged prostate gland can can have significant symptoms, while other men with very large
cause uncomfortable urinary prostate can only have minor urinary symptoms. Symptoms usually
symptoms such as blocking stabilize or might even improve over time.
the flow of urine out of the
bladder. So with the blockage, it causes stasis, urinary Complications:
tract and kidney problems. o Urinary retention
Risk Factors: - Sudden inability to urinate, the need to have a
o Aging catheter inserted into the bladder to drain the
- 60-years-old and above urine.
o Family history of BPH - In some men with larger prostate, they need surgery
o Diabetes and heart diseases to relieve the retention.
Complications: - Because of the use of beta blockers o UTI (Urinary Tract Infection)
o Osteoporosis o Obesity - The inability to fully empty the bladder can increase the risk
- Due to loss of estrogen in the body of infection in the urinary tract.
- Will lose up to 25% of our bone density following - If UTI occurs frequently, the need for surgery to remove part
menopause up to the age of 60 of the prostate.
- Makes a woman susceptible to bone fractures o Bladder stones and damage
particularly in the hips, spine, and wrists - Generally caused by inability to empty the bladder
o Cardiovascular diseases Prostate gland - normal - Bladder stones can cause infection, bladder irritation, blood
o Obesity - located beneath the bladder. in the urine, and obstruction of urine.
- Due to slowed metabolism - The tube that transports urine from the bladder out of the o Damaged bladder
o Vaginal dryness penis and passes through the center of the prostate, that - Is also a complication of BPH.
o Urinary incontinence tube is called the urethra. - A bladder that hasn’t emptied completely, can stretch and
Treatment: - When the prostate enlarges, it begins to block the urine flow. weaken over time. As a result, the muscular wall of the
o Hormone therapy - Most men have continued prostate growth throughout life, bladder no longer contracts properly and makes it hardto
- Replacement of declined hormones and with the enlarged prostate, this can cause urinary fully empty the bladder.
o Gabapentin symptoms or significant blocked urine. o Kidney damage
- For hot flashes - Pressure in the kidney from urinary retention can directly
- Is said to be an anticonvulsant drug but it is used to treat Enlarged prostate damage the kidneys and allow bladder infection to reach
vasomotor symptoms in premenstrual women with - it pushes through the urethra causing blockage. the kidney or ascending infection.
contraindications to hormonal therapy - There is little amount of urine passed through the urethra because Diagnosis:
o Vitamin D and calcium supplements of the increased size of the prostate. o DRE (Direct Rectal Exam)
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- This is when the doctor inserts a finger into the rectum to - Only partly relieves symptoms and it might take some time before a  The egocentrism of the previous stage begins to disappear as
check the prostate for enlargement. man notices the result. kids become better at thinking about how other people might
o PSA Test (Prostate Specific Antigen) view a situation.
- Blood test 4. Formal Operational Stage (12 and up)
- A substance produced in the prostate, an increased level of  The adolescent or young adult begins to think abstractly and
which is seen in large prostate. However, elevated PSA reason about hypothetical problems. Abstract thoughts
level can also be due to recent procedure, infection, emerge at this point.
surgery, and prostate cancer.  Teen begins to think more about moral, philosophical,
o UTZ, Bx (Ultrasound and Biopsy) ethical, social, and political issues that require theoretical
- Transrectal ultrasound and abstract reasoning.
- An ultrasound probe is inserted in the rectum to measure  They also begin to use deductive logic or reasoning from a
and evaluate the prostate. Prostate biopsy, this is an Nursing Considerations: general principle to specific information.
examination wherein a tissue sample is taken to help the o Instruct the patient to spread the fluid intake throughout the  The final stage of Piaget’s theory involves an increase in logic,
doctor diagnose and rule out prostate gland cancer. day. the ability to use deductive reasoning, and understanding
- A transrectal ultrasound guides the needle and takes tissue o Limit beverages at night, caffeine and alcohol. of abstract ideas.
samples for biopsy. - To prevent nocturia
o Cystoscopy - This increases the needs to urinate Early school-age children
- Wherein an instrument called a cystoscope is inserted to the o Bladder care  ● Generally know quite a bit about the workings of their major
urethra, allowing the doctor to see the inside of the urethra - Take plenty of time to urinate and try to relax. body parts.
and the bladder. - Read or think of other things while waiting.  Able to name the function of heart, lungs, and stomach.
- A local anesthesia is given before the test - For dribbling (?) problems, wash penis daily to avoid skin  Not able to see the body as a system until the age of 10 to 11
Treatment: irritation and infection. years.
 For medication or drug therapy, this is the most common treatment o Healthy diet, minimize obesity. Younger children
for mild to moderate symptoms of prostate enlargement.  May think the cause of illness is magical or a consequence of
o Alpha-blockers (Tamsulosin, Alfuzosin, Doxazosin)
WEEK 7: Nursing Care of a Family with an Ill Child
Meaning of an illness to children breaking a rule. They think they get well after they follow
- A medication that relaxes the bladder neck muscle and another set of rules (e.g. staying in bed or taking medicine).
The Meaning of Illness to Children
muscle fiber in the prostate making urination easier. Because of this, children may see a passive role for themselves
Depends on:
o 5-alpha reductase inhibitor (Finasteride, Dutasteride) in getting well like being susceptible to chickenpox because
o Cognitive ability
- This medication shrinks the prostate by preventing hormonal they did not get the vaccine.
o Past experiences
changes that cause prostate growth.  By 4th grade, they are generally aware of the role germs play in
o Level of knowledge
 Transurethral Resection of the Prostate (TURP)
● All of these can be related to Piaget’s cognitive development wherein illness.
- Surgical management  By 8th grade, they are able to voice an understanding that
the focus of this theory is more on understanding how children acquire
- Done using a lighted scope inserted into the urethra, then
knowledge, and also understanding their nature of intelligence. If we illness can occur from several causes which is due to the formal
the surgeon removes all but the outer part of the
recall the four stages, we have: logical stage that they are in.
prostate.
1. Sensory Motor Stage (Birth to 2-years-old)
- Generally relieves the symptoms quickly and most men have
 Infant uses senses and motor skills. An illness in a child is a stress especially if it includes hospitalization
a strong urine flow soon after the procedure. After TURP
 They also know items by its use and object prominence. Knowing how children of each age view illnesses affects the planning
catheter is inserted temporarily to drain the bladder of nursing care and influences how it should be worded:
● Transurethral incision of the prostate (TUIP) 2. Pre-operational Stage (2 to 7-years-old)
 The child becomes a symbolic thinker. They begin to think  saying you are going to “stick” a child for blood work could be
- Same with TURP; a lighted scope into the urethra and the surgeon interpreted by young children as meaning you are actually
makes one or two cuts in the prostate gland, making it easier symbolically and begin to use words and pictures to represent
them going to put a stick in their arm. Saying a child will receive dye
for the urine to pass through the urethra for a test could be interpreted as meaning the child will “die”
- This surgery might be an option if the man has a small to moderate  Children at this stage tend to be egocentric and struggle to see
things from the perspective of others. during the procedure. Explanations of procedures can sound
enlarged prostate gland, especially if the man has health confusing if words sound alike or have double meanings (e.g.,
problems that make other surgeries too risky. 3. Concrete-Operational Stage (7 to 11-years-old)
 During this stage, children begin to think logically about “drawing” as in making a picture vs. “drawing” blood). Because
● Transurethral Microwave Thermotherapy (TUMT) of these distorted perceptions, explanations of procedures do
- The doctor inserts special electrodes through the urethra into the concrete events.
 They begin to understand the concept of conservation that the not always relieve children’s stress
prostate area.  wise to talk to preschool and early school-age children about
- The microwave energy from the electrodes destroy the inner amount of liquid in a short wide cup is equal to that in a tall
skinny glass. “fixing” body parts, such as tonsils, rather than “taking them
portion of the enlarged prostate gland, shrinking it and easing
out”
the urine flow.
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 Loss of body parts, loss of life, and loss of - Most adults have achieved immunity to common infectious
Differences in Responses of Children and Adults to friends. diseases and children are very susceptible to illnesses such as
Illness Children in a strange environment, such as a hospital, have not learned measles, mumps, and chicken pox.
● Inability to communicate coping skills as yet and so require proportionally more support and active - Because of the growth requirements and their immaturity, they are
● Inability to Monitor Own Care and Manage Fear intervention to manage their stress and fears. Otherwise, hospitalization, susceptible to some diseases that do not affect the adults.
● Nutritional Needs particularly if it follows trauma from unintentional injury, can result in - Example: Rickets, lack of vitamin D in children and it may lead to
● Fluid and Electrolyte Balance posttraumatic stress disorder (PTSD) or the development of characteristic skeletal deformities, the adult does not affect them.
● Systemic Response to illness symptoms, such as difficulty falling asleep, outbursts of anger, difficulty - Another example is febrile seizure at age 5-10 years old. Children
● Age-specific Disease concentrating, difficulty completing tasks, or experiencing symptoms such with high temperature may respond to generalized seizure but
as stomach aches or headaches they do not have any problems in the brain only specific to
Inability to Communicate their age.
● Very young children Nutritional Needs - Febrile children between the ages 6 and 60 months who do not
 Do not have the vocabulary to describe symptoms, like when According to CDC or Center for Disease Control and Prevention (2015), have an intracranial infection or metabolic disturbance are
they have a headache, or they are dizzy or nauseated. o Children have greater metabolic demand typically diagnosed with “febrile seizure”
 They cannot express what they are feeling because of lack of o Children breathe in more air per pound of body
vocabulary. weight CARE OF THE ILL CHILD AND FAMILY IN THE HOSPITAL
 They may intend to minimize or intensify symptoms. o Higher surface to body mass ratio - The parents of children admitted in the ICU are predicted to
 It is important to evaluate by observation, like when the baby o greater risk for insensible fluid loss when they experience a high degree of stress during their child’s
is crying, she probably has symptoms but she cannot describe are sick. hospitalization. Due to the severity of the child’s illness and of
so we need to observe or show guarding behavior. - In other words, children need more nutrients like calories, proteins, course the hightech setting of the ICU. Dealing with these
● School age minerals or vitamins per pound of body weight. Because their parents requires patience because parents under stress can
 Most can describe symptoms with accuracy. metabolic rate is faster, intake must only be encouraged for have difficulty comprehending instruction.
 They may intensify their concerns if they believe someone tissue repair but also enough to allow for growth. An example
expects symptoms to be more serious. They may minimize to this, an infant needs 120 kcal per kg whereas an adult needs The Effect of Hospital Separation on Children: Decreasing Separation
symptoms if they are afraid that an illness will interfere withan only 30-35 kcal per kg of body weight per day. Anxiety
activity they want to do; thus, it is important to evaluate a - Social/emotional development begins early in infancy. Babies
child’s symptoms as much by observation as by a child’s report. Fluid and Electrolyte Balance display sadness, happiness, and anger at a young age, and they
A crying, whining preschooler who is “just not herself” - Adults: Extracellular water (plasma and outside body cells) begin to change their facial expressions to register changes in
probably has a symptom she cannot describe. A school-age represents approximately 23% of total body water. their emotions around 5 months.
child who guards her abdomen (i.e., keeps abdominal muscles - Newborn: Extracellular water is closer to 40%. - Infants of age 5-9 months
rigid) is in pain just as clearly as a child who verbalizes a source  This means that an infant does not have as much as  We all know that they are attached to their parents or
of discomfort. water stores in their cells like an adult does. caregivers.
 They are more likely to lose a devastating amount of  When in the presence of strangers, infants fix their
Inability to Monitor Own Care and Manage Fear body water in diarrhea and vomiting. Because of eyes on them, become restless, perhaps thrash
 Adults often ask questions about medications and procedures. this, there’s no such thing as “only diarrhea or arms or legs, and begin to cry.
If the nurse is late in giving the medication, the adults would simple diarrhea” in a child younger than 1 year old. o This activity peaks at approximately 9
often follow-up. Systemic Response to Illness months of age
 School age and younger children cannot monitor their own - Because children have immature bodies, younger children tend to o a developmental milestone that shows
care. They may not know which medicine or procedures they respond to disease systemically rather than locally. that an infant is able to distinguish a
have to receive. If they do know, they may be confused about - Example: When a child has pneumonia, supposed to be the primary caregiver from other persons.
time. presenting symptoms for pneumonia is cough, but children will  The timing of separation anxiety can vary widely from
 Children have fears: be admitted not because of the cough but because of the other child to child.
 8-9 months accompanying systemic symptoms such as fever, vomiting, and  To reduce separation anxiety, we need to establish a
 Fear of separation; if they are taken away from diarrhea. primary nurse.
their mother or their primary care provider. - Systemic reactions can delay diagnosis and therapy and can cause - Toddlers and preschoolers
 Toddler and preschoolers increased fluid and nutrient loss.  The effects of separation become especially intense in
 Fear of separation, the dark, intrusive - nausea and vomiting occur so frequently in children with any type young children before they understand time. We
of illness that these symptoms do not have the diagnostic value need to establish a primary nurse.
procedures, and mutilation of body parts
 School age child and adolescent
that they may have in adults.  Although many toddlers and preschoolers attend day
Age-Specific Diseases care and have had prior experiences with
separation, others may have had only limited
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experiences being away from their parents. Being may be anxiety if the child is told about an approaching the child’s usual meal plan? Are there foods the child does not
hospitalized may be the first time they are away hospitalization too far in advance. Conversely, few things are eat? Did the child pack a favorite toy for the hospital? What are
from parents in a strange setting or away from more frightening for children than to hear a conversation halt the child’s favorite games and hobbies or interests? Are there
home overnight. as they enter a room or to hear adults spelling out unknown television programs the parents especially like the child to see
 The effect of separation can become especially intense words. or not see?.
in young children before they are able to - On the day of hospital admission, it is important for you to ask the Developmental survey
understand time, because statements such as parents what preparation they have done to ensure the child - This would include if the child feeds herself or does the child use a
“Mom will visit again tomorrow” or “Dad will be and family accurately understand the child’s condition and spoon, can use cups, bottles, can dress herself, and what grade
here by 6 o’clock” are meaningless unless they upcoming procedures. is the child.
know what “tomorrow” or “6 o’clock” means. - Bringing a favorite toy or personal item such as a blanket can help. Special Information
- Primary nurse - The nurse will care for them for the entire course of Referred to as “transitional objects,” these items are - This determines what the parents think would make the child more
their hospitalization and establish trust to the child and reduce reminders about something familiar from home. comfortable in the hospital.
separation anxiety.
- School-age children and adolescent Admitting the Ill Child and Family: Assessment on Admission Book:
 Reacts better than younger children to the separation Whether an ambulatory or inpatient hospital unit admission,
because they have experiences they can use for Chief concern children and parents need to be admitted as a single entity to
comparison. They have been to school for whole - Determine what the parents’ understanding is of why the child is encourage parents to feel that they are true partners in care
days, perhaps they have stayed with a grandparent being admitted. (This view may differ widely from the family If parents are left standing at a counter without being
or a friend overnight, and they may have been to a care provider’s view regarding the reason the child is being addressed, they can easily feel that no one appreciates their
summer camp. admitted.) What has the child been told about the reason for concern and that possibly their child will not receive optimal
 This can make hospitalization a time for developing hospitalization? care.
self-esteem and confidence in their ability to be Family profile Introduce yourself, explain your role to the parents and child,
independent. - Obtain child’s name and birthday. Who lives at home (including and find a comfortable place for the family to wait until
 Even in light of this, ill school-age children and pets)? Ask about the parents’ occupation and education levels. someone is available to orient them to the unit.
adolescents appreciate their parents being near Who is the child’s primary caregiver? Have there been any When introducing yourself to children, stoop down so that
them and reassurance that their parents will be disruptive happenings lately in the child’s life, such as a move your face is level with the child’s face. Call the child by his or
there to support them through this crisis or a divorce, that would make the child particularly insecure at her name or ask for a nickname.
- Reducing the ill effects of separation and hospitalization to the this time? Will a parent be staying with the child? If parents are All children should have an armband attached which lists their
extent possible should be a high priority for all healthcare separated or divorced, what will the visiting arrangements be? name, date of birth, and hospital medical record number.
providers Who has legal authority to sign medical permission? Because their hands are not much larger than their wrists, and
Past experience with illness or separation their feet are not much larger than their ankles, small infants
Preparing the Ill Child and Family for Hospitalization - Ask about previous hospital experiences and how the child feels often need two bands in place as an extra safeguard. If a band
- The preparation the parents make for their child varies according to about them. Has there been a recent hospitalization for should fall off, verify the patient’s identity using at least two
the child’s age and individual experience no matter what the anyone in the family that resulted in a bad outcome? Has the patient identifiers (acceptable identifiers may be the
child’s age. However, the parents are encouraged to convey a child been away from the parents before? Overnight at a individual’s name, an assigned identification number,
good positive attitude towards hospitalization. grandparent’s? telephone number, or other person-specific identifier) and
- Children between 2 to 7-years-old should be told about the Summer camp? What is the child’s past experience with taking secure it back onto the child; never tape it to the crib or
scheduled ambulatory or in-patient hospitalization as many medicine? Has the child swallowed pills before? Does the child bedside stand because this will not properly identify the
days before the procedure as the child ages in years. have any known allergies to food or medications? patient, and the child could be given a wrong medication or
- Example: A child who is 2 years old, they should be informed 2 days Document these by asking for exact symptoms and have an unintentional procedure.
before hospitalization. For 4 years old, 4 days before. happenings.
- Children older than 7 years of age can be told, as soon as the Daily routines Promoting A Positive Hospital Stay
parents are aware of it. - Ask about the child’s regular bedtime and sleep times. Does the - This is very important for the health of both children and their
- Many childhood illnesses such as febrile seizures, appendicitis, child nap? Is there an important bedtime ritual? What type of families like
poisonings, and asthma exacerbations are acute, making bed does the child sleep in at home? Does the child sleep with - Providing continuity of care or primary nursing.
advance preparation for hospital admission impossible. a favorite toy or blanket? What is the bath time routine? Does  This ensures that children are exposed to a few substitute
However, when hospitalizations such as elective surgeries are the child need help brushing teeth or combing hair or is this care people as possible to maintain consistency and
scheduled, advance preparation is possible with programs such done independently? What words does the child use for quality care.
as preoperative orientation. The preparations parents make for voiding and defecating? Is the child completely toilet trained?  nursing assignments are best if one nurse gives as much
a child obviously vary depending on the child’s developmental If a preschooler, is the child accustomed to using a potty chair care to the same child as possible
age and experiences. Depending on the age of the child, there or toilet? Does the child have enuresis (bed-wetting)? What is
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 promotes ongoing communication between the patient, - If limit setting is necessary, such as with a child who hits or bites the parents from the noise and tension of the larger,
family, nurses, and physicians by building rapport and other children, confer with the child’s parents about the need unstructured room
facilitating discharge planning beginning on admission for limit setting and what measures they would suggest.  Unless a child is diagnosed with failure to thrive or is
 These staffing patterns allow the same nurse to admit the - Gain their cooperation and approval so that what you do is obviously underweight, illness is not an ideal period in
child, take the nursing history, establish nursing consistent with their usual care. which to introduce new foods or formula.
diagnoses, set goals for care in cooperation with the - Using “time-out” periods or removing the child to a nonstimulating  Breastfeeding should be continued if at all possible. If a
parents and the child, and evaluate progress toward area for a short time could be an effective measure. Be certain mother cannot be at the hospital constantly, urge her to
achieving goals. It allows children to have one main nurse a child understands time-out rules (e.g., if the child bites or hits pump milk, freeze it, and bring it in so her child can
to call their own. It is also helpful to parents because it again, sitting alone for a designated period will be necessary). continue to receive the immunologic protection of breast
allows them to establish a meaningful contact with the The next time the child does misbehave, give one warning that milk.
hospital staff and maintains continuity of care, planning, the behavior is against the rules; if the behavior continues,  Overall, because infants cannot begin to understand the
and implementation. take the child to the time-out spot. strange feelings accompanying illness, they need
Providing Adequate Play Facilities (Therapeutic Play) - If the child is disruptive, begin timing the period from when the increased swaddling and comforting. As their condition
- In children, play is important so one way of promoting a positive child quiets down. When the child has been quiet for the improves, provide stimulation and play opportunities
hospital stay is to incorporate therapeutic play as part of their specified duration (usually 1 minute per year of age), the child suitable for their developmental age.
treatment and setting limits on behavior. can leave the time-out place and rejoin activities - For ill toddler and preschooler
- Play  promote both autonomy in toddler and initiative in
 described as the work of children because it is the Discharge Planning preschool. Example would be to urge the parents to
medium through which they learn. - not only an important link between the hospital and the home, but encourage their children to make choices about
 indicator of how the child is coping with the stressors of it is also a final way to create a satisfying hospital experience. their care whenever possible; coloring the
hospitalization and may act as way to control their - As part of our discharge plan, we need to include information like medication schedule, it is the kind of task that helps
environment tantrums and nightmares after returning home from hospital initiative in preschool.
 Children need to be able to play as much as possible not stay for school-age children may manifest these behaviors to a  taking medications is not a choice, so never ask “Do
only to aid in distraction but also to encourage emotional lesser extent. you want to take your medicine now?” unless
well-being. - You can assure the parents that these behaviors are part of the there’s really a choice—almost all children will say
- Most children’s hospital units are equipped with a playroom or play child’s normal response to hospitalization. These behaviors do “NO!” Instead ask, “Which do you want to take first,
space that is maintained as a “pain-free” zone. No medical not happen because the child has been spoiled by the staff or the white medicine or the pink?”
procedures, not even painless ones, should be performed in by the parents during the illness but because of the experience  Toddlers and preschoolers who are not used to
this area because the child may then perceive the space as that was too intense for the child to handle. sleeping in cribs at home may resent being placedin
frightening. a crib in a hospital unless you explain to them, “All
- Children who are on bed rest need age-appropriate activities Promoting Growth and Development of the Ill Child our beds here have side rails.”
supplied for them to prevent boredom and a loss of control, - Children often fall behind in the growth and development because  Watch energetic toddlers closely to be certain they do
which can lead to depression or behavioral regression. of their illness. Mostly, we would often see nursing problems not attempt to climb over crib rails to get out of
- Therapeutic play like risk for delayed growth and development related to the bed. A child who does try to climb out of a crib
 play designed to help children express their feelings effects of illness. To counter this, we need to promote growth might be safer sleeping in a bed or may need a
about painful or frightening procedures and development. safety crib cover when a parent is not in the room.
 play needs are different for each child. A child’s - For ill infants  As with infants, illness is a poor time to change the
characteristics, such as temperament, coping style, maintain their at-home schedule when possible. Example eating habits of toddlers and preschoolers. Because
and cognitive abilities; family variables such as would be the feeding schedule. children of this age insist on self-feeding, they often
parental anxiety, presence, and involvement; and  To promote optimal growth and development in infants, eat better at a small table than using a tray in bed.
diagnosis/treatment variables are known to affect maintain their at-home schedule when possible.  Many child care units organize “toddler tables” so
psychosocial vulnerability and thus influence the Sameness provides security to an infant and encourages children this age can eat together. Supervise
child’s particular needs in terms of play the development of trust. children carefully if they are eating with others to
Setting Limits on Behavior  An infant who is used to sleeping in a bassinet, for be certain they eat only their own food, not food
- play needs are different for each child. A child’s characteristics, example, may feel loose and insecure in a large crib. belonging to someone else. Also be certain they are
such as temperament, coping style, and cognitive abilities; Swaddling such a child in a receiving blanket in a large not so distracted by other children that they do not
family variables such as parental anxiety, presence, and crib would help to offer the same close, bound feeling of eat. All children may eat better when a parent joins
involvement; and diagnosis/treatment variables are known to a smaller sleeping area. them for a meal.
affect psychosocial vulnerability and thus influence the child’s  Providing a singular room in a NICU has been shown to  Illness is also a poor time to introduce toilet training,
particular needs in terms of play improve parent satisfaction with care because it removes even if this is an appropriate activity for the child’s

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age. However, if parents have already begun toilet  Encourage them to maintain self- care activities and - Nursing responsibilities related to nutrition for ill children include:
training, continue this if possible, so you maintain a good hygiene practices to help preserve  maintaining optimal nutritional status in the fa ce of an
usual routine. self-esteem. illness or therapy that interferes with adequate
- For ill school-age children,  Illness can be especially difficult for adolescents also intake
 they need to work on a sense of industry or learning because peer relationships are so important to  correcting nutritional deficiencies or otherwise aiding
more about how and why things are done. them and a hospitalization automatically interferes children and families to follow the nutritional care
 Explaining specific procedures and involving them as with those. plan devised by the healthcare team
much as possible in planning their care allows  They may miss acting in a school play, being chosen for  educating a child and family regarding specific
school-age children to have some semblance of a sports team, or competing for a scholarship. A nutritional needs as well as overall sound nutritional
independence and control, which in turn promotes girlfriend or boyfriend may break off a relationship. health.
self-care. To help avoid feelings of exclusion and hurt, urge  Specific procedures for promoting nutrition such as
 Self-care attributes the practice of activities that an them to welcome visitors from their peer group. measuring fluid intake and output and providing
individual initiates and performs on his or her own  Suggest electronic communication formats such as enteral feedings, gastrostomy tube feedings, and
behalf to maintain life, health, and well- being texting or e-mailing as easy ways to keep in contact total parenteral nutrition
 School-age children (and adolescents) who are with friends and maintain relationships with Areas of concern when planning nutrition for ill children:
hospitalized for the short or long term become individuals who are important to them while Meaning of food
socially isolated from their families, classmates, and separated from them. - Early in life, infants learn to associate eating with being held and
friends and from the normalcy of everyday life  Adolescents usually appreciate being hospitalized in a loved; if they cannot eat for some reason, such as while waiting
 They need to continue schooling, provided their special adolescent unit or at least in a room free of for surgery, they may view the restriction as punishment or a
condition allows it. Maintaining that routine, childish decor. Consider that parents of an restriction of love.
everyday activity provides security to an otherwise adolescent have the same anxiety and concerns as - Encourage a parent to sit and rock them or read to them to lessen
insecure day. With increased, readily available parents with younger children. this uncomfortable time.
technologies providing access, communication and Fear of procedures and pain of separation are not
interaction, and with a variety of tools and software Opportunity for socialization
limited to the younger than 13 years of age set.
applications, the use of technology may offer - Mealtime is an ideal time for family members to socialize and share
Although many adolescents enjoy having parents their day; being separated from family for meals can create
opportunities for learning for children in hospitals
who otherwise will not be able to connect to their stay overnight because it is reassuring to know that loneliness and, consequently, a poor appetite.
original schools they are concerned, they may also enjoy being - Urge parents to visit at mealtime if possible, so “sharing a day” can
 school-age children also are developing moral separated (assuming everything is going well) and continue.
responsibility and so may find comfort in spiritual may not want their parents present all day and
practices. night. Level of stress
 Encourage school-age children to carry out as much  Often, adolescents convey a blasé attitude toward - Children under stress may either feel a loss of appetite or
self-care as usual, and, if being cared for at home, to procedures (e.g., having an X- ray taken is nothing, experience a need to snack frequently; this can make it
continue to contribute to household routines, such surgery is a cinch, a cast change is a snap). Listen necessary to be certain children maintain adequate intake if
as helping with dishes or picking up after carefully to make certain adolescents really feel this not hungry and that, when hungry, their snacks are nutritious.
themselves as much as they are able. This not only way and are not trying to convince themselves that
takes some burden off caregivers but also sends a a procedure is harmless. Remember that Custom and culture
signal that people expect this illness to pass and the adolescents are extremely worried about their body - here are some children who want their food to be separated and
child to become a full family member again image. Explain to them what is going to happen in not mixed up. In a hospital setting, we need to ask the parents
- For ill adolescents surgery or in other departments because it is easy to bring favorite food treats to stimulate the child's appetite.
 An adolescent who is struggling to develop a sense of to assume from their attitude they know more than
identity may find it difficult to be ill because the they do. Environment
limitations imposed by an illness make the - Hunger is associated with the sight and smell of food; many
development of a sense of identity so difficult. If Promoting Nutritional Health of the Ill Child children are normally in the kitchen and help prepare meals;
possible, help adolescents to continue to participate - As nurses, it is part of our responsibility to monitor and maintain they may not feel as hungry, therefore, when food is served to
in activities they did before becoming hospitalized optimal nutritional status of children in the hospital facing them without their having seen and smelled it being prepared.
to help them feel that their world is not totally illness or treatment that interferes with adequate intake. - Allowing them to pick what foods they want for meals, if possible,
changing. - To correct nutritional deficiency, we need to help and aid these gives them at least some sense of food preparation and
children and families to follow nutritional care plans. In selection.
planning for nutrition for these ill children, there are areas of
concern that we need to look into or we need to take note. Encourage Fluid Intake
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o Offer small, full glasses frequently rather than larger half-full - Ensure that doors of healthcare facilities have working alarms to o State of health
glasses. children are mid–school age before they evaluate the prevent children from going out and to prevent strangers from o Habit
amount of fluid in a container rather than the size of the coming in. o Medication
container. - Be sure windows are covered by screens or guards so children o Environment at the time of sleep
o Determine the child’s favorite fluid and then offer it, if cannot climb up on sills and fall out. Stages:
appropriate. - Check that the side rails of beds and beds are in good condition, Stage Description Nursing Implications
o Popsicles and Jell-O count as fluids. raised appropriately and locked. Non-Rapid A feeling of drifting or falling. A child can be
o Children can drink more of a clear fluid (e.g., ginger ale, water) - Test crib rail after it is raised to ensure the lock is caught. Eye Often aroused
than a thicker fluid (e.g., milk shakes, cream soups) because - Push bedside tables or stands away from cribs so as a child cannot Movement described as twilight sleep. easily from this early
thicker fluids are absorbed from the stomach much more climb over the railing and use the stand as a step down. (NREM) Temperature and heart rate sleep by the slightest
slowly. - Ensure that electrical cords or appliances such as hair dryers are not Stage I decrease slightly; noise or silent
o Suggest soothing beverages such as milk or Pedialyte popsicles used in bathrooms to prevent electrocution. electroencephalogram (EEG) presence of another
for children with mouth lesions. - Always raise bedside rails after a child has received preoperative or waves show peaked, frequent person in the room.
o Avoid carbonated beverages and citrus or acidic fruit juices sedative medication. (alpha) waves.; first phase of Reduce noise level in
because the acid content and/or carbonation sting their - Test a crib rail after it is raised to ensure the lock has caught so the sleep; This type of sleep occurs room to
mouths. Ice melts to one half its volume. Count a glass of ice rail will remain raised. up to 80% of the total sleep time. promote sleep.
chips as only a half-full glass of fluid. - Be certain crib caps are available for small children to prevent them Purpose: rest and restoration of
o Encourage breast feeding whenever possible. from climbing the body; this stage keeps body
o Unless contraindicated, let children drink fluids with a straw; - out of bed. cells functioning and healthy
this is a novelty to many who do not normally use these and so - Fasten the seat belt restraint for infants in high chairs. Never leave NREM Sleep deepens. Temperature and It is more difficult to
encourages intake. an infant in a high chair (at home or in a hospital) without Stage II heart rate wake a child from
o Introduce a game, such as Simon Says (Simon says, “Drink”) or someone close enough to reach the child because infants can decrease slightly more. sleep
a board game in which a child takes turns and with each turn easily squirm out of a high chair restraint. when this point is
has to take a drink. Use play as a method of teaching nutrition - Ensure that electrical cords or appliances such as hair dryers are not reached.
and sound dietary habits to children used in bathrooms, where they could come in contact with NREM Sleep deepens still further. An It is very difficult to
water. Stage III EEG tracing wake
Encourage Food Intake - Be careful of the placement of television/call cords or window blind reveals mixed spindle and slow a child from stage III
o Calorie counting cords so they cannot lead to strangulation. (delta) sleep. Use patience to
- Record all the foods that a child eats during each 24-hour - Never leave children alone in a bathtub; they could turn on the hot waves. Temperature and heart wake a child fully to
period. water and scald themselves or slip under the water and drown. rate offer medicine.
- Includes snacks, candy, gum - Never leave equipment or items that would be harmful to eat decrease further. This period
- A dietician then will analyse the list and determine the within the reach of children. lasts about
calorie intake of the child. - Adhere to all fire precaution measures. 10 min.
- Be certain when doing this that you describe the types of - Closely follow standard infection precautions to prevent the spread NREM Approximately 20–30 min after Children may be
food and amounts (i.e., not “some toast,” but “half a slice of infections stage IV beginning to fall asleep, a child confused and unable
of whole wheat toast”). enters stage IV sleep. to orient themselves
- Make sure that everyone caring for the child (including Promoting Adequate Sleep for the Ill Child Respirations and heart rate slow readily if awakened
parents) is aware that calories are being counted so that - Children need adequate rest and sleep so their body and tissue can even more, and blood pressure from stage IV sleep.
they also record this information accurately effectively use nutrients for repair and normal growth to and Use patience until a
continue. temperature decrease; EEG child is fully awake,
Promoting Safety for the Ill Child - Children may not sleep well when they are ill because of the shows slow, steady (delta) waves. particularly if asking a
- It is our prime consideration as nurses to keep a child safe during discomfort, pain or the administration of the medications or Children remain at a stage IV question.
illness care. intensified symptoms of chronic sleep problems. sleep level for approximately 30
- Always be sure of the location of all children in your care to ensure - Another factor is the strange hospital setting. min and then progress back
safety, we need to be sure of the location and the - Also procedures that the child has to undergo. This has to do with through
whereabouts and we need to account for all the children in our deprivation of nap or rest as much during the day as compared stages III and II until they then
care. to their usual. We encourage the parents to stay with the pass into a phase of REM sleep.
- Ensure that doors or gates are provided near stairways or elevators children for support and comfort. Rapid Eye Eyes move in rapid, involuntary Dreaming occurs
to prevent falls. Sleep Patterns Movement motions. Respirations are during REM sleep.
Influenced by: (REM) irregular; body turnings, Although children
o Apprehension level
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movements, and penile erections appear to be close to - Growth hormone is necessary for protein synthesis, for the growth - Children with sensory overload react similarly to those with sensory
may occur. Lasts 10 to 30 min waking because of new cells, and for the repair and maintenance of all cells. deprivation or feel confused, unable to make decisions, and
and then a new of the active eye - Corticosteroids and adrenaline from the adrenal gland, which are feel severely fatigued. Sometimes, it is difficult to determine
sleep cycle with NREM sleep movements, they are instrumental in the catabolism or breakdown of cells, are at the cause of these symptoms (whether they are caused by
begins. really very soundly their lowest levels. This balance of hormones produces the sensory deprivation or overload) unless assessed carefully.
asleep. Children may ideal combination for protein synthesis and cell growth and - The lights in ICUs, for example, are never turned out. Although
wake afraid and repair. children may find this comforting, it can also result in excessive
crying, REM Sleep stimulation. In addition to constant light, there is excessive
disturbed by a - purpose of REM sleep is less clear. sound such as the whir of machines, the buzzing of ventilators,
frightening dream. - The REMs may serve to coordinate binocular vision. the ringing of alarms, or the mix of voices in consultation.
child can be confused - Dreams that occur during this time apparently serve as a release - Excessive noise levels in the NICU have been studied as a factor
and unable to orient of tension or help to integrate new knowledge and experiences influencing the function of a premature infant’s brain through
himself readily if with the old in the brain’s memory system. alterations of cortisol levels, apnea, decreased oxygen
awakened from stage - Vital signs may fall during NREM sleep. saturation and perfusion from exaggerated startle response.
4 sleep. Use patience - During REM sleep, vital signs rise to near normal levels. These and abrupt fluctuations in heart rate
until a child is fully periods of REM sleep interspersed with NREM sleep, therefore, - hospital noise not exceed 45 dB during daytime hours and 35 dB at
awake particularly if may be a fail-safe measure to prevent vital signs from falling night.
asking questions. too low during sleep - Using indirect lighting whenever possible, implementing the
national recommended safe sound level (NRL) of 45 dB in
Sleep Deprivation Promoting Adequate Stimulation for the Ill Child infants’ rooms, reducing unnecessary conversations, and
- Children who don't receive enough sleep can suffer sleep Sensory Deprivation covering incubators for “quiet times” are all measures used to
deprivation just like adults do. - The condition of being deprived of, or lacking adequate sensory, reduce these types of stimulation
- Infants are dependent on sleep to promote brain development. social, physical or cognitive stimulation.
- If sleep loss is mainly REM deprivation, children show symptoms of - When this happens, children tend to lose the ability to make Promoting Play for the Ill Child
irritability and difficulty concentrating. decisions and become easily confused and depressed. - Play, often described as “the work of children,” is an invaluable
- If Stage IV NREM sleep is lacking, tends to cause apathy, physical - Ill children may have sensory deprivation because they are confined component of child health care. Providing a space and
and depression and can slow recovery. to their homes or hospital rooms and their varied activities opportunity for play can help children feel more comfortable
- Sleep is very important for ill children. We need to take special step such as school, sports, and clubs are replaced with hours of and allow for an important release of energy for children who
to ensure that this children is able to sleep during illness. Make watching television or playing video games. are confined to a room or bed.
certain that they are free from pain and worry as possible. We - Hospitalized children respond best to a diversity of readily available, - Play also may be used to help assess children’s level of knowledge
try to let them maintain normal bedtime routine as possible. independently accessible, age- appropriate, and feelings about their condition so that more individualized
- We need to provide an atmosphere conducive to sleep like turning gender-appropriate, and developmentally appropriate leisure nursing care can be planned
off the light, quiet surrounding, reassuring people around. and entertainment facilities seamlessly integrated throughout - play is any voluntary activity engaged in for the purpose of
- Children who are bored with bedrest may cut nap constantly, the hospital environment enjoyment. If a child views an activity as enjoyment, therefore,
providing more interesting activity for them during the day can - Children with hearing or visual deficits are more prone than others no matter what it is and whether it would be fun or not for an
help reduce their nap and increase nighttime sleep to sensory deprivation. Children with forms of sensory nerve adult, it is play.
- parents who sleep in hospital rooms do not obtain adequate sleep loss or those receiving chemotherapy may lose their sense of - Play is clearly the means by which children develop increasing
either. touch, taste, or proprioception (the sense of where they are in cognitive, psychomotor, and social capabilities. Touching a soft
- Although their presence is healthy for children, it can limit the space). After losing these forms of perception, children may toy, passing colored blocks from one hand to the other,
parents’ capacity to meet the child’s needs draw back from interacting with other people because they are pounding with a plastic hammer, feeding a doll, and playing
- Deprivation of sleep from 2 to 4 hours in healthy infants has been self-conscious about the loss, so they may be further board games are all ways in which children are exposed to and
studied and thought to lead to short-term variations in cardiac - deprived of social and cognitive stimulation. learn about different textures and colors, experience the
function as well as an increase in apneic events - Some children receive medication to lessen awareness of the feeling of possessing and owning, and learn about competition,
- After approximately 4 days of poor sleep, this can cause them to stimulating factors in their environment. winning, and losing as well as develop fine motor skills.
experience difficulty in concentrating and episodes of - To ensure they do not suffer sensory deprivation, give them - Colored blocks reveal how parts can join to make a whole, how
disorientation and misperception. definite orientation measures, such as always mentioning the things stacked too high will fall (there are limits one cannot go
time of day and the day of the week in conversations with beyond), and practice makes perfect. As children talk with
Growth hormones them playmates during play, they develop both language and social
- During the periods of stages III and IV NREM sleep, the secretion of Sensory Overload skills.
growth hormone (somatotropic hormone) from the pituitary is - Occurs when children receive more stimulation than they can - The repetitive acts involved in most games encourage the
at its highest level. tolerate or process. development of musculoskeletal skills.
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- play is not something children do when they have nothing else to - Well siblings who accompany a parent and sick child to the facility  Have child blow soap bubbles in a glass of soapy water
do, but rather, it is something children have to do. During can play with toys to distract them as well so that a parent can with a straw.
illness, it provides a feeling of security because it is an activity concentrate on the ailing child. Some hospitals furnish  Have child blow a cotton ball across the surface of a
that has continuity with everyday life. computer games for older children for this reason. bedside table.
- The manner in which children play differs as they mature. Aid with Distract child’s attention with puppet during  Play Simon Says, in which Simon says, “Take a deep
Type of Description Example physical respiratory and cardiac assessment. breath.”
Play/Age assessment Play Simon Says to encourage child to take deep  Allow the child to score points for reaching a high number
Observation/i Child watches particular play Watching a mobile breaths for respiratory assessment. on an incentive spirometer.
nfant intently, although not actively Allow child to listen to own heart with a stethoscope. - Muscle-strengthening Exercises
engaged in it. Play Follow the Leader to assess gait.  Have children throw bean bags or large wads of paper
Parallel/toddl Two children play side by side Playing separately with Draw a face on the tongue blade used to assess the (computer waste) at a wastebasket.
er but seldom attempt to interact a similar push toy throat.  Play Simon Says, in which Simon says, “Raise your arms,”
with each other. Show child how to “blow out” the otoscope light. and so forth.
Associative/p Children play together in a Engaging in typical Draw child’s outline on the table examining paper and  Have children throw and catch a ball.
reschooler similar activity; there is little backyard play give it to the child to take home to color.  Have children squeeze and mold modeling clay.
organization of responsibilities. Health teaching Use puppets as a teacher.  Help preschoolers pretend they are butterflies, airplanes,
Cooperative/ structure or compete for desired Playing organized Create word scrambles or crossword puzzles. and so forth
school age goal or outcome. games with rules - Procedures such as blood transfusion
● Providing play in the hospital.  Save a favorite game or activity only for these times
● Assessing child health through play - all hospital units in which children are cared for should have a play - Health teaching
- Children who are acutely ill do not play or play very little because space big enough for most of the children on the unit to come  Use puppets as teacher.
they do not have the strength, the attention span, or the to.  Make up board games, word scrambles, and crossword
interest in activities required for play. - There should be enough space to accommodate children who are - Infants need toys in their cribs, such as mobiles, blocks, soft toys,
- They continue to enjoy being read to, and they find comfort in not fully ambulatory, such as those with casts or who are in and rattles.
holding a favorite toy even if they do not actively manipulate it. wheelchairs  They also need to be out of cribs, sitting on a parent’s
Once children are over the acute phase of an illness, interest in - Tables for board games and play materials such as crayons and
or a healthcare provider’s lap, or securely sitting in
play returns. paints should be available.
strollers or swings. As soon as they are able, they
- whether a child is spontaneously playing is a good index of health. - Children can release a great deal of anger or tension by splashing
need some time on the floor (with a sheet or other
- The toys children use at play are a good indication of their growth water, squeezing or pouring sand, or smearing finger paint.
covering under them) to practice crawling or
and development level and emotional state. School-age children can play games and create objects with
walking.
- Parents typically know a child’s play preferences and current arts and crafts.
 At about 3 months, when infants discover their
favorite game or toy. - Adolescents enjoy table tennis and pool tables. A great deal of
hands, those become that month’s “toys.”
- Asking for this information during a health interview helps to assess “play” by older school- age children and adolescents centers on
 For a child learning to crawl, “cruise,” or walk, that
a child’s developmental level and helps to assess the quality of conversation with peers they meet in the playroom
activity is the toy or interest for the month.
parenting (if parents view play as important or are familiar with ● Providing play for children on bedrest.
- Toddlers need put-in and take-out types of toys such as blocks that
the child’s activities). - Children who are on bed rest, at home or in a hospital, need to
can be repeatedly dropped into a box or that can be stacked to
● Providing play in ambulatory settings. have play periods built into their day. The length of time for
play with in bed.
- Children and families in ambulatory department may be under a play and the toys individual children can play with depend on
 They enjoy listening to songs and nursery rhymes.
great deal of stress as they sit in a waiting room, waiting for their developmental age and physical and emotional states.
- Bathing: Allow children to play in bath water with water toys.  Toddlers are in constant motion. They need to be out
their name to be called. This anxiety for the family may be
- Encouraging fluid of bed as much as their physical condition allows,
diverted with the use of child life services, if available, or
playing with take-apart, put-together, or
toys/books/games that the child may redirect their focus to.  Hold a pretend “tea party” for a preschooler and drink
pull-and-push toys.
- It is best if ambulatory departments are stocked with toys that can “tea” with important but imaginary guests.
- Preschoolers need creative materials such as modeling clay or sand.
be played with quickly and by single children.  Play a board game with a school-age child in which each
- School-age children need quiet games such as books or crayons or
- There should be a low table and chair so a parent can come to a turn starts with taking a drink.
markers by their bedside. They also enjoy electronic devices
table and play with a child.  Draw a circle and let the child color in a section each time
such as tablets, iPads, or iPods.
- Examining rooms should have toys, which maybe used to distract a a drink is taken.
- Most activities for hospitalized children must be short-term projects
child while a procedure such as an ear examination is  Play Simon Says, in which Simon says, “Drink.”
because children are called away for treatments or procedures,
performed, and because the wait in an examining room may be - Deep breathing exercises and because, when they are ill, their attention span is shorter
as long as the wait in a waiting room. than usual. Short-term projects always appeal to the

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school-age child because they help a child of this age achieve a ensure that the total healthcare environment is conducive to Anatomically correct dolls are used to help children
sense of industry. children’s well-being. describe their feelings about sexual maltreatment.
- Watching television is a nonparticipant activity, so it is not the best - Such a program not only aids in promoting children’s mental health  It is good to have a play session with a child near the
activity for children. but also leads to more cooperative responses of children to beginning of an illness to see whether the child
● Safety with play. treatments or procedures. It is complementary to play communicates any fears about this experience
- Inspect all toys for safety. They should be washable to prevent programs through play.
spreading disease, without sharp edges and small parts that initiated by nurses  This initial session also serves as a way of preparing
could be swallowed or aspirated. ● Therapeutic Play (3 Types) the child for events that will occur during the illness
- Toys should be at least 1¼ in. (3 cm) in diameter and 2¼ in. (6 cm) - only the child’s verbal cues are used as responses.  Repeat a play session after any painful or traumatic
in length to prevent aspiration and choking. - Anything almost automatically becomes less threatening when a procedure such as surgery so that the child can
- A cylinder 1 in. in diameter, such as a rubber hot dog, is the most person can talk about it. express new feelings. If such play sessions reveal
dangerous size for a toy because it totally occludes the trachea - Many children cannot talk about what is happening to them during fears, a child should be scheduled for other play
if it is aspirated. illness because of fear or because their vocabulary is so limited sessions, perhaps once daily
- A toy smaller than this would cause only partial obstruction; they cannot describe their feelings.  Furnish children with a wide range of equipment and
something larger could not be inhaled into the trachea. - Because play is the language of children, children who have then let them choose those items with which they
- As a rule, if a toy can fit through the center of a toilet tissue tube, it difficulty voicing their thoughts in words can often speak wish to play.
is too small for safe play. clearly through play.  Children invariably choose a piece of equipment that
- Consider the type of toy for a specific patient. Tossing a ball to a - Play that involves specialized activities that are developmentally has been used with them. They poke at a doll with a
child on bed rest is generally a safe activity. supportive and facilitate the emotional well-being of a syringe without a needle or with a small rubber
- One who has a large cast in place, however, might lean over to pediatric patient is considered therapeutic play. It should be tube attached to simulate a needle or enjoy giving it
- If children become bored with an activity or toy because it is not noted that therapeutic play and play therapy are different. a “shot.” They wrap the doll in bandages or put
stimulating enough or they have had it for too long a time, they - Play therapy tubes into its mouth or stomach, acting out things
may begin to use the toy in an unsafe way.  addresses basic and persistent psychological issues that were done to them or that they saw done to
- After toddlers grow tired of stacking blocks, for example, they may associated with how a child may interact with his or other children on a nursing unit or at a clinic visit
begin to throw them. her world they fear will be done to them. Allow play to be
- Children who normally play safely with modeling clay but who are - Energy Release nondirective (let children proceed at their own
on a restricted diet may eat it because they are hungry.  Pounding, hitting, running, punching and shouting pace, choosing freely what equipment to play with
Knowing where children are and what activity they are  Furnishing children with materials that allow them to and what they want to do with equipment). As a
engaged in at all times is the best prevention against unsafe do these things helps them release anxiety as well. child works through an experience this way, the
play.  Toddlers enjoy pounding pegs with a plastic hammer experience becomes less fearful and the child gains
- For the child cared for at home, parents may need to purchase new or pretending to cut wood with a toy saw. Other increased control over it.
toys. This is especially true if the bulk of the toys they furnished examples include giving modeling clay to a  Observe for children who may be using equipment in
previously were for outside play such as balls, in-line skates, or preschooler (an anxious child often pounds it flat; a an unusual way, such as hitting dolls with
skateboards. Because of an illness, they may now need to relaxed child, however, will build it into shapes). stethoscopes or poking them in the eye with a
provide more “sit-down” toys such as markers, puzzles, or  The overall goal is to maintain a sense of thermometer (suggesting they are confused about
board games empowerment and self-efficacy during the purpose of such equipment or are acting out for
● Child support programs hospitalization another reason). Such behavior can alert you to the
- Child support programs, such as child life services, are incorporated - Dramatic Play importance of explaining the purpose of equipment
into major children’s hospitals and are an integral feature of  Acting out an anxiety producing situation to children. Listen to what children say as they play.
child health care  It is most effective with preschool children because A comment such as “I’m giving shots to all the bad
- As part of a child support program, a specialist offers children the they are at the peak of imagination. dolls” suggests the child thinks injections are
opportunity to reenact and thereby master the unease  During illness, the situations about which children punishment.
associated with illness. need to express feelings are illness related, and  It would be important to stress the next time the child
- Through therapeutic play, child specialists provide programs that therefore, the equipment needed for therapeutic needs an injection that medicine is to make the
prepare children for hospitalization and, once hospitalized, play is common healthcare equipment, such as child feel well again. A comment such as “They are
prepare children for surgery or for procedures that could be dolls, doll beds, play stethoscopes, IV equipment, going to put you to sleep” when explaining
painful. syringes, masks, and gowns. anesthesia could infer that she will never wake up
- They consult with parents about good toys to choose for home  Puppets of doctors, nurses, mothers, fathers, and (she may have had a pet that needed to be put to
care. These specialists also help children air their frustration children help young children express their feelings. sleep). Do not be surprised about the force with
about painful or intrusive procedures, prevent social isolation which children insert nasogastric tubes into dolls. In
of children by means of an active recreation program, and part, this reflects how they perceive these
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procedures, but it also represents energy or that the parent cannot find the child because she’s gone - Many drugs are distributed bound to serum albumin (which is
nervous release, in the way that pounding or hitting to the hospital. They need to be reassured that their manufactured by the liver), so adequate albumen must be
releases anger. parents know where they are and, although they’re not present for the drug to reach its site of action.
 To better understand how a child feels, repeat what there constantly, they will visit them each day after work. - This binding action limits the amount of free drug in the circulation,
the child says verbally: “You are giving the bad dolls  Older school-age children and adolescents may not be thereby providing protection against toxic levels of a drug. As
shots?” or ask the child to tell you more about the interested in drawing but can be interested in making a free drug is used, the bound drug is released to maintain a
activity: “Do you think that’s the only kind of list of procedures or experiences they like and dislike. therapeutic level.
children who get shots—bad children?”  Examine the dislike list for procedures such as “shots” or - Newborns with immature liver function may not have enough
 Do not rush to reassure (“Do not worry, that is not “chemo.” Mark the nursing care plan for nurses to take serum albumin to transport drugs readily. This is particularly
going to happen to you”). Quick reassurance tells special time to explain these procedures and to offer true if elevated bilirubin levels are present because bilirubin is
children they should not ask any more questions or special support when they must be done. also carried by serum albumin. Bound to serum albumin this
that the topic is not open for discussion. way, bilirubin is harmless. In free form, however, it can leave
 Sometimes, even children who seem well prepared NURSING CARE OF THE CHILD UNDERGOING MEDICATION the bloodstream and enter other body tissues. If it enters the
may be taken by surprise during a procedure. ADMINISTRATION & INTRAVENOUS THERAPY brain cells, it destroys their ability to function (acute bilirubin
 Children older than 9 or 10 years of age may find encephalopathy).
playing with dolls too childish to be of benefit. They Variety of Routes - If a newborn who has a high level of bilirubin from destruction of
would rather handle equipment such as nasogastric ● Orally fetal hemoglobin receives a drug such as a sulfonamide that
tubes in advance of them being inserted. Active ● Intranasally competes for albumin binding sites, a large quantity of bilirubin
handling helps to eliminate fear because it identifies ● Transdermally may be left unbound and the infant may develop acute
exactly what the child has to face, and it meets their ● Topically bilirubin encephalopathy or may not receive benefit from the
concrete-level learning needs. ● Rectally sulfonamide because it cannot be carried to the infection
- Creative Play - Example: Drawing ● Injection site.
 Some children are too angry to be able to act out their ● Inhalation - newborns have sluggish peripheral circulation, so distribution to
feelings through dramatic play. Safe medication administration is a priority in child health nursing. Each arms or legs in children this young may not be effective.
 However, they may be able to draw a picture that dose of a drug must be calculated individually. - Any child with cardiovascular disease also may have limited
expresses their emotions or conveys the extent of their distribution of drugs because of general poor circulation.
knowledge. To encourage this, give a child a blank paper Pharmacokinetics
and crayons or markers. Metabolism
 If a child seems reluctant to draw something Absorption - involves conversion of the drug into an active form
spontaneously, suggest a topic: “Why don’t you draw a - (the transfer of the drug from its point of entry in the body into the (biotransformation) or into an inactive form (inactivation).
picture of yourself?” bloodstream) - Because a child’s basic metabolic rate is faster than that of an adult,
 Some children are so concerned with particular parts of - influenced by the route of administration as well as by the certain drugs are metabolized more rapidly in children.
their bodies that when asked to draw pictures of concentration and acidity of the drug. - This means that the drug must be administered more frequently to
themselves, they draw only the body part about which - Some routes of administration in children are limited and so are a child to maintain effective drug levels than it would be in
they are worried. Such children generally are saying they rarely used. adults.
need to talk about that part of their body to be given - For example, children younger than school age usually cannot hold - Whether drugs are coadministered can also make a difference
reassurance that it is going to be all right.bed or shut tablets under their tongue for sublingual administration; they because this could cause the drugs to metabolize more quickly
behind bars, or doctors and nurses frowning at them, tend to swallow them instead. or more slowly than usual.
obviously unhappy with them - The small muscle size of young children limits sites for IM injection. - Because liver enzymes are not fully developed in newborns, these
 Such children may need assurance that they are not being Transdermal patches can be easily removed by infants. drugs cannot be metabolized and so can reach toxic levels
- The gastrointestinal system may be so immature at birth that rapidly.
punished but rather that they need to stay in bed or are
being cared for by doctors and nurses to be made well. gastrointestinal absorption can be ineffective. Vomiting and - Older children with liver disease who have impaired liver enzymes
 Other children draw pictures that are symbolic of death: diarrhea, frequent symptoms of childhood illnesses, also also have a decreased ability to inactivate or transform drugs
airplanes crashing, boats sinking, buildings on fire, or interfere with absorption because a drug does not remain in
children in graveyards. They need assurance that they will the gastrointestinal tract long enough to be absorbed. Excretion
not die. Distribution - elimination of raw drug or drug metabolites, a process that largely
 Other concerns such as fear of abandonment and loss of - the movement of the drug through the bloodstream to a specific prevents properly administered drugs from becoming toxic) is
site of action. potentially limited until about 12 months of age, when kidney
independence may also be manifested in drawings. For
- Children tend to have more fluid held in interstitial spaces and less function becomes mature. If a child has kidney disease,
example, preschoolers may draw a child in one corner of
in intracellular spaces than adults, so drugs may not be excretion potential is limited at any age
a picture and an adult in a far corner. They may comment
distributed as quickly as in adults.
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- Most newborns have sluggish bile formation, so excretion of these - Always be certain that medicines are stored in a safe place.  Offer a “chaser” if necessary and not contraindicated.
drugs is questionable. - In the nursing unit, there’s a particular unit there for medication Chaser like oranges or any juice available and
- Monitoring intake and output is important in children receiving wherein only the medication nurse can enter and prepare and accessible.
drugs to be certain urine excretion or an outlet for drug store all the medication in that unit. - If a child is having difficulty in swallowing a tablet, they can be
metabolites is adequate. - On a children’s unit, leaving a cart in the hallway is inappropriate. crushed and added to a teaspoonful of applesauce or a
- As medication nurses, we always look after all the medication that flavored syrup.
Adverse Drug Effects in Children we prepared to prevent tampering, switching medication or - Let the child practice on small bits of ice before teaching them to
- Children may experience unique or exaggerated side effects. even stealing. swallow tablets.
- Newborns may suffer from adverse effects from drugs taken by the - Never leave medicine on a bedside table for a child to take later. As - Children younger than 3 years of age are unable to swallow pills.
mother prenatally or from drugs taken during breast-feeding. soon as you enter the room always offer a glass of water and - The best practice is to ask the child and parent whether they are
make sure that the medicine is taken by the child right away able to swallow tablets before offering the tablet form of the
before leaving the room. medication.
Safe Storage of Drugs - Most oral medications for young children are available in liquid,
- Adolescents can deliberately take extra doses of drugs such as: Safe Administration of Drugs chewable, or meltaway forms
Steroids or Pain medicine hoping for an added effect. - Administering drugs safely to the children, we should determine - Because oral solutions are pleasantly flavored, most infants resist
- Children like adults, may hoard drugs and then use them in a that we are giving the right drug to the right child, in the right the first drop but then suck the remainder of the medicine into
suicide attempt. dosage and by the right route, at the right time. their mouth
- Because young children do not appreciate that overdoses of - Also we need to ensure that parents or children have the right - Some children may be old enough to swallow tablets but have
medicine can be serious and even fatal, they may information about the medicine they are taking. In giving this never done it before.
self-administer additional doses of medicine resulting in toxic medication we always remember the golden rules of drug - To let them practice learning how to do this, give them small bits of
levels of medications. administration. ice to use for practice; these melt rapidly and so do not stick in
- This can occur with prescription medications, over-the-counter the back of the throat or esophagus.
medication, and even alternative/complementary medications Oral Administration - Tell the child to put the ice on the back of the tongue, tip the head
- Adults always need to be certain to store medicine in a safe place. - Children younger than 9 years old often have difficulty swallowing slightly to the side, take a sip of water, and swallow the water.
- Because poisoning from medicine is a frequent type of poisoning in tablets. Give generous praise for learning this new skill.
preschool children, children’s medicine—whether prescription, - Most oral medication is furnished in liquid form. - Another useful technique to help the child learn to swallow pills is
over-the-counter, or alternative/complimentary—should be - In infants: to push them into a teaspoonful of ice cream or pudding.
secured in a locked and safe place.  Oral medication can be given with a medicine dropper Children tend not to chew this type of food; rather, as they
- In most homes, this is in a locked medicine cabinet or a locked or a unit dose syringe (without needle) swallow the pudding, they also swallow the pill. If using this
drawer above the height their child can reach; a motivated  Gently restrain the child’s arm and head technique, push the pill into the ice cream or pudding in front
toddler can climb so well that just placing medicines “out of  Never give medicine with the child lying completely of the child so it’s obvious what you’re doing.
reach” is not sufficient. flat for the risk of aspiration - The intent is not to hide the pill or fool the child but to help the
- Remind parents that most childhood poisonings occur when a - It is easy to administer oral medication when the child is crying as child learn to swallow the medicine
family is under stress because, during these times, the family the mouth is already open, or gently open the mouth by
may forget usual procedures and leave medications unlocked pressing on the child’s chin.
or within reach. Intranasal Administration
- In administering oral medication using a dropper or syringe, gently
- Be certain to teach parents that they should never take medicine in press the bulb on the medicine dropper or use the plunger of - Place the child on his or her back.
front of children; children may imitate this action with the the syringe so that the fluid flows slowly in the side of the - Extend the head over the side of the bed.
parent’s medication when the parents are out of sight. child’s mouth. The end of the drying or dropper should resist - A school-age child can extend the head over the side of the bed so
- Another caution is not to pour or prepare medicine in the dark. on the side of the mouth to help prevent aspiration. that it is lower than the trunk.
Because almost all medicine bottles dispensed from local - Oral medication may also be given through a small glass or spoon, - Preschoolers are too frightened by this strange position. Place them
pharmacies look and feel the same, it is easy to pour the wrong allowing fluid to flow a little at a time so the child has time to a pillow under their shoulders instead.
liquid, extract the wrong pills, or read the bottle instructions swallow between small sips. - An infant may need to be restrained in a mummy restraint, where
incorrectly without adequate light. - Because firm pressure was used to give the medicine to the infant, you wrap the baby from the neck down to the feet, where the
- Teaching parents the importance of reading over-the-counter he or she may be frightened, so take time to sit and comfort. feet and the hands cannot move, and easy administration of
medication labels for proper dosing and frequency is critical. - Preschoolers and Early school-age: Responds well to rewards each the drug is performed.
- Remember that these same rules apply in a healthcare setting. time they take their medicine like giving of stickers so they can - Instill the appropriate number of drops into one nostril.
- Medications left at a bedside table in the hospital or on a paste it in a book each time they take a medicine. - Turn the child’s head to the side—to the left after the left nostril,to
medication cart could be easily accessible to an unsupervised - Older children: the right after the right nostril—so that the medicine stays in
toddler or preschool child walking around.  Hand them a glass of medicine as if they are expected the nose longer.
In hospitals: to take it.
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- If the child is a preschooler or older, ask him or her to further “sniff”  If the eye is pus-filled, apply from the medical aspect to - Because the child cannot see what is happening during rectal
the medicine. the outer core. This is to prevent transferring infected administration, and what parents discuss with them about
- Have the child remain in a head flat position for at least 1 minute to mucus from one eye to the other. “safe touching” and private body parts, a child can be easily
let the medicine come in contact with the mucous membrane  Eye medicine should be individually prescribed and not frightened by this procedure.
of the nose. used by other children, because if the tip of the dropper - Show the child the medication so the child can be certain that it is
- Give children high praise even if they did not cooperate well. Praise or tube touches the conjunctival sac it is contaminated not an injection.
tells children you understand how hard it was to stay still. with body fluid. - Many suppositories are supplied already lubricated. If not, add a
- If using spray bottles, let the patient stand or sit upright, hold the - This type of administration, like nose drops, is frightening for drop of water-based lubricant such as K-Y Jelly to the tip
spray bottle upright with the tip just inside the nose, and children because the eyes are a sensitive area and a natural
gently squeeze the spray bottle. reflex occurs to avoid contact with the eyes. Also, children Transdermal/Topical Administration
- Drugs are well absorbed across the nasal mucosa, so this route is an know that getting something such as dust in their eye can be - Most children accept this type of application well because the
effective means of drug administration and can be a route for very painful. medicine brings most immediate relief.
important and even life-sustaining drugs - Be certain the child’s skin is dry and intact at the site.
- Children over about age 6 years may be able to use nasal sprays Otic Administration - Apply patches over the trunk or major muscle, not on distal
competently after they have been introduced to the technique. - Refers to administering medicine into the ear canal. extremities, for best absorption.
- Acknowledge that spraying a liquid into the nose is uncomfortable - Remind the child that ear drops can feel funny. - Assess and change the site every time a new patch is applied.
because it tickles or causes a sneezing sensation. Have the - Ear drops must always be used at room temperature or warmed - Put clothes on the young child immediately so that the patch is out
child sit or stand upright, hold the spray bottle upright with the slightly. of site.
tip just inside one side of the nose, and gently squeeze the  Fluids stored in the fridge and are used can cause pain - Be certain patches applied to children wearing diapers are not
spray bottle. In most instances, a child should then tip the head and severe vertigo once it touches the tympanic placed where a leaking diaper could wet the patch.
to the side (the right side for the right nostril, the left side for membrane. - administration of topical creams or lotions for skin irritation or to
the left nostril) or sniff, depending on the bottle instructions, - Place the child on the back in a mummy restraint if necessary. relieve itching or dryness.
for best absorption. - Turn head to one side to expose the ear. - Most children are more tolerant of this type of application because
- The administration is then repeated for the second nostril. - For a child younger than 3, straighten the ear canal by pulling the it may provide immediate relief of symptoms. Older children
- Spray bottles should be individually prescribed for children and pinna down and back. may be able to assist with topical applications with your
should not be used by any other child to prevent the spread of - For a child older than 3 years, pull the pinna of the ear up and back. supervision. Be certain they wash their hands afterward so
disease organisms. - Instill the specified number of drops into the ear canal. they do not lick any extra off their fingers and inadvertently
- Hold the child’s head in the sideways position for at least 1 minute take it orally.
Ophthalmic Administration to ensure that the medication fills the entire ear canal. - Transdermal patches are an effective and pain-free route of
- Eye medications - Most often dropped into the conjunctival sac of - Praise the child for his or her cooperation after the procedure. administration of medication absorbed through the skin.
the eye. - Young children tend to remove transdermal patches the same as
- Infants and preschoolers must be restrained in a mummy restraint. Rectal Administration they do Band-Aids because of normal curiosity about what is
 Place the child on the back - This allows the medication to be absorbed across the mucous underneath. Putting clothes on the young child immediately so
 Open the eyes of infants and preschoolers gently by membrane of the intestine. the patch is out of sight is helpful. Assess infants carefully to be
firmly pressing on the lower lid with the thumbs and on - Medications are given by rectal suppository or by retention enema certain they have not pulled off the patch and are chewing on
the upper lid with the index finger. - Suppositories are supplied already lubricated. If not, add a drop of it because this can lead to drug toxicity.
- You may need to rest a hand on the eyelid to keep the eye open water-based lubricant to the tip. Intramuscular and Subcutaneous Administration
long enough and allow the eyelid to close after. - Use a glove and insert the suppository gently but quickly beyond
- Avoid placing the drops directly on the cornea because this can be the rectal sphincters. - Intramuscular (IM) injections are rarely prescribed in children
painful and to prevent the conjunctiva from drying.  Approximately ½ inch or as far as the first knuckle of because children do not have sufficient muscle mass for easy
- Do not hold the eyelids apart any longer than necessary. the little finger for infants, and 1 inch or as far as deposition of medication.
- After the child has blinked two or three times, allow the child to get the first knuckle of the index finger for older - For infants, the mandatory site is the vastus lateralis muscle of the
up. children. anterior thigh.
- Praise the child for his or her cooperation even if cooperation was  Withdraw your finger and press the buttocks together  Use the lateral aspect rather than the medial portion.
not evident. He or she accomplished a major feat by allowing firmly until the child’s urge to evacuate the  Using the gluteal muscle in children younger than 1
to touch and invade the eye this way. suppository passes. year is extremely hazardous due to the risk of
- To instill ophthalmic ointment: - assist in absorption across the mucous membrane of the intestine damage to the sciatic nerve
 Apply a fine line of the ointment along the inside rim of but also avoids the danger of aspiration in certain situations  Older children and adults: deltoid muscle or
the conjunctival sac, working from the inner to the outer such as seizures or when a patient is unconscious ventrogluteal muscle
eye canthus. - This method may be difficult for children due to its invasive nature; - Continuous Subcutaneous Pump Infusion
therefore, it is not a major route of administration.
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 The administration of medication by constant infusion NURSING CONSIDERATIONS IN ADMINISTERING INTRAVENOUS THERAPY
of a medication into the subcutaneous tissue using Infusion Pump TO PEDIATRIC CLIENTS
a medication pump. - Nursing Considerations: Intravenous Therapy
 supply a constant level of medicine to sustain  The insertion site is changed every 1 to 2 days. - The quickest and most effective means of administering fluid or
consistent blood levels  If the child is not toilet trained, it is important to keep the medicine
 drug is delivered by the pump via a medicine-filled pump and insertion away from an area that can be soiled - Used to:
syringe. with urine or stool.  Maintain fluid and electrolyte balance.
 Disadvantage: The child must be careful to protect the  With small children cover the pump with clothing.  To produce therapeutic levels of drugs in the body
pump from damage. - Injecting an infant or child while he or she is sleeping should be quickly.
 Site Chosen: Abdomen bec this both protects the avoided because they will be awaken and may be terrified of  To provide rehydration and nutritional support.
pump and allows it to be out of site being attacked. Instead, play with the infant until they are - IV fluid may be infused into a peripheral vein, a central venous
 Insulin and heparin are two drugs often prescribed awake, and depending on the developmental stage of young access device, or a peripherally inserted central venous
for use with infusion pumps. children, you may provide a short explanation immediately catheter.
 The syringe is filled with medicine and a small tube prior to injection. Be honest and do not make promises you - The amount, type and rate of IV fluids for children are prescribed
with the needle attached at the distal end is cannot keep, such as telling the child it will not hurt. carefully.
attached to the hub of the syringe. - To reduce pain, ask for a prescription anesthetic cream to be - was used extensively as a rapid means of hydrating children who
 The syringe is then clamped into the pump and the applied to the injection site 30 minutes before the injection were dehydrated as a r esult of diarrhea
skin is cleaned with alcohol and the needle inserted - When giving injections, once you have described to the caregiver - IV fluid may be infused into a peripheral vein, a central venous
at a 45 degree angle. the drug’s purpose and what you are going to do, do not delay access device, o a peripherally inserted central venous
 The needle is typically retracted, leaving a small the injection further because the anticipation the child may catheter
catheter in the subcutaneous tissue, which is taped feel while waiting can be worse than the actual injection. - all IV access sites must be assessed at least hourly for signs of
in place before the pump is turned on - Give the injection quickly, always keeping in mind safe technique. infiltration because children move and tend to move the
 The insertion site should be changed every 3 days to Remember to aspirate (if indicated). bandages
reduce the possibility of infection. - Massage the area briefly after the injection to help ensure - With movement, peripheral IV catheters can poke through fragile
 The pump should be removed before showering so it absorption of the medication, although rubbing may be veins, central access devices can become dislodged, and ports
doesn’t get wet, although the catheter can remain painful. can disconnect from the internal tubing, especially with the
in the subcutaneous tissue. For swimming or tub - Statements such as “Don’t cry” while yougive an injection are not activity level of most children. Carefully inspect sites in orderto
bathing, the entire pump, syringe, tubing, and therapeutic. When children feel pain, they should be allowed identify any swelling or disconnections.
catheter should be removed and then replaced to cry. Acknowledge that an injection may be painful and that - Infection is another problem associated with IV access. If a line
again immediately. it is “okay to cry or even scream” when they feel pain from the becomes infected, it is usually removed, which may involve
 Pumps may not be advocated for children who are not insertion of the needle. Squeezing a hand or a stuffed animal, surgery for a centrally placed device. To avoid infection,
yet toilet trained because it’s important to keep the singing a song,counting may help with pain tolerance and/or insertion sites must be changed using a sterile technique as
pump and insertion site away from an area that distraction during an injection. well as be carefully monitored.
could be soiled with urine or stool. - If necessary, ask for help in restraining a child when giving an - Keeping an IV site wrapped with something such as Kling gauze may
 Older children, like adults, often worry at first that the injection to ensure safe administration. help protect a curious toddler from removing the dressing and
- Evaluate children individually, however; school-age children may disrupting the site. However, remain vigilant about removing
pump will fail to operate, so they check frequently
take pride in their ability to lie still and would not appreciate the gauze to inspect the site frequently if the gauze covers the
to be certain the syringe is emptying. With small
being restrained. insertion site.
children, cover the pump with clothing to prevent
- Always hold and comfort a young child, or encourage parents to do Determining Fluids and Caloric Needs of the Child
them from touching or trying to inadvertently
so, after an injection or any other painful procedure. - IV fluids administered to children and infants must be isotonic
 manipulate the syringe. Careful monitoring of the
- Record the site of any injection while documenting the medication (exerts the same osmotic pressure as their bloodstream)
patient’s response to the medication is necessary
administration, so that sites can be rotated for better  prevents fluid shifting from the bloodstream into
for at least the first several days so that dosage
absorption. For subcutaneous injections, use the same interstitial tissue or fluid shifting from interstitial
adjustments can be made as necessary
injection sites, the lateral aspect of the thigh or upper arm, and tissue into the bloodstream
inject the vaccine at a 45-degree angle.  0.9% sodium chloride (0.9% sodium chloride is
- If children are going to receive a series of injections, you can teach normal saline solution) is the IV fluid most
them distraction techniques, for example, imagery (e.g., commonly used in children because it is isotonic
thinking of the needle as a long thin rocket ship landing on  Dextrose 10% in 0.9% sodium chloride or mannitol
their arm to help reduce apprehension). solution are examples of a hypertonic solution that
might be used to cause fluid to shift into the

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bloodstream to relieve cerebral edema for a child child because needles there do not infiltrate readily. If  Prevent overloading of IV fluids
with a head injury. any hair will be shaved away to place such a needle, ask - Minidropper
- Important to know this to protect against overhydration, parents if they wish to save the child’s hair because this  Device that reduces the size of the drop in the control
underhydration, or electrolyte imbalances such as may be baby’s first haircut. chamber to 60 drops per mL.
hyponatremia - Another safety measure is the use of programmable infusion pumps
Body Weight Fluid Requirement per 24 Hours that can be programmed to infuse fluids and medications in a
Up to 10 kg 100 ml/kg prescribed rate. This allows for flow to be easily regulated and
11–20 kg 1,000 ml + 50 ml/kg for each provides more accurate IV administration.
additional kilogram over 10 kg - Keep a careful record of both the rate and amount of IV fluid
More than 20 kg 1,500 ml + 20 ml/kg for each administered to guard against fluid overload. At least once an
additional kilogram over 20 kg hour, record the type and amount of fluid and the rate of flow
Example of isotonic: Lactated ringer’s (including the number of drops per minute).
and 0.9% normal saline - Keeping a careful record of both rate and amount of fluid.
Example of hypotonic: Normal saline - Signs of fluid overload are those of congestive heart failure.
0.45%  coarse breath sounds and increased pulse rate and
Example of hypertonic: Dextrose 10% blood pressure.
in 0.9% sodium chloride  As the heart becomes overwhelmed by excessive fluid,
blood pressure falls and signs of edema develop.
- Children who have IV infusions for long periods may - In addition to observing for changes in vital signs such as these,
Obtaining Venous Access require the placement of an Intracath (a slim, pliable catheter assess intake and output per the following guidelines:
- The needle size for IV therapy varies depending on the solution and threaded into a vein).  Infants = 2 ml/kg/hr
the rate at which it will be administered.  Advantage: It cannot be dislodged as easily.  Children = 0.5 to 1 ml/kg/hr
- Commonly used catheter sizes: 22-gauge, 24-gauge, 25-gauge (in - IV infusions must be secured in place with at least a small  Adolescents and adults = 40 to 80 ml/hr
newborns) armboard. - It is difficult for children to lie still and wait for an infusion to finish.
- “Butterfly” needles or “scalp vein needles” are metal needles - Preschoolers and - Infants and preschoolers may need to have their other arm
with a flange of plastic added on both sides of the needle hub. older children restrained. Let parents know and understand.
- A length of narrow tubing leads from the needle to the fluid often express - Be sure parents understand the importance of the IV therapy.
administration tubing. a preference
 This tubing must be flushed with IV solution before the regarding Intravenous Medication Administration
needle is inserted to avoid air embolus. where they - Medications may be added to an IV line as a small, one-time
- Common sites: want an IV administration (bolus) or piggyback for longer infusions and
 The veins on the dorsal surface of the hand inserted. larger children
 On the flexor surface of the wrist Offer a choice, - Give more fluid than the usual IV medication, 10-20 cc syringe.
 Leg and foot veins may also be used. if possible, or - Ensure that the drug to be injected is compatible with an IV fluid
 Scalp vein over the temporal area ultimately causes the suggest the nondominant hand. being infused.
- Advocate for the child to ensure their wishes are respected. - If incompatible, it will crystalize.
least discomfort for their child because needles do not
- Without an arm board, it is easy to unintentionally and accidentally - To administer medicine by a bolus technique.
infiltrate readily. Seeing IV fluid infusing into a scalp vein
pull the catheter.
can be frightening for parents because it looks like a
much more serious procedure than an infusion  IVTT medication should not be administered by nurses
Determining Rate and Amount of Fluid Administration because it will lead to 30 day extension.
administered into a hand. You can explain to parents that
- Because children’s hearts and circulatory systems are smaller than  Give slowly; veins are sensitive so if given fastly, it may
scalp vein infusion is just another site to use to
those of adults, IV fluid must be infused at a slower rate to swell.
administer
keep the child’s cardiovascular system from becoming quickly  Check for patency of the line by opening the flow rate
fluid or
overloaded. and bringing the solution down to the hand. If blood
medicine to
- Infusion pumps are required in most settings for infants and comes in the tubing, the site is patent.
infants and
children receiving IV fluids and when giving potent medications  depending on what is available and the protocol at
ultimately
and always for small children because they regulate the flow
might cause your facility, you may use a syringe pump for
accurately to a few drops per minute
the least administering a medication or, if giving an IV push
- Fluid chambers
discomfort medication, clamp the IV tubing above the medicine
 Devices that allow only 50 to 100 mL of fluid into the
for their port in the IV line, clean the port with alcohol, insert
drip chamber at a time.
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the needleless syringe filled with the prescribed - maintain open venous access for medicine administration  usually inserted in the operating room because
medicine into the port, and inject the medicine while allowing children to b free to move about without tunneling under the skin is required and general
slowly and gently based on the manufacturer’s being restricted by IV tubing anesthesia is preferred.
instructions. - Heparin locks - Advantage: Discomfort from further skin punctures is
 Once the medication has been given, remove the  Devices that maintain open venous access for avoided.
syringe and reopen the IV line immediately to allow medicine administration while allowing children to - Disadvantage: Catheter could become snagged on something
the IV solution to flush the medicine into the child. be free out of bed. and accidentally be pulled out.
- Scalp vein tubing is used and capped at the end with a - Patients are not allowed to swim or take showers to avoid
specially designed rubber stopper or a commercial trap. infection, unless there is a waterproof dressing
- The tubing and stopper must be firmly secured to the wrist
and an armboard taped in place to remind the child to
protect the site from trauma.
- For hospitalized or receiving home care for a long time and
who only need IV medication, not additional fluid,
- IV medicines can be added to the site as needed without
further venipunctures
- Can also be used if frequent venous blood samples are
required (can extract blood through it).
- A vein on the back of the hand is generally chosen as the IV
site. The saline lock is flushed as frequently as hospital
policy requires to keep it patent. Be certain the tubing
and stopper are both firmly secured to the wrist and, if
necessary, an arm board is taped in place to remind the
child to protect the site from trauma.

Using Central Venous Access Catheters and Devices

- Venous access for long-term IV therapy
 Obtained using a tunneled catheter inserted into the Vascular Access Ports (VAPs)
- For piggyback infusion of medicine: vena cava just outside the right atrium. - Are small plastic devices that are implanted
 Clean the medicine port on the IV line, and insert the  catheter then exits the chest just under the clavicle for under the skin, usually on the anterior
piggyback system into the port. easy access chest just under the clavicle, for long term
 Lower the level of the main (but ana si miss piggyback - Typical catheters: Broviac, Hickman, Groshong catheters fluid or medication administration via
daw so medj libog) infusion bag and adjust the flow rate.  These semipermanent catheters can be used to bolus or continuous administration.
 Elevate the maintenance bag (main) of fluid again and administer bolus or continuous infusions of - A small catheter threads from the port
regulate at the proper rate. medications and fluid. internally into a central vein
 Main infusion bag – soluset or piggyback  have a wrinkle-resistant fabric (Dacron) cuff that - Common brands:
 Maintenance bag – main line; should be higher than the adheres to the subcutaneous tissue and helps to  Port-A-Cath
piggyback seal the catheter in place and keep out infection.  Infuse-a-Port
 Lower the level of the main infusion bag and adjust the  Groshong Venous Port
flow rate to that desired to allow the piggyback systemto - After skin cleansing, blood samples can be
operate. As soon as the piggyback bag has emptied, removed or medication can be injected by
elevate the maintenance bag of fluid again and make a puncture through the chest/skin into the
certain the IV line is flowing well and at the proper rate. port.
- this device requires a skin puncture, but no
dressing is required. It allows a full range of activities like
showering and swimming.
- Puncturing the chest causes pain, so advocate for the child to
Using Intermittent Infusion Devices receive a topical anesthetic at least 30 minutes prior to
- Sometimes called saline locks inserting the needle. Unlike the other types of central venous
catheter that are visible outside of the chest, no dressing is

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required for these ports when they are not accessed with a - It must be initiated with sterile technique, and if continued for an
needle. extended time, the infusion point is rotated about every 2 to 3
- central lines, air emboli, bleeding from a disconnected line, and days.
infection are major concerns with VAPs also. - Tubing must be changed every 48 hours and the dressing over the
site must be changed every 24 hours.
- Assess for a distal pulse and adequate temperature
and color of the leg every hour throughout the infusion to
ensure there is adequate circulation to the extremity
- All fluids that can be administered intravenously,
including whole blood or medication, can also be Administering a Subcutaneous (Hypodermoclysis) Infusion
administered by this route. - Used for children with blood disorders who receive a medication to
- used in an emergency when it is difficult to establish remove stored iron from their body.
usual IV access or in a child with such extensive burns that - Sites used for hypodermoclysis generally include the pectoral
the usual sites for IV infusion are not available region, the back, and the anterolateral aspects of the thigh.
- painful as the needle enters the bone marrow cavity. Prepare the PAIN MANAGEMENT WEEK 8
child for this and off r support to both the child and caregiver. Pain is a difficult concept to define because it is a subjective symptom
Peripherally Inserted Central Catheters (PICC lines). - To optimize assessment, place a pulse oximeter on a toe distal to (experienced by the person), not an objective one (able to be determined
- Advantage: Can remain in place for up to 4 months without being the infusion and monitor waveform. using an objective scale)
changed. - If the needle should become dislodged, symptoms of circulatory Pain
- These catheters are inserted into an arm vein (usually at the impairment or pain and taut skin over the site occur - “The sensation of pain is whatever the person experiencing it says it
antecubital space into the median, cephalic, or basilic vein) and - Occasionally during fluid administration, a bone chip or thick is, and it exists whenever the person says it does.”
advanced until the tip rests in the superior vena cava. marrow will occlude an intraosseous needle and slow the - Fifth vital sign
- All central venous access systems have the potential to cause infusion. If this occurs, a stylet passed through the needle - Children may have difficulty describing pain in a manner that adults
thromboses because they partially occlude a vein. clears it and allows for continued fluid administration. can understand
- Dressing must be changed using strict aseptic techniques to prevent - A minor surgery
infection. - Used if all veins are collapsed NURSING PROCESS OVERVIEW
- If a shorter catheter is used, the tip will rest closer to the head of - Prone to air embolism and thrombus Assessment
the clavicle (a midline insertion). - Emboli: blood clot that travel - Children, like adults, experience pain individually depending on the
- Drugs commonly administered via PICC lines are antibiotics and - Steps: type and cause of the pain, their temperament, their previous
analgesics. o The skin over the chosen site is cleaned as per protocol experience with pain, and their expectation of relief
- After medication is administered, the line is flushed with a small and anesthetized with a local anesthetic. - it is most efficient to assess pain levels using an appropriate scoring
amount of a solution such as normal saline o A small incision is made into the skin with a scalpel tool along with a vital sign measurement.
- Many parents seem more comfortable with this type of insertion blade. Diagnosis
than with a central venous catheter because it appears so o A large hypodermic or bone marrow needle is - Pain related to an invasive procedure
much more like a routine IV. inserted through the incision into the cavity of the - Fear related to anticipation of painful procedure
- Newborns can also have a catheter inserted into an umbilical bone. - Disturbed sleep pattern related to chronic pain
vessel, with fluid and medications being administered by that o To ensure the needle tip has reached the bone marrow - Anxiety related to planned dressing changes that cause pain
route cavity, a syringe is attached to the needle and bone Outcome Identification and Planning
marrow is aspirated. - Mark of efficient pain control: is to anticipate when pain will occur
Administering an Intraosseous Infusion o When bone marrow is obtained, the syringe is and plan interventions to prevent it rather than let it occur and
- Infusion of fluid into the bone marrow, usually the distal or removed and IV tubing, including a filter and the then relieve it
proximal tibia, the distal femur, or the iliac crest. fluid to be administered, is attached to the needle - Three common reasons why nurses and other pediatric providers
- Because the bone marrow communicates directly with the and opened to a gravity flow. may not provide adequate pain relief to children
circulatory system, fluid reaches the bloodstream as quickly by o A dressing with additional antiseptic is then applied o belief that infants and young children do not
this route as if it were administered intravenously. over the needle site. experience pain
- Is used in an emergency when it is difficult to establish usual IV o A restraint is applied to the leg to help the child hold o a fear children will become addicted to pain relief
access. the leg still medications
- It is a temporary measure until a usual route of administration can o fear of causing respiratory depression from analgesics
be obtained because the danger of osteomyelitis, a Implementation
devastating infection with long term effects to bone marrow

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- Everyone involved in a child’s care needs to be aware of the signs Chronic pain the injury site responsible for transmitting pain impulses
and symptoms that an individual child uses to express pain and - lasts for a prolonged period or beyond the time span anticipated for appears to decrease.
specific ways that will help the child manage pain. healing. - Rubbing an injured part such as a stubbed toe and applying heat or
Evaluation Cutaneous pain cold to the site are types of maneuvers that suppress pain
- look for nonverbal clues, assess vital signs, and listen to the child’s - pain that arises from superficial structures because these actions activate the nearby peripheral fibers.
statements about pain to determine whether a drug was - skin and mucous membrane; paper cut is an example. - This technique is especially effective with children because the
effective Somatic pain rubbing is not only comforting from a physical standpoint but
REASONS FOR ACUTE PAIN: - originates from deep body structures such as muscles or bones; also conveys psychological warmth.
o reduced pH alterations which cause depletion of oxygen in pain of a sprained ankle is somatic pain. Distraction
tissues - ischemia Visceral pain - allows the cells of the brain stem that register an impulse as pain to
o pressure on tissue - sensations that arise from internal organ such as intestines; pain of be preoccupied with other stimuli so a pain impulse cannot
o external injury appendicitis is visceral pain. register.
o overstretching of body cavities with fluid or air - Having a child focus intently on an action or a thought or telling a
child to say “ouch” while an injection is administered are
Referred pain common uses of this technique.
- pain that is perceived at a site distant from its point of origin.
- For a child in pain after a procedure, a gift of a Mylar balloon or
CHRONIC PAIN - The pain of right lower lobe pneumonia, for example, is often first
their favorite toy to hug can be wonderful distractions.
- often involves irritation of nerves and/or tissue, which can occur thought to be abdominal pain because the pain is referred or
with the pain of shingles, fibromyalgia, or other long-term felt in the abdomen.
Anxiety reduction
injuries and irritations Pain threshold
- Pain impulses are perceived more quickly by the brain if anxiety is
- the point at which the child first senses pain
present.
PHYSIOLOGY OF PAIN - most influenced by heredity
- any attempt to reduce a child’s anxiety as much as possible, such as
- The stimulus causing pain is not always visible or measurable. Pain tolerance
teaching a school-age child what to expect with a procedure so
- anxiety can lead to increased pain regardless of the physical stimuli. - a point above which they are not willing to bear any additional pain.
there are no surprises, can help reduce the intensity of pain.
Pain Conduction - Most influenced by heredity
- In addition to teaching when something is going to happen, be
1. Transduction (sensing the pain sensation; right then and there)
certain you also teach when nothing is going to happen. Being
2. Transmission (routing the pain sensation to the spinal cord), When pain is felt, the pituitary and hypothalamus glands both
told a clinic visit is just for a checkup and so will not involve
3. perception (the brain interprets the sensation as pain) respond reflexively by releasing endorphins or polypeptide
painful procedures allows a child to relax and feel less anxiety.
4. modulation (steps the body takes to relieve pain). compounds that simulate opiates in their ability to produce
- Pain impulses join central nervous system (CNS) fibers in the dorsal analgesia and a sense of well-being. Children also consciously
effectiveness of gate control theory techniques varies with a child’s
horn of the spinal cord. Here, the impulses are projected upward to try to modify pain by physical actions such as shifting position
age, ability to coop rate, degree of pain, and time allowed for
the brain, where they will be perceived as pain. or rubbing the body part.
learning and applying pain management techniques
Because memory may influence the sensation of pain (expecting to
Neurotransmitters that are stimulated and involved in conducting pain GATE CONTROL THEORY OF PAIN
have pain produces anxiety, which increases pain), these techniques
- Sharp pain impulses are conducted by both A-alpha and A-beta - attempts to explain how pain impulses travel from a site of injury to
are best taught to children before they begin to have pain. In all
fibers (rapid rate) the brain, where the impulse is registered
instances, children should know to use them just before or at the
- Light pressure and vibration are conducted by A-delta fibers (slower - envisions gating mechanisms in the substantia gelatinosa of the
moment they first feel the pain. If they wait until pain is intense, the
rate) dorsal horn of the spinal cord that, when activated, can halt an
pain may be so distracting that they cannot concentrate on using a
- C-fibers are smaller yet and conduct at an even slower rate impulse at that level of the cord.
technique. Children who were able to use a distraction technique in
- This prevents the pain impulse from being received at the brain
the past but can no longer do so need to be evaluated for what has
Acute pain level and interpreted as pain.
changed.
- sharp pain; A-alpha and A-beta fibers - Close faster rate and allows slower rate
- generally occurs abruptly after an injury. The pain of a pinprick is an - Gating mechanisms can be stimulated by four techniques: ASSESSING THE TYPE AND DEGREE OF PAIN
example. 1. Cutaneous stimulation - Pain assessment can be difficult with children not only because
- hyperalgesia 2. Distraction children have difficulty describing pain but also because some
o acute pain causes extreme distress and anxiety; chronic pain 3. Anxiety reduction children will suffer with pain rather than report it, unaware that
can lead to depression and decrease patient’s ability to achieve 4. Nerve blocks
someone could make it go away.
relief as the threshold to sense pain lowers and creates a
- Cultural differences also influence how pain is expressed
“feedback loop” Cutaneous stimulation (skin stimulation)
- Keeping in mind each child’s developmental level as well as
o increased sensitivity to pain and is seen when patients have a - has an effect because, when the peripheral nerves next to an injury
chronologic age are important when assessing pain because
heightened response to minimal painful stimuli. site are stimulated, the ability of the A-δ or C fiber nerves at
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assessment varies widely from that of a nonverbal infant to a very sometimes difficult to comfort children of this age during  Some try to be stoic or not show pain in order to avoid
verbal adolescent painful procedures by a statement such as “It’s only for a stereotypes of “crybaby” or “chicken.”
Infants minute” because they do not yet have a perception of time.  This tendency makes an assessment for body motions
- myelination is not necessary for pain perception - behavior changes you may see in preschoolers are regression or that could indicate pain
- physiologic changes occur with pain even in preterm infants, so even withdrawal. o clenched hands, clenched teeth, rapid
with a lack of memory, it is clear that pain is experienced. - To help evaluate if they have pain, ask yourself, “What would this breathing, and guarding of body parts,
- Even newborns instinctively guard a body part by holding an
child normally be doing?” (e.g., playing, eating, sleeping). Input  the age when concerns about addiction may begin to
extremity still or tensing the abdomen. appear. A nurse can use this opportunity to discuss what
from parents on how their child usually behaves can be
- Other clues it is adolescents may have heard about pain medications,
o diffuse body movements; tears; a high- pitched, harsh cry; a valuable in an evaluation. If a trial dose of analgesia is used,
preconceived ideas about pain, and their risk for abuse of
stiff posture; alterations in facial expression such as eyes you can then evaluate behavior changes after the dose is given.
pain medications It is important for a nurse to read both
squeezed shut; a quivering chin; lack of play; and fisting - Children who resume their usual behavior after analgesia were verbal and nonverbal cues from the patient when having
- Chief mark in infants: when pain is present, they cannot be com probably in pain before the analgesia took effect. these discussions.
forted completely. PAIN ASSESSMENT
- Preterm neonates particularly may have a difficult time organizing a School-Age Child and Adolescent
distress response to cue a healthcare provider to the presence - Children who think concretely can have difficulty envisioning that a Pain Experience Inventory
of pain. word like “sharp” applies both to knives and to the feeling in their - tool consisting of eight questions for children and eight questions for
- When working with any infant, be sensitive to situations that could abdomen. the child’s parents.
cause pain and try to reduce them to the maximum extent  Because of this, they continue to have difficulty - designed to elicit the terms a child uses to denote pain and what
possible. describing pain. actions a child thinks will best alleviate pain.
 They may also assume, like preschoolers, that you, as an - can be used when a child is admitted to an acute care facility or on
Toddler & Preschooler authority figure, already know they have pain. an initial home care visit
- may not have a word in their limited vocabularies to describe the - School-age children - used before the child has pain.
sensation they feel because words such as “sharp,” “nagging,”  guarding (tensing of body parts) is common.
or “aching” have little meaning until a child has experienced  Sometimes, children can report they are fine while CRIES Neonatal Postoperative Pain Measurement Scale
each type looking uncomfortable and being unwilling to move; as a - 10-point scale named for five physiologic and behavioral variables
- Parents often encourage children of this age to refer to pain as “my nurse, you cannot always rely on what a child says; you commonly associated with neonatal pain:
have to read their body language, too.
boo-boo” or to use other word such as “hurt” or “ouchie,” so - C = crying; R = requires increased oxygen administration;
 regress with pain such as returning to baby talk or lying in I = increased vital signs; E =expression; S = sleeplessness
children often are not sure if what you mean by the word
a fetal position. - Infants with a total score of 4 or more are most likely to be in pain
“pain” (to be most accurate in assessment, use the child’s term
 If pain will last only an instant, such as with an injection, and need interventions to reduce discomfort
for pain or teach the child that “pain” is the same as children this age are old enough to control the pain - Used post-operatively
“boo-boo”). through nonpharmacologic activities such as distraction - Cannot be used for intubated or paralyzed for ventilatory assistance
- For some toddlers, pain is such a strange sensation that aside from techniques. because they would have no score for crying and because, if
crying in response to it, they may react aggressively (e.g., - Children may be in middle school before they can understand how their faces are obscured, it is difficult to rate them for facial
pounding, rocking) as if to fight it off. They also may avoid to use a numerical pain rating scale or that the scale intensifies from expression
being touched or held. left to right. Assessment 0 1 2
- Preschool children can describe that they have pain but continue to  Doing preassessment work with them, such as giving Crying No cry or cry is Cry is high Cry is high
have difficulty describing its intensity. them 10 different-sized triangles and asking them to not pitched but pitched and
o begin to use comforting mechanisms, such as gritting teeth, arrange them from smallest to largest, is a good way to high pitched. baby is easily baby is
pressing a hand against a forehead, pulling on their ear, evaluate if they understand incremental measurements consolable. inconsolable.
holding their throat, rubbing an arm, or grimacing, to or “least to most” and are primed to describe pain Oxygen No oxygen ≤30% oxygen <30% oxygen
intensity in a measurable way. required required. required. required.
control or express pain.
- A scale of 1 to 5 can be used in younger children if 1 to 10 seems for SpO2
- Some preschoolers do not think to mention they have pain because
overwhelming. If it seems clearer, you can turn a pain rating scale >95%
they believe it is something to be expected or,
vertically so it measures bottom (little pain) to top (a lot of pain) to Increased Heart rate and Baseline heart Baseline heart
because of their egocentric thinking, they assume adults are help a child learn incremental measurement. vital blood rate or rate or
already aware of their pain. - Adolescents are able to use adult pain scales for assessment and signs pressure blood pressure blood
also may think pain is punishment for some act, so this is what also commonly use unchanged increased >20% pressure
they deserve.  adult mechanisms for controlling pain such as grimacing or less than of increased
or verbal outbursts.
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baseline. baseline. ≥20% of - scale by which healthcare providers can rate a young child’s pain 3. Next, ask the child to choose the face that best describes
baseline. when a child cannot give input, there is a language barrier, or the the child’s pain and record the number under the face
Expression No grimace Grimace alone Grimace and child has a developmental delay the child chooses.
present. is noncry - incorporates five types of behaviors that can be used to rate pain: - The scale is popular with young children and can be used for those
present. vocalization o facial expression, leg movement, activity, cry, and as young as 3 years of age
grunt is consolability. - The scale is widely used by healthcare providers because this appeal
present. - Because a child does not provide active input, older children may to children makes the evidence-based tool easy to use in practice.
Sleepless Infant has been Infant has Infant has prefer a pain rating system in which they actively participate.
continually wakened at been awake
asleep frequent constantly.
for past hour. intervals for
past hour.

OUCHER Pain Rating Scale

- consists of six photographs of children’s faces representing “no hurt”
to “biggest hurt you could ever have.”
- included is a vertical scale with numbers from 0 to 100.
- To use the photograph portion
 point to each photograph and explain what each photo
represents.
Poker Chip Tool  Ask the child to point to the photo that best represents
- uses four red poker chips placed in a horizontal line in front of the the child’s degree of hurt
child. - To use the numbered scale portion,
- technique can be used with children as young as 4 years of age,  point to each section of the scale and explain
provided the child has some concept of “more” or “less.”  that 0 means “no hurt,”
- To use the tool,  1 to 29 means “a little hurt,”
1. tell the child, “These are pieces of hurt.”  30 to 69 means “middle hurt,”
2. Beginning at the chip nearest the child’s left hand and  70 to 99 means “big hurt,”
ending at the one nearest the child’s right hand, point to  100 means “the biggest hurt you could ever have.”
the chips and say, “This is a little bit of hurt, this is a little  Ask the child to point to the section of the scale that
more hurt, this is more hurt, and this [the fourth chip] is represents the present level of hurt.
the most hurt you could ever have.” - Children as young as 3 years of age can use the tool by pointing to
3. Then, ask the child, “How many pieces of hurt do you the photograph that best describes their level of pain.
have right now?” - If the child can count to 100 by ones and understands the concept of
4. Children without pain will reply they don’t hurt; others increasing value, the numbered scale can be used.
will point to one of the poker chips. - has White, Black, and Hispanic American photograph versions. If
COMFORT Behavior Scale 5. To gain more understanding of how much pain the child children are most comfortable with the tool, allow them to select
- pain rating scale devised by nurses to rate pain in very young infant is feeling, clarify the child’s answer by a follow-up the version they want to use or present the version that most closely
- six different categories question such as “Oh, you have a little hurt? Tell me matches the cultural characteristics of the child.
o alertness, calmness/agitation, crying, physical movement, about that.”
muscle tone, and facial expression - This is an effective tool for young children because the poker chips Numerical or Visual Analog Scale
o rated from 1 to 5 are concrete items and children are concrete thinkers - uses a line with end points marked “0 = no pain” on the left and “10
o lowest score is 6 ( no pain), and 30 is the highest (a gr eat = worst pain” on the right.
deal of pain) WONG-BAKER FACES PAIN RATING SCALE - Divisions along the line are marked in units from 1 to 9. Explain to
- infant is then observed for 2 minutes - consists of six cartoonlike faces ranging from smiling to tearful children that the left end of the line (0) means that a person feels no
- the evaluation of the baby’s pain is documented on an analog (1 to 1. Explain to the child that each face from left to right pain.
10) visual scale corresponds to a person who has no hurt up to a lot of - At the other end is a 10, which means that a person feels the worst
hurt pain possible.
FLACC Pain Assessment Tool 2. Use the words under each face to describe the amount of - The numbers 1 to 9 in the middle are for “a little pain” to “a lot of
pain the face represents. pain.”

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- Ask children to choose a number that best describes their pain. As group need so much help reading and interpreting the - When helping parents choose a distraction technique such as
soon as they can count and have a concept of “less to more,” multitude of words that describe pain, it makes the form blowing soap bubbles with their child, be certain they do not
children are ready to use a numerical scale. impractical for them. interpret “distraction” as just talking to the child or suggesting a
- Be certain to show school-age children the scale; do not just say - This is a useful tool for involving parents to talk with their child video game to divert attention.
score your pain from 0 to 10. about pain. Reading the words together helps children - Although these are distractions,
- Until children reach late adolescence, they use concrete thought examine the type, location, and level of pain they are a distraction activity must require concentration; simple distractions
processes and so need the help of seeing the line to rate their pain experiencing. can allow pain to break through.
best. - also helps parents to better understand what their child is
experiencing. SUBSTITUTION OF MEANING OR IMAGERY
- or guided imagery is a distraction technique to help a child place
another meaning (a nonpainful one) on a painful procedure
- Children are often more adept at imagery than adults because their
imagination is less inhibited.
- This technique works well with both quick, simple procedures such
as venipunctures and chronic pain. Success with this technique
Logs and Diaries requires practice, however, so it may have limited application in an
- Having children keep logs or diaries in which they note when pain acute care setting.
occurs and the intensity of the pain each time it occurs can be useful - As an example, a child could imagine a venipuncture needle as a
for assessing children with chronic but intermittent pain. silver rocket ship probing the moon or a submarine diving under the
- Examining such a diary not only reveals when pain occurs but also water to escape a torpedo just in time. Be certain a child thinks of a
provides direction for pain management. For example, if the diary specific image.
shows the child always awakens with pain in the morning, the child - Help the child elaborate on the image to make it more concrete each
may need a longer acting analgesic to take at bedtime; if pain is time it is used by asking questions such as “What color is the rocket
worse during weekends spent at a grandparent’s house, investigate ship?” “Are there stripes on the sides?” and “What does the pilot
whether something different is happening in that setting than at look like?”This helps the child’s mind stay on the image and not the
Adolescent Pediatric Pain Tool home that could be causing increased pain. venipuncture pain.
- combines a visual activity and a numerical scale
- On one half of the form is an outline figure showing the anterior PAIN MANAGEMENT Thought stopping
- vary greatly depending on the age of a child and the degree and type - technique in which children learn to stop anxious thoughts by
and posterior view of a child.
of pain a child is experiencing substituting a positive or relaxing thought in its place.
- To use the tool
- A good rule for determining whether children need pain relief for a - requires practice before it can be used in a painful situation
1. tell a child to color in the figure drawing at the point procedure is to rem ember that if the procedure would cause pain in - It may be most helpful in relieving anticipatory anxiety, a negative
where pain is felt. an adult, it will also cause pain in child. force that not only increases a pain experience during a procedure
2. on the right side of the form, tell the child to rate the but also makes the time before it full of anxiety as well.
present pain in reference to “no pain,” “little pain,” Nonpharmacologic Pain Management - For this technique
“medium pain,” “large pain,” and “worst possible - often called alternative or complementary therapies 1. help children think of a set of positive things about the
pain.” - can be used either independently or as complements to
approaching feared procedure
3. For a third activity, tell children to point to or circle as pharmacologic pain relief.
2. Whenever children start to think about the impending
many words as possible on the form that describe
Distraction procedure, they should stop whatever they are doing and
their pain (words such as horrible, pounding,
- shifting a child’s focus from pain to another activity or interest recite the list of positive thoughts to themselves if others are
cutting, and stinging). present or out loud if they are alone or only important support
- is suggested for - Blowing soap bubbles, for example, could be used during an
injection to accomplish this. people are present.
use in
- If oral glucose is offered to infants during painful procedures, the 3. Children can then return to a usual activity.
children 8
pain they experience appears to be significantly less. It is 4. Every time the anxious thoughts appear, however, a child
through 17
years of age. hypothesized that drinking glucose not only serves as a distraction should stop and recite the list again
- Because many technique but also activates endorphins and produces a central - Thought stopping is different from merely saying “Don’t think about
children analgesic effect it.” because the technique does not suppress thoughts; rather, it
younger than - Breastfeeding may also be used in this way but is not advised to changes them into positive ones.
this age avoid the infant making an association between breastfeeding and - also gives children a feeling of control.
pain.
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- The secret for success is for the child to use the technique every - may be helpful at reducing pain through its ability to create total Therapeutic Touch and Massage
time the disturbing, anxious thoughts appear even if, at first, such relaxation and possibly through distraction or the release of - Massage is the use of rubbing or kneading of body parts to aid
thoughts crowd in as frequently as every few minutes. endorphins circulation and relax muscles.
- Therapeutic touch is the use of touch to provide comfort and relieve
Hypnosis Acupuncture and Acupressure pain; based on the principle that the body contains energy fields.
- is not a common pain management technique with children but can - Acupuncture involves the insertion of needles into critical positions - When these are plentiful and arranged correctly, they lead to health;
be effective if a child is properly trained in the techniquea (meridian lines) in the body to achieve pain relief when they are in lesser supply, ill health results.
- child needs to train with a therapist before anticipated pain, so at - Acupressure involves applying deep pressure at the same points. - Although therapeutic touch may serve as a form of distraction,
the time of the pain, the child can produce a trancelike state to - Although acupuncture is almost painless, children can be very afraid proponents believe it is possible to redirect energy fields to increase
effectively avoid sensing pain. of it at first because of the sight of the needles. the supply and the release of endorphins.
- This level of stress can make it not as attractive an option for pain
Aromatherapy management with children as acupressure. Transcutaneous electrical nerve stimulation (TENS)
- based on the principle that the sense of smell plays a significant role - Children who consent to either technique, however, particularly - involves applying small electrodes to the dermatomes that supply
in overall health. those with chronic pain, report that the overall process is pleasant the body portion where pain is experienced
- When an essential oil is inhaled, its molecules are transported via and the method offers relief from stress - When children sense pain, they push a button on a control box,
the olfactory system to the limbic system in the brain. The brain which then delivers a small electrical current to the skin. T
then responds to particular aromas with emotional responses. - he principle underlying this technique is the same as rubbing an
- When applied externally, the oils are absorbed by the skin and then injured part or acupressure—the current interferes with the
carried throughout the body. Crystal or Gemstone Therapy transmission of the pain impulse across small nerve fibers.
- Essential oils may be able to penetrate cell walls and transport - gemstones or crystals have healing powers when they are arranged - can be used to manage either acute or chronic pain.
nutrients or oxygen to the inside of cells. in certain positions around the body. - Some children (and parents) dislike TENS therapy because they are
- Jasmine and lavender are oils thought to be responsible for relieving - If these are being used, be careful when changing bedding or nervous about the electric current.
pain rearranging equipment in a child’s room that you do not tip them - Assure them that the current is a very mild one and will not harm
over or move them. their child.
Magnet Therapy - A child may feel they may lose their pain-relieving powers if placed - not recommended if the child is incontinent or has a wound that is
- based on the belief that magnets can control or shift body energy in a different position likely to cause the electrodes to get wet.
lines to restore he lth or relieve pain. - Skin should also be monitored for irritation from the TENS pads.
- Magnets can be applied as jewelry or sewn into clothing or shoes. Herbal Therapies
- Although many people find relief from magnet therapy, the relief - for relieving pain or for generally improving children’s health Heat or Cold Application
may be more of a placebo effect than an actual change in pain level - chamomile tea (inflammation reduction), garlic (anti-inflammatory - Cold reduces pain by constricting capillaries and therefore reducing
- Copper also is believed to have pain-relieving ability and is often reduction, anticancer prevention), ginger (nausea or vomiting vessel permeability and edema and pressure at an injured site.
incorporated into rings and bracelets for this reason. reduction), goldenrod (urinary tract inflammation reduction), or - After the first 24 hours of an injury, applying heat may be more
peppermint (abdominal pain relief) helpful because this dilates capillaries, increases blood flow to the
Music Therapy - Always ask when taking health histories if a child is being given any area, and again helps reduce edema.
- use of music for calming or improving well-being herbs to be informed about common herbs and to be certain what
- can be effective for all ages of children or adolescents, even as the child is receiving will complement, and not interfere with, the Pharmacologic Pain Relief
young as preterm infants. effects of prescribed pain medication - administration of a wide variety of analgesic medications.
- works to relieve pain because it can be relaxing and also serves as a - Medications can be applied topically or given orally, intramuscularly,
distraction Biofeedback intravenously, or by epidural injection
- based on the theory people can regulate internal events such as - intramuscularly administered analgesia should be avoided in
Yoga and Meditation heart rate and pain in response to a stimulus children
- Yoga, a term derived from the Sanskrit word for “union,” involves a - biofeedback apparatus is used to measure muscle tone or the child’s
series of exercises that were originally designed to bring people who ability to relax. Topical Anesthetic Cream
practice it closer to spirituality. - effective with adolescents but is less effective with school-age and - To reduce the pain of procedures such as venipuncture, lumbar
- offers a significant variety of proven health benefits, such as younger children because they tend to resist the biofeedback puncture, and bone marrow aspiration, a local anesthetic cream that
increasing the efficiency of the heart, slowing the respiratory rate, information or cannot concentrate for long enough for training to be contains 4% lidocaine can be used
lowering blood pressure, promoting relaxation, reducing stress, and optimal. - The cream is applied to the skin, and the site is then covered with an
allaying anxiety. - Although some children grasp the technique in one demonstration occlusive dressing or plastic wrap to keep young children from
- Exercises consist of deep-breathing exercises, body postures to session, most need to attend several sessions to condition wiping away or tasting the cream.
stretch and strengthen muscles, and meditation to focus the mind themselves to adequately regulate their pain response.
and relax the body.
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- The time needed for effect between different brands varies from 30 - Children should not receive acetylsalicylic acid (aspirin) for pain - Other side effects include
minutes to 1 hour and so must be applied within that time frame relief, especially in the presence of flulike symptoms, because there  nausea, pruritus, vasodilatation, cough suppression,
before an expected procedure is an association between aspirin administration and the urinary retention, and constipation.
- Parents can apply anesthetic cream at home before bringing a child development of Reye syndrome, a severe neurologic disorder - If toxicity with opioids should occur, low-dose naloxone (Narcan), an
to a clinic visit for a procedure such as bone marrow aspiration to - For managing severe or acute pain, such as postoperative pain or the opiate antagonist, can be administered to counteract the effects.
avoid a long waiting time pain of a sickle-cell crisis, opioids, such as morphine, oxycodone, and This low dose for side effect management is a different dose than
- Caution them not to allow their child to remove the dressing hydromorphone (Dilaudid), are frequently prescribed. the rescue dose needed for respiratory complications.
because the cream could anesthetize the gag reflex if eaten or cause  Because this class of drugs is also referred to as narcotics or
eye damage if rubbed into the eyes. opioids, parents may be reluctant to give their children these Patient-controlled analgesia (PCA)
- Effective with: medications out of concern that their child will become - allows a child or a parent to self-administer boluses of medication,
 procedures such as venipuncture, intramuscular (IM), or addicted. usually opioids, with an IV medication pump
subcutaneous injections.  Acknowledge their concern but reassure them the risk for - Children as young as 5 or 6 years of age are able to assess when they
 for pain relief with circumcision addiction during short-term use is remote. need a bolus of medicine and press the button on the pump to
- EMLA cream, a combination of local anesthetics, is a popular cream  Reinforce that the main concern is supplying adequate pain deliver the new dose through an established IV line.
used but has to be applied at least 1 hour before the procedure; relief for their child. - Parents or a nurse are able to administer a new dose to children
however, it can be applied up to 3 hours before a procedure and  A reminder about the consequences of undertreated pain and younger than this as long as the child is awake.
a discussion about how anxiety can increase levels of pain may - Morphine is a common analgesic used for PCA administration
be helpful in the discussion as well. - The pump is set with a lockout time so that after each dose, the
pump will not release further medication even if the button is
pushed again; because of this, children cannot overmedicate
themselves.
Oral analgesia - If pain is constant, a continuous infusion should be used so that pain
- is advantageous because it is cost-effective and relatively easy to relief continues even while the child sleeps.
administer. Intramuscular Injection - The pump can still be programmed for bolus dosing to cover
- Many analgesics are supplied in liquid form and flavored with cherry - Although opiates are available as IM injections, analgesia for episodes of increased pain.
or grape syrup to disguise unpleasant tastes. children is rarely given by this route because the number of suitable
- Caution parents that even though such drugs taste sweet, they injection sites in children is limited, injections are associated with Conscious sedation
should never refer to them as “candy.” pain on administration, and such an injection can produce great fear - refers to a state of depressed consciousness usually obtained
- Reinforce with parents the need for proper storage (locked in a in children. through IV analgesia therapy
cabinet or out of the child’s reach) because, otherwise, children may - An IM injection also can lead to several risks, including uneven - allows a child to be both pain free and sedated for a procedure.
help themselves to more of the pleasantly flavored “candy” parent absorption, unpredictable onset of action, and nerve and tissue - Unlike the use of general anesthesia, protective reflexes are left
leaves the room. damage. intact and a child can respond to instructions during the procedure.
- Toxicity from too frequent or overly large doses of when the - other routes are used whenever possible. - The technique is used for painful procedures such as dental
acetaminophen is the number one reason for poisoning in small extractions, wound care, and bone marrow aspiration, as well as for
children and can lead to severe liver damage in children Intravenous Administration magnetic resonance imaging and endoscopy, both of which require a
- If swallowing pills or large volume of liquids is not an option, - the most rapid-acting route, is the method of choice in emergency child to lie still for a long period of time and can be potentially
enterally dosed opioids can also be given sublingually or rectally, if situations, in the child with acute pain, and in a child requiring frightening.
appropriate. frequent doses of analgesia but in who the gastrointestinal tract - Drugs used for conscious sedation can be something as common as
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen cannot be used chloral hydrate or as involved as a sedative-hypnotic-analgesic
or naproxen are excellent for reducing pain because, as their name - can be given by bolus injection or by continuous infusion. combination, which relieves both anxiety and pain and depresses
implies, they reduce inflammation as well as pain in conditions such - If doses will be given periodically by an IV line, advocate for the use the child’s memory of the event.
as sprained ankles or rheumatic conditions. of an intermittent infusion device to avoid repeated venipunctures - In many healthcare settings, conscious sedation is administered
 Long-term administration of any NSAID can lead to severe with each dose or the need for a confining IV line to be in place. and monitored by nurses specially prepared in the technique
gastric irritation, so this category of analgesics should not - If a child’s pain is frequent or constant so a continuous IV line is
be used longer than prescribed. necessary, advocate for a patient-controlled pump to offer the child Intranasal administration
 Help parents giving any analgesia around the clock for a sense of control and rapid analgesia. - is becoming an attractive way to dispense medicine for children
several days to make out a medication sheet to hang on - As the child becomes able to take medications by mouth, oral forms because it’s easy for parents to administer and the medicine absorbs
their refrigerator door or some other method to remind of analgesics will then be administered. well from the nasal mucous membrane.
them when the next dose will be due and alert them not - When switching from IV to oral medications, be certain the oral - Influenza vaccine, for example, is now available in an intranasal form
to give drug doses too close together. medication is supplied in an equianalgesic dose. - Because it has a very short duration of action, it may require repeat
- All opioids have the potential to decrease respiratory rate. administration.
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- Because it has no analgesic action, an analgesic should be Stage I: Denial - With a child who has a long-term illness, parents may never reach
administered concurrently if the procedure will be painful - Parents have difficulty realizing what has occurred. They ask, “How this stage but will always remain in the chronic sorrow of the
could this have happened?” depression stage.
Local anesthetics - shock or denial; parents are usually unable to plan past immediate - some parents need guidance in making plans to avoid ignoring the
- stop pain transmission by blocking nerve conduction of the impulse or short-term actions (learning to change a dressing, what pills to needs and wishes of other family members.
at the site of pain. give each day). - For example, parents may spend every waking moment with their ill
- Children receive local anesthetic injections, such as lidocaine, before - Trying to establish long-term outcomes at this point (e.g., what type child. Talking to them about the importance of self-care and the
procedures such as bone marrow aspiration, peritoneal dialysis, or of school the child will attend, future surgery that will be needed) is burdens of caregiving are helpful.
suturing of lacerations. rarely productive because this must all be done again when parents - Help them approach their child’s care with moderation and allow
- For many children, the sight of the anesthetic needle is so are truly ready to look this far ahead. time for all family members as well. Helping them to plan a respite
frightening that they cannot listen to the assurance that the from the care of a sick child, such as an evening out while a
momentary needlestick will actually prevent further pain. Stage II: Anger babysitter cares for the child, could be part of this approach
- The use of an anesthetic cream before the injection can be helpful to - Parents react to the injustice of being singled out this way. They say,
relieve the needlestick pain and allow the anesthetic to numb the “It isn’t fair this is happening.” If parents had a chronically ill child late in life, by the time the child is
tissues to prevent pain - parents may be unwilling to concentrate on goals (e.g., the whole school age, parents need to face one more step in their development as
thing is so unfair; planning is asking too much of them; besides, if parents of a chronically ill child: to begin to make some concrete plans as
Epidural analgesia you were really helpful, you would cure their child and not talk to who will care for the child in the event of their death.
- an injection of an analgesic agent into the epidural space just about ways they have to adjust).
outside the spinal canal, can be used to provide analgesia to the - may also be a time of waiting. Parental Coping Response
lower chest, abdomen, and lower body for 12 to 24 hours or longer - parents develop important coping mechanisms to help them
if needed. through this crisis in their life.
- An opioid, often combined with a long-acting anesthetic, is instilled - Problem solving is always an effective coping strategy as long as the
continuously or administered intermittently by a catheter into the parents are realistic about which problems they can solve
epidural space. Stage III: Bargaining - You may also need to help parents who are not comfortable
- Children who have orthopedic or chest surgery, for example, may - Parents attempt to work out a “deal” to buy their way out of the accepting the help of others to learn how to do so or to simply
have an epidural catheter inserted in the operating room and then situation. They say, “If my child gets well, I’ll devote the rest of my learn how to feel comfortable expressing their feeling to others.
continue to receive analgesia by this method to relieve postsurgical life to doing good.”
pain - parents are still not ready to plan. Anticipatory Grief
- This is a very effective route of analgesia for the postoperative child - believe that if their bargain is fulfilled (e.g., if their child is able to - Parents who have been warned that their child’s death should be
in the first few days after surgery. walk, and they promise to spend the rest of their life doing good), expected from the time the child’s illness is diagnosed may begin a
- Some parents may be reluctant to allow this type of analgesia - they do not have to make plans such as purchasing a wheelchair preparatory or anticipatory grief phase in which they gradually
because they equate it with spinal anesthesia, which they know can because these will be unnecessary after their wish is granted and the incorporate the reality of their child’s fate into their thoughts
cause severe headaches. You can assure them that an epidural child’s condition improves. - Anticipatory mourning in this way can prepare parents for their
needle does not enter the cerebrospinal fluid, so spinal headaches child’s death and spare them the abrupt, devastating, and
are extremely rare. Stage IV: Depression intolerable grief reaction that comes to parents whose child dies
- Parents begin to face what is happening; feel sad and unprotected. suddenly from trauma, such as in a car accident or sudden infant
THE CHILD WITH A LONG-TERM ILLNESS - parents are ready to make plans but need a great deal of support death syndrome
because they feel sad and fatigued. - A danger o anticipatory grief is that a parent may reach the
The Parent’s Adjustment - critical to make plans with them not for them. acceptance stage of the grief process too far in advance of the
- an assessment begins with an examination of the parents’ response - Many parents of children who are physically or cognitively child’s death. If this happens, parents may be in to treat the child as
to the stress of long-term illness challenged develop low self-esteem as well as depression. if the child has already died.
- Their low confidence in their parenting abilities may make them - They stop visiting, or when they do visit, they spend most of their
Grief Response believe your suggestions are superior to their own. time visiting other children on the unit or sitting in the waiting room
- Parents can be expected to experience a grief process - Upon their return home, they are the ones who must implement talking to other parents.
 the regulated steps in grieving, after diagnosis of a these plans and mitigate challenges they will experience so they - Once they spent time comforting their child; now, they may fail to
terminal illness and physical or cognitive challenges their need to participate in the planning process. rock or touch the child as much. They may clean out the child’s room
child will experience and throw out or give away toys. They are gradually drawing back
- Many parents with a child who is physically or cognitively challenged Stage V: Acceptance from emotional attachment to shield themselves from the abrupt,
never arrive at the final stage of acceptance or they spend years - Acceptance is being able to say, “Yes, this is happening, and it is all stabbing pain that death will bring.
with chronic sorrow (complicated grief) right it is happening.”

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- Children need a great deal of support if anticipatory grieving blocks - They envision death as temporary and therefore may not have the be, a child who is dying may be moved to the end of the hallway,
out communication this way, just as they did during the initial denial same fears adults may have about death. away from the nurses’ station. However, this further isolates both a
stage. - This view of death is sometimes interpreted as unfeeling. child who needs support and the child’s parents, who also need your
- Parents cannot help that the grief process did not coincide with the  For example, the first response of a child who is told his support and your presence nearby.
child’s death. brother has just been killed in an automobile accident - Advocate as necessary for both the child and the parents so they can
- Extend understanding and do not provide criticism for this reaction. might be to ask if he can have his brother’s cell phone. have continued interaction not just with each other but also with
- For some parents, because of anticipatory grief, the event seems  This happens because he thinks of his brother as being outside sources.
anticlimactic when the child actually dies. They have anticipated
gone for only a short time, making this a chance to take
death so long that when it does occur, they cannot believe it has Adolescents
advantage of his property.
actually happened. - the capacity to think in abstract terms grows and an adolescent has
- They may be so used to thinking constantly about their child’s needs - The understanding of death as temporary may be strengthened by a realistic perspective on death.
and having their child dependent on them that they feel lost or feel fictional depictions of death in children’s animation or stories in - have an unrealistic view of their own mortality and see themselves
as if there is a hole in their thoughts and life. Some parents are which sometimes characters that are killed come back to life. as invincible.
reluctant to leave the hospital this final time because leaving with - The separation anxiety preschoolers experience can complicate their - Risky activities such as driving at high speeds reflect this judgment.
the child’s possessions is the step that will make the death real. response to death. When confronted with their own death, their - They may deny symptoms that reveal their condition is worsening
main concern may be separation from their parents. Constant
for longer than you’d expect because they believe it is impossible
Vulnerable or Fragile Child Syndrome reassurances and having a caregiver present with the child helps
that anything serious could be happening to them.
- When anticipatory grief proceeds so effectively that parents begin to mitigate these fears.
- They appreciate time provided for discussion of how they have
think of a youngster as already dead but then the child does not die,
School-Age Children contributed to their family or community while their own death is
parents may find their grief reaction was so complete that they are
unable to reverse it and they cannot view the child in the same way - begin to have additional experiences with death, so their knowledge imminent.
as they did before. of its finality increases. - Continuing to participate in favorite activities helps them maintain
- Instead, they begin to treat the child in a cold and unfeeling way, as - They may think of it, however, as something that happens only to a sense of control.
if the child were not really there but had actually died. adults.
 vulnerable children, or fragile children - Children’s books tend to deal only superficially with the subject,
- They may develop behavior problems as they grow older (e.g., acting although many books that deal specifically with death are available
out behavior, such as temper tantrums; stealing in school; for children ENVIRONMENT FOR DEATH
shoplifting as adolescents) as if to say, “Notice me! I’m not dead!” - As children near 8 or 9 years of age, they begin to appreciate that
- They may require skilled counseling so they can feel secure that they death is permanent. They may experience the same feeling of Hospital
are still loved and can learn to react effectively with others loneliness experienced when they went away to camp or just for a - In a hospital setting, be certain that visiting hours are adequately
weekend, but this time, the separation will be permanent. extended for parents and other family members so that children are
Children’s Reactions To Impending - Most school-age children are aware of what is happening to them not left alone when they need people around the most.
- Children’s reactions to death are strongly influenced by the previous when their disorder has a fatal prognosis. Unfortunately, they may - Be certain also that children have opportunities to maintain contact
experiences and the family’s attitude toward death. learn of this prognosis from other children on the unit or at school, with peers.
- Children’s reactions to death are also influenced by their stage of from their parents’ unusual responses to questions, or from Home
development and cognitive ability. overhearing conversations about reports or physical findings. - Many families prefer that their child die at home, surrounded by
- Children are accustomed to adapting to new situations (e.g., starting family and familiar possessions rather than in a hospital.
Infants and Toddlers school, visiting a museum for the first time, boarding an airplane for - Assess how the family will schedule leisure time so they can balance
- too young to appreciate that their death is imminent. the first time), and they are able to effectively cope with these the care of the ill child and their self-care.
- If the person who cared for them dies, they experience a deep loss experiences as long as they know someone they care about will be - Including safeguards in the home plan of care will involve
and a void in their life. there to support them. interventions for car givers’ emotional and physical health
- If such a loss interferes with the development of a sense of trust, its - Dying can be viewed as another new experience, which they are able
implications for the child’s ability to achieve warm, close to cope with as long as they know they will have someone with Hospice
relationships could last a lifetime. them. - friends, family, and even younger children and pets are allowed
- If the parents are unable to relate to a child because of their grief, a unlimited visiting.
Preschoolers nurse may need to step in and fill the gap - Children are invited to bring possessions with them that are
- cannot always differentiate what is real from what is make-believe - Many children associate death with sleep, so they may be afraid to important to them.
play. fall asleep without someone near them and will need to have you sit - They are given choices regarding the degree of pain relief they want.
- This is a normal part of development and extends to abstract with them while they fall asleep. - Strong analgesia is often used to make a child pain free.
concepts such as illness and death. - They may need the light left on at night because they associate - The philosophy of hospice care is that death is an extension or part
death with darkness. Considering how busy a unit nurses’ station can of life, not a separate entity; therefore, it can be accepted not with

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separate or awkward rituals but with the same warm concern as - This includes omitting the use of such common expressions as “How - If irregularities occur (e.g., changes in sleeping pattern or loss of
other situations in everyday life. are you this morning?” to avoid having to hear the answer. appetite), assess whether depression may be the underlying
- For many children, hospice care is furnished as part of home care so - Denial may be so extensive that you avoid going into a child’s room cause.
that they are not separated from their families unless an important procedure must be done. This is - If you feel you are depressed, try to make no major decisions for at
unfortunate because it can be confusing and lonely for children least a week or you may find later you have made an unwise,
PREPARATION FOR A NURSING ROLSE WITH DYING CHILDREN AND because they miss the normal exchange of conversation and irreversible decision.
THEIR FAMILIES contact. 5. Acceptance
- End-of-life care for children can be an emotionally distressing - The moral distress felt by nurses after the death of a child to whom - The average person can reach a stage of acceptance in grief
experience for healthcare providers as well as family members they felt close may result in them reevaluating the profession because people are subjected to few true losses in a lifetime.
and whether they want to continue this career. - A nurse on a unit, where many terminally ill children come for care,
Self-Awareness 2. Anger may find him or herself facing loss or death repeatedly.
- Before you can offer support to children in any circumstance, be - Anger may be intense when a young child dies because the death - a stage of acceptance may not be reached fully.
aware of your own reactions and feelings. seems so unfair. - A caregiver who cannot reach a stage of acceptance is left ina stage
- To offer support to a child who is dying, one must recognize their - Feelings of anger cause difficulty in offering effective care. of distress and may have difficulty functioning.
own feelings, values, and beliefs about death of children. - Anger also clouds nursing judgment, such as to which analgesic - To achieve a stage of acceptance, you may need to modify your
1. Fear would be best to administer or whether a change in vital signs perspective.
- natural response to death, and to overcome this fear, it is important. - You may not be able to accept the unfairness of death in children,
should be put into perspective. - It is disappointing from a child’s perspective because dying children but you can accept your ability to offer care that facilitates
- In nursing, you care for many people who have illnesses and may not fully grasp the anger in caregivers and identify its death with dignity and compassion and maintains quality of
experiences you will never have, so caring for people with origin. They may feel lonely and perhaps feel guilty that they life.
experiences beyond your own is not really strange but caused this anger. - It is important for parents to take care of their own emotional
almost routine. 3. Bargaining health, and they will improve their ability to care for others as
- People who have never seen someone die may fear the - statement such as “If Tommy just makes it through the weekend they nurture themselves and their child.
moment of death and how they will respond to it. while I’m off, I’ll spend all my extra time with him next week” is
- People who were declared dead and then resuscitated by a bargaining statement.
heroic measures report that death was not at all  Bargains of this kind are easy to overlook in your Caring for the Dying Child
frightening but actually involved a feeling of exceptional coworkers or yourself. - Attentive physical and emotional care is essential for a child to
calm and comfort; people have reported afterward they - Listening for them helps you to evaluate when a fellow worker is maintain a sense of security a d positive self-esteem during this
wished they had been allowed to die rather than being having difficulty caring for a particular child and perhaps needs time. It is also essential to assess if parents are coping well if this
called back to their body because death seemed so a change in assignments. period is prolonged. Frequent and substantive communication is a
appealing - Hearing yourself express these sentiments should alert you that you major part of providing this care.
2. Failure may be more involved with a child than you perhaps have - Children, like their parents, need the opportunity to talk about their
- Some healthcare professionals find themselves drawing back from realized. fears and feelings about death.
caring for dying children because death symbolizes failure to - It’s a warning that you need to talk to someone about your feelings - Practicing good communication skills when providing any care such
them. or ask for help. as when administering pain medication, starting intravenous lines, or
- Remind yourself that death is the ultimate outcome for everyone. - Remember that when bargaining fails, people reach their lowest providing basic comfort measures such as a bath help to establish a
- At the point that death becomes unpreventable, the only failure point in grief. trusting relationship with the child, hopefully making the child feel
that can exist is the failure of healthcare professionals to help a - Recognizing bargaining statements in yourself, therefore, helps you more comfortable about openly sharing their feelings with you
child die with dignity and consideration and free of pain. prepare for the sadness that may follow.
4. Depression Child’s Family
Grief - Nurses who enter this phase may be ineffective caregivers because - For many children, terminal illness involves a series of hospital
- Because nurses develop such close bonds with terminally ill children, depression may cloud judgment and result in inadequate admissions interspersed with ambulatory care or home visits.
they may experience profound grief when a child dies or no longer problem-solving skills. - Parents need time during these visits to talk about the problems
requires their care. - It’s easy for nurses to make unwise decisions in their personal lives they are having, not only with physical care (e.g., Should the child
- The grief that accompanies caring for dying children can be broken as a result of the ineffective problem solving. attend regular school? Could he come on vacation? How many times
down into the same stages of grief experienced by the children - Depression is twice as destructive because when you are a day are we supposed to give the immunosuppressant?) but also
themselves when they learn they are dying depressed, your reasoning processes are so distorted that you about how it feels to live with a child who is dying (e.g., How should
1. Denial lose the ability to recognize that depression is the problem. they answer the child’s or siblings’ questions about death?).
- a danger that a nurse who is in a stage of denial may care for - When caring for a child who is expected to die, monitor your - Although many parents are reluctant to tell a child that he is dying,
children without mentioning they have more than a simple behavior to see if you are following your usual pattern. this is probably the soundest course once the child can see that his
illness. or her condition is deteriorating because there is often less anxiety
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in knowing what is happening than in hearing people whispering or c.Be certain the child’s chest is not compressed so that the e. If the conjunctivae appear dry, ask for a prescription of
spelling out words. child has optimal lung expansion to do this. moistening eye drops, and keep any crusting at the
- If a child with a chronic illness experiences an exacerbation of the - A decrease in muscular function eyelids washed away so that optimal vision is possible.
disease, parents may again begin an anticipatory grief reaction: a.leads to severe weakness and fatigue. - Be certain to keep skin surfaces from rubbing against one another by
anger, bargaining, depression, and acceptance. b. More and more, children maintain the exact position using supportive pillows and good positioning.
- The process will be cut short by improvement, only to begin again at into which they were placed. - Keep the skin free of urine or feces from incontinence to prevent
the next exacerbation. For this reason, the parents of a child who is c.As the throat muscles become lax, the possibility of painful ulcers.
being admitted to the hospital for the 12th time for a fatal illness aspiration increases. - These are concerns in that are due to the decreased peripheral
may be in the same stage of grief as the parents of a child with a d. Offer only a small amount of oral fluid until you’re certain blood perfusion.
newly diagnosed fatal illness. the child’s swallowing reflex is intact before offering a full - Assess for indications of pain (e.g., thrashing, moaning) and provide
- During health supervision visits, ask parents how other children in glass. relief with appropriate comfort measures.
the family are managing. The parents may need to be reminded that, e. If the gag or swallowing reflex is impaired, position the
although the dying child does need a lot of their time, other children child on the side to allow saliva to drain from the mouth DOCUMENTATION OF DEATH
find this illness in a sibling just as baffling as the parents. to prevent aspiration. Signs of death in a child not receiving ventilatory or mechanical
- When the ill child dies, siblings need the same active support to help - A loss of consciousness assistance are the same as in adults:
them grieve a.occurs as children grow closer and closer to death, although o Absence of respirations
they may remain perfectly alert until seconds before o No audible heart sounds by stethoscope
THE ONSET OF DEATH death. o No pulse by palpation
- As death nears in children, physiologic changes, such as slowed b. Vision apparently blurs because children tend to turn o No apparent blood pressure
metabolism, decreased cell oxygenation, and cell dysfunction, begin their head toward a light. o Absence of body movement or reflexes
to occur, thus changing children’s appearance c.Touch seems to remain intact as they often quiet to a gentle o Dilated, fixed pupils
- Stroke volume of the heart decreases stroking of the arm or shoulder, and they will grasp your o Death is officially determined by:
a.the power to circulate blood is reduced. hand meaningfully, as if touch is appreciated and felt.  a lack of receptivity and responsivity
b. The child’s skin feels cool and may appear mottled or d. Because hearing is one of the last senses lost, you may  no spontaneous muscular movement or breath
cyanotic because blood can no longer be pushed to distal need to remind family members and, on occasion, other  no reflex response; flat electroencephalogram
sites. healthcare personnel, that the child may not be able to AFTERCARE
c.Just before death, blood begins to pool in dependent body respond but may be able to hear. - Before beginning any aftercare for a child who has died in a
parts, making them appear purple.  Continue to explain procedures to unconscious healthcare facility or at home, check with family members to see if
d. As circulation fails, absorption of a drug from a muscle children as if they were conscious because they they want to spend a few minutes with the child or if there are any
becomes virtually impossible; if emergency drugs need to undoubtedly do hear you. religious rites they want to complete before the body is transported
be administered, they need to be injected intravenously  Never make any comment in their presence that you to the morgue or funeral parlor.
or often don’t have an effect. would not make if they were alert. - Some parents need this time for closure.
- As peripheral circulation fails  Continue to use the same gentle touch and nonverbal - Some people have special prayers or traditions and rituals they need
a. less heat is lost from the body and the internal communication motions, such as holding a hand or to follow; others want to say a final, private goodbye.
temperature rises. brushing hair from the forehead as if children were - Check that the child’s bed and room is orderly before you ask a
b. The child’s body compensates for this by increased fully conscious because they may be fully aware of family whether they would like to spend some time in the room,
perspiration to increase heat loss through evaporation. your actions even though they can give no particularly if the death was following an unsuccessful resuscitation
c. This makes the child’s skin feel cool and damp. indication of it. attempt.
d. You may need to change linens frequently because of the - Another body function that slows is digestion as total body - Remain in the room with the family in case they need your support,
increased moisture on the skin. metabolism slows. but be unobtrusive.
e. Because perfusion of distal body parts is impaired, turn a.Constipation because of poor bowel tone and decreased - Some parents fear touching a child’s body after death, but touch is a
the child slowly to allow the circulatory system to peristaltic action will occur. strong and intimate gesture that a family member may need to be
accommodate to the change in position. b. The abdomen may become distended from intestinal encouraged to make.
- Slowed respirations flatus. - Some parents may seem unable to leave the room or to let go of the
a.lead to increased secretions in the lungs and the appearance c.Dehydration with dry mucous membranes and conjunctivae child’s hand.
of rales, the sound of air being pulled through fluid in the will occur unless intravenous fluid replacement is - It may be necessary for you to gradually separate their hands while
alveoli. initiated. showing empathy for what they are experiencing.
b. To compensate for a few minutes of very slow d. Mouth dryness will lead to cracking, secondary infection, - This helps parents begin to accept the fact that, in more than a
respirations, a child may take several quick or extremely and pain; prevent this by frequently cleaning the mucous physical sense, it is time to let go.
deep inhalations periodically. membrane with clear water and with the application of
an ointment to the lips.
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- Crying is helpful for parents. You may need to reassure them that  Document the outcome of the procedure and the child’s  When feasible, it is always better to discuss why the legal
crying is not a sign of weakness but a normal response to a loved reaction to the procedure. guardian is refusing treatment so that an ameliorable
one’s death. plan for the child’s health can take place.
- Do not, however, interpret a lack of tears as a lack of feeling because OBTAINING INFORMED CONSENT - The pediatric population is considered vulnerable; thus, parents
crying is not everyone’s response to death. - Informed consent must consent on the child’s behalf prior to a procedure or
- It is not unprofessional for nurses to cry when a child dies.  is a process in which the healthcare provider discloses or involvement in research.
- A parent’s warmest memory of a hospital experience may be that a explains a proposed medical treatment, along with the  To maintain the child’s autonomy, assent is also often
nurse cried as she said goodbye to their child—the implication being risk(s), benefit(s), and alternative(s) for that treatment. obtained much like consent is. assent must have at least
the child made an important impact on people other than the family.  legally required and must be obtained before any the following four elements:
procedure or treatment that has a risk of causing injury to o helping the patient achieve a developmentally
the child is performed. appropriate awareness of the nature of his or her
- Each procedure or treatment must have a documented consent. condition
- The benefits and risks of the treatment or procedure must be o telling the patient what he or she can expect with tests
discussed along with the risks if the treatment or procedure was not and treatment(s)
performed. o making a clinical assessment of the patient’s
- Although obtaining consent is the provider’s responsibility, understanding of the situation and the factors
ensuring that it is obtained is a nursing responsibility. influencing how he or she is responding (including
- Acting as an advocate for a family if they do not understand the whether there is inappropriate pressure to accept
consent form, the procedure, or the risks of the procedure is an testing or therapy)
important nursing role. o soliciting an expression of the patient’s willingness to
- informed consent is valid when the following criteria are met: accept the proposed care.
 Disclosure of information to patients or their surrogates
 Assessment of patient and surrogate understanding of EXPLAINING PROCEDURES
the information and their capacity for medical decision - To be able to explain procedures clearly and answer questions about
making them appropriately, try to observe as many procedures as you can.
 Obtaining informed consent before treatments and - After any procedure, asking children to describe what sensations
interventions they experienced can help them work through possibly frightening
- A minor who is emancipated by the state is considered to have the situations (often called “debriefing”) and can also increase your
NURSING CARE OF A FAMILY WHEN A CHILD NEEDS DIAGNOSTIC OR same legal rights as an adult and may consent to treatment. knowledge of common procedures.
THERAPEUTIC MODALITIES - Adolescents - As a general guide, before a procedure, a child needs a detailed
Remember to maintain safety and legal responsibilities for care:  who are living on their own, are married, and/or description of what to expect, such as “I’ll clean your finger. You will
 Verify that an informed consent is obtained, as needed. serving with the armed forces are generally feel a small pinprick” as well as an explanation of:
 Utilize the electronic health record to verify the prescription considered legally emancipated and able to provide o Why the procedure is being performed (e.g., “Your
for the procedure. informed consent or refusal for their own medical doctor needs to look at your blood to see why
 Explain the procedure to the child and parents to ensure both care you’re so sick”)
are well informed.  adolescent’s right to consent for healthcare needs o Where the procedure will be done (e.g., the X-ray
 Schedule the procedure. related to sexual activity, including treatment of department, a treatment room)
 Prepare the child physically and psychologically. sexually transmitted infections, contraceptive o Any unusual sensations to be expected during the
 Obtain necessary equipment for the procedure. services, and prenatal care however, consenting to procedure (e.g., “The alcohol I use to clean your skin
 Accompany a child to a treatment room or hospital these services does not always guarantee will feel cold”)
department where the procedure will be performed. confidentiality. o Any pain involved (e.g., “The needle will sting,
 Coordinate and collaborate with other healthcare providers to - In emergent or life-threatening situations, when a legal guardian or although I’ll put some cream on first to dull the
ensure the safety and efficacy of all procedures. parent is unavailable to consent, the Emergency Medical feeling”)
 Provide support during the procedure, using the least amount Treatment and Active Labor Act mandates that a medical o Any equipment that will be unfamiliar such as a
of restraint possible. screening examination and delivery of appropriate medical magnetic resonance imaging machine
 Ensure adherence to standard infection precautions. care for the pediatric patient are never withheld or delayed. o The approximate length of time the procedure will
 Assess a child’s response to the procedure. - When a legal guardian refuses to consent to medical care or take
 Provide care to a child and specimens obtained once the transport that is necessary to save the child’s life, law o Any special care after the procedure (e.g., “You will
procedure is completed. enforcement may be needed. need to lie quietly for 15 minutes afterward”)
- Use age-appropriate language when explaining procedures and be
careful not to use words that might be confusing during an
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explanation, such as “transducer” or “electrode,” without defining - Using moderate sedation is an excellent technique to allow children - Some parents may ask to hold their child during a procedure that
them in age-appropriate terms. to accept a potentially painful procedure both emotionally and causes pain, but do not ask parents to restrain the child during such
- Try to associate the procedure with something you know the child is physically. a procedure.
already familiar and comfortable with, such as describing an X-ray - Preparation is essential for both the child and the family in terms of - Their role should be supportive and comforting, not one that
machine as “a big camera.” medication and possible side effects that may occur. causes pain.
- Try not to use the word test in explanations because school-age - Infants become dehydrated quickly, so the time they can remain
children associate the word test with a pass/fail situation. ACCOMPANYING THE CHILD nothing by mouth (NPO) for procedures should not exceed 6 hours
Wondering if they “passed” a procedure can make them unduly - Parental presence is essential when a child is undergoing a (4 hours for breast milk and 6 hours for formula
worried afterward. procedure because it reduces the child’s stress - You may need to advocate time for breastfeeding before and after a
- If you are unfamiliar with what a procedure entails, do not guess the - if the parents are unable to be present during a procedure, allow procedure for the comfort of both the infant and mother.
answers to a child’s questions because nothing is more confusing them to remain close by, such as a waiting room, so that they can be - If a procedure continues for longer than 3 to 4 hours, provide the
than being told two different versions of an answer to the same called once the procedure is completed. mother a room in which to use a breast pump, if needed.
question. - Ideally, a nurse whom the child knows should accompany the child - Assess the infant’s temperature to guard against extremes.
- Familiarize yourself with the procedure and explain to the child to the procedure and remain with the child throughout the - Have a blanket available to prevent chilling.
and/or parent in terms that are understandable. procedure, or at least until the child has met a primary person who - After procedures, allow parents to pick up infants and actively
- When possible, encourage parents to stay with their child during the will be responsible for the procedure. comfort them.
procedure, if possible, as they can be extremely helpful in reducing - Check for any medication or specific baseline assessment procedures
the threatening aspects of a procedure. such as vital signs that should be performed before leaving the unit Toddler and Preschooler
for another department, in case the child will be away from the - resist any diagnostic testing that involves any degree of discomfort
SCHEDULING primary unit for an extended time. or pain or any procedure that is unfamiliar to them
- If a child is having more than one diagnostic procedure in a day, try - If a child is an inpatient, also check that the identification band is - Give children of this age short explanations of what to expect close
to arrange for the child to have time for meals and some free play securely in place and readily visible despite any intravenous to the time of the procedure so that little time can be spent
time between the procedures. equipment. worrying.
- If food or fluid must be restricted, monitor the child’s degree of - If there will be a considerable wait in another department, ask - Try to associate any new equipment with things that they are
discomfort and physiologic needs related to the restriction. children if they would like to bring along an activity such as a game already familiar, such as comparing a magnetic resonance imaging to
Advocate as necessary for sufficient periods of time between or book. In addition, hallways can be cool. a giant cell phone camera.
examinations so a child can eat or for decreased time between - Provide adequate blankets for comfort, especially for infants; - If possible, introduce any equipment that will be used in procedures
procedures so the time spent without food or fluid is limited. because their temperature-control mechanisms are such as a nasogastric tube in a play session with a doll so the child
underdeveloped, their temperature can decrease quickly. can handle the new object and see that the doll is not injured or
PREPARING A CHILD AND FAMILY PHYSICALLY AND PSYCHOLOGICALLY - Always use cart straps and side rails for safety because safety is a minds having the tube inserted.
- Physical preparation varies with each procedure to be performed. priority during all procedures performed on children
- In many instances, preparing a child for an examination, such as a PROVIDING SUPPORT
barium enema, involves another procedure such as a saline enema, - Children do well with diagnostic and evaluative procedures as long
so that physical preparation also becomes education for the actual as they have adequate support from a familiar provider or parent School-age Child and Adolescent
examination. with them. - School-age children
- In all instances, explain both the preparative and actual procedures - Try to provide support both verbally (i.e., explain what is going to - are concrete thinkers and so are interested in the theory and
and allow the child to ask questions because appropriate happen in age-appropriate terms) and nonverbally (e.g., a hand on reason for procedures.
explanations aid in reducing anxiety and fear the arm or a nearby presence) - can often be persuaded to cooperate for a procedure by
- While under moderate sedation, being promised a look at their X-ray or a point-of-care
 children are able to maintain their ability to breathe MODIFYING PROCEDURES ACCORDING TO A CHILD’S AGE AND meter readout afterward.
independently and also respond appropriately to verbal DEVELOPMENTAL STAGE - Be careful, however, to ensure that viewing the results is
commands such as “Lift your head.” actually possible before promising this to children;
 They feel minimal pain, however, because of the Infant otherwise, it can be difficult to obtain any further
analgesic administered. - The number of painful or uncomfortable procedures done on infants cooperation.
- Before the technique is started, emergency equipment, including should be kept to an absolute minimum to avoid interfering with an - Adolescents
respiratory and pharmacologic measures for medication reversal, infant’s developing sense of trust.  may project an air of maturity or sophistication beyond
must be on hand. - Advocate for limitation of unnecessary procedures and always keep their years to remain in control of themselves in the face
- The child’s level of consciousness and ability to respond, heart rate, parents informed of what type of procedure the infant may need to of frightening procedures.
respiratory rate, blood pressure, oxygen saturation, and end tidal undergo.  Do not be misled into thinking an adolescent would not
CO2 must be monitored throughout the procedure. - Advocate for parents to remain during procedures to offer support. appreciate an explanation or a comforting hand on a
shoulder during a procedure.
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- Use the phrase special medicine instead.
PROMOTING SAFETY DURING PROCEDURES Electrical impulse studies - Children easily grow bored during this type of procedure because of
- Children are unable to guard their own safety because they are - those that include electrical conduction the time involved waiting for the contrast medium to reach and
unable to form mature judgments, a situation that leaves them - Children need special preparation for studies such as outline the specific organ to be studied.
vulnerable to harm unless their caregivers give special consideration electrocardiograms (ECGs) or electroencephalograms (EEGs) because - Have the child take along an activity to the exam room to make the
to promoting safety during procedures. they have been warned not to play with electric wires and so may time pass faster.
worry about being burned or electrocuted. - Maintaining NPO status may also be difficult for lengthy procedures.
Use of Restraints - You can assure a child the electricity passes from their body to the - Ensure that parents understand children do not “radiate” X-rays or
- purpose of a restraint (physical or chemical) during a procedure is to machine, not the other way around. Except for electromyelograms radioactivity after the procedure, so they will not be afraid to hold a
keep a child safe from injury. (i.e., study of the conduction paths of the spinal cord), you can also child closely for comfort.
- Whenever possible, healthcare providers should use alternative assure them these tests are painless.
means of keeping a child safe. - The electrodes are attached to the body by paste or sticky tape, Computed tomography (CT)
- Alternative methods include: which is easily removed afterward. - more commonly known as a CT or CAT scan, is an X- ray procedure in
o family member presence, the use of sitters, distraction, and which many views of an organ or body part are obtained to
placing the patient near the nurses’ station. X-ray studies represent what the organ would look like if it were cut into thin
- When alternative methods are deemed ineffective or the actions of - used to inspect internal aspects of the body slices.
the patient indicate immediate need for restraints, the least Flat-Plate X-rays - As with any X-ray, dense structures appear white and less dense
restrictive type of restraint should be utilized and only as a last - used to diagnose and evaluate the progress of illnesses as well as structures appear gray to black on the films.
resort. assess the placement of apparatuses such as gastrointestinal - The procedure may include injection of an iodine-based radioisotope
- restraints should be removed at the earliest opportunity feeding tubes. contrast medium.
- No part of a child’s body other than that which is necessary should - children - If this is necessary, the study may be referred to as positron
be restrained. - accept X-rays without protest because the X-ray machine can be emission tomography (PET) or single-photon emission computed
- Check restraint every 15 minutes to see if they are not occluding compared with a camera, an instrument with which they are familiar tomography (SPECT).
circulation - A lead apron and thyroid shield are used on portions of the body - A CT scanner is a large machine with a hole, or short tunnel, in the
- Remove restraint every hour so the body part can be exercised where X-ray exposure is not needed center.
- Remove any objects that contain metal because they may obscure - A moveable examination table slides into and out of this tunnel. In
Providing Care After Procedures the image. the center of the machine, the X-ray tube and electronic X-ray
- assess how well a child reacted to the procedure by both detectors are located opposite each other on a ring, called a gantry,
observation and history. Dye Contrast Studies which rotates around the patient
- Allowing children to explain what happened helps them retrace the - visualize a body cavity, radiopaque dye may be swallowed, instilled - It’s important for children to lie still during the procedure to avoid
procedure in their mind so they can conquer their fear of it. by enema, or administered intravenously and then revealed by X-ray creating artifacts on the film.
- Fill in gaps in information as necessary to improve a child’s - Barium Contrast Studies, IVP or Intravenous Pyelogram - Sedation may be needed to aid in the procedure.
perception of the procedure. - For IVP, check if the child is allergic to iodine because iodine is - You can assure parents that although the radiation exposure from CT
- Provide therapeutic play, as necessary, to help reduce anxiety incorporated in most of the radiopaque material scans occurs over a long period of time, such low doses are used that
- If tissue samples are obtained during a procedure, such as bone - Caution the child who is asked to drink barium for a gastrointestinal the actual exposure is comparable to a regular X-ray.
marrow aspiration send the specimen to the proper laboratory for study that even if flavored, it does not taste terribly good (more like - Radiation dose from CT procedures varies from patient to patient.
analysis as soon as possible. warm thick milk). The particular radiation dose will depend on the size of the body
- Guard against specimens being dropped or improperly labeled. - Always check the child’s allergy status before administering anything part examined, the type of procedure, and the type of CT equipment
that they have to ingest or be injected with. and its operation
- If moderate sedation was used, children may be discharged home or
- Evidence exists of a nonspecific cross-reactivity between contrast
to an inpatient hospital unit as early as 30 minutes after the
material sensitivity and allergy to seafood as well as other foods Magnetic resonance imaging (MRI)
procedure if:
o they are awake and oriented; - The frequency of allergic-like and physiologic adverse events related - combines a magnetic field, radio frequency, and computer
o have a patent airway to the intravascular administration of iodinated contrast media technology to produce diagnostic images that aid in the diagnosis of
o respiratory status is without retraction, stridor, or wheezing (ICM) is low and has decreased considerably with changes in the use disorders such as the cause of renal or brain pathology.
o oxygen saturation is 95% or greater on room air. of ionic high-osmolality contrast media (HOCM) to nonionic - The child lies on a moving pallet that is pushed into the core of the
o Blood pressure, heart rate, and respiratory rates should be low-osmolality contrast media (LOCM) machine, where the magnet is housed
- As the contrast dye is injected, the child may feel a hot flush, a - When the magnetic field surrounding the child is turned on, it causes
age-appropriate
sensation that can be frightening if the child is unprepared for this. tissue atoms to line up in a parallel fashion.
o child should be reasonably free of pain.
- Try not to use the word dye when describing a contrast medium to - As radio waves are turned on and off, the atoms change position.
prevent young children from worrying they will be dyed like an - This change is sensed and converted into a visual display on a
COMMON DIAGNOSTIC PROCEDURES
Easter egg or will die. computer screen
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- The procedure has an advantage over X-rays in that it has no - Within the media are a number of reports about the medical use of - used with children who have aspirated a foreign object, to instill
apparent ill effects, it can reveal astonishingly clear structural radiation and the risk of neoplasm development. certain medications, or to take culture and or biopsy specimens
defects in soft tissue - It is important to effectively communicate with families and patients - the throat is sprayed with a local pharyngeal anesthetic to numbthe
- if a contrast medium is required, it is not iodine based, so the danger about the medical use of radiation, the level of radiation exposure, area.
of a reaction is minimal. and its potential risks - Moderate sedation is then administered, and continuous monitoring
- Because metal may deflect the magnetic waves, children with a of vital signs is standard care.
metal prosthesis or metal dental braces are poor candidates for the Direct Visualization Procedures - Different types of bronchoscopes are used depending on the age of
procedure. - involve the observation of an internal body cavity by way of a thin the child and/or the size of the endotracheal tube being used.
- Hairpins and eye makeup (which often has a metallic base), watches, tube inserted through a body surface opening.\ - Procedural complications are not common but may include
or other jewelry should be removed. Remove any metal from the compromise to the airway such as:
child’s hospital gown, which may include metal snaps. Endoscopy o hemorrhage, pneumothorax and airway edema.
- When the radio waves are turned on and off during the procedure, a - involves the use of an endoscope, which is passed through the - After the procedure, continue to assess the child’s respiratory
booming noise can be heard. mouth, to examine the gastrointestinal tract function and airway patency.
- Prepare children for this sound (which is often compared with the - a common method of diagnosis for gastrointestinal disorders in - Postprocedure complications may include:
sound of drums) as well as the feeling of claustrophobia they may children. o bronchospasm, stridor, desaturation, or respiratory distress.
experience. - used as an emergency measure to remove foreign objects such as - Observe children carefully the first time they drink after the
- Except for cranial exams, headphones can be provided to decrease quarters or toys swallowed by children. procedure to assess that their gag reflex is intact and they do not
the noise. - When first developed, endoscopes were straight and stiff metal choke.
- Because the total procedure (excluding cranial examinations) may instruments, so their use was limited.
take up to 45 minutes, sedation may be indicated so they can lie - Currently, they are made up of fiberscopes, which are extremely Colonoscopy
quietly for this length of time and not skew the images recorded. flexible and easily maneuvered, so these examinations are not nearly - an endoscopic examination of the large intestine with a flexible
as uncomfortable as before. fiberscope that is inserted through the anus and advanced as far as
Ultrasound - The thought of having a tube passed down the throat can be very the ileocecal valve.
- is a painless procedure in which images of internal tissue and organs, frightening. - Air is then infused to expand the bowel walls for good visualization.
such as the appendix, are produced by the use of sound waves - Even after children understand what the procedure will consist of, - The technique allows the colon walls to be visualized; if
- Because it is noninvasive, children accept ultrasound easily and may they can still be very uncomfortable at the thought of a tube being abnormalities are found, photographs can be taken for analysis.
even enjoy watching the oscilloscope screen during the procedure. passed into them. - to diagnose inflammatory bowel disease or to obtain biopsies if a
- Alert a child that the clear gel, which is applied to the skin over the - Before the procedure, children must remain on an NPO status for malignancy is suspected.
body part to be studied, may feel cool and sticky. between 4 and 6 hours. - Before the procedure, children are given a clear liquid diet for about
- Compare the transducer that is used on the body surface to pick up - They will need a sedative or moderate sedation so they can lie 24 hours and then they are asked to drink an isotonic saline laxative
internal images to a television camera so it is not viewed as quietly for the time required. that causes fluid diarrhea so their bowel is clean for the procedure.
something strange - Good support during both the anxious time waiting for the - It can be difficult for younger children to drink as much of the
- Explain that the ultrasound procedure is not an X-ray, so they can procedure and during the procedure is crucial. laxative solution as is needed so their bowel is cleared completely of
remain in the room to comfort their child during the procedure. - Ask whether the child can have a digital photograph taken during stool
- Because ultrasound appears to have no long-term effects, it can be the procedure to keep as a scrapbook souvenir. - If a child cannot swallow all the laxative, a saline enema may be
repeated over and over for serial determinations. - Because the endoscope is passed through the throat, edema of the necessary.
throat may occur from the pressure on the esophagus and pharynx. - Moderate sedation is used during the procedure to reduce
Nuclear Medicine Studies  child requires close observation afterward for at least an discomfort.
- Radiopharmaceuticals are radioactive-combined substances that hour to confirm that the edema is not interfering with - Postprocedure, children may pass a great deal of flatus in the first 12
when given orally or by injection, flow to designated body organs. respirations or causing discomfort. hours because of the air introduced during the procedure.
- When a scintillation machine (a form of Geiger counter) is passed  Observe closely the first time the child drinks after the - If the procedure was done on an ambulatory basis, children are
over the organ where the radiopharmaceutical has collected, the procedure to ensure that the gag reflex is intact despite discharged about 2 hours after the procedure (but they are kept
pattern of the collected material outlines the organ. throat edema or the effect of a local pharyngeal NPO during that time to allow the bowel to have a brief rest).
 The pattern can then be reproduced as a screen image or anesthetic that may have been sprayed into the throat - Provide parents with instructions on what observations they should
a photograph. before the procedure. make and report if they occur after they return home, such as:
- Parents may worry that a child will be ha rmed by exposure to a o abdominal pain, blood in stool, weakness, or pallor (signs of
radioactive substance and although this procedure exposes the Bronchoscopy bowel bleeding) especially if a polyp was removed or a biopsy
patient to low levels of ionizing radiation, the risk is minimal when - direct visualization of the larynx, trachea, and bronchi through a lit, specimen was obtained.
used judiciously. flexible, fiberoptic tube (i.e., a bronchofiberscope) that is passed - Even with moderate sedation, colonoscopies are difficult
through the naris or trachea. procedures for children to accept.

anb 2021 82
 83
- Give generous praise afterward for their cooperation with both the
preparation for the procedure and the actual procedure.

anb 2021 83
WEEK 1 – CARE OF VULNERABLE GROUPS OF PREGNANT WOMEN o Maternal anemia o Gonorrhea culture & syphilis screening
HIGH-RISK PREGNANCY o RH sensitization o Rubella titer
It is one in which a concurrent disorder, pregnancy-related complication o Antepartal bleeding (Placenta previa, Abruptio o Papanicolau smear – done during initial prenatal
or external factor jeopardizes the health of the woman, the fetus or placenta) exam to screen for cervical neoplasia or possible
both. o Pregnancy-induced hypertension sexually transmitted infections
• Demographic Factors o Multiple gestation PREGESTATIONAL CONDITIONS
o Age o Pre/Postmature labor Cardiac Disease
Under 16 or over 35 years old o Polyhydramnios Pregnancy taxes the circulatory system of every woman even without
Optimal age for child-bearing is between 20- o Premature rupture of membrane (PROM) cardiac disease because both the blood volume & cardiac output
30 years old o Fetus inappropriately large or small increases approximately 30%. Half of this increase occurs by 8 weeks. It
o Weight – over/underweight before pregnancy o Abnormality in tests for fetal well-being is maximized by mid-pregnancy. The danger of pregnancy in women
o Height – less than 5 feet o Abnormality in presentation with cardiac disease occurs primarily because of the increase in
• Socioeconomic Status • Maternal Medical History circulatory volume. The most dangerous time for a woman is in weeks
o Inadequate finances o Cardiac or pulmonary diseases of the mother 28-32, just after the blood volume peaks.
o Overcrowding poor standards of housing o Metabolic diseases such as diabetes mellitus or • LHF – respiratory or pulmonary
o Poor hygiene thyroid diseases o Orthopnea
o Nutritional deprivation o Endocrine disorders (pituitary & adrenal) As pulmonary edema becomes severe, a
o Severe social problems o Chronic renal diseases with repeated UTI & woman cannot sleep in any position except
o Unplanned & unprepared pregnancy (esp. among bacteriuria with her head & chest elevated.
adolescents) – root of this problem: poverty & low o Chronic hypertension Elevating her chest allows fluid to settle to
educational status o Venereal & other infectious diseases the bottom of her lungs & free space for gas
• Obstetric History o Major congenital anomalies of the reproductive tract exchange.
o History of infertility or multiple gestation o Hemoglobinopathy o Paroxysmal Nocturnal Dyspnea – occurs because
o Grand multiparity o Seizure disorders heart action is more effective when she is at rest
o Previous abortion or ectopic pregnancy o Malignancy • RHF – circulatory
o Previous losses such as fetal death, stillbirth, neonatal o Major Emotional Disorders New York Heart Association Functional Classification of Heart
or perinatal deaths o Retardations Failure
o Previous operative obstetrics: • Habituation Class Description
Caesarean section, forceps delivery o Smoking during pregnancy I No limitations of physical activity
Previous uterine or cervical abnormality o Taking alcohol No heart failure symptoms
Previous abnormal labor (Pre/Post-mature o Drug use/abuse II Mild imitation of physical activity
labor or prolonged) Assessment: Heart failure symptoms with
Previous high-risk infants (low-birth weight, • Health History significant exertion; comfortable
infants that are macrosomic or large for • Determine if the client belongs to the vulnerable group at rest or with mild activity
gestational age with neurological deficit, • Physical Assessment III Marked limitation of physical
birth Injury or malformation) • Laboratory Assessment activity
Previous hydatidiform mole o CBC Heart failure symptoms with
Root of this problem: poverty & low o Blood Typing (and Rh factor) mild exertion; only comfortable
educational status o Alpha-feto protein – check for neural tube defect or at rest
• Current OB Status abdominal defect in fetus IV Discomfort with any activity
o Late or no prenatal care at all o Hepatitis B

majjyap ‘21
 Heart failure symptoms occur at 24 to 28 weeks AOG o Serial UTZ (ultrasonography) – for fetal growth
rest 50 g oral glucose evaluation & fetal surveillance testing (28-34 weeks
Diabetes Mellitus Finding: plasma glucose of > 140 mg/dl = gestation; earlier than 26 if with additional
• Risk Factors: perform OGTT complications)
o Family History Oral Glucose Challenge Test Values (Fasting Plasma Glucose o Provide teaching on signs & symptoms of hypo- &
o Rapid hormonal change in pregnancy Values) for Pregnancy hyperglycemia, regular exercise, self-administration
o Tumor/Infection of the pancreas Test Type Pregnant Glucose Level of insulin, & prompt reporting of danger signs & signs
o Obesity & stress (mg/dL)* of infection.
• Effects of DM Fasting 95 o Teach patient on infection prevention & stress
Mother Baby 1 hour 180 management.
• Infertility • Congenital anomalies 2 hours 155 Infection is considered a stressor; stress can
• Spontaneous abortion • Polyhydramnios 3 hours 140 cause hyperglycemia & increase the need for
• PIH • Macrosomia (LGA) *Following a 100-g glucose load. Rate is abnormal if two values are insulin.
exceeded. o Continued monitoring on mother & fetus during
• Infections: moniliasis, • Fetal hypoxia leading to
o Oral Glucose Tolerance Test intrapartal period
UTI IUFD & stillbirths
Having 2/4 abnormal > GDM o Monitor maternal need for postpartal insulin.
• Uteroplacental • Neonatal hypoglycemia
FBS > 100 g oral glucose > venous blood o Encourage breastfeeding.
insufficiency • Prematurity
sample taken after 1, 2, & 3 hours Hematologic Disease
• Premature labor • RDS
o Glycosylated Hemoglobin (HbA1C) • Pseudo-anemia VS True anemia
• Dystocia • Hypocalcemia
Maternal hemoglobin irreversibly bound to o Because the blood volume expands during pregnancy
• Uncontrolled DM:
glucose, measures long term, up to 3 months (slightly ahead of the red cell count), most women
hypoglycemia/hypergl
of compliance to treatment have a pseudo-anemia of early pregnancy.
ycemia
Normal value of 4-8% of women’s total o True anemia is present when a woman’s hemoglobin
• Cesarean section often concentration is less than 11 g/dl in the 1st or 3rd
hemoglobin increase during hyperglycemia
is indicated
• Medical Management trimester of pregnancy, or hemoglobin concentration
• Uterine atony is less than 10.5 g/dl in the 2nd trimester.
o Insulin Requirement: (Regular & NPH)
1st trimester – stable o However, physiologic anemia of pregnancy is
2nd trimester – rapid increase considered hemodelusional (?). There will be an
3rd trimester – rapid increase increase in blood volume of 30-50% higher before
Labor: IV regular insulin labor, causing disproportioning increase in blood
Postpartum: rapid decrease volume & blood cells resulting to physiologic anemia
o Early labor induction or cesarean section of pregnancy.
• Nursing Management: • Iron supplementation = 60 mg/day or 120 to 200 mg/day
o Early detection & regular prenatal visits o Iron deficiency anemia, the most common anemia in
o Dietary modification: 1,800 – 2,000 kcal/day pregnancy resulting from a diet low in iron, having
Carbs: 200 mg per day menstrual periods, or unwise producing stores (?) are
Protein: 70 g daily up to below in women who were pregnant less than 2
Unsaturated fats & regular time in taking years before the 3rd pregnancy or those from low
food socioeconomic levels who have not had iron-rich
o Insulin administration diets.
• Diagnostic Tests
o Oral Glucose Challenge Test
majjyap ‘21
 o When the hemoglobin level is below 12 mg/dl, iron Any respiratory condition can worsen in pregnancy because the rising Hyperemesis Gravidarum
deficiency is suspected. Other hematologic problems uterus compresses the diaphragm, reducing the size of the thoracic - Prolonged N/V past 16th week of pregnancy
in pregnant clients may have are: cavity & available lung space. Any respiratory disorder can pose serious - Unknown cause
Folic Acid Deficiency – anemia (common in hazards to the fetus if allowed to progress to the point where the - AKA pernicious or persistence of vomiting
multiple gestations) mother’s oxygen-carbon dioxide exchange is compromised. - Symptoms occur in the first 12 weeks of pregnancy
Thalassemia Nursing Considerations: - There is an increase thyroid function because of thyroid
Malaria • Rest & sleep stimulating properties of HCG
Coagulation disorders • Foods rich in vitamin C – orange juice & fruits to boost immune - Associated with Helicobacter pylori (same bacteria that causes
Renal and Urinary Diseases system peptic ulcers)
Urinary Tract Infection (UTI) • Room humidifier – especially at night to moisten nasal - Inability to retain fluid has resulted in hemoconcentration, in
Pregnant women are at a high risk as progesterone causes ureters to secretions & help mucous drain contrast, concentration of sodium, potassium, & chloride may be
dilate. This results a stasis (?) of urine. Pregnancy also enhances • Antibiotic (Category A) reduced because of a woman’s low intake
glycosuria or abnormal amount of glucose in the urine which provides • Oxygen therapy - Hypokalemic alkalosis may develop from loss of hydrochloric acid
an ideal medium for bacterial growth. Some clients may appear • Keep away from allergens from the stomach
asymptomatic & put them at risk to develop pyelonephritis or infection • Nebulization • Signs/Symptoms:
in the renal pelvis. Infection may induce preterm labor & premature • TB: R-I-E (rifampicin, isoniazid, ethambutol) o Severe weight loss, nausea, & vomiting
rupture of membranes. Substance Abuse o Ketonuria
• Etiology: • Assessment Findings: o Elevated HCT
o Bacterial: E. coli (most commonly responsible o Parental neglect o Dehydration
organism), Streptococcus B. o Malnutrition o Electrolyte imbalance
• Assessment: o Presence of other infectious diseases • Medical Management:
o Dysuria, pain in the lumbar region (pyelonephritis) • Management: o IV hydration (such as PLR with added Vitamin B1),
o N/V, malaise, dysuria, mild fever o Therapy (depending on the substance used) NPO (for first 24 hours)
o Urine culture o Counseling & rehabilitation o Antiemetic [such as metoclopramide (category B)
• Medical Management: Infectious Diseases may be prescribed to control vomiting]
o Antibiotic • Hepatitis B • Nursing Management:
• Nursing Considerations: o Transplacental transmission o Taper diet from NPO to clear fluids then small
o Void frequently (at least every 2 hours). o Treatment: Hepatitis B Immunoglobulin quantities of dry toast, crackers, or cereal. Soft diet to
o Wipe front to back after voiding & bowl movements. • HIV – AIDS regular diet afterwards.
o Wear cotton, not synthetic fiber, underwear. o Monitor I/O & blood chemistry (needs to be
o Standard Precaution:
o Void immediately after sexual intercourse. Wear gloves, fluid-resistant gown, mask, & hospitalized; to restore hydration).
o Increase oral fluids. goggles. o Provide pleasant & small portions of food (if no
Give a specific amount to drink everyday up No breastfeeding vomiting after 24 hours).
to 3-4 L for 24 hours Pregestational Conditions Ectopic Pregnancy
o Assume a knee-chest position for 15 minutes, • Rheumatic heart disease
morning & evening. In this position, the weight of the
• Diabetes mellitus
uterus is shifted forward, releasing the pressure on
• Substance abuse
the ureters & allowing urine to drain more freely.
• HIV/AIDS
o Ensure compliance of antibiotic treatment.
• Rh sensitization
Respiratory Diseases
• Anemia
GESTATIONAL CONDITIONS
majjyap ‘21
 • Risk Factors: o Assess for shock. o UTZ – reveals no fetal sac & parts
o Constriction or narrowing of fallopian tube o Position on modified Trendelenburg. • Medical Management:
o PID o Infuse IV fluids as ordered. o Methotrexate
o Puerperal & postpartum sepsis o Provide physical & psychological support (pre- & post- o Evacuation: D&C or hysterectomy [performed if there
o Surgery or congenital anomalies of the fallopian tube op). is no spontaneous evacuation, this is to be used (also
o Adhesions, spasms, tumors Gestational Trophoblastic Disease for over 45 years olf & no future pregnancy)]
o Use of IUD This is a benign neoplasm of the chorion (fails to be full term & o Chest x-ray – detect early lung metastasis
• Types: degenerates instead). • Nursing Management:
1. Tubal – most common • Risk Factors: o Bedrest
2. Cervical o Increased or decreased maternal age o Monitor I/O, molar tissue passage.
3. Abdominal o Low socioeconomic status, low protein diet o Maintain fluid & electrolyte balance, plasma & blood
4. Ovarian o History of abortion & Clomiphene (induces labor; volume through replacements as ordered.
• Signs & Symptoms: works similarly like estrogen) therapy o Prepare for D&C or hysterectomy as indicated.
o Amenorrhea or abnormal menstrual period • Signs & Symptoms: o Provide psychological support.
o Tubal rupture: sudden sharp, low abdominal pain o Brownish or reddish, intermittent or profuse vaginal Anticipate fear related to potential
radiating to shoulder (Kehr’s sign); before 12 weeks bleeding by 12 weeks development of cancer, disturbance in self-
o N/V, positive pregnancy test o Rapid uterine enlargement inconsistent with AOG esteem for carrying an abnormal pregnancy
o Cullen’s sign o Excessive HCG –> excessive N/V o Reinforce instructions on no pregnancy for 1 year.
characterized by edema, bruising, & (bluish) o Positive pregnancy test o Teach patient on contraceptive use especially for 1
discoloration of fatty tissue surrounding the o No fetal signs year.
umbilicus/navel o Cause is unknown o Emphasize the need for follow-up HCG determination
can be due to pancreatitis, pancreatic o PIH symptoms may appear before 20 weeks AOG for 1 year (no pregnancies for the year).
cancer, ectopic pregnancy, liver problems, Incompetent Cervix
- Characterized by a mechanical defect in the cervix causing cervical
thyroid cancer or other sources of internal
effacement & dilation & expulsion of the product of conception &
bleeding in the abdomen
with trimester of pregnancy
o Rectal pressure
o Shock
• Laboratory:
o Low Hgb, Hct, & HCG
o Elevated WBC
• Diagnostic Tests:
o Pelvic UTZ
o Culdocentesis H-mole: Uterus is distended by thin wooled (not sure mao na iyang gi
• Medical Management: ingon bc di maklaro) translucent like vesicles of different sizes. These
o Methotrexate – folic acid antagonist are generated chorionic vili filled with fluid. Enlarges over time making
chemotherapeutic agent without attacks & destroys the woman think she is pregnant but not really.
fast growing cells • Diagnosis:
o Salpingectomy • Risk Factors:
o Passage of vesicles
o Blood Transfusion o Increased maternal age
o Triad: enlarged uterus, vaginal bleeding (brownish &
o Antibiotics o Congenital defect of the cervix
intermittent discharges) & HCG (normal value:
• Nursing Management: 400,000 iu/L) > 1 million
majjyap ‘21
 ○ Trauma – forceful dilatation & curettage & difficult • Nursing Management:
delivery o Provide psychological support.
o Cervical lacerations To clients who may have negative feelings
• Signs & Symptoms: such as low self-esteem theory related to
○ Painless contractions - resulting in delivery of a dead inability to complete pregnancy, guilt, or
or non-viable fetus anticipatory grief related to loss of expected
o Pink-stained show baby
o Relaxed cervical os o Provide post-cerclage care.
o History – abortions o Advise limitation of physical activities within 2 weeks
• Medical Management: after treatment.
o Cerclage o Routine prenatal care.
14 to 16 weeks AOG o Instruct client to report promptly signs of labor.
Threatened miscarriage – scant bright red vaginal bleeding & slight
When a suture or a ribbon is placed beneath o Assess for signs of labor, infection or premature
cramping pain
cervical mucosa to close the cervix rupture of membranes.
Inevitable miscarriage – characterized by threatened miscarriage with
o Post-McDonald Cerclage – prepare stitch removal set
labor
during labor
Complete miscarriage
Spontaneous Abortion
- the entire products of conception are expelled spontaneously
- It is a termination of pregnancy before the age of viability usually
without assistance
before 22-24 weeks AOG.
- no specific treatment, only to monitor bleeding
- Induced abortion is a termination of pregnancy with medical or
Incomplete miscarriage
mechanical intervention.
- part of the conception is expelled but membranes are retained
- Spontaneous & induced spontaneous abortion means without
- woman is at risk for hemorrhage with this kind of miscarriage
medical or mechanical interventions.
Missed miscarriage
• Etiology:
- An early pregnancy failure. Fetus dies in utero, but not
o Defective ovum
expelled.
o Maternal causes
- A woman may be induced for labor if more than 14 weeks
o Maternal factors: viral infection, malnutrition,
a) Shirodkar – permanent pregnant.
trauma, incompetent cervix, hormonal, increased
b) McDonald – temporary Habitual or recurrent pregnancy loss with 3 or more consecutive
temperature, systemic disease, environmental
abortion
hazards, Rh incompatibility
- AKA habitual aborters
• Signs & Symptoms: - cause for this would be autoimmune uterine infection
o Vaginal bleeding deviation in the uterus; could also be hormonal or there could
o Uterine/Abdominal cramps be defect in the sperm or the ovum
o Passage of products of conception
• Medical Management:
o Shock
o Surgery: dilation & curettage
o Antibiotic
o Fluid replacement: blood & plasma
o Habitual abortion: cerclage
• Nursing Management:
a. Threatened Abortion

majjyap ‘21
 i. Advise on complete bedrest for 24 to 28 Fresh, bright red external in 3rd trimester or Mother in labor & progressing well mother &
hours. 7th month fetus are stable & if the woman is not in labor
ii. Teach to save all blood clots passed & o Flaccid uterus – soft & plastered or in shock & or the fetus is distressed, only
perineal pads used. o Intermittent pain – if it happens in labor secondary to one setup is to be prepared, An emergency
iii. Advise prompt reporting to the hospital if uterine contractions classical cesarean section setup.
bleeding persists or increases. o Intermittent hardening – if in labor For the delivery, if conditions for watchful
iv. Prevention of abortion: avoid coitus or o Bleeding may be slight or perfused which may come waiting are absent, then vaginal delivery if
orgasm especially around normal time of after an activity coitus or internal examination the birth canal is not obstructed could be
menstrual period • Diagnosis: done.
a. Inevitable Abortion o Ultrasound o Classical Cesarean section
i. Save or monitor clots, pads, & tissues for Gives 95% accurate result & it detects the If placental placement prevents vaginal
correct diagnosis. birth. In previa, classical cs is indicated as the
site of placenta
i. Monitor VS, blood loss, I&O, change in status lower uterine segment is occupied by the
& signs of infection & refer any deviation Uterus is normally positioned on the higher placenta.
i. Institute measures to treat shock as corner of the uterus. However in placenta Future pregnancies will then be terminated
necessary: replace blood, plasma, & fluids as previa, it is implanted in the lower segment by another cs because a presence of classical
ordered. of the uterus. cs scar is a contraindication to vaginal
i. Prepare for surgery. delivery. It is a leading cause of uterine
i. Provide psychological support. rupture.
i. Prevent isoimmunization: administer • Nursing Management:
RhoGAM as offered if: o Bedrest – LLR
1. Mother is Rh negative; abortus is Rh o NO I.E.
positive o Monitor for profuse bleeding.
2. Coomb’s test result is negative (no o Provide psychological & physical comfort.
iso immunization yet –> no o Monitor for postpartum bleeding.
antibodies formed yet) Abruptio Placenta
• Medical Management:
i. Observe client for 48 to 72 hours; provide - A complication of late pregnancy or labor characterized by
o Watchful waiting
psychological & physical support care. complete separation of a normally implanted placenta. Also
Expected management & conservative if the
Placenta Previa termed as accidental hemorrhage & ablatio placenta.
mother is not in labor. Fetus is premature
- Premature separation of abnormally low implanted placenta. The - Second leading cause of bleeding in the 3rd trimester & occurs in
stable & not in distress & bleeding is not
most common cause of bleeding in the third trimester. 1/300 pregnancies.
severe.
- Complications: hemorrhage, prematurity, obstruction of birth • Risk Factors:
o Amniotomy
canal o Maternal HPN
An artificial rupture of the bag of water
• Risk Factors: o Sudden uterine decompression (multiple
which causes the fetal head to descend
o Multiparity pregnancies, polyhydramnios)
causing mechanical pressure at placental site
o Scarring & tumor in the upper uterine segment o Advance age, multiparity
controlling bleeding.
o Increased maternal age – above 35 years old o Short umbilical cord
o Double Set-up
o Decrease vascularity in the upper uterine segment as o Trauma
Setting up for vaginal delivery & another for
in scarring & tumor
classical cs. This is to prepare for an internal • Signs & Symptoms:
o Multiple pregnancy o Painful, vaginal bleeding in the 3rd trimester
examination in suspected placenta previa in
• Signs & Symptoms: o Rigid, board-like abdomen
the following condition term gestation.
o Painless vaginal bleeding o Enlarged uterus
majjyap ‘21
 o Tetanic contractions – if in labor 1st & 2nd trimester • Miscarriage o Hypotension
• Complications: • Ectopic pregnancy o Easy bruising
o Hemorrhagic shock 2nd trimester • H-mole o Rectal or vaginal bleeding
o Couvelaire uterus – the bleeding behind the placenta • Premature cervical o Petechiae
& may cause some of the blood to enter the uterine dilation Disseminated Intravascular Coagulation (DIC)
musculature causing uterine muscles not to contract 3rd trimester • Placenta previa - It is a rare life-threatening condition. In the early stages of this
well once the placenta is delivered • Abruptio placenta condition, this causes the blood to clot excessively.
o Disseminated Intravascular Coagulopathy (DIC) • Preterm labor
- As a result, blood clots may reduce blood flow & block blood from
o Cerebrovascular accident (CVA) reaching bodily organs.
o Hypofibrinogenemia - As a condition progresses, platelets & clotting factors, the
o Renal failure substances in the blood that are responsible for forming clots are
o Prematurity or IUFD used up. When this happens, the person could experience
o Infection excessive bleeding.
- Serious condition that can lead to death
• Diagnosis:
o Blood: CBC, PLT count
o Partial thromboplastin time
o D-dimer test
o Serum fibrinogen
o Prothrombin time
• Complications:
o Blood clot
o Stroke
o Excessive bleeding that leads to death
• Management:
Concealed Covert/Central Type/Classic Type (A): Bleeding happens
o Halt the source of bleeding
under the placenta; Placenta separates at the center causing blood to
o Heparin
accumulate behind the placenta; The external bleeding is not evident,
o Blood transfusion
signs of shock not proportional to the amount of external bleeding.
Premature Rupture of Membranes
Marginal (B): AKA overt or external bleeding type; The placenta
- PPROM (Preterm premature rupture of membrane): occurs to 37
separates at the margins & bleeding is external, usually proportional to
weeks AOG
the amount of internal bleeding; May be complete or incomplete
- SPROM (Spontaneous preterm rupture of membrane): occurs
depending on the degree of detachment.
after or with onset of labor occurring before 37 weeks
• Management:
- Prolonged rupture of membrane
o Maintain bedrest, LLR
• Complications:
o Careful monitoring
o Chorioamnionitis
o Administer fluids through a large-bore needle
o Fetal sepsis
o Provide psychological support
o Cord prolapse
o Prepare for emergency birth
• Signs & Symptoms: • Diagnosis:
o Observe for postpartal complications
o Bleeding o Vaginal speculum – pooling amniotic fluid
Bleeding during Pregnancy
o Presence of blood clots o Nitrazine paper, ferning test
Time Cause
majjyap ‘21
 • Management: hours apart after ii. Antidote on standby: 10% calcium
o Monitor FHR & initiation of labor. bedrest gluconate
o Labor induction PROTEINURIA 1+ or 1 g/day 3+ to 4+ or 5 g/day iii. Procainamide hydrochloride or
o Administer IV fluids as ordered. or more Lidocaine cocktail
o Administer betamethasone x2 doses as ordered. EDEMA Generalized, Generalized, severe
o Antibiotics confined to face facial puffiness,
o Prepare for delivery (CS or NSVD) (periorbital) & severe swelling of
Pregnancy-Induced Hypertension fingers face.
- This is characterized by 3 symptoms namely hypertension edema Weekly weight gain Excessive weight
& proteinuria – 1 lb/week gain – 5 lbs/week
- Appears 20-24 weeks AOG Epigastric pain
- Disappear 6 weeks after delivery Cerebral
- 7-10% of all pregnancies & one of the major causes of maternal & distrubances
neonatal mortality OLIGURIA Absent Present
- Cause is unknown IUGR (Intrauterine Absent Present
- Extremes of age are 17 years old and below & 35 years old and growth retardation) b. During:
above OTHERS Hypoproteinemia
- Low protein diet & low calories Hemoconcentration
- Coexisting conditions: diabetes mellitus, multiple pregnancies Hypernatremia
polyhydramnios chronic hypertension & renal disease Eclampsia – convulsion & coma
• Etiology: • Management:
o Nulliparity with extremes of age o Diet: high protein, moderate sodium & supplemental
o Severe nutritional deficiency iron
o Presence of co-existing conditions o Promote adequate rest & sleep in LLR
• Signs & Symptoms: o Regular prenatal care & report danger signs c. After:
o Kidneys o Teach client in monitoring own BP. i. Monitor BP, RR, DTR, I&O, & FHT
Proteinuria, hypeproteinemia o Monitor I/O strictly. 2. Hydralazine (Apresoline) – could easily drop the blood
Edema o Weigh daily. pressure of client
Vasospasm, HPN o Monitor DTR, onset of labor, or abruptio placenta. 3. Diazepam (Valium) – used for convulsion
o Brain o Administer magnesium sulfate as ordered. 4. Blood volume expanders – used for shock
Visual disturbances o Seizure precaution: HELLP Syndrome
Hyperreflexia/hyperirritability Reduce environmental stimuli of room at - This is a life-threatening disorder associated with pre-eclampsia.
Convulsion near station - Affects the liver and blood and is fatal if left untreated
o Uterus Restrict visitors - Symptoms can be difficult to diagnose because they are vague
Decreased placental perfusion –> SGA Monitor for signs of impending convulsion - Develops in last trimester of pregnancy but may occur earlier and
Abruptio placenta Have on bedside: airway, urinary catheter even present postpartum
SIGNS MILD SEVERE set, IV fluids & emergency drugs - Causes of symptoms is unknown
PREECLAMPSIA PREECLAMPSIA • Pharmacologic Management: - Hemolysis is the breaking down of blood cells too early and too
HPN 140 to 170/90 to > 160/110 on two 1. Magnesium sulfate rapidly which can lead to anemia.
105 mmHg readings taken 6 a. Before:
i. Assess RR, DTR, & BP

majjyap ‘21
 Incidence of 13% 8% No increased b. Monochorionic Monozygotic – If the amnion
bleeding risk has already developed approximately eight
• Management: days after fertilization, division results in two
o Intravenous fluids should be given cautiously. embryos with a common amniotic sac &
o Treat HPN. common chorion.
o Delivery (either vaginal delivery or cesarean section) 2. Dizygotic Twins
is indicated if HELLP syndrome occurs close to 34 a. Fraternal
weeks’ gestation. b. Exists between the dizygotic twins is similar
o Monitor bleeding. to the relationship that exists between
Multiple Pregnancy siblings, they may be of the same or different
This is the gestation of 2 or more fetuses or carrying of more than 1 sex the incidence of fraternal twins varies
fetus during the same pregnancy. with maternal race, age, parity & heredity
• Risk Factors: 3. Supertwins – common term for rare triplets & other
o Infertility management higher order multiple births such as quadruplets or
o Advanced maternal age quintuplets & these babies can be identical, fraternal
o Use of Clomiphene citrate or a combination of both.
o Multiparity
• Types:
1. Monozygotic Twins – identical
Share all one set of traits 1 placenta, 1 chorion. They
usually have 1 amnion except for the umbilical cord.
Each fetus has their own umbilical cord, they are of
the same genotype or appearance & of the same sex.
• Risk Factors:
The incidence of monozygotic twin is about 1 in 250
o Maternal age of greater than 34
births the survival of monozygotic twins is 10% lower
o Multiparity
than that of dizygotic twins & congenital defects are
• Signs & Symptoms: more prevalent.
o Malaise, N/V a. Diamnionic Monozygotic
o Edema with secondary weight gain i. Occurs within the first 72 hours
o Epigastric or right upper quadrant pain after fertilization before the inner
o Dyspnea (if pulmonary edema present) cell mass & chorion is formed
o Jaundice ii. There will be 2 embryos, 2 amnions,
o Signs of dehydration including sunken eyes • Manifestations:
& 2 chorions that will develop. o Positive history of twinning
o Edema leading to puffy eyes iii. It occurs in 20-30% of the time.
o Dry mucous membranes o Large uterus
They may be 1 distinct placenta or a o 2 or more FHTs – asynchronous
Class 1 Class 2 Class 3 (Mild) single-fused placenta.
(Severe) (Moderate) o Palpation of 3 or more large parts
iv. If division occurs 4-8 days after o 2 fetal outlines by UTZ
Platelets ≤ 50,000/µL 50,000 to 100,000 to fertilization, 2 embryos develop o Increased maternal weight
100,000/µL 150,000/µL with separate amniotic sacs later to • Diagnosis:
AST or ALT ≥ 70 IU/L ≥ 70 IU/L ≥ 40 IU/L be covered by a common chorion. o UTZ & palpation
LDH ≥ 600 IU/L ≥ 600 IU/L ≥ 600 IU/L
o High Serial Estriol
majjyap ‘21
 • Complications: 2. The baby can urinate (fluid move from the baby into the
A. Maternal amniotic space therefore increasing fluid)
o IDA Polyhydramnios – too much amniotic fluid in the amniotic space
o Threatened abortion Oligohydramnios – too little amniotic fluid in the amniotic space
o Preterm Labor/PROM Video Transcript:
o PIH - Anything that prevents the baby from adequately swallowing
o Hyperemesis gravidarum liquid will cause the swelling to occur & therefore more fluid
B. Fetal will build up in the at the amniotic space causing
o Prematurity polyhydramnios.
o RDS
- Anything that decreases swallowing, anything that prevents
o Conjoining abnormalities
o Birth injuries the baby from adequately swallowing liquid will cause the Video Transcript:
• Medical Management: swelling to not occur & therefore more fluid will build up in the - The baby has its own unique blood type because it inherits half of
o Early diagnosis amniotic space causing polyhydramnios. its genetic makeup from its father.
o Frequent monitoring - Developmental abnormalities that cause decreased urination - The mother & baby’s bloods do not mix but they come in very close
o Nutritional support include any type of bladder outlet obstruction or polycystic contact with each other across the placental membrane.
Non-pregnant kcal +300 kcal/day/singleton • Rhesus positive: red blood cells have the rhesus antigen
kidney disease (anything that causes the baby not to urinate).
60 to 100 mg/day of iron o If you have the rhesus antigen, your body learns to
- In oligohydramnios, you get something called pulmonary
1 gram/day of folate recognize that antigen as being part of your body so it
o Delivery: vaginal or cesarean section hypoplasia. The baby is sitting in the sac in the womb & outside does not attack it.
• Nursing Management: of it should have this amniotic fluid. So normally at normal • Rhesus negative: no rhesus antigen
o Teach client on frequent prenatal care & balance diet. physiology, the baby is going to be swallowing an adequate o When you do not have the rhesus antigen & you come
o Emphasize importance of frequent rest & prompt amount of that amniotic fluid & it is going to go down into the in contact with that antigen, your body thinks that is
reporting of danger signs. baby's lungs, expand, & put a little internal stress on the lungs. a pathogen & attack.
o Psychological assessment & support - If you were transfused with blood that contained the rhesus
And as part of normal pulmonary development without
o Intranatal: antigen & your body did not have the rhesus antigen, then the B
amniotic fluid being swallowed by the baby going into the
Strict asepsis cells of your immune system would recognize that as something
Label babies as Baby A, B… lungs & expanding the lungs space, causing a little bit of that does not belong to your body & would launch an immune
Assist safe delivery of the second child internal stress, there is going to be an abnormal pulmonary response & create anti-D antibodies against that rhesus antigen.
o Prevent bleeding: development that leads to pulmonary hypoplasia. - This is important in pregnancy because if the mother is Rh-
Administer oxytocin after delivery of last Isoimmunization (Rh Incompatibility) positive, there is nothing to worry about because the baby can be
baby. - Occurs when a Rh-negative mother carries a fetus with a Rh- Rh-negative or Rh-positive & she is never going to try & attack the
Do not massage uterus until delivery of positive blood type; for this situation to occur, the father of the baby’s blood cells. But if the mom is Rh-negative & the baby is Rh-
placenta. child must either be homozygous or heterozygous Rh-positive positive, anytime the baby’s blood gets into the mother’s
o Promote bonding & psychological support. - If the father of the child is homozygous, for the factor, 100% of the bloodstream, she will create anti-rhesus antibodies.
Oligohydramnios & Polyhydramnios couple’s children will be Rh-positive. If the father is heterozygous, - This can happen at sensitizing events; could be a miscarriage after
Movements of amniotic fluid are done in one of 2 ways or both: for the trait, then 50% of their children can be expected to be Rh- 12 weeks, abdominal trauma where there has been some bleeding
1. The baby swallows amniotic fluid, amniotic fluid will move positive. inside the placenta & some blood cells have to cross, or at birth
from the amniotic sac into the baby's body (the fluid in the - Although this is basically a problem that affects the fetus, it causes when there is lots of bleeding & mixing of the mother & baby’s
amniotic space will decrease because it's no longer than the concern & apprehension in a woman during pregnancy that it blood.
amniotic space & out in the baby's body) becomes a maternal problem. - This does not have much of an impact at that time because the
mother will just destroy the blood cells that got into her system
majjyap ‘21
 but in future pregnancies, the antibodies that the mother has - An acute, viral infection caused by a mix of virus.
developed will be able to cross the placental barrier because there - Maternal infection is mild but fetus is severe.
are only very small proteins & they will get into the bloodstream - Incubation Period: 2-3 weeks
of the baby & start attacking the baby’s blood cells as the baby’s - Communicability happens within 7 days
blood cells are hemolyzed or destroyed, that releases chemicals 1st trimester 2nd trimester
(bilirubin) into the baby’s body. • Deafness • IUFD
- Bilirubin is responsible for creating jaundice. A slight jaundice in • Eye defects • Thyroid problem
babies is normal which is called a physiological jaundice. When the • CNS defects • Progressive
bilirubin level gets very high, it can cause significant brain damage • Cardiac malformation panencephalitis
& long-term learning difficulties & disabilities. This process of • Assessment Findings:
antibodies crossing the placenta into the baby’s bloodstream & o Pink maculopapular rash
causing a hemolytic anemia & a severe jaundice is called hemolytic o Slight fever, malaise
disease of the newborn or HDN. o Anorexia
- To prevent this, we use an anti-D immunoglobulin which are the o Posterior auricular & occipital adenopathy
anti-D antibodies given by an intramuscular (IM) injection at any o Arthritic/arthralgia
event where the mother might become sensitized. So anytime the • Management:
baby’s blood might have gone into the mother’s bloodstream, this o Supportive treatment
injection circulates around the blood & destroys any of the baby’s o Immune serum globulin
blood or any of the blood cells in the mother than contain the Given to exposed women to prevent
rhesus antigen. By destroying all of the baby’s blood cells before aggravation of maternal symptoms but will
the mother has an opportunity to launch an immune response, not alter fetal infection nor reverse fetal
you prevent the mother becoming sensitized & developing her defects already present
own antibodies against the rhesus antigen. o Immunization
• Assessment: Rubella vaccine
o Anti-D antibody titer (mother) Should avoid pregnancy for 1 month or
At 1st pregnancy visit weeks after immunization
Repeated at week 28 of pregnancy if results All children should receive MMR at age 15
are normal from 1st pregnancy visit months
No therapy needed if results are still normal o Pregnant non-immune women should be immunized
o Anemia IMMEDIATE POSTPARTUM.
o Jaundice Never during pregnancy because defects
o Swelling of the body, which can lead to heart failure may be delayed for up to 21 days
or breathing problems
• Management:
o Rh (D) antibodies (RhIG)
Injected in arm or backside
If doctor determines that the mother & baby
may be Rh incompatible, then the shot of
RhoGAM will be given 26-28 weeks AOG &
again at 72 hours after delivery to ensure
future pregnancies are as safe as the first.
German Measles/Rubella
majjyap ‘21
NURSING CARE OF THE HIGH-RISK PREGNANT CLIENT DURING
LABOR & DELIVERY 5th slide
Fetal Malposition
Although labor often proceeds without any deviation from the Occurs when the occiput of the fetus who are in vertex
normal, many potential complications can occur. presentation is rotated so that it is not oriented anteriorly in the
maternal pelvis. The most common fetal malposition is the
2nd Slide Occipitoposterior.
Components of Labor Based on the picture below, normal position and presentation
1. Passenger (Fetus) - Fetal malposition, Fetal Diamond-shaped - Anterior Fontanel should be well flexed, and the occiput should be on the anterior part
malpresentation, Fetal distress, Prolapsed umbilical cord Triangle-shaped - Posterior Fontanel of the pelvis. However, if the fetus occiput is towards the posterior
2. Passageway - Abnormal size or shape of the pelvis, part of the pelvis then that is considered as an abnormal position.
Cephalopelvic disproportion, Shoulder Dystocia Though as mentioned, the fetus can still position himself correctly to
3. Power - Dystocia, Premature labor & birth, Uterine the maternal pelvis allowing a successful vaginal delivery.
Prolapse, Uterine Rupture
4. Psyche - Fear & anxiety on labor progress

3rd and 4th slide

PASSENGER
Ideally for labor, the baby is positioned head down facing
the mothers back where the chin is tucked to its chest and the back This is the ideal position of the fetus in the maternal pelvis and
of the head ready to enter the pelvis. This position is called Cephalic ideally the head should be(putol audio ni miss)… for the vertex
Presentation. should be on the anterior portion of the maternal pelvis. Meaning
Most babies settle into this position within the 32nd - 36th the fetus is facing towards the back. This would facilitate successful
week of pregnancy. Fetal Malposition occurs when the occiput of the cardinal movements during labor & delivery.
fetus, who are in vertex presentation, is rotated so that it is not
oriented anteriorly in the maternal pelvis. Other risk factors that contribute to having problems to the
It is very important that you remember the different passenger having successful vaginal delivery would include:
sutures and fontanels that are present in the fetus. ➔ GDM Take note, part of their cardinal mechanism that upon complete
extension, ideally the head should be facing downwards. The
➔ Multiple Pregnancy (which could alter the position and the
symphysis pubis will serve as a joint wherein the head could pivot
lie)
during complete extension. However, if the fetus would maintain in
➔ Malpositioned Fetus
an abnormal position which is occipitoposterior, tendency would be
➔ Immature or Preterm
the fetus could be facing upward causing problems during complete ➔ Provide IV glucose for prolonged labor (to prevent
extension. hypoglycemia)
➔ Cesarean delivery if there is a positive arrest in transverse
Take a look of the picture below position and fetal distress and the presence of obstruction.
➔ Induce or Augmentation of labor could be done for a
possible NSVD if the bag of water is still intact and there is
a successful dilatation to 10cm with no signs of obstruction.
However, vacuum could still be done or use to assist the
delivery.
Take note that the delivery may be complicated by perineal cares or
extension of episiotomy. If there are signs of obstruction or if the On the other hand, the 2nd and 4th picture is what the chin posterior
fetal heart rate is abnormal which could mean that there is fetal would look like. The chin is directed towards the back portion of the
distress, then cesarean could be done. However, if intact then there mother.
could be amniotomy done by the doctor and allow labor to continue. Prolonged labor is common. Descent in delivery of the head
The picture above is an example of an occipitoposterior. Ideally if the by flexion may occur in the chin anterior position. Thus, the chin
If the cervix is not fully dilated, then oxytocin could be used
fetus is about to be delivered, the fetus needs to have a long anterior could still have a normal vaginal delivery. However, the chin
to induce or augment the labor. If the cervix is fully dilated, but there
rotation. Meaning, she needs to rotate ⅜ of the total circumference posterior position with a fully extended head, it is blocked by sacrum,
is no descent in expulsive(?) face then assess for signs of obstruction,
of the pelvis, so that is considered a long rotation and that would thus, this prevents descent and labor is arrested.
possibly the fetus could be arrested in transverse position. However,
lead to successful vaginal delivery. In most cases, the chin posterior is delivered through
if there are no signs of obstruction then the woman can still continue
with her labor. cesarean section. Always remember that with face and brow
Fetal Malposition presentation, though it could be done through normal vaginal
If the cervix is fully dilated and the fetal head is ⅗ palpable
Risk Factors: delivery, vacuum extraction should not be used.
above the symphysis pubis or the bony prominence of the head is
Common among women with android pelvis, anthropoid or And also, one of the common findings upon delivery of a
above -2 station then cesarean section could be done.
contracted pelvis fetus with face presentation could be edematous upon delivery
Assessment Findings: especially the lips. This could be diagnosed through:
8th slide
Upon assessment, the mother would complain the
Fetal Malpresentation ➔ Leopold's Maneuver
sensation of pressure and pain in the lower back
1. Face and Brow Presentation ➔ UTZ - could confirm the presentation
Management: ➔ Internal Examination (the examiner will feel the chin
Instead of having the ideal occiput presentation, the fetus
To manage this, it is important to provide comfort measures instead of the occiput.
may have face and brow presentation, the chin serves as a reference
by:
point in describing the position of the head. It is necessary to
➔ Providing back rub distinguish only chin anterior positions in which the chin is anterior
➔ Keep the bladder empty (to allow descent of the fetus) in relation to the maternal pelvis (similar with the 1st picture the
upper left pic)
9th slide 2. Breech Presentation 11th slide
2. Breech Presentation
The frequency of breech presentation falls as pregnancy > Risk factors for breech presentation includes:
advances. At the 30th week of pregnancy, 15% of the fetuses present
as a breech. For the 35th week, the proportion has fallen to 6% and ● Gestational age of <40 wks. (could still be managed)
by term only 3% as a breech. Most of the babies continuously turn ● Fetal abnormality
to become cephalic. ● Polyhydramnios
● Midseptum of the uterus
There are different types of breech presentation: ● Tumor growth in the uterus
○ These two (midseptum & tumor growth) could
➔ Frank Breech Position - breech with extended leg
prevent the fetus to position correctly or to a
➔ Complete Breech Position - breech with flexed legs. The
cephalic position
hips and the knees are completely flexed. > Management:
● Pendulous abdomen
➔ Footling Breech Position - could be a single or double
● Multiple gestation ● External cephalic version- a procedure that externally
footling wherein both legs could be dropped into the
maternal cervix. rotates the fetus from a breech presentation to a cephalic
> Assessment
presentation. Successful version of a breech into cephalic
The presentation of the fetus is of no clinical importance presentation, allows a woman to avoid cesarian delivery
● FHR-high in the abdomen – upon assessment, fetal heart
before the 32nd - 35th weeks. At this stage of pregnancy, the rate could be detected in the higher portion of the
diagnosis of a breech presentation is made by finding on palpation, Examples of anatomy call restrains that may restrict fetal
abdomen. Instead of palpating it below the umbilicus level,
that the lower pole(?) of the uterus is occupied by a soft irregular movement into the vertex presentation would include:
then the heartbeat could be felt higher than the umbilicus
mass and that in the fundal area is a firm, smooth, rounded mass ○ Extended fetal legs
● UTZ- can confirm the presentation of the fetus
that is present which bounces between the fingers if ganguly(?) push ○ Placental implantation
and this would refer to the fetal head. > Complications ○ Contracted maternal pelvis
On auscultation, the fetal heartbeat is loudest above the ○ Tumors
umbilicus if any doubt remains after palpation in a vaginal ● Hip dysplasia ○ Certain fetal anomalies (hydrocephaly, teratoma)
examination and ultrasound image will clarify the diagnosis and will ● Anoxia from cord prolapse- the head was not able to fit into ○ Multiple gestation
exclude fetal malformation. the cervix
● Head trauma A fetus with altered mobility such as fetal neurologic impairments
● Arm or spine fracture and short umbilical cord are less likely to move into the vertex
● Early rupture of membrane
There are certain criteria that we need to consider before
● Meconium staining- does not mean fetal distress, it is
attempting external version because we need to induce/use
common to breech presentation because of the pressure
anesthesia for this because it could be painful.
applied in the rectum or the anus of the fetus
 ○ Make sure that the uterus is not contracting to > Management: The head is born in gentle pressure to flex the head fully.
allow free moving of the fetus . And by gentle traction to the shoulder, upward and
○ There should also be enough amniotic fluid. ● Breech birth – not that common because doctors opt to forward.
○ Only attempt external version if breech have cesarean section. Lift up the baby’s body then pull it downwards. Additional
presentation is present at or after 37 weeks. A vaginal breech delivery is done by a skilled healthcare pressure might be applied by an assistant to the abdominal
Before 37 weeks, a successful version is more likely provider with safe and feasible conditions. There should be wall to ensure head flexion.
to spontaneously revert back to breech complete or frank breech (only positions that it could be
presentation. done) ● Cesarean section
There should be adequate clinical pelvimetry, fetus is not ○ double foot
Vaginal delivery is possible but we need to make sure that the too large, no previous cesarian section for CPD, and flexed ○ small or malformed pelvis
woman did not have any history of: head. ○ very large fetus
It is very important to examine the woman and refer the ○ previous caesarean section for CPD
○ CPD progress based on her CPG(??). If the membranes are ○ hyperextended or deflexed head.
○ membranes are intact ruptured, examine the woman immediately to (explode,
○ amniotic fluid is adequate explore??) cord prolapse 13th slide
○ no complications such as fetal growth restriction If the cord prolapses and the delivery is not imminent, then
○ uterine bleeding the woman needs to have cesarean section. If there are
○ previous cesarean delivery signs of fetal distress or prolonged labor, then she cannot
○ fetal abnormality have vaginal breech birth
○ twin pregnancy Should not push until the cervix is fully dilated. Full
○ hypertension dilatation should be confirmed by vaginal examination
○ fetal death. Breech birth:

If successful may proceed with normal vaginal delivery, if not, 1. Before labor, position into left sacral posterior
cesarean.
2. Descent and internal rotation, legs are being born 3. Shoulder presentation
12th slide
3. Shoulders turn to present anterior to posterior diameter > Risk factors:

4. Head is born last wherein the external rotation has put ● Pendulous abdomen
the anterior posterior diameter of the head inline with the ● Uterine fibroid tumors
anterior posterior diameter of the woman’s pelvis. Head ● Congenital abnormality in the uterus
should be facing downwards ● Premature infant
> Management: Often, the only way to stop fetal distress is to deliver the baby, with no oxytocin. Turn then mother to her left if it is a case
allowing doctors and nurses to administer medical care. This is of vena cava syndrome
● Delivery through cesarean section. usually accomplished by cesarean section. ● Monitor FHT and the mother as well
If the woman is in early labor and the membranes are intact, ● Notify the physician
then attempt for external version could be done > Risk Factors: ● Prepare for emergency CS if indicated

14th slide ● Dystocia 16th slide

● Cord coil or compression
● Improper use of oxytocin
● Co-existing conditions of the mother
● Bleeding
● PIH
● Supine Hypotension Syndrome

> Assessment findings:

● FHT >160 or <120 bpm

● Meconium-stained amniotic fluid Umbilical Cord Prolapse- a loop of umbilical cord slips down in front
Fetal Distress- emergency pregnancy labor and delivery ● Fetal hypermobility of the presenting fetal front.
complication in which the baby experiences oxygen deprivation or
birth asphyxia. > Management: Prolapse may occur at anytime after the membranes rupture if the
presenting fetal part is not fitted firmly into the cervix.
May include changes in the: ● Position in LLR (left lateral recumbent)- this relieves
pressure on inferior vena cava, thereby increasing venous 17th slide
● baby’s heart rate, could be tachycardic or bradycardic return resulting in increased perfusion of placenta and
● decreased fetal movement or hypermobility fetus. Umbilical Cord Prolapse
● Meconium in the amniotic fluid ● Stop the oxytocin drip- in some cases fetal distress could be
● decreased fetal muscle tone cause by improper use of oxytocin, analgesia, or anesthesia, > Risk Factors:
it is very important to stop the oxytocin or any drug that is
Must immediately address and mange fetal destress to avoid serious causing the distress ● PROM
complication, such as: ● Administer oxygen per mask as 6-7 L per minute ● Malpresentation
● Correct hypotension. By elevating the legs, increase IV rate ● Placenta previa
● HIE (hypoxic, ischemic, encephalopathy) or increase hydration, provided that the IV fluid is plain and ● Intrauterine tumors preventing the presenting part from
● Cerebral palsy and other birth injuries engaging
 ● Small fetus The prolapse cord is always an emergency situation because the PASSAGEWAY
● CPD preventing firm engagement pressure of the fetal head against the cord at the pelvic brim leads The birth canal is a passage so labor may be prolonged if the
● Polyhydramnios to cardiac compression and decreased oxygenation to the fetus. mother’s pelvis is to small for the baby to pass through or the pelvis
● Multiple gestation Management is aimed therefor at relieving the pressure on the cord. is in an abnormal shape.
Thereby relieving the compression and resulting fetal anoxia.
The incidence is about 0.5% of cephalic birth but can rise as 10% or There are alot of risk factors that could affect any distortion in the
higher with breech or transverse lies Management: passageway, minimzing chances for ormal vaginal delivery.
● Assess FHR every after rupture of membrane.
> Assessment Findings: ● Place gloved hand into the vagina and elevate fetal head off Risk Factors:
the cord. - BONY PELVIS
● Felt upon vaginal examination
● Position woman in knee-chest or Trendelenburg to cause - Contracted (due to malnutrition)
● Visible at the vulva
the fetal head to fall back from the cord - Deformed (due to trauma, polio)
● Deceleration of FHR
● Administer oxygen at 10 L per minute by face mask. A - SOFT TISSUE
troctolitic(??) agent may be prescribed to reduce uterine - Tumour in the pelvis
In rare instances, the cord may be felt as the presenting part on an
activity and pressure on the fetus - Viral infection in the uterus or abdomen
initial vaginal examination during labor or can be visualized on
● Amnioinfusion- another way to relive pressure on then - Scars
ultrasound if one of these is taken during labor. More often, cord
cord. Method in which isotonic fluid is instilled into the
prolapse is first discovered only after the membranes have ruptured.
uterine cavity. Primarily used as a treatment to correct fetal Bony pelvis it could be contracted due to malnutrition of the mother.
It readily slips down then vagina; thus it is palpable upon IE.
heart rate changes caused by umbilical cord compression Or there could be deformation due to trauma or polio. With regards
When the FHR is discovered to be unusually slow or variable indicated by variable deceleration seen on CTG. to soft tissue, there could be presence of tumour or other physical
deceleration, FHR pattern suddenly become apparent on fetal ● If the cord has prolapsed to the extent, it is exposed to obstruction in the pelvis that could alter the passage of the
monitor. On inspection, the cord may be visible at the vulva. womb air, drying will begin leading to constriction and passenger. Viral infection in the uterus or abdomen or scars along
atrophy of the umbilical levels. Do not push back the card the passageway could alter the result of normal vaginal delivery.
To rule out cord prolapse always assess fetal heart sounds into the vagina. This could add to the compression by
immediately after rupture of the membranes, whether this occurs causing knotting or (kinking??).
spontaneously or by amniotomy. ● Cover any exposed cord with gauze wet with sterile saline.
● If the cervical dilatation is complete at the point where the
18th-19th slide(s?) cord prolapse occurred, the birth method of choice is
upward pressure on the presenting part applied by a
practitioner’s hand in the woman’s vagina. And when this is
done, the woman needs to undergo cesarean section.
● Cesarean section
Through PELVIMETRY or ULTRASOUND PASSAGEWAY > Assessment
-this could be used to compare the size of the fetus to the Cephalopelvic Disproportion (CPD) • High Station or floating
woman’s pelvic capacity. • Prolonged and arrest of labor
- You can also be able to identify the type of pelvis one has →One of the most common problems of the passageway is the • Signs of fetal distress
These are the different kinds of pelvis presence of CPD or Cephalopelvic Disproportion > Diagnosis
1. GYNECOID →CPD or Cephalopelvic Disproportion - is a pregnancy complication • History of vaginal delivery rules out CPD
- ideal passage for childbirth in which there is a size mismatch between the mother’s pelvis and • Pelvimetry
- the gynecoid pelvis is thought to be the most favorable fetal head. The baby’s head is proportionally too large of the > Complications
pelvis for a vaginal birth. This is because of the wide open mother’s pelvis is too small to easily allow the baby to fit through the • Hyperstimulation of oxytocin
shape give the baby plenty of room during delivery vaginal opening. This can make the vaginal delivery dangerous or • Prolonged labor
2. ANDROID impossible • Shoulder Dystocia
- The narrower shape of the android pelvis can → If an attempted vaginal delivery is unsuccessful, doctors should • Umbilical cord compression
make labor difficult because the baby might move move on to > Management:
more slowly through the birth canal. Some Cesarean section. If they fail to do this, prolonged or obstructed - Scheduled cesarean section
pregnant women who has an android pelvis may labor from CPD may result in birth injuries such as: - Emergent Cesarean section after trial of labor
require a C section -Hypoxic Ischemic Encephalopathy or HIE
3. ANTHROPOID - Cerebral Palsy
- The elongated shape of the anthropoid pelvis → Risk factors of CPD would include: ‘
makes it ___rumeire(?) from front to back than the Risk Factors:
android pelvis but it is still narrower than the • Infertility treatment
gynecoid pelvis. Some women with this pelvis type • Maternal obesity
may be able to have vaginal birth but their labor • Previous Cesarean section
might last longer. • Polyhydramnios
4. PLATYPELLOID • Gestational Diabetes (which could result to macrosomic
- The shape of the platypelloid pelvis make a vaginal babies)
birth difficult because the baby may having trouble • Postmaturity
passing through the pelvic inlet. Many pregnant • Multiparity
women with a platypelloid pelvic need to have a • Advanced maternal age
Cesarean section. • Short stature The presence of certain conditions during delivery indicate that
• Transverse diagonal measurement < 9.5 cm there may be a case of CPD. If the fetus maintains high station, even
• History of childhood calcium deficiency or rickets after significant amounts of contraction, this indicates that fetal
descent through the birth canal may be difficult.
Upon IE of the doctor,if the station would maintain within “the - and also with the use of pelvimetry. Shoulder Dystocia
negative part” (refer to the picture) or it does not totally descent > Complications: - this occurs when the baby’s head passes through the birth canal
even after strong contractions, then it could mean that CPD is - Hyperstimulation of oxytocin and their shoulder becomes stuck during labor
present. Although it is not the only potential explanation, CPD could (one of the major problems of CPD is that physicians may - so there will be an obstruction during the delivery after the fetal
be evaluated as a possible cause of failure to descend react by administering fetusin(???? ambot) or oxytocin in head has extended but the shoulders are stuck.
an effort to speed up delivery. This is in regards to trial of - this prevents the doctor from fully delivering the baby and can
PROLONGED AND ARREST OF LABOR labor. Too much of this drug may cause excessive and extend the length of time for delivery. If this occurs the doctor will
- Can result into oxygen deprivation traumatic contractions which can cause hyperstimulation.) have to use extra interventions to help the baby shoulder move
FETAL DISTRESS through, so that the baby can be delivered
- Medical professionals should also watch for signs of fetal - Prolonged labor - this is considered as medical emergency, the doctor must work
distress (many doctors allowed labor to progress for too long, labor quickly to prevent complications related to this
is a trying time for the baby and if it is prolonged, oxygen - certain women may be more at risk for having babies with having
True CPD cannot always be diagnosed before the beginning of labor, deprivation injuries may occur. These injuries can lead to : shoulder dystocia than the others. It includes:
if medical professionals believe that they may be dealing with a case 1. Hypoxic Ischemic Encephalopathy > Risk factors:
of CPD, but aren;t entirely sure, they may still attempt a VAGINAL 2. Cerebral Palsy ● GDM
DELIVERY. So there will a TRIAL OF LABOR before warranting or 3. Developmental delays ● History of macrosomic baby
choosing CS section. However, they should be prepared or quickly Furthermore, the trauma from ● History of shoulder dystocia
move into an emergency C Section or other interventions. continued labor, may result to: ● Labor induced
Treatment for CPD varries for severity and when it is diagnosed 1. Serious intracranial hemorrhages ● Obesity
● Post-term
SEVERE and DIAGNOSED EARLY - Shoulder Dystocia ● (HAVING AN OPERATIVE VAGINAL BIRTH -which means the
- a planned C section is indicated or scheduled Cesarean section (when cpd is present, the baby is more likely to have doctor uses forceps or vacuum to guide the baby through
shoulder dystocia injury, including: the birth canal
In cases CPD may be treated a 1. Erb’s palsy ● Multiple Gestation
Symphysiotomy - the surgical division of pubic cartilage or an 2. Klumpke’s palsy
EMERGENCY C SECTION after the trial of labor. However there are other women who have shoulder dystocia
- Umbilical cord compression without having any risk factors
When CPD is present, continued attempt to deliver the baby ( when there is a decreased room in the uterus either
vaginally can cause trauma and permanent injury of the baby. because there is a large baby or small maternal pelvis. The doctor can identify shoulder dystocia, when they see part of the
Oxygen deprivation may occur due to a trapped umbilical baby’s head coming out of the birth canal, but the rest of the baby
> Diagnosis cord.) isn’t able to be delivered. The called shoulder dystocia symptoms,
This is diagnosed if the mother, the TURTLE SIGN
- is a repeater of CS section due to CPD
> Assessment - doctor should ask for help such as assistance from other doctors - pressure on a certain area on the pelvis to encourage the
• Turtle sign and nurses baby’s shoulder to rotate to an oblique position
- crowning but retracts during contractions E - evaluate for Episiotomy
- fetal head first come out of the body but will then go Episiotomy- an incision or cut in the perineum E - Enter maneuvers
back into the birth canal - does not solve the entire concern for should dystocia - this means helping to rotate the baby’s shoulders to where
• Prolonged second stage of labor L - Legs: they can pass through more easily
( due to the obstruction) McRoberts Maneuver - doctor asks the patient to pull her - internal rotation ( another term )
• Arrest of descent legs towards the stomach/chest - pressing the suprapubic downwards to facilitate the
- helps to flatten and rotate the pelvis shoulders to turn internally to an oblique position
Most mother or babies with shoulder dystocia dont ecperience long which helps the baby pass through more
term complications, however although rare, it can also occur easily R - remove the posterior arm from the birth canal
- If the doctor can free one of the baby’s arm from the birth
> Complications: canal this makes it easier for the baby’s should t pass
- Hemorrhage ( excessive bleeding in the mother) through the birth canal
- Injuries to a baby’s shoulders, arms or hands
- Lack of oxygen to the baby’s brain which can cause brain R - roll the patient to her hands and knees
damage - this movement can help the baby to pass more easily
- Vaginal or cervical tears (tearing of the mother’s tissues through the birth canal
such as the cervix, rectum or vagina)
- Cord Compression (worst case scenario) POWER
- Fractured clavicle of newborn - Contraction phase is consists of a descending gradient, the wave
- Brachial plexus injury (due to its compression) begins in the fundus wherein there is the greatest number of
myometrial cells then moves downwards through the corpus of the
> Management: uterus.

HELPERR - Intensity of the contraction diminishes from fundus to cervix. That’s

- guide for treating shoulder dystocia why when you do your labor watch your hands should be placed on
- doesn’t have to be performed on the order listed the fundal area to feel the utmost contractions.
- There are other techniques depending on the doctor’s
experience - Retraction phase which is throughout the labor the upper uterine
segment is more active, contracting more intensely and for a longer
H - call for help P - Suprapubic pressure time than the lower uterine segment
- The second part of the contraction is retraction phase after the - Etiology: such as sedatives should be given if the mother is greater then 3-4
muscles has contracted it retracts as it relaxes by pulling up the - Hypotonic uterine contractions cm cervical dilated. They may occur in a uterus that is overstretched
cervix and lower uterine segment. The upper uterine segment - Hypertonic uterine contractions by multiple gestation, a larger than usual single fetus, hydramnios or
becomes thicker in time, while the more passive lower segment - Dysfunctional labor in a uterus that is lack from a grand multiparity. Such contractions
become thinner. - Pathologic retraction ring are not exceedingly painful because pf their lack of intensity. Keep in
mind that however that a strength of a contraction is subjective
- The synchronous nature of contractions is necessary for efficient In comparing hypotonic uterine inertia and hypertonic uterine symptom, some women may interpret this contraction as very
dilatation and effacement of the cervix. inertia painful.
- Hypotonic has a late onset and it is usually in the active phase - Hypotonic contractions increase the length of labor because more
- Women who are dehydrated frequently experience preterm labor - Hypertonic happens during the early and the latent phase of them are necessary to achieve cervical dilatation. This can cause
that can be stop by hydration. Normal uterine contractions are like uterus to not contract as effectively during the post partal period
waves composed of: CTG STRIPS because of exhaustion increasing a woman’s chest for post partal
▪ Increment -or the building of or ascending portion. hemorrhage
▪ Acme - peak. - In the first hour after birth following a labor of hypotonic
▪ Decrement - coming down or descending portion contractions, palpate the uterus and assess lochia every 15 mins. to
- A normal or an ideal contraction: maximum duration of 80 ensure that post partal contractions are not also hypotonic and
secs. And with a minimum relaxation of 2 mins. therefore inadequate to halt bleeding.
- Any alteration with power may be brought about deep OB score or
OB history of a pregnant women 3rd CTG strip: hypertonic uterine inertia
- These are marked by an increase in resting tone to more than 15
> Risk factors millimeters mercury , however the intensity of the contraction
• Primigravida maybe no stronger than that associated with hypotonic
• Pelvic bone contraction contractions. In contrast to hypotonic contraction, hypertonic ones
First CTG strip : ideal uterine activity during an active labor
• Posterior fetal position or extension of fetal head tend to occurs frequently and are most commonly seen in the latent
• Failure of uterine muscle to contract phase of labor, this type of contraction occurs because the muscle
Second CTG strip : shows a hypotonic uterine inertia
• Non-ripe cervix fibers of the myometrium do not repolarize or relax after a
- the resting tone of the uterus remains less than 10 millimeters contraction thereby wiping it clean to accept a new pacemaker
• Full rectum of bladder
mercury and the strength of contractions does not rise above 25 stimulus. They may occur because more than one pacemaker is
• Exhaustion form labor
millimeters mercury stimulating contractions. they tend to be more painful than usual
• Inappropriate use of analgesia
- Hypotonic contractions are most opt to occur during the active because the myometrium becomes tender from constant lack of
phase of labor, they may occur after the administration of analgesia relaxation and the anoxia of uterine cells that results.
Dystocia
especially if the cervix is not dilated to 3-4 cm or if bowel or bladder - A woman may become frustrated or disappointed with her
- prolonged difficult labor and/or delivery because of problems with
distention prevents descent or firm engagement that’s pain relievers breathing exercises for childbirth because such technique are
the factors of labor
ineffective with the type of contraction. A danger of hypertonic - uterus is in a hypertonic state - occurs if the rate of descent is less than ( see
contractions is that the lack of relaxation between contractions may - Relaxation between contractions is inadequate table)
not allow optimal uterine artery filling this could lead to fetal anoxia and contractions are only mild, therefore - It can be suspected if the second stage lasts for
early in the latent phase of labor. Any woman who is pain sense is ineffective than 2 hrs in a multipara
out of proportion to the equality of her contractions should have - One segment of the uterus may be contracting
both a uterine and fetal external monitor applied for at least 15 with more force than the other segment Arrest of descent
minutes to ensure that the resting phase of the contraction is - Managed by helping the uterus to rest, provide - no descent has occurred for 2 hrs nullipara and 1
adequate and that the fetal pattern is not showing late deceleration. adequate fluid for hydration and pain relief with a hr in multipara
If deceleration in the fetal heart rate or FHR or an abnormally long drug such as morphine sulfate. - Failure of descent occurs when expected descent
first stage of labor or lack of progress with pushing occurs, cesarean of fetus does not begin or engagement or
birth may be necessary. Both the woman and her support person Protracted Active Phase movement beyond 0 station does not occur
need to understand that although the contractions are strong, they - usually associated with fetal malposition or CPD, - if most likely the cause is CPD, cesarean is
are ineffective or not achieving cervical dilatation. although it may reflect ineffective myometrial necessary
- to help identify the difference between hypotonic and hypertonic activity. - No contraindication to vaginal birth, oxytocin
contractions are here being compared - This phase is prolong if cervical dilatation does may be used
not occur atleast 1.2cm/hr in nullipara and 1.5
Table dysfunctional labor cm/hr in multipara or if the ative pahse last longer Pathologic retraction ring ( Bandl’s ring)
then 12 hrs in nulligravida or 6 hrs in multigravida - abnormal junction between the two segments of the
- If thecause of delay is malposition or CPD, uterus which is a late sign associated with obstructed labor.
cesarean brith is necessary - appears during the second stage of labor
- Prior to the onset of labor, the junction between the lower
Prolonged deceleration phase and the upper uterine segment is slightly thickened ring.
- If it most often results from abnormal head Ideally it should be on the lower part of the uterus,
position, cesarean birth is frequently required however, bandl’s ring is apparent in the upper part of the
uterus.
Secondary arrest of dilatation - In abnormal and obstructed labors, after the cervix has
- occurred if there is no progress in cervical reached full dilatation further contractions cause the upper
dilatation for langer than 2 hrs, CS birth is uterine segment muscle fibers to shorten so the actively
First stage necessary contracting upper segment becomes thicker and shorter.
Prolonged latent phase - The ridge of the pathologic ring of the bandl’s can be felt
- occurs if the cervix is not ripe at the beginning of Second stage or seen rising as far as high up the umbilicus so upon
labor. It may occur if there is excessive use of Prolong descent assessment there could be the retraction ring inspected
analgesia early in labor along the umbilicus level. The lower segment becomes
 stretched and thinner and if neglected may lead to uterine o Excessive fatigue = lack of rest ● Administer Tocolytics (e.g. MgSo4, Terbutaline and
rupture. o Smoking Rtrodine) to arrest labor by causing relaxation of the uterus
- Major pathology behind obstructed labor a circular groove o Emotional stress
encircling the uterus is formed between the active upper ● Fetal factors Contraindications to arresting labor
segment and the distended lower segment. Due to o Multiple pregnancy > ruptured BOW
pronounce retraction there is fetal jeopardy or even death. o Infections >Maternal diseases - bleeding, complication, PIH, cardiovascular
o Polyhydramnios disease
> Management: o Congenital adrenal hyperplasia >Fetal distress
- administration of morphine sulfate or amyl nitrate to o Fetal malformations >Rh Isoimmunization
alleviate the pain ● Placental factors ● Administer corticosteroids (e.g. Betamethasone) - to
- Tocolytic agent to halt contractions o Placental separation enhance maturation of fetal lungs by stimulating the
- CS delivery o Placental disorders production of surfactant when there are contraindication to
37th slide > Complications: arrest preterm labor. Administer the ordered drugs
PRETERM LABOR ● Prematurity according to protocol. Assess effect of drugs on labor and
- A labor that occurs after the 20th week and before 37th week ● Fetal death fetus and monitor side effects of drugs
of gestation ● SGA/IUGR ● Client may be discharged once contractions have stopped
and maternal and fetal conditions stabilized
> Risk factor: 38th slide 39th slide
● Maternal Factors > Management: > Health teachings:
o Maternal infection = · leading cause. Illness or ● Bed rest on LLR 1. Maintain bed rest - LLR position
disease such as renal or cardiovascular diseases ● Hydration - through oral and parenteral route 2. Well-balanced diet: high in iron, vitamins, and important
and diabetes mellitus may be included ● Monitor: minerals
o PROM o Contractions = q1-2 hrs to determine increasing or 3. Continuation of oral medications as ordered
o Bleeding = uterine abnormalities or overdistention decreasing contractions 4. Frequent prenatal visits every week
o Incompetent cervix o v/s, I/O 5. Activity restrictions
o History of preterm labor = spontaneous or induced o Signs of infection 6. Chronic illnesses should be monitored while acute cases
abortion, preeclampsia, short interval of <1yr and o Cardiac and respiratory status should be treated immediately
between pregnancies o Cervical dilatation and effacement 7. Teach client on the observable signs and symptoms of
o Trauma, poor nutrition = due to low o Fetal well-being preterm labor and importance of prompt reporting to the
socioeconomic status, no prenatal care, lack of o Edema = e.g. pulmonary edema is a possible physician when present. Also provision of psychological
childbirth experience complication of tocolytics support and encouragement should be established
o Extremes of age = decreased weight and less ● Promote physical and emotions comfort = keep the client
height informed of the progress 40th slide
PRECIPITATE LABOR (41st slide) ● Support the fetal body during expulsion
> Risk factors: PRECIPITATE LABOR ● Perform cord care - care for the cord. If materials are
● Multiparity - most common and most important ● Impending delivery: available, clamp cord into places, and cut between with the
● Trauma o Desire to push knife or scissors. If there is no available instruments for cord
● Large pelvis and lax soft tissues o Strong contractions clumping and cutting, just double tie using the cleanest
● Small fetus o Rupture membranes possible piece of cloth or string ensuring there is no
● Labor induction - by oxytocin and rupture of membranes o Heavy bloody show pulsation between the two ties to prevent transfusing
● Severe emotional stress o Bulging rectum newborn blood to the outside leading to hemorrhage and
> Complications: o Severe anxiety shock.
● Maternal: > Management: ● Allow placenta to separate naturally - wrap placenta, cord
o Laceration ● Never leave client and baby together. Have the fetal side near to newborn.
o Hemorrhage = secondary to premature separation ● Monitor FHT q15 mins - to detect the stress from fetal Place infant on mother’s abdomen or better encourage
of placenta hypoxia secondary to tetanic contractions mother to breastfeed to induce uterine contractions and for
o Infection ● Provide emotional support - by reassuring that you will stay. reassurance that all is well. institute measure as prescribes
o Uterine rupture = if birth canal is not readily Explain precipitate labor in simple terms. Inform the client in the 3rd and 4th stage of labor. Handle delivery gently to
distensible and hypotonic contractions which can of what is happening. Provide care until the physician or prevent injury to the mother and baby
cause hemorrhage especially postpartum help arrives. Assist the client in retaining a sense of control. ● Perform unang yakap
● Fetal ● Assist with delivery - never hold baby back. Put on sterile
o Hypoxia, anoxia gloves if possible and if there is still time. 42nd slide
o Sepsis ● Instruct client to pant and not to push UTERINE RUPTURE
o Intracranial hemorrhage ● Rupture the membrane if intact - gently flip the cord over
> Treatment: the head with free hand if the cord is draped around the
● Episiotomy neck. Use gentle pressure to fetal head upward toward the
● Facilitate delivery vagina to prevent damage or injury to fetal head and vaginal
> Assessment findings: laceration
● Tetanic-like contractions ● Deliver head in between contractions - shoulders are
● Rapid labor and delivery usually born spontaneously after external rotation. If not,
- Nullipara = 5cm/hr use gentle downward pressure to move anterior shoulder
- Multipara = 10cm/hr under symphysis pubis then use upward pressure for the
delivery of posterior shoulder. Right after the head is
delivered and before the shoulders are out, suction the
mouth and nose using bulb syringe if available and if not,
use towel to wipe blood and ,mucus from mouth and nose.
Rupture of the uterus because of the stress of labor with extrusion > Assessment findings: 45th slide
of uterine content into the abdominal cavity. This is common among
women who had history if Cesarean section and it happens along the ● Sudden acute abdominal pain and tenderness UTERINE INVERSION
incision of the previous CS delivery. When it ruptures, the content of ● Cessation of contractions and FHT - resending part no
pregnancy may disperse throughout the abdominal cavity longer felt through cervix. A feeling in the mother. That
something happened inside her, signs of internal bleeding,
43rd slide signs of shock and presence of predisposing factors
● Shock

44th slide

> Complications:

● Shock
● Maternal and fetal mortality
● Infection - ·from traumatized fetus

> Management: Uterine Inversion - It is the potentially life threatening complication

of child birth. Normal placenta detached from the uterus and exits
● Laparotomy - to deliver the fetus from the vagina around half an hour after the baby is delivered.
> Risk factors: ● Hysterectomy - or complete rupture although in most Uterine inversion means the placenta remains attached and its exit
cases, the uterus may be sutured and left in. pulls the uterus inside out. In most cases, the doctor can manually
● Previous CS scar - common cause or contributory factor ● Blood transfusion detach the placenta and push the uterus back into position.
● Improper use of oxytocin ● IV fluid replacement Occasionally, abdominal surgery is required to reposition the uterus.
● Overdistention ● Antibiotics
● Strong contractions with non-progressive labor - with non- ● Stay with the client and call for assistance - if uterine There are different kind or uterine inversion is grade by its severity
progressive labor rupture is suspected include:
● Abnormal presentation ● Position - trendelenburg position = considered as shock
● Trauma position 1. Incomplete inversion/First degree inversion – when
● Injudicious obstetrics - application of forceps when the ● Provision of warmth the top of the uterus or fundus has collapsed but the uterus
cervix is not fully dilated. Second stage of labor, fundal ● Prompt IV infusion - notify physician. Inform support person hasn’t come through the cervix
pressure and forced delivery of fetus with abnormality such ● Prepare for immediate surgery
as hydrocephalus. ● Provide psychological support 2. Complete/ second degree inversion – uterus is inside
● Ill-advised podalic version out and coming out through the cervix
 3. Prolapsed inversion – the fundus of the uterus is ● Manual reinsertion of the uterus while the woman is under AMNIOTIC FLUID EMBOLISM - This is the escape of amniotic fluid
coming out of the vagina general anesthesia into the maternal circulation through the placental site and into the
● Abdominal surgery - to reposition the uterus if all other pulmonary arterials.
4. Fourth degree inversion / total inversion – both uterus attempts to reinsert have failed
and vagina protrude inside out. This occurs more commonly ● Antibiotics - to reduce the risk of infection This is common among premature or normal rupture of membranes
in cases of cancer than child birth. ● Intravenous liquids when there is amniotic fluid embolism starts from the moment the
● Blood transfusion bag of water rupture, abruptio placenta, and difficult labor, this is
46th Slide ● Administration of oxytocin to trigger contractions and stop rare but usually fatal. Mortality in the first hour in 25% of pregnant
the uterus to inverting again women with amniotic fluid embolism is usually fatal for both the
> Risk Factors: mother and baby, and this is considered an obstetric emergency.
● Emergency hysterectomy or surgical removal of the uterus.
● Prior delivery of Long labor > Assessment Findings
* Take note that oxytocin should be administered after placing the
● Use of muscle relaxing such as magnesium sulfate during
uterus back, and should not be given before or during the
labor ● Acute dyspnea
replacement of the uterus. Close monitoring in intensive care for few
● Short umbilical cord ● Respiratory distress
days may be necessary *
● Pulling too hard of the umbilical cord to hasten the delivery ● Cyanosis
of placenta particularly when the placenta is attached to 47thslide ● Sudden chest pain
the fundus. ● Pulmonary shock & edema
● Placenta accreta or when the placenta had invaded to ● Shock (circulatory collapse as a sign of shock)
deeply to the uterine wall ● DIC
● Presence of congenital abnormalities or weaknesses of the
uterus > Management

> Management ● Perform CPR or Cardiorespiratory support

● Oxygenation
● Treatment options vary depending on individual ● Improve hydration by administration by IV fluid and plasma,
This is the manual replacing of the uterus, so using the glove
circumstances and the preference of the practitioner but full blood fibrinogen monitoring fluid INO, digitalis for
hand of the practitioner it will pushed back in to its original
could also include attempts to reinsert the uterus by hand feeling cardiac function
position in making a fist to apply pressure maintaining its
and the administration of the drug to softened the uterus ● Heparin as ordered
original position, make sure not to administer oxytocin or any
during reinsertion, ● Antibiotics
oxytocin drugs during this process and it should be given after
● IV fluid replacement especially if bleeding occurs ● Delivery through forceps if the cervix is fully dilated or
repositioning the uterus.
● Flashing the vagina with saline water so that the water vaginal if open and dilating well
pressure inflates the uterus and props it back into position ● Continue monitoring of mother and fetus is very vital
48th slide
 *Placental Delivery (Forceps Delivery)* - It is the of the baby using
obstetrics instruments such as forceps which consist of the blade,
shank, handle, and a lock

> This is indicated to fetus who are in:

● 2nd stage of labor - fetal distress & shorten the labor

● Abnormal presentation or arrested descent
● Preterm labor or to protect fetal head from injuries
● Maternal factors include to shorten the 2nd stage of labor:
➔ ineffective expulsive effort or poor progress
➔ Exhaustion
In the institution in the measures to support life:
➔ Medical diseases such as cardiac disease
50th slide
➔ place the mother on shock position as indicated which is
> Criteria
Trendelenburg position and also still turn the mother > Complications
towards the left to facilitate the perfusion of the blood It is important that the mother is:
towards the fetus, ● (Maternal) Lacerations Hemorrhage
➔ oxygenate promptly, ● Fully dilated ● Uterine rupture
➔ maintain__? fluids, ● Ruptured BOW ● Uterine prolapse
➔ and blood transfusion, ● Engaged head ● Cystocele, rectocele
➔ provide the administered drugs, ● Empty bowel & bladder ● Facial paralysis of the newborn or Bell’s palsy
● No CPD ● Increase perinatal morbidity and mortality
➔ inform family of the woman’s conditions,
● Episiotomy and to provide ● Intracranial hemorrhage
➔ provide support,
● Anesthesia ● Brain damage
➔ transfer to ICU when stabilized for close monitoring and
● Skull fracture
intensive care
2 types of forceps delivery ● Tissue trauma
● Cord compression
49th slide
● Low or Outlet Forceps Delivery
➔ This is the application of forceps on the fetal head
OPERATIVE OBSTETRICS - procedures done to manage
which is on the perineal floor
complications in labor and delivery
● Mid Forceps Delivery
➔ Wherein the fetal head is at the level of ischial
51st slide
spines.
*Vacuum Extraction (Vacuum-assisted Delivery)* > Criteria will not all be unsuccessful, but may result in
complications.
● Fully dilated, and if the doctor attempts vacuum extraction o The pregnancy must be termed or near term. The
that it is not fully dilated there is a significant chance of risk of vacuum extraction is increased in
injury or tearing of cervix, Cervical injury requires surgical premature infants. Therefore, it should not be
repair and may lead to problem in future pregnancies. performed before 34 weeks in pregnancy.
o The exact position of the baby’s head must be ● Ruptured BOW
known and the vacuum should never be placed on ● Engaged head
the baby’s face or brow. The ideal position of the ● Empty bowel & bladder
vacuum cup is directly over the midline on top of ● No CPD
the baby’s head. ● Episiotomy and to provide
It is a procedure sometime done during the course of vaginal child o Vacuum delivery is less likely to succeed if the baby ● Anesthesia (lesser than forceps delivery)
birth. During vacuum-assisted vaginal delivery, the health care is facing straight up and when the client is lying on
provider applies the vacuum which is a soft or rigid cup with a handle her back. The baby’s head must be engaged within > Risks
and a vacuum pump to a baby’s head to help guide the baby out of the birth canal. The position of the baby’s head in
the birth canal is measured in relation to the ● Pain in the perineum
the birth canal. This is typically done during a contraction while the
narrowest point of the child birth canal. The baby ● Vaginal tears
mother pushes.
should be in the lower position. ● Lower genital tract tears
52nd slide o Before vacuum extraction is attempted the top of ● Short term difficulty in urinating or emptying the bladder
the baby’s head is even with the ischial spine which could be temporary
> Indications: preferably the baby’s head has descended 1 to 2 ● Dysuria
cm below the spine. So the chances for the success ● (Short term or long term) Temporary urinary or fecal
● 2nd stage of labor - fetal distress & shorten the labor of vacuum delivery increase. It also increases when incontinence
● Abnormal presentation or arrested descent the baby’s head can be seen at the vaginal opening ● Fetal scalp wounds
● Preterm labor or to protect fetal head from injuries during. The membrane should be also ruptured to ● High risk of getting the baby’s shoulder stuck after the
● Maternal factors include to shorten the 2nd stage of labor: apply the vacuum cup to the baby’s head; the baby’s head has been delivered (Shoulder dystocia)
➔ ineffective expulsive effort or poor progress amniotic membranes must be ruptured. This ● Skull fracture
➔ Exhaustion usually occurs well before vacuum extraction is ● Bleeding within the skull
➔ Medical diseases such as cardiac disease considered. The baby should smugly fit to the birth ● Serious infant injuries after
canal there should be no CPD. There are times vacuum extractions are rare
when the baby is too big or the birth canal or the ● Caput formation
birth canal is too small for a successful delivery,
attempting a vacuum extraction in this situation
53rd slide Cesarean section is done under either regional or general anesthesia into the woman’s back, and the flow of the
medication can be controlled. And it is usually
*Cesarean Section* Upon the induction of anesthesia there could be varying incisions maintained hours after or hours during
done through the classical way (look like a vertical line from below postpartum.
Cesarean Delivery might be scheduled by the doctor in advanced by the umbilicus down to the hypogastric area) or low transverse b. Spinal - In a Spinal block the anesthesia
the due date or it may become necessary during labor because of incision (done transversely on the lower segment of the uterus) medication is injected in one single dose, into a
emergency part of a woman’s spinal column. For this
medication given can give a longer effect
1. Scheduled elective CS
compared to epidural anesthesia. The pain
➔ Common among women who has history of CPD know to relieving effects of a spinal block are almost instant
have a transverse lie or pregnant client who have breech and they last about 1-2 hours, after the injection,
presentation which could cover the whole procedure of c-
2. Emergent CS section.
➔ Common in women who have undergone trial of labor or
who have tried labor however have encountered problem
54th-61st slide
during the 1st stage of labor
Cesarean Section
> Indications: •Anesthesia
1. Regional Anesthesia
● Prolonged Labor - it happens when a primigravida is in labor ➔ Regional anesthetics, such as Epidurals and Spinal blocks,
for 20 hours or more or 14 hours or more for mothers who numb the area from the waist down and allow the woman
have given birth before. Also for baby;s who are too large to remain awake during the surgery.
for birth, slow cervical thinning, and caring multiple which
can cause prolonged labor. ➔ So to compare the epidural and spinal anesthesia, the
● Abnormal Positioning spinal anesthetic is directed once into the spinal space,
● Fetal distress while with epidural anesthesia, a catheter or an epidural
● Birth defects catheter is inserted into the epidural space, providing 2. General Anesthesia
● History of CS continuous administration of the medication. ➔ While on the other hand, general anesthesia puts
● Chronic Health Condition such as heart disease
the woman to sleep and is frequently used for
● Cord prolapse a. Epidural - In an epidural anesthesia a fine tube is emergency CS such as cord prolapse.
● CPD inserted to a woman’s back, into a space between
➔ Inhalation is used and then after the inhalation
● Placental issues or Placenta abruptio the spinal cord and its outer membrane. The
then the mother needs to be intubated for
● Multiple Pregnancy anesthesia medication moves through the tube
continuous sedation
● Vaginal Infection: Herpes
 ➔ Intra-operative ◆ Assess for danger signs such as local redness,
◆ Skin preparation to prevent infections warm to touch swelling and pain.
◆ Assist birth of infant
◆ Newborn care Exercises following Cesarean Section
➔ Post-operative
◆ Ensure patent airway, prevent respiratory Rationale
obstruction, and equip the recovery room with 1. Foot & leg exercises - to
suction and oxygen. If under anesthesia, position improve circulation, reduce
the patient on her side, to promote drainage of edema and prevent DVT.
So this is how an epidural catheter would look like (below). It is
secretions.
inserted into the epidural space and part of the catheter is placed 2. Abdominal tightening,
◆ Monitor V/S q5 mins until stable, q15 mins for 1
safe and it should be taped for security (yellow rectangle). And then pelvic tilting/rocking, knee
hour and q 30 mins until discharge to the post
on this yellow part here (yellow circle), this is where the doctor rolling - to ease backache
partum floor & I/O observe urine for bloody tinge
would administer the medication on a regular period. and flatulence, abdominal
which is a dangerous sign of trauma to the bladder
during surgery tightening tones, deep -
◆ Monitor uterine fundus - the fundus must be muscles, which are the main
palpated by placing a hand to support the incision, support of the spine and will
but do not tamper with the abdominal dressing. help prevent backache in the
◆ Regularly check dressing and perineal pad q 15 future
mins for at least 2 hours. Do pad count or weigh
pad if feasible 3. Pelvic floor exercises,
◆ Maintain fluid & electrolyte balance curl-ups, hip hitching - to
◆ Provide assistance during mother/father-infant prevent stress ~
Management:
interaction
➔ Pre-operative - we need to follow regular preparation for
◆ Administer medications as ordered: 4. Strenuous keep-fit
abdominal or pelvic surgery such as:
● Oxytocin - to ensure a firm fundus exercises, aerobics,
◆ Deep breathing techniques
● Analgesics - to relieve post-operative pain competitive sports - to keep
◆ Incentive Spirometry
● Antibiotics - prevent puerperal sepsis fit and help regain strength
◆ Turning the patient
◆ Encourage exercises
◆ Ambulation
◆ Assess for complications such hemorrhage, Always remember that the exercises leg lift and sit-ups should never
◆ Informed consent
infection and leg thrombophlebitis be performed. Avoid lifting, if inevitable keep the object as light as
◆ GI prep (NPO- post midnight)
◆ Assist in regular repositioning of patient in bed possible, and closer to the body, bend knees and straighten back.
with passive and active leg exercises.
Trial of Labor ➔ It is also important to emphasize, but do not overstress,
•Trial of labor after Cesarean Section that it is best for their baby to be born vaginally. If the tolac Also previous experiences could facilitate good psychological
A number of women would like to perform TOLAC or trial of labor fails and Cesarean birth is scheduled, provide an response to labor and delivery. Anticipation of pain can increase
after Cesarean Section. It is often those successful which can lead to explanation as to why Cesarean birth is necessary and why emotional tension, which could increase the pain perception. Even
VBAC or vaginal birth after Cesarean Section. it has become the best route for the birth of their baby though perception of childbirth is greatly influenced by a lot of
● Indications: ➔ Provide psychological support. psychosocial factors, there is a physiologic basis for this comfort
○ Low transverse incision or side-to-side incision in during labor as well.
the uterus used for all CS birth PSYCHE
○ Client should not have health problems that would A pregnant woman’s general behavior and influences upon her (?)
prevent VBAC. and also affect labor progress. Some factors that make labor a
○ Normal position and presentation meaningful positive or negative event were identified, such as
cultural influences integrating maternal attitudes, how a particular
Tolac would provide a shorter recovery period for the woman and society views childbirth, expectation and goals for the labor process
could also lead to lower health risk such as bleeding, infection and whether realistic achievable or otherwise feedback from other
death. However tolac is contraindicated by the following: people participating in the birth process.
● Contraindications
○ Classical incision Pregnant women’s psychological responses to uterine contractions,
○ History of uterine rupture & surgeries fear and anxiety, affect labor progress. A woman who is relaxed,
○ Previous delivery within 18 months aware of, and participates in the birth process, usually has a shorter
○ History of 2 or more CS or less intense labor.
○ Pre-eclampsia
○ Post-term Other factors that affects psychological response of the mother
would include childbirth preparation process or attending to
prenatal classes. This is considered to be a viable tranquilizer during
Management: the birth process, which leads to decreased need for analgesics in
➔ Monitor FHT & contraindications frequently. labor.
➔ Urge woman to empty the bladder every 2 hours so her
urinary bladder is as empty as possible, allowing the fetal Also the support system is another factor. The husband’s presence
head to use as much space as possible. If after a definite in the labor and delivery unit, can provide emotional support which
period, 6-12 hours, adequate progress in labor cannot be could lead to less anxiety, less emotional tension and less pain
documented, or if at any time fetal distress occurs, the tolac perception. The attending nurse should provide a caring and
will be discontinued and the woman will be scheduled for supporting environment as well, by respecting the client and family’s
Cesarean birth. needs and attitude. This could lead to therapeutic communication.
Slide 1-2 > Assessment:
POSTPARTAL HEMORRHAGE ➔ Copiuosvaginal bleeding
- It is the excessive bleeding which ➔ Soft, boggy, non-palpable uterus
reaches about 500 ml or more, ➔ Incomplete placenta
which can happen anytime after ➔ Obvious lacerations
delivery, up to 6 weeks. So there
are different types of postpartal Slide 4
hemorrhage.

Slide3
1. Early or Primary Postpartal
Hemorrhage ​– third stage up to 24
hours of delivery (PP). Uterine
atony is the most common cause
of early postpartal bleeding.
2. Late or secondary Postpartal
Hemorrhage – this is the bleeding
after 24hours until 6thwk. PP.
> Risk Factors:
This is a very crucial part of our
● Uterine atony
assessment to check for vaginal
● Over distension brought about
discharges. We always need to remember
multiple pregnancy
the different lochia that is expected
● Diabetic pregnancy
postpartum. Any deviation from the
● Polyhydramnios
inclusion days wherein the lochia is
● Effect of anesthesia (General
prominent would mean there could be
anesthesia that causes the uterus
possibly postpartum bleeding.
to be atonic)
Take note that during the first four days,
● Multiparity
bright red is expected, and it turns into
● Precipitate labor which brings
pinkish and then ​brownish until
about excessive contraction within
cream-colored​. There should be no
1 hour causing uterine muscle
prominent blood clots or heavy bleeding
insufficient opportunity in strength
present which could mean postpartum
to retract
bleeding. Always instruct the mother ​to
● Prolonged difficult labor resulting in
use large and soft sanitary pads and not
uterine inertia.
tampons​. Also, it’s always important to
● Placenta previa which is the lower
change pads not more than 4 hours​, this
uterine segment that is not
is also to prevent infections.
contracted as the upper fundal
portion
Slide 5-6
● Abruptio placenta wherein it could Vaginal Lacerations/ Vaginal Tears​- this
cause Couvelaire uterus and
occurs when the baby’s head is coming
prevent normal uterine contractility.
through the vaginal opening and is either too
● Incomplete placental separation
large or the head is normal sized but the
which causes inefficient
vagina does not stretch easily
contraction and retraction
● Lacerations brought about
operative obstetrics such as 4 Degrees of Tears/Vaginal Lacerations​:
forceps for management of the
second stage of labor.
● Large size of the fetus
● Precipitate labor
● Incomplete placenta
● Bleeding from the wounds
● Retained placental fragments ->
subinvolution.
 • Fundal massage until firm.
-FIrst nursing action to uterine atony.
• Expel clots
-Avoid over massaging as it can tire the
muscles causing relaxation.
• Provide oxytocic drugs. (e.g. oxytocin,
methergine, carboprost)
• Apply ice pack over hypogastric area &
perineum
-Reduce swelling, thus reduce pain and
bleeding
1. First Degree Tears
• Promote bladder emptying
-only the perineal skin
-To keep the uterus contracted
-mild pain during urination • Initiate early breastfeeding
-might or might not require stitches -Perform nipple stimulation to stimulate
-typically heal within a few weeks oxytocin secretion by the posterior
pituitary gland
2. Second Degree Tears • Check vital signs and fundus q 15 mins
-skin and muscles of the perineum (might • Assess & estimate blood loss frequently
extend deep into the vagina) • Keep all pads and linens to assess the
-requires stitches volume of blood lost
-heals within a few weeks • Notify the physician for repair of
lacerations and retain membranes
respectively.
• Maintain asepsis
-hemorrhage predisposes the mother to
infection
• Monitor I/O, fluid and bladder placement

• Be alert for blood reactions

• Provide psychological support

• Increase iron diet and to adhere to

3. Third Degree Tears follow-up care schedule
-extend into the anal sphincter PUERPERIAL INFECTION
-require repair with anesthesia in an operating ● Any infection of the reproductive
room organs that occurs between the
-longer than a few weeks to heal first 6 weeks after child birth or first
-complications: stool leakage, painful week after abortion.
intercourse ● Usually localized in the
endometrium causing endometritis.
4. Fourth Degree Tears ● Postpartum infections are the
-most severe; extend into the anal sphincter leading cause of nosocomial
and into the mucous membranes that line the infection and maternal morbidity
rectum and mortality.
-require repair with anesthesia in an operating ❖ Criteria:
room • Fever on any 2 of the first 10 days
-causes postpartum bleeding if not dealt with postpartum, excluding the first 24 hours
immediately after delivery which is more or less
brought about dehydration.
❖ ​Etiology​:
Slide 7-8 • Bacterial
❖ ​Management: -Both aerobic and anaerobic
(Streptococci)
• E. coli
❖ Risk Factors: • History of infection
• Prolonged labor -UTI or STD
-lasts more than 18 hours
• Prenatal factors
• CS over NSVD -Obesity, anemia and malnutrition
-The single most significant risk of
postpartum infection having 20 times
greater than in the vaginal birth cesarean
section and colonization of immunity.

• Frequent IE.
- procedures in prolonged labor with
frequent vaginal examination

• Prolonged delivery after ROM.

-Greater than 24 hours

• Positive amniotic fluid culture.

-E. Coli and Klebsiella

❖ So the kind of infection would vary ● inflammation of the uterus lining;

depending on the area where infection is usually due to an infection during
present or its manifestation: postpartum
❖It could be within the fallopian tubes and ● usually not life threatening but it is
ovaries, it could also be within the uterus
itself. it could be within the cervix which important to get it treated as soon
could cause cervicitis. as possible
❖ The bacteria could be coming from the ● Generally goes away with
vagina and it goes after the uterus and it antibiotics
could affect the fallopian tube and lastly, ● Occurs together with the
the ovaries. inflammation of the cervix
(cervicitis)
Slide 9-10 ● This condition may or may not
cause symptoms
ENDOMETRITIS
Signs & Symptoms, if ever...

➢ Abdominal swelling
➢ Abdominal vaginal bleeding
➢ Abdominal vaginal discharges
➢ Pelvic pain
➢ Constipation
➢ Discomfort during bowel
movements
➢ Fever
➢ Fatigue

URINARY TRACT INFECTION (UTI)

 Slide 11-12
Wound Infection
- May happen on incisions done after cesarean
section or on episiotomies with NSVDs
● Risk Factors:
○ Obesity
○ Diabetes Mellitus
○ Immunocompromised disorders
■ HIV
■ Chorioamnionitis
■ Taking long-term
steroids orally or
● The pelvic floor muscles help in intravenously
keeping the urethra closed so that ■ Poor prenatal care
the urine does not leak. During ■ Previous cesarean
labor, these muscles go into an deliveries
■ Lack of cautionary
overdrive along with the ligaments,
antibiotics or
nerves and muscles of the lower preincision
abdomen. antimicrobial care
● Excessive wear and tear during ■ Long labor or surgery
delivery can lead to injury and ■ Excessive blood loss
during labor delivery or
trauma to this set of muscles and
surgery
ligaments. ● Signs & Symptoms:
● These might subsequently do their ○ Abdominal pain
job as they did pre-labor. ○ Redness at the incision site
● Pregnancy might also cause the ○ Swelling
bladder to lose its tone, making it ○ Pus drainage
○ Pain in the incision site
difficult for women to empty their ○ Fever
bladder. ○ Painful urination
● Urine is more susceptible to flow ○ Foul-smelling discharges
back to the ureters and the longer ○ Bleeding (that soaks the
the urine stays in the urinary tract, dressing, that contains large
clots)
the higher the chances of bacteria
○ Leg pain/swelling
to multiply, hence, higher ● Assessment Findings:
vulnerability to infection. ○ Fever, chills, & tachycardia
● If the woman is in pain after ○ Change in color, amount, & odor
delivery or does not void due to ○ Inconsistency of lochia
○ Painful/tender uterine fundus
activity restrictions then the mother
○ Delayed uterine involution
could suffer from UTI postpartum ○ Body malaise, anorexia, &
headache
Signs & Symptoms ○ Dysuria
○ Burning sensation in urination
➢ Pelvic and abdominal pain ○ Costovertebral tenderness
➢ Inflamed bladder and urethra ○ Subinvolution
➢ Strong urge to urinate but only ● Management:
○ Antibiotics
urinates only few drops ■ Start with ordered
➢ Dysuria & polyuria antibiotics immediately
➢ Foul odor urine after the appropriate
➢ Body pain, fever, fatigue, and chills specimen is obtained.
 ■ Broad Spectrum
Antibiotics, directed at
multiple organisms, are
often administered.
○ Maintain bedrest
■ Isolate the mother from
the newborn, if
necessary.
○ Observe standard precaution &
careful handwashing
■ Personnel with signs of
infection should not be
assigned to render
direct care.
■ Monitor vital signs, I&O, THROMBOPHLEBITIS
forced fluids up to This is the inflammation of the vein
3,000-4,000 ml; if not resulting in vascular occlusion of vessels
contraindicated, in pelvis or lower extremities.
encourage frequent There are 2 types of thrombophlebitis:
voiding. Superficial Thrombophlebitis
○ Increase oral fluids - common from 4-10 days
○ Position: Fowler’s or postpartum
Semi-Fowler’s
- Manifested by having slight pyrexia
○ Teach regarding perineal hygiene
(mild fever), tender varicose veins,
○ Diet modification
swelling, hardness and redness of
■ High caloric, high
the affected vein.
protein, high iron diet
Deep Vein Thrombosis
○ Promote comfort
- manifest during the first 2 weeks
after delivery
Slide 13
- Manifested by calf pain or positive
It is important for us nurses to regularly
Homan’s sign, edema and swelling
evaluate episiotomy healing using the
of the legs (2-3 cm larger than the
REEDA
non affected leg), pain, fever and
EVALUATION OF EPISIOTOMY
chills.
HEALING
Slide 15
REEDDA - ​is an instrument designed to
THROMBOPHLEBITIS
measure the healing process of the
Etiology:
perineum following an episiotomy and/or
- Infection from the uterine cavity
laceration during childbirth.
- Circulatory stasis
R ​- redness
- Hypercoagulability
E ​- edema
Risk Factors:
E​ - ecchymosis (bruises)
- Bedrest
D​ - discharges
- CS
D​ - drainage
- Multiparity and advanced age
D - approximation of wound edges (edges
- Obesity
of wound fit together snugly)
- Estrogen therapy
Each part of the REEDA should be
- History of Thrombophlebitis
assessed accurately and regularly for the
Management:
medical health care team to monitor the
- Early ambulation
involution or the recovery of the woman’s
- Avoid pressure behind the knees
postpartum
- Maintain bedrest
Slide 14
- Heparin
- Analgesia except for aspirin
- Do not massage the affected area
- Allow Client to express feelings
 - Monitor for signs of pulmonary small pulmonary embolism, sudden
embolism intense chest pain, marked distress,
Discussion: severe dyspnea, pallor or cyanosis,
Thrombophlebitis is caused by i​nfection hemoptysis, Syncope, apprehension,
from the uterine cavity or the placental irregular thready pulse, diaphoresis, signs
site into the pelvic and femoral veins. of shock, sudden collapse.
It can also be caused by ​circulatory If the client is undergoing heparin therapy,
stasis ​(especially if the mother tends to be it is important to monitor the client for
bedridden or stays nonambulatory signs of bleeding and make sure to have
postpartum Protamine sulfate ​which is an antidote for
Increased post(?) delivery coagulability of heparin
blood, progesterone effect, trauma of Slide 16
childbirth, lack of activity, clot formation of ● Postpartum period is a demanding
pelvic veins following cs and clot formation period characterized by
in cut (?) of legs due to poor circulation overwhelming biological, physical,
Risk factors: social and emotional changes
-Bed rest, or prolonged immobility ● It requires significant personal and
- operative delivery such as cesarean interpersonal adaptation especially
section in case of primigravida
- multiparity and advanced age of over 30 ● Pregnant women and their families
years old have lots of aspirations from the
-obesity postpartum period which is colored
- women on estrogen therapy for by the joyful arrival of the new
suppression lactation baby. Unfortunately, women in the
- history of thrombophlebitis postpartum period can be
Most common complication is ​Pulmonary vulnerable through a range of
Embolism - ​or the passage of thrombus psychiatric disorders like
usually originating in one of the uterine or postpartum blues, depression and
other pelvic veins to one of the lungs psychosis.
where it disrupts circulation of blood ● Perinatal mental illness is largely
causing embolism and death under diagnosed and can have far
Management: reaching magnifications for both
-Teach client preventive measure such as the mother and the infant.
early ambulation ● Early screening diagnosis and
- Avoid pressure of the knees, avoiding management are very important
crossing of the legs and constricting and must be considered as
garters mandatory part of postpartum care
- Maintain bedrest. If using bed cradle to
support linens and beddings by elevating
the affected leg or hip, apply heat or warm
compress for 15-20 minutes, use support
bandage or stockings, administer
antibiotics or anticoagulants as ordered
Heparin​- the most commonly used
anticoagulant
- provide analgesic for pain but ​not
aspirin​, as it alters clotting and causes
bleeding
-Caution mother not to massage the legs
to prevent clot dislodgement and - To compare these three:
pulmonary embolism ● Postpartum blues
- allow client to express fears and ○ also known as baby blues
concerns, provide support and maternity blues
- Monitor for signs of complications or
pulmonary embolism. Such as sign of
 ○ it is a very common but self ● Offer positive feedback to improve
limited condition that begins self esteem
shortly after childbirth and ● Refer to other health team
can present with a variety members or agency to improve the
of symptoms such as mood resources of the client or the family
swings, irritability and ● Prognosis of postpartal
tearfulness maladaptation is good but may
○ Mothers may experience recur after subsequent
negative mood symptoms pregnancies and recurrence may
mixed with intense periods happen with chances of 33-51%
of joy
● Postpartum depression - is
gradual and may occur 2 weeks
postpartum and may last up to 3
to 6 months with incidence of at
least 1 out of 10 postpartum
women
● Acute Postpartum psychosis
○ has low incidence, it is
divided into depressed and
manic types
○ Symptoms typically begin
2-3 days after delivery. The
period of highest risk for
developing postpartum
psychosis is within the first
month after delivery

Slide 17
Risk Factors:
● Mental illness
● Stress- stresses of pregnancy or
delivery, physical health problems,
stresses of near responsibility of
parenthood, separation because of
maternal and neonatal problems,
● Social Factors- lack of support
system, low of socio-economic
status, disturbed family
relationship, surfacing of deep
(???) feelings about female myth
and concept
Management:
● Execute early recognition of the
problem
● Explore potential resources that
the client and family might use to
reduce the stress of parenthood.
● Maintain contact with the infant
● Support positive parenting
behaviors- Give feedback, as
much as possible
● Administer psychotropic
medications as ordered- Each
client and family parenting skills
NURSING CARE OF THE HIGH-RISK NEWBORN and interchange of cardiac massage at a ratio of 1:5. The need 5. Intake of adequate nourishment
to monitor transcutaneous oxygen or pulse oximeter to
The focus of the discussion today is geared from Nursing Care evaluate respiratory function in cardiac efficiency. - An infant who experience severe asphyxia at birth usually
of the High-Risk Newborn and 1 of the objectives is to assess receive intravenous fluid so they do not become exhausted by
a high risk newborn to determine whether safe transition of the 3. Maintenance of fluid and electrolyte balance sucking, there are times that because of the temporary
baby from intrauterine life to extrauterine life. This topic will also reduction in oxygen of the bowel, this will result to
add information on how to care for a newborn that is ill, or a - After initial resuscitation attempts, hypoglycemia may result NECROTIZING ENTEROCOLITIS (this is a condition in the
significant variation in gestational age or weight. This is an from the effort of the newborn expended to begin breathing. bowel that we need to prevent intake of fluids through the bowel
important information, because learning to recognize these Dehydration may result from increased insensible water loss (?)). If the infant’s respiratory rate remains rapid, and NEC has
infants at birth and recognizing care for them can be from rapid respiration. Fluids such as Lactated Ringers or been ruled out, gavage feeding may be introduced, preterm
instrumental in helping protect both their present and future Ringer Lactate or 5% dextrose in water are commonly used infant should be breastfeed if possible. If it is not possible then
health. to maintain fluid and electrolyte level. Electrolytes particularly mother can express her breastmilk and use those milk to initiate
sodium and potassium and glucose are added as necessary feeding. We need to increase the feeding according to its
PRIORITIES IN THE FIRST DAYS OF LIFE depending on the electrolyte analysis. Another way to fluid demand and caloric needs.
demand, are fluid administration must be carefully maintained
1. Initiation and maintenance of respirations because of high fluid intake can lead to heart failure. Using also 6. Establishment of waste elimination
radiant warmer, increases water loss from convection and
- It is important to establish the airway and maintain respiration, radiation. Newborn on warmer therefore, will require more fluid - Although/All (?) the most immature infant void within 24 hours
since most deaths occurring during the 1st 48 hours after birth than one who were placed in double walled incubators. of birth, they may void labor than term newborn because due
result from newborn’s inability to establish or maintain to all the procedures that may be necessary for resuscitation,
adequate respiration. An infant who has difficulty 4. Control of body temperature their blood pressure may not be adequate to optimally supply
accomplishing effective respiratory actions in the 1st hour of life their kidneys, so carefully we need to document any voiding
and yet survive many experience residual neurologic - Any high risk infant may have difficulty maintaining normal that occur during resuscitation, this is a proof that hypotension
dysfunction because of cerebral hypoxia, we need to be prompt temperature in addition to stress from an illness or immaturity. is improving and the kidneys are being perfused. Immature
and thorough care is necessary for effective intervention. An infant’s body is often exposed during procedures such as infants may pass stool late than term infants, because
resuscitation and blood drawing. It is important to keep meconium has not yet reached the end of the intestine by birth.
2. Establishment of extrauterine circulation newborn in a neutral temperature environment, so one that is
neither too hot or too cold, as doing so places less demand on 7. Prevention of infection
- Although establishing respiration is the usual priority of high infant to maintain and minimal metabolic rate necessary for
risk infants, birth, lack of cardiac functions may be present effective body functioning. To prevent newborn from becoming - Contracting an infection could drastically complicate a high
concurrently or may develop if respiratory function cannot be chilled after birth, wipe infant dry, cover the head with a cup and risk newborn ability to adjust in the extrauterine life. Infection
quickly initiated and maintained. Now, if an infant has no place him/her immediately under a prewarmed radiant warmer like chilling increase metabolic demand, which stress the baby
audible heartbeat or if cardiac rate is below 80 bpm, closed or warm incubator or you can also establish skin to skin contact out. Remember that newborns have immature immune system
chest massage should be started and a combination of lung against the baby's skin to the mother’s skin to establish so they are prone to infection. Infection stresses the immature
ventilation at a rate of 30 times per minute should be continued thermoregulation. immune system and already stress defense mechanism of a
high risk newborn. So infection may be, (“uhm”haha) the baby 9. Institution of developmental care products, acids to the cell causing temporary damage, could
can be exposed to an infection through prenatal, perinatal, or also be permanent damage to the brain of the baby.
even postnatal causes. So some instances, such as preterm or - Most high risk infants enjoy catch up growth once they
premature rupture of membrane, it is the infection that places stabilize from the trauma of birth or whatever caused them to - In prolonged periods, this damage can cause lifelong
an infant in an high risk category. Others also from viruses that classified as high risk. They quickly move to playing with each disabilities to the baby. For example : birth defects, seizures,
affect infant in the utero. For example: Cytomegalovirus, appropriate toys, some parents needs support before and after cerebral palsy, mental delays, permanent brain damage or
toxoplasmosis virus. Infant with either of these infection may their infant are discharged home to begin and view them well even death to the baby.
have born with congenital anomalies from the virus invasion. and capable of doing all the things they are now capable of
AGAIN, infant has low immune system and we need to be very doing. So, anticipatory guidance help them to be ready for next Physiology of asphyxia
careful to prevent an infant in contacting infections. All persons developmental steps.
coming in or in contact with infant must observe good Primary Apnea – when an infant is deprived of oxygen, initially,
handwashing technique and standard precautions to reduce BIRTH ASPHYXIA rapid breathing occurs. If the asphyxia continues, the
the risk of infection transmission. Healthcare personnel with an respiratory movements cease, heart rate begins to fall,
infection has a professional and moral obligation to refrain from neuromuscular tone ceases
for newborns.
(in order to counter primary apnea we need to:)
8. Establishment of an infant-parent relationship
- Tactile stimulation and exposure to O2 will induce respiration
- Be sure of parents of high-risk newborns are kept informed of
what is happening during resuscitation at birth. They should be Secondary apnea – if asphyxia continues, baby develops
able to visit the special nursing unit to which the child is deep gasping response, Heart rate continues to fall ( there will
admitted as often as they choose. We need to inform them that be significant bradycardia) , BP begins to fall. The infant is now
they have to wash their hands, gown and hold and touch their unresponsive to stimulation and will not spontaneously resume
child. This helps to make the child’s birth more real to them - condition in which the baby does not receive or get enough respiration unless PPV (positive pressure ventilation) is
Should the child not survive with the illness, this interaction can oxygen. With that deprivation of oxygen this can lead to brain initiated.
help make the death more real. Only the birth and death seem suffering to the baby and prolonged period this can also cause
real can help parents begin to work through their feelings and death to the baby. This can occur before delivery, or before
help the parents begin truly accept this event. All parents so labor, during and after delivery.
handled newborn babies tentatively until they have claimed
them or have become better acquainted. So weed to urge - Also known as perinatal asphyxia or neonatal asphyxia
parent to spend time with the infant in the intensive care or
Perinatal Asphyxia – is an insult to the fetus or newborn due
nursery as the infant improve. Be sure they have access to
to lack of oxygen or lack of perfusion to various organs
healthcare personnel after discharge to help them care
confidently to the child at home.
- The problem of birth asphyxia is deprivation of oxygen, with
this the cell cannot sustain that status. This build up waste
From the time the baby is delivered, we get the apgar score -ideal position in performing intubation. 1. We make sure that the glabella (the part between the
right away, as soon as we observe the apgar score is very poor, brows of the baby) and the chin are horizontally
like there is nasal flaring , bluish discoloration of the body and - the head of the baby is extended and the neck of the baby is aligned.
the absence of cry. Within the 2 minute period we need to flexed 2. Make sure that the neck should be open.
resuscitate right away. How? 3. External Auditory Meatus of the ear and the sternal
- Attach to pulse oximeter notch are horizontally aligned.
a. Establish an airway (establish a patent airway) - In order to monitor the O2 saturation
Fetal Resuscitation
- Make sure there is no obstruction, we need to clear off all the - APGAR scoring
➔ APGAR Score
secretions from the mouth and nose to help expand the lungs, - continues to do this until the baby will have a good score
➔ Airway management
with the patent airway we are also helping the baby to breathe
- Airway management ➔ OGT
and initiate breathing thus by this the lungs will expand.
- these are sets of maneuver or medical procedures that is ➔ Radiant warmer
b. Expand the lungs performed to prevent and relieve airway obstruction. This ➔ Hypoglycemia
ensures an open pathway of gas exchange between the px/s In the event that the baby does not respond to any of
c. Initiate and maintain effective ventilation lungs and atmosphere the stimulation being performed by the doctors or the nurses,
you need to anticipate and be ready that the doctor will have to
- If the baby has no effort in beathing, we have to do positive Sniffing Position do the fetal resuscitation or the airway management.
pressure ventilation. We have to initiate and maintain effective Instrument:
ventilation. Laryngoscope - a light can be found at the end of the
tip which serves as a guide and helps the doctor in viewing the
> Nursing management: part where the endotracheal tube is inserted so that we can
establish a patent airway. Anticipate that the tube is connected
- Stimulate the newborn to the oxygen and that the oxygen should be readily available
and it should be warmed and humidified.
- tactile stimulation or stimulate the newborn by drying the baby, Also, we have to make sure that the O2 sat established
touching the baby. We need to wake up the baby. or good O2 saturation. We have to hook the baby to a O2 sat
instrument
- Suction Continuously monitor or auscultate the heartbeat of the
baby and anticipate that after the insertion of the endotracheal
- the baby is covered with secretions so we need to suction
tube, a chest x-ray will be ordered to ensure proper placing of
those secretions and remember that this baby is asphyxiated First step: Simple Head Extension
the endotracheal tube.
we have to clear off everything that blocks the airway. (clear As mentioned, we need to extend the head.
After the airway management, the doctor will also
mouth and nose) Remember, no shoulder roll or headrest for babies.
order for insertion of Oral Gastric Tube (OGT) for feeding.
- Sniffing position
 And we expect that the distress that baby is facing, the
baby will have a problem in thermoregulation so we have to set
up a radiant warmer and the baby will as well go to
hypoglycemia so we have to monitor for the capillary blood
glucose level.

Pulse Oximeter
- May be able to detect the heart rate of the baby as well
as the O2 saturation.

With the stress that the baby is facing during resuscitation, it is

expected that infants will have problems in thermoregulation.
As mentioned, we have to prepare radiant warmer or machine This chart here…on the bottom, you will see week of gestation
that can help regulate the temperature of the baby. One of that and on the right side, you will see weight in grams. This chart
is: will be used to assume or will show that the baby’s growth is
● Radiant warmer - wherein there’s a probe that is appropriate or if it’s showing an appropriate sign by its
APGAR Score is taken 1 min and 5 min after birth. attached to the baby to continuously monitor the gestational age. Constantly the baby is monitored through
Newborns are observed and rated according to its APGAR. An temperature of the baby. ultrasound during intra uterine life. One of the data that is
APGAR Score standardized infant assessment at birth and ● Isolette or incubator - serves a good thermoregulating collected in the utz is the estimated weight. By the estimated
serves as a baseline for future evaluation. We take note of the machine, help in thermoregulation on the temperature weight, you can also get the AOG so you can also monitor the
heart rate, respiratory effort, muscle tone, reflex and irritability, of the baby weight of the baby if it’s appropriate. If the baby falls below the
and color of the infant. Each rated as 0, 1 and 2. The 5 scores 10th percentile (the curve line, niya below ana(second line)), if
are then added and a newborn that has a total score of below Altered gestational age/Fetal growth abnormalities the baby’s weight is above the 90%, then the baby is expected
4 is in serious danger and needs resuscitation; a score of 4-6 ● Term infants to be large for gestational age. If in between, then the baby is
means the infant’s condition is guarded and the baby may need ● Preterm infants appropriate for its gestational age.
clearing of airway and supplemental oxygen; a score of 7-10 is ● Post term infants
considered good, indicating that the infant’s score is high as ● AGA (appropriate gestational age) Classification of Size:
70%-90% to all infants at 1-5 mins afterbirth. ● SGA (small for gestational age) ● SGA- small for gestational age-weight below 10th
● LGA (large for gestational age percentile. Note not all SGA are the same with IUGR.
Can be a small baby and can have a normal growth.
One goo example is that when parents are small, you
will expect that the baby will also be small, as long as
there are no growth restrictions in the intrauterine
 ● AGA - weight between 10 and 90th percentiles ● Disproportionate large head - the head is bigger than ● Feeding schedule - feeding of the preterm infant. If
(between 5lb 12 oz (2.5kg) and 8 lb 12 oz (4 kg) the body of the baby the baby is born <28 weeks, we expect that the
● LGA - weight above 90th percentile ● Ruddy skin - skin is generally ruddy because the infant nutritional need of the baby can be addressed through
IUGR (intrauterine growth retardation/restriction)-deviation in has little subcutaneous underneath it, veins are easily intravenous fluid.
expected fetal growth pattern, caused by multiple adverse noticeable. ▪ If the baby is born 28-32 weeks, the
conditions, not all IUGR infants are SGA. Failure to achieve ● Large acrocyanosis - high degree of acrocyanosis baby will be inserted with OGT (
potential size. These babies (IUGR baby) are considered may be present Orogastric tube ) where feeding can
pathologic. ● Extensive lanugo - the lanugo will usually cover from be done.
the back, forearm of the baby, forehead of the baby and ▪ 32-34 weeks - feeding can be
PRETERM INFANT the sides of the face of the baby. introduced through cup feeding
● Few or no creases on soles of feet - the sole and the ▪ 34 weeks and above - the baby can
palms of the baby would feel very smooth and soft now have breastfeeding as long as it
because of the little to no creases on this type of baby. is tolerated.
○ Feeding may be safely delayed until an infant
> Nursing management: has stabilized his/her respiratory effort from
● Usually if we deal with preterm labor our goal would be birth.
to hold the pregnancy so that the baby will be able to ○ Preterm infant may be feed by total parenteral
survive in the extrauterine life nutrition until they are stable enough for other
● Emergency CS- if incase the baby will go into distress. means ( OGT, cup feeding and breastfeeding)
In preterms, a lack of lung surfactant makes them ● Caloric need
extremely vulnerable to respiratory distress syndrome. ○ Preterm infant : 115-140 calories per kilogram
○ Surfactant will be produced at 34 weeks of body weight per day.
gestation ○ Term infant : 100-110 calories per kilogram of
- is usually defined as a life born infant, born before 37 weeks
○ Before the 34 week gestation and the baby will body weight per day
gestation
be delivered early, the baby will be attached to ● Protein requirement :
- Another criterion for this, is through the weight of the baby ( supplemental oxygen so this baby will be ○ Preterm: 3-3.5 grams per kilogram of body
less than 2,500 grams and about 5 lbs) bombarded with oxygen. weight
○ One risk of having large amount of oxygen is ○ Term: 2-2.5 grams per kilogram of body weight
- Ballard scoring - we get the physical and neurologic score in pulmonary edema and retinopathy of ● A preterm infant has a small stomach capacity, this
order to determine if the baby is term, preterm or post term prematurity baby can't take a large feeding so feeding schedule
● Monitor intake and output - in preterm infant, intake would be more frequent with smaller amount.
>Clinical manifestations: and output is very strict, we need to be very accurate ● Feeding may be as small as 1 or 2 mL every 2-3 hrs
● Size: comparison of the person’s palm and the size of in getting the I&O of the baby. ● Thermoregulation: preterm infant’s skin has less fat
the baby. The preterm infant is very small, almost the ○ I&O monitoring should be every 2 hours in so they are prone to heat loss. Preterm infants are
same size as the palm of an individual. absolute figures.
 monitored closely for the temperature and they should ● Abdomen may be sunken and the cord often appears - Postterm infant is one born after the 41st week of a
be placed under radiant warmer. dry and may be stained with yellow pregnancy.
● Small liver - which may cause difficulty regulating - Commonly nurses, midwifes, an obstetrician would
INTRAUTERINE GROWTH RESTRICTION (IUGR) glucose, protein and bilirubin level after birth recommend inducing labor at 2 weeks postterm to
● IUGR babies are babies who fail to achieve potential ● Blood studies for IUGR babies show a high level of avoid post mature birth, however when gestational age
size hematocrit, there is lesser amount of plasma in is miscalculated or for some other reason labor is not
● Growth curve: these babies falls below the tenth proportion to the level of RBC present due to the lack induced until 43 weeks of pregnancy, or after the
percentile of fluid present in the intrautero. pregnancy may result in a post-term infant.
● Causes for IUGR: maternal and placental ● Polycythemia - increase in the total number of RBC is - Infants who stay in utero past 41 weeks are at special
○ Maternal: due to a state of anoxia during the intrauterine life risk because a placenta appears to function effectively
■ substance abused mother ○ Polycythemia causes increased blood for only 40weeks.
■ mother who’s taking medications viscosity that puts extra effort in the infant’s
■ mother with medical condition like heart because it is more difficult to effectively After that time, it seems to lose its ability to carry
diabetes mellitus and hypertension circulate thick blood. nutrients effectively to the fetus, and fetus who remains to the
■ Mother is exposed to ● Consequence of acrocyanosis or blueness of the hand uterus with a failing placenta may die or develop postterm
torch???infection and feet may be prolonged and persistent and more syndrome.
○ Placental causes: mild than usual. Now if the polycythemia is extreme,
■ Insufficiency in the placenta - placenta vessels may actually become black and thrombus Infants with this syndrome demonstrate many of the
was not able to penetrate well, poor formation can result. characteristics of the SGA infant:
perfusion to the placenta can lead to ● Hypoglycemia (one of the most common problem in
intrauterine growth restriction IUGR ) - decrease glycogen stores. Such infant may ● dry, cracked, almost leather-like skin from lack of fluid
need intravenous glucose to sustain blood sugar until ● and an absence of vernix caseosa.
Difference between IUGR and SGA (small for gestational they are able to suck vigorously enough to take ● They may be SGA,
age) sufficient oral feeding ● and the amount of amniotic fluid surrounding them may
● IUGR - it has a pathologic cause be less at birth than usual at new and it may be
● SGA - no pathologic cause POSTTERM INFANT meconium stained.
● Fingernails have gone well beyond the end of the
Clinical Manifestation of IUGR fingertips, because they are older than a term infant,
● Infant has an overall wasted appearance ● they may demonstrate alertness much more like a two-
● Poor skin turgor week old baby than a newborn.
● Generally appears to have a large head because the
rest of the body is so small. At birth, the postterm baby is likely to have difficulty
● Skull sutures may be widely separated from lack of establishing respirations, especially if meconium aspiration
normal bone growth. Hair is dull and luster less. occurred. In the first hour of life Hypoglycemia may develop
because the fetus may use stores of glycogen for nutrition or
nourishment in the last week of intrauterine life. Subcutaneous need significant manipulation to pass through the outlet of the
fat level may also be low, having been used in the utero. This pelvis) would halt vaginal birth at that point.
loss of fat can make temperature regulation difficult, making it
important to prevent a postterm infant from becoming chilled at > Complications:
birth or during transport. Polycythemia may have developed After birth LGA infants may show immature reflexes
from decreased oxygenation in the final weeks. The hematocrit and low scores in gestational age examinations in relation to
may be elevated because polycythemia and dehydration have their size.
lowered the circulating plasma level. ● Babies may have extensive bruising or a birth injury
> Etiology: such as a broken clavicle or Erb-Duchenne paralysis
> Nursing Management: from trauma to the cervical nerves they were stressed
● Make certain a woman spends enough time with her Infants who are LGA have been subjected to an in order for the wide shoulders to be born vaginally.
newborn to assure herself that although birth did not overproduction of nutrients and growth hormone in utero. ● Caput succedaneum (appeared in a large LGA baby
occur at the predicted time the baby should do well with because of the pressure. There is extensive or more
appropriate intervention to control possible ● This happens most often to infants of women who are pressure than usual during birth. With pressure it forms
hypoglycemia or meconium aspiration obese or who have diabetes mellitus. edema to the loose connective tissue wherein there is
● all postterm infants need follow-up care until at least ● Multiparous women may also have large babies buildup of fluids in the connective tissue and extends
school age to track their developmental abilities because with each succeeding pregnancy babies tend across the numbers of sutures. It disappears within 24
because the lack of nutrients and oxygen in utero may to grow larger. hours.)
have left them with neurologic symptoms that will not ● Beckwith-Wiedemann syndrome, a rare condition ● Cephalohematoma, or molding (ruptures of blood
become apparent until they attempt fine motor tasks characterized by general body overgrowth and vessels in the subperiosteal layer, a buildup of blood
congenital anomalies, such as omphalocele, may also under the periosteum. Disappears 2-3 days)
be a cause. ● Rebound hypoglycemia (LG infants also need to be
LARGE-FOR-GESTATIONAL-AGE (LGA) carefully assessed for hypoglycemia in the early hours
> Assessment:
of life because large infants require large amounts of
An infant is LGA (also termed macrosomia) if the birth nutritional stores to sustain their weight. If the mother
rate is above the 90th percentile on an intrauterine growth chart If a fetus is suspected of being LGA when a woman's
had diabetes that was poorly controlled (the cause of
for that gestational age. Such a baby appears deceptively uterus appears to be unusually large for the date of pregnancy.
the large size), the infant would have had an increased
healthy at birth because of the weight, but a gestational age Abdominal size can be deceptive, however. Because a fetus
blood glucose level in the utero to match the mother's
examination often reveals immature development. lies in the flexed fetal position, he or she does not occupy
glucose level; this caused the infant to produce
significantly more space at 10lb than at 7lb.
elevated levels of insulin. After birth, these increased
It is important that LGA infants be identified insulin levels will continue for up to 24 hours of life,
immediately so they can be given care appropriate to their If an infant's large size was not detected during
possibly causing rebound hypoglycemia)
gestational age rather than being treated as term newborns. pregnancy, it may be first recognized during labor when the
baby appears too large to descend through the pelvic rim. If this
> Nursing Management:
happens as a cesarean birth may be necessary because
● Breastfeed the baby immediately
shoulder dystocia (The wide fetal shoulders cannot pass; or
 > Functions of Surfactant
RESPIRATORY DISTRESS SYNDROME (RDS) ● Decreases the surface tension 1. Breathing - is compromised in this condition due to
- Also called hyaline membrane disease ● To promote lung expansion during inspiration high pressure, it’s required to fill the lungs with air for
- Most common cause of respiratory distress in preterm ● To prevent alveolar collapse and loss of lung volume the first time to overcome the pressure of lung fluid. If
infants. Also, infants of diabetic mothers, infants born at the end of expiration alveoli collapse with each inspiration, as to what
by cesarean birth or those for any reason who have ● Facilitates recruitment of collapsed alveoli happens when surfactant is deficient. Forceful
decreased blood perfusion of the lungs, such as > Incidence: inspiration are still required to inflate them that is why
newborns with meconium aspiration. ● 60-80% of babies born at 28 weeks - are very there is repetitive reopening and overdistension in the
susceptible to developing this complication (RDS) absence or little surfactant causes the Lung damage
● 15-30% of babies born 32-36 weeks - are also 2. Lung Damage - poor oxygen exchange leads to tissue
susceptible to having Respiratory Distress Syndrome hypoxia which causes the release of lactic acid
● Rarely in those above 37 weeks 3. Hyaline Deposits - this lactic acid combines with
> Etiology: carbon dioxide level resulting from the formation of
● Prematurity hyaline membrane on the alveolar surface thus leads
● Meconium aspiration syndrome - due to poor or to severe acidosis. Proteinaceous debris leaks into the
decreased blood perfusion to the lungs that causes membrane thus acidosis causes vasoconstriction and
RDS decreased pulmonary perfusion from vasoconstriction
● Pneumonia further limits the surfactant production.
> Increased incidence of RDS in preterm babies: 4. Surfactant Deficiency - with decreased surfactant
● Term Babies - have storage pool of approximately 100 production, the ability to stop alveoli from collapsing
The pathologic features of RDS is a hyaline like mg/kg of surfactant at birth with each expiration becomes impaired. This vicious
(fibrous) membrane formed from an exudate of an infant's ● Preterm Babies - have a storage pool of cycle continues until oxygen-carbon dioxide exchange
blood that begins to line the terminal bronchioles, alveolar approximately 4-5 mg/kg surfactant at birth in the alveoli is no longer adequate to sustain life
ducts, and alveoli. This membrane prevents the exchange of without the ventilator or eventually this will lead to
oxygen and carbon dioxide at the alveolar-capillary membrane, Pathophysiology of Respiratory Distress Syndrome respiratory failure and death.
interfering with effective oxygenation. The cause of RDS is the
low level or absence of surfactant, the phospholipid that RESPIRATORY DISTRESS SYNDROME
normally lines the alveoli and reduces surface tension to keep
the alveoli from collapsing on expiration. In short, this results in > Signs and Symptoms:
decreased lung compliance and unstable alveoli. A preterm newborn will manifest...
○ Expiratory grunting - due to closure of the
Surfactant - are produced normally until the 34th week of glottis that creates a prolonged expiratory time
gestation ○ Nasal flaring
○ Central cyanosis in room air
 ○ Tachypnea - more than 60 respirations per ■ Complications: Retinopathy of the child’s blood volume remains
minute prematurity adequate
○ Substernal and subcostal retractions ○ Airway Management - need to attach the ○ Prevention
>Diagnosis: baby to endotracheal tube and attach to a ■ Dating a pregnancy by sonogram and
○ Chest x-ray - will reveal a diffused pattern of ventilator by documenting the level of lecithin in
radioptic (?) areas that looks like a ground ○ Extracorporeal Membrane Oxygenation surfactant obtained from mutic fluid
glass (?) or haziness (ECMO) exceeds that of sphingomyelin by 2:1,
○ ABG (Arterial Blood Gas) - or blood gas ■ First developed as means of are important ways to certain an infant
studies are taken from an umbilical vessel oxygenating blood during cardiac born by cesarean birth or has labor-
catheter which will reveal respiratory acidosis surgery, so it is currently used and has induced is mature enough that RDS is
> Therapeutic Management: expanded to management of chronic not like to occur
○ Surfactant severe hypoxemia in newborns with ■ Using tocolytic agents such as
■ From an endotracheal tube at birth for illnesses such as meconium magnesium sulfate or terbutaline can
infants at risk because of low aspiration, RDS, pneumonia, help prevent preterm (?) for a few days
gestational age diaphragmatic hernia because steroids appears to quicken
■ Synthetic surfactant is sprayed into ■ Also used for near-drowning victims or the formation of lecithin, so it may be
the lungs by a syringe or through infants with severe lung infections possible to prevent RDS in infants by
endotracheal tube at birth while the ■ Blood is removed from the baby by administering to injections of
infant is positioned with the head held gravity using a venous catheter, glucocorticosteroids such
upright and then tilted downwards advanced into the right atrium of the betamethasone to the mother at 12 &
■ It is important that the infant’s airway heart then the blood circulates from 24 hours during this time; most
is not suctioned for a long period as the catheter to the ECMO machine effective when given between 24-34
possible after administration to avoid where it is oxygenated rewarmed so it weeks of pregnancy
suctioning the drug away is then returned to the infant’s aortic
○ Oxygen Administration arch by a catheter advanced through
■ Is necessary to maintain correction of the carotid artery MECONIUM ASPIRATION SYNDROME
PO2 and pH levels ■ Used for 4-7 days - Meconium is present in the fetal bowel as early as 10
■ Continuous Positive Airway Pressure ■ Has many potential complications weeks gestation
(CPAP) or assisted ventilation with such as intracranial hemorrhage - An infant with hypoxia in utero experiences vagal reflex
Positive and Expiratory Pressure possibly from the anticoagulants; relaxation of the rectosphicter which then release
(PEP) will exert pressure on the alveoli anticoagulant therapy is necessary to meconium into the amniotic fluid
at the end of expiratory, and keep the prevent thromboembolism - Babies born through breech presentation may expel
alveoli from collapsing ■ Constant nursing care is required for a meconium into amniotic fluid from pressure of the buttocks
■ Greatly improves oxygen exchange child receiving ECMO to ensure that
 ○ Oxygen administration and assisted ➔ Viral or Respiratory Ptyalism Infection
ventilation ➔ Pulmonary Edema
○ Antibiotic therapy ➔ Brainstem abnormalities, Neurotransmitter
○ Pharmacologic deficiencies
○ Chest physiotherapy - with clapping and
➔ Heart Rate Abnormalities
vibration may be helpful to encourage removal
➔ Distorted Familial Breathing Pattern
of remnants of meconium from the lungs
○ Extracorporeal Membrane Oxygenation ➔ Decreased Arousal Response
(ECMO) - to ensure adequate oxygenation ➔ Possible Lack of Surfactant in the alveoli
➔ Sleeping Prone
➢ Infant may have slight head cold after being put to bed,
infant is found dead a few hours later. Infants who die
this way do not appear to make any sound as they die:
indicates death due to Laryngospasm
➢ Many infants are found with blood, sputum or vomitus
in their mouth or in their clothes autopsy often reveals
Petechiae in the lungs and mild inflammation and
congestion in the respiratory tract-however, these
symptoms are not severe enough to cause sudden
death
> Diagnosis - diagnosis of Exclusion (rule out all other cause)
^Meconium Aspirator- attached to a suction machine, in ➔ Autopsy should be performed
another side it is attached to an endotracheal tube (where deep > Risk Factors:
> Signs and Symptoms:
suctioning is performed and is Inserted through the trachea For the baby:
○ Low APGAR score - because almost and bronchi)
immediately, tachypnea retractions and ● How they sleep
- Suctioning done so that meconium stained amniotic ● Male neonate (more prone to develop SIDS)
cyanosis occurs
fluid will be aspirated. ● 2-4 months
○ Retractions
SUDDEN INFANT DEATH SYNDROME (SIDS) ● Formula feeding
○ Barrel chest
● Crib Death (other term for SIDS): Sudden, ● Premature baby
○ X-ray - bilateral coarse infiltrates unexplainable death during 1st year of Life
> Therapeutic Management: ● Low birth weight
○ Amnioinfusion - can be used to dilute the For the mother:
> Etiology: ● Little to no prenatal care
amount of meconium in the amniotic fluid and
- unknown ● Teen mother
reduces the risk of aspiration
- postulated theories about prolonged and unexplained apnea ● Smoking during pregnancy
○ CS Others include: ● Drinks Alcohol
(Addtn’l:) ● Green stool (because of excess bilirubin) & dark urine - In actuality, occasional placental villi breaks and a drop
● Closely spaced pregnancies (because of urobilinogen formation) - when exposed or two, enters the maternal circulation (this is where the
● Tween Native-American Infants to post-phototherapy problem begins)
● Alaskan-Native Infants - Infants with Type B blood have the most serious cases.
● Economically disadvantaged black Infants - Hemolysis can become a problem with the first
● Narcotic-dependent mothers pregnancy in which there is an ABO incompatibility as
the antibody to A & B cells are naturally occurring
ABO/RH INCOMPATIBILITY antibodies or are present from birth (individuals whose
> Etiology: incompatible RH and ABO red blood cells lack this antigen)
> Signs & Symptoms: - These antibodies are of large class and does not cross
● Coombs Test - direct (shown on the table below) & the placental barrier (this refers to Immunoglobulin M
indirect: Rh incompatibility: rising Rh titer or antibody in or IgM)
the mother during pregnancy - An infant with ABO incompatibility is not born anemic.
● Enlarged liver & spleen - due to the attempts to destroy - Hemolysis of blood begins with birth when the blood
blood cells and antibodies are exchanged during the mixing of
● A baby can suffer RH incompatibility: mother is RH -
○ If the number of RBC has significantly maternal-fetal blood as the placenta is loosen.
& baby is RH +
decreased, the blood in the circulation may be - Destruction of RBC may continue up to 2
● Example: The mother is RH - & baby is RH + in which
hypotonic to interstitial fluid. weeks of age.
the RH positive contains the D antigen. Introduction of
○ Fluid will shift from lower to higher isotonic - Preterms do not seem to be affected by ABO
the fetal blood cells causes synthesization to occur and
pressure by osmosis (causes extreme incompatibility (this may be because of the
the mother begins to form antibodies against that D
edema). receptor site for anti- A & anti- B antibody
antigen.
○ Severe anemia - can result in heart failure which does not appear to the RBC until late in
● Most form in the mother’s blood stream in the first 72
● Hydrops fetalis - is an old term for appearance severely fetal life).
hrs. after birth because there is an active exchange of
involved infant at birth - The direct hostess may be only weakly positive
fetal-maternal circulation or blood as placental villi
○ Hydrops refers to edema because of few anti-A & anti-B sites present
loosens and placenta is delivered.
○ Fetalis refers to the little state
● After the synthesization, during the 2nd pregnancy,
● Pathologic jaundice - occurring within the first 24 hours
there will be a high level of antibody D circulating the
of life; will begin indicating in both ABO & Rh
mother’s blood stream in which this will act to destroy
incompatibility that an hemolytic process is at work
the fetal blood cells early in pregnancy, if the new fetus
○ This is due to a RBC has been destroyed &
is RH POSITIVE.
indirect bilirubin has been released.
- ABO incompatibility: the mother is Type O & the baby
○ Indirect bilirubin - a fat soluble that cannot be
is either Type A, B, or AB
excreted in the body
- Theoretically, there is no connection between fetal &
● Hypoglycemia - infant needs to use glucose stores to > Nursing Management:
maternal circulations (no fetal blood cells can enter into
maintain metabolism in the presence of anemia
the maternal circulation) ➢ Early breastfeeding
 ➢ Phototherapy - quartz halogen, cool white daylight or - The term temperature can be very crucial so - This can be transmitted to the newborn through contact
blue fluorescent light at 12-30 inches above the that's why we need to make sure that the with infected vaginal blood at birth when the mother is
bassinet or incubator baby’s thermoregulation is established. positive for the virus
➢ Exchange transfusion - alternating drawing small - A destructive illness accounts for 70-90% of infected
amounts of infant blood of about 2-10 ml and replacing ACQUIRED MATERNAL INFECTION infants because they become chronic carriers of the
it with equal amount of donors blood; exchanged slowly ● Newborns are susceptible to infection at birth because virus and a number of infants will develop liver cancer
to prevent alternating hypovolemia and hypervolemia of their ability to produce antibody is immature later in life.
○ Duration: 1 - 3 hours ● Many infections in newborns: Toxoplasmosis rubella, - To reduce the possibility of HBSAG being spread to
○ umbilical vein is the site for transfusion syphilis, cytomegalovirus infection which are spread newborns nowadays, infants are routinely vaccinated
➢ Erythropoietin some to fetus across the placenta in utero. at birth
● Other infections are contracted from exposure to - If the mother is identified as a HBSAG positive, the
> Nursing Considerations: vaginal secretions at birth. infant is also administered immune serum globulin
● Protect eyes and genitalia ❑ Group B Beta-Hemolytic Streptococcal Infection (GBS) within 12 hours of birth to decrease the possibility of
- Put on eye patches to avoid damage on the retina and - The major cause of infection in newborn. This is a infection
genital patches gram-positive bacterium and is naturally an inhabitant ❑ Generalized Herpes Virus Infection
- Monitor the baby to see if the eye patch is properly in of female genital tract - Herpes simplex virus type 2 infection is the most
place to avoid suffocation - It may be spread from baby to baby if good hand prevalent among women with multiple sexual partners
● Frequently feed washing technique is not used in handling newborns. - It can be contracted by a fetus across the placenta if
- Remove from under the light for feeding so that he or - If a mother is found to be positive with GBS during late the mother has active or primary infection during
she continues to have interaction with the mother and pregnancy, ampicillin administration is given pregnancy
in addition to supplemental feeding, formula may be intravenously at 28 weeks and again during labor to - Often, the virus can be contracted from vaginal
recommended to prevent dehydration help reduce the possibility of newborn exposure. secretions of a mother who has active herpetic
❑ Ophthalmia Neonatorum vulvovaginitis at the time of birth.
- This is an eye infection that occurs ❑ HIV Infection
● Promote mother and child interaction at birth during the first month and the most common - Human immunodeficiency virus infection and acquired
- Removal of the eye patches while the infant is causative organism is Neisseria gonorrhoeae and immunodeficiency syndrome or AIDS can be caused by
with the mother, this gives an infant a period of Chlamydia trachomatis. placental transfer or direct contact with maternal blood during
visual stimulation and other way this can also - An infant contracted an organism during birth from birth
promote mother and infant interaction vaginal secretion by Neisseria gonorrhoeae infection is ❖DX
● Thermoregulation an extreme serious form of conjunctivitis because if left ● Blood culture
- Monitor the temperature because exposure to untreated, the infection progresses to corneal ❖ S/S
phototherapy can have a radiation, convection, ulceration and destruction and resulting to opacity of - Symptoms would commonly manifest as pneumonia-
heat loss and transfer of heat the cornea and severe vision impairment. like symptoms.
❑ Hepatitis B Virus
 - Early signs of pneumonia become apparent within the • Acyclovir (Herpes simplex) because of hypomagnesemia from excessive renal
first day of life as well as tachypnea, apnea, and signs - For herpes simplex, Acyclovir is given losses of magnesium.
of shock: such as decreased urine output, extreme • Antenatal prevention ● Hyperbilirubinemia
paleness and hypotonia. Hypotonia is when muscles - Follow antenatal management in order not to transfer - Hyperbilirubinemia also may occur in these infants
are relaxed. the infection to the baby because, if immature, they cannot effectively clear
● Hypothermia bilirubin from their system.
● Hypotonia INFANT OF MOTHER WITH DIABETES MELLITUS ❖ NSG. CONSIDERATIONS:
● Tachypnea, paleness -An infant of a woman who has diabetes mellitus whose illness ● Early feeding
was poorly controlled during pregnancy is typically longer and - In a newborn, hypoglycemia is defined as a serum
weighs more than other babies (macrosomia). The baby also glucose level of less than 45 mg/dL. To avoid a serum
has a greater chance of having a congenital anomaly such as glucose level from falling this low, infants of diabetic
a cardiac anomaly, as if hyperglycemia is teratogenic to a women are fed early with formula or administered a
rapidly growing fetus. Caudal regression syndrome (hypoplasia continuous infusion of glucose. It is important the infant
of the lower extremities) is a syndrome that occurs almost not be given only a bolus of glucose; otherwise,
exclusively in such infants. rebound hypoglycemia (accentuating the problem)
may occur.
❖ MANAGEMENT ❖ S/S ● Monitor bowel movement
• Prophylaxis ● Macrosomia - Some infants of diabetic women have a smaller-than-
- Some of the causative agents of this infection is - Results from overstimulation of pituitary growth usual left colon, apparently another effect of
caused by gram-positive bacteria so that's why the hormone and extra fat deposits created by high levels intrauterine hyperglycemia, which limits the amount of
babies are covered with antibiotic therapy known as of insulin during pregnancy. oral feedings they can take in their first days of life.
prophylaxis. ● Severe hypoglycemia Signs of an inadequate colon include vomiting or
• Standard and contact infection precautions - Immediately after birth, the infant tends to be abdominal distention after the first few feedings.
- Is observed in order not to transfer or spread the hyperglycemic because the mother was at least slightly Careful monitoring for normal bowel movements is
viruses from one baby to another. hyperglycemic during pregnancy and excess glucose important.
- Wear a mask, gloves, gowns in order to stop the chain transfused across the placenta. During pregnancy, the
of infection. fetal pancreas responds to this high glucose level with INFANT OF A DRUG-DEPENDENT MOTHER
• Eye irrigation islet cell hypertrophy, resulting in matching high insulin - Infants of drug-dependent women tend to be SGA (small for
- For Ophthalmia neonatorum levels. After birth, as an infant’s glucose level begins to gestational age).
• Bath baby immediately (HBsAg+ mother) fall because the mother’s circulation is no longer ❖ S/S: NAS (Neonatal Abstinence Syndrome)
- Bath immediately to remove the secretions and blood supplying glucose, the overproduction of insulin will - If the woman is dependent on a drug, an infant will show
from the baby cause the development of severe hypoglycemia. withdrawal symptoms (neonatal abstinence syndrome) shortly
• HBIG + HBV ● Hypocalcemia after birth.
- Babies are given vaccines and immune serum globulin - Hypocalcemia also frequently develops because These include such signs as:
for protection parathyroid hormone levels are lower in these infants ● Irritability
 ● Disturbed sleep pattern essential. If an infant has vomiting or diarrhea,
● Constant movement, possibly leading to abrasions on intravenous administration of fluid may be indicated.
the elbows, knees, or nose ● Avoid breastfeed with narcotic-use mothers.
● Tremors - An infant should not be breastfed to avoid passing
● Frequent sneezing narcotics in breast milk to the child.
● Shrill, high-pitched cry - Once an infant has been identified as having been
● Possible hyperreflexia and clonus (neuromuscular exposed to drugs in utero, the mother needs treatment
irritability) for withdrawal symptoms and follow-up care as much
● Convulsions as the infant. In addition, evaluation is necessary to
● Tachypnea (rapid respirations), possibly so severe that determine before discharge, whether an environment
it leads to hyperventilation and alkalosis that allowed for drug abuse, will be safe for an infant at
● Vomiting and diarrhea, leading to large fluid losses and home. Infants who are exposed to drugs in utero may
- As you can see in the eyes, there are small palpebral
secondary dehydration have long term neurologic problems.
fissures, low nasal bridge, epicanthal folds. Then in
- Specific neonatal abstinence scoring tools may be used to
between the nose and the mouth, supposed to be there’s a fold
quantify and assess an infant’s status. In newborns INFANT WITH FETAL ALCOHOL EXPOSURE
there. So what happens in fetal alcohol syndrome, there is
experiencing opiate withdrawal, signs usually begin 24 to 48 ❖ S/S: FASD (Fetal Alcohol Spectrum Disorder)
smooth philtrum. Upper lip is also thin and the presence of
hours after birth, but in some infants they may not appear for - Alcohol crosses the placenta in the same concentration as is micrognathia. A micrognathia is a condition in which the jaw is
up to 10 days. Generally signs last approximately 2 weeks, but present in the maternal bloodstream. This results in fetal lower or undersized. There are also minor ear anomalies.
mild signs may appear for up to 6 months. alcohol exposure and fetal alcohol syndrome. The syndrome
❖ NSG. CONSIDERATIONS: appears in about 2 per 1000 newborns and is often more - During the neonatal period, an infant may be tremulous,
● Remove excessive stimuli difficult to document than recreational drug exposure. Because fidgety, and irritable and may demonstrate a weak sucking
- Infants of drug-dependent women usually seem most it is unknown if there is a safe threshold of alcohol ingestion reflex. Sleep disturbances are common, with the baby tending
comfortable when firmly swaddled. Keep them in an during pregnancy, all pregnant women are advised to avoid to be either always awake or always asleep, depending on the
environment free from excessive stimuli (a small alcohol intake to prevent any teratogenic effects on their mother’s alcohol level close to birth.
isolation nursery, not a large, noisy one). Some quiet newborn.
best if the room is darkened. Many infants of heroin- - The newborn with fetal alcohol syndrome has several possible - The most serious long-term effect is cognitive challenge.
addicted women suck vigorously and continuously and problems at birth. Characteristics that mark the syndrome Behavior problems such as hyperactivity may occur in school
seem to find comfort and quiet if given a pacifier. include prenatal and postnatal growth restriction; central age children. Growth deficiencies may remain throughout life.
Infants of methadone- and cocaine-addicted women nervous system involvement such as cognitive challenge, An infant needs follow-up so any future problems can be
may have extremely poor sucking ability and may have microcephaly, and cerebral palsy; and a distinctive facial discovered. The mother needs follow-up to see if she can
difficulty achieving sufficient fluid intake unless gavage feature of a short palpebral fissure and thin upper lip. reduce her alcohol intake for better overall health.
fed (gavage feeding).
- Specific therapy for an infant is individualized
according to the nature and severity of the signs.
Maintenance of electrolyte and fluid balance is
MCN WEEK 6 NOTES
Causes of Infertility: ● Both - 20%
NURSING CARE OF CLIENTS WITH GENERAL
● Male - 35% ○ Environmental factors
DISTURBANCE IN REPRODUCTION AND
○ Pretesticular ■ Exposure to radiation or chemicals
SEXUALITY
■ These are problems or disorders concerning ○ Drugs
Slides 1-7 extragonadal endocrine, such as those ■ Drug users or prolonged maintenance of a drug
originating in the hypothalamus, pituitary or that can lead to infertility
The inability to conceive a child or sustain a pregnancy to
adrenals, in which these affect ○ Diet/Exercise
birth that affects as many as 14% of couples who desire
spermatogenesis (production of sperm cells). ■ Heavy exercises or faulty eating habits can also
children. Couples exploring fertility testing come in all
Pretesticular in other words are problems lead to infertility
different types: many are married couples who are having
concerning the amount of sperm or low sperm ● Unexplained - 10%
trouble conceiving; some are couples who have plans to
count.
marry and wonder if they will have trouble conceiving;
○ Testicular Assessment & Evaluation of Infertility:
some desire to remain single or partner with someone of
■ These are primary defects in the testis. From ● Health history and perform physical assessment
their own sex and bear a child, through an assisted fertility
the word primary, this concerns the shape and ● Nurses often assume the responsibility for initial history
method; some are gay or lesbian.
morphology of the sperm. taking with a subfertile couple. Because of the wide
○ Post-testicular variety of factors that may be responsible for
When a couple first pursues fertility counseling, they
■ These are factors affecting the ability of the subfertility.
usually have fears and anxieties not only about their
sperm to travel from the site of production, the ● Most couples assume that subfertility is the woman’s
inability to conceive but also about what this condition will
testicle, to leave the body in ejaculation. So it is problem. Many women, even after careful explanation
mean to their future lifestyle and family.
more on the problem of sperm motility or the that the problem is their male partner and not theirs,
movement of sperm. Such as those problems continue to show low self-esteem, as if the fault did rest
Infertility (Subfertility)
that develop due to autoimmunity which with them. For a thorough women’s health history, ask
- Inability to conceive a child or sustain a pregnancy to
immobilizes sperms. Another could be problems about:
birth after at least 1 year of unprotected sex.
in the ejaculation or deposition preventing ○ Current or past reproductive tract problems, such
- There are two types of infertility or subfertility:
spermatozoa from being placed close enough as infections
● Primary Subfertility
to a woman’s cervix to allow ready penetration ○ Overall health, emphasizing endocrine problems
○ There is no history of conception, which means
and fertilization. such as galactorrhea (breast nipple secretions) or
that there has been no previous conception at
● Female - 35% symptoms of thyroid dysfunction
all.
○ The factors that cause subfertility in women are ○ Abdominal or pelvic operations that could have
● Secondary Subfertility
analogous to those causing subfertility in men: compromised blood flow to pelvic organs
○ There has been a previous viable pregnancy
anovulation (faulty or inadequate production of ○ Past history of a childhood cancer treated with
but the couple is unable to conceive at present.
ova), problems of ova transport through the radiation that might have reduced ovarian function
fallopian tubes to the uterus, uterine factors such as ○ The use of douches or intravaginal medications or
Sterility - the inability to conceive because of a known
tumors or poor endometrial development, and sprays that could interfere with vaginal pH
condition, such as the absence of a uterus.
cervical and vaginal factors that immobilize ● Exposure to occupational hazards such as x-rays or
spermatozoa. toxic substances
MCN WEEK 6 NOTES
● Nutrition including an adequate source of folic acid and ● For both, nurses have to check into the lifestyle, use of ● Solutions to the problem can include psychological or
avoidance of trans-fats. contraception, STDs, smoking practices, exercises and sexual counseling as well as use of a drug such as
● If she can detect ovulation through such symptoms as the type of occupation. sildenafil (Viagra).
breast tenderness, mid cycle “wetness,” or lower ● Premature ejaculation (ejaculation before
abdominal pain (mittelschmerz). Diagnosis: penetration) is another factor that may interfere with
● Also obtain a menstrual history including: ● To determine and diagnose problems of infertility, the the proper deposition of sperm. . It is another problem
○ Age of menarche couple or an individual has to undergo a series of often attributed to psychological causes. Adolescents
○ Length, regularity, and frequency of menstrual diagnostic tests and procedures. may experience it until they become more experienced
periods ● In male infertility, problems in spermatogenesis, or in sexual techniques.
○ Amount of flow inadequate sperm count are determined by the ● In females, monitor and check for the production of
○ Any difficulties experienced, such as dysmenorrhea diagnostic test semen analysis. ova. Anovulation (absence of ovulation), the most
or premenstrual dysphoric disorder (PDD) ● For a semen analysis, after 2 to 4 days of sexual common cause of subfertility in women, may occur
○ History of contraceptive use abstinence, the man ejaculates by masturbation into a from a genetic abnormality such as Turner’s syndrome
○ History of any previous pregnancies or abortions clean, dry specimen jar. The number of sperm in the (hypogonadism) in which there are no ovaries to
● A minimum history for the man should include: specimen are counted and then examined under a produce ova.
○ General health microscope within 1 hour, then their appearance and ● It may result from a hormonal imbalance caused by a
○ Nutrition motility are noted. An average ejaculation should condition such as hypothyroidism that interferes with
○ Alcohol, drug, or tobacco use produce 2.5 to 5.0 mL of semen and should contain a hypothalamus-pituitary-ovarian interaction.
○ Congenital health problems such as hypospadias minimum of 20 million spermatozoa per milliliter of fluid ● Ovarian tumors may also produce anovulation because
or cryptorchidism (the average normal sperm count is 50 to 200 million of feedback stimulation on the pituitary, thus ova is not
○ Illnesses such as mumps orchitis, urinary tract per milliliter). produced.
infection, or sexually transmitted diseases ● In this procedure, the male should be instructed that a ● Chronic or excessive exposure to x-rays or radioactive
○ Radiation to his testes because of childhood cancer repeat is done after 2 or 3 months, because substances, general ill health, poor diet, and stress
or another cause spermatogenesis is an ongoing process, and 30 to 90 may all contribute to poor ovarian function.
○ Operations such as surgical repair of a hernia, days is needed for new sperm to reach maturity. ● The most frequent cause, however, is naturally
which could have resulted in a blood compromise ● Another male infertility factor is ejaculation problem or occurring variations in ovulatory patterns or polycystic
to the testes. sperm transport disorder, which includes erectile ovary syndrome, a condition in which the ovaries
○ Current illnesses, particularly endocrine illnesses or dysfunction or impotence (inability to achieve produce excess testosterone, lowering FSH and LH
low grade infections erection). This condition is primary if the man has levels.
○ Past and current occupation and work habits never been able to achieve erection and ejaculation ● Ovulation monitoring is the least costly way to
○ Sexual practices such as the frequency of coitus and secondary if the man has been able to achieve determine a woman’s ovulation pattern. Patient is
and masturbation, failure to achieve ejaculation, ejaculation in the past but now has difficulty. asked to record her basal body temperature (BBT) for
premature ejaculation, coital positions used, and ● This condition is primary if the man has never been at least 4 months (according sa book; 1 month gi ingon
use of lubricants able to achieve erection and ejaculation and secondary ni Miss so dili ko sure).
○ Past contraceptive measures, and existence of any if the man has been able to achieve ejaculation in the ● To determine this, a woman takes her temperature
children produced from a previous relationship. past but now has difficulty. each morning, before getting out of bed or engaging in
MCN WEEK 6 NOTES
any activity, eating, or drinking, using a special BBT or passed through the vagina, into the pouch of douglas, Management:
tympanic thermometer. and an optic scope is placed through the trocar sleeve, ● Pharmacologic:
● She plots this daily temperature on a monthly graph, allowing close examination to the uterus, ovaries, ○ Sildenafil (Viagra)
noticing conditions that might affect her temperature fallopian tube, and peritoneum. ■ This drug is used to treat male’s sexual function
(e.g., colds, other infections, sleeplessness). ● In this procedure, no abdominal incision is required. problems, like impotence or erectile dysfunction
● At the time of ovulation, the basal temperature can be The procedure can be accomplished in the office disorder. This is in combination with sexual
seen to dip slightly (about 0.5° F); it then rises to a setting. stimulation. It works by increasing the blood
level no higher than normal body temperature. ● Uterine endometrial biopsy may be used as a test for flow to the penis, to help a man get and keep
● Towards the end of the cycle, during the 24th day, her ovulation or to reveal an endometrial problem such as an erection.
temperature begins to decline, indicating that a luteal phase defect. ○ Dapoxetine
progesterone levels are falling, and that she did not ● Endometrial biopsies are done 2 or 3 days before an ■ A selective serotonin reuptake inhibitor (SSRI)
conceive. expected menstrual flow (day 25 or 26 of a typical which is specially developed for treatment of
● Another way is through tubal patency. Both ultrasound 28-day menstrual cycle). It will start with the induction premature ejaculation. This increases the time
and x-ray imaging can be used to determine the of a paracervical block or anesthesia, then a thin to ejaculate and can improve the control of
patency of fallopian tubes and assess the depth and probe and biopsy forceps are introduced through the ejaculation. It starts to work very quickly so it is
consistency of the endometrial lining. cervix. A woman may experience mild to moderate taken when you anticipate having sex, rather
● Nurses need to assess the tubal patency to determine discomfort from the maneuvering of the instruments. than taking it everyday. You have to take it 1-2
tubal transport problems. Difficulty with tubal transport There may be a moment of sharp pain as the biopsy hours before an individual will engage in sexual
usually occurs because scarring has developed in the specimen is taken from the anterior or posterior uterine activity.
fallopian tubes. This typically is caused by chronic wall. Possible complications include pain, excessive ○ Hormone Therapy
salpingitis (chronic pelvic inflammatory disease). It can bleeding, infection, and uterine perforation. ■ For couples who are unable to have children,
result from a ruptured appendix or from abdominal ● This procedure is contraindicated if pregnancy is this treatment can increase the chance of
surgery involving infection that spread to the fallopian suspected (although the chance that it would interfere pregnancy.
tubes and left adhesion formation in the tubes. with a pregnancy is probably less than 10%) or if an ■ In many cases, inability to have children can be
● Sonohysterography is an ultrasound technique infection such as acute PID or cervicitis is present. attributed to hormonal imbalance. Although
designed for inspecting the uterus and fallopian tube. Caution a woman that she might notice a small amount hormonal imbalance can be present in both
The uterus is filled with sterile saline, introduced of vaginal spotting after the procedure. For follow-up, men and women, hormone treatment is usually
through a narrow catheter inserted into the uterine she needs to call her primary care FIGURE 8.3 performed in women.
cervix. A transvaginal ultrasound transducer is then Insertion of dye for a hysterosalpingogram. The ■ Hormone treatment, in women, aims to promote
inserted into the vagina to inspect the uterus for contrast dye outlines the uterus and fallopian tubes on egg maturation and triggers ovulation. So this
abnormalities such as septal deviation or the presence radiographs to demonstrate patency. If she develops a increases the likelihood of successful
of a myoma and assess the patency of the fallopian temperature greater than 101° F, has a large amount of fertilization. Under hormone therapy we have
tube. Because this is a minimally invasive technique, it bleeding, or passes clots. Clomiphene citrate or clomid. This is an oral
can be done at any time during the menstrual cycle. ● She also needs to call the health care agency when medication that is often used to treat certain
● Transvaginal Hydrolaparoscopy allows direct she has her next menstrual flow. This helps “date” the types of women infertility. Clomid works by
visualization of female peritoneal cavity. A trocar is endometrium and the accuracy of the analysis. making the body think that your estrogen levels
MCN WEEK 6 NOTES
are lower than they are, which causes the ■ Antibiotic therapy is given if underlying cause is
Slides 8-14
pituitary gland to increase secretion of FSH brought about by infection, such as in pelvic
(follicle stimulating hormone) and LH (luteinizing inflammatory diseases.
hormone). High levels of FSH stimulate the ● Canalization of fallopian tube
ovary to produce an egg cell or multiple follicles ○ This is a nonsurgical procedure to clear the
that would develop and release during blockage in the fallopian tube and this is performed
ovulation, while high levels of LH stimulate through a speculum placed in the vagina, and a
ovulation. small plastic tube is inserted into the cervix to the
■ Letrozole is a medication that has been used in uterus. Then a liquid contrast agent is injected
women with breast cancer. It is sold under the through a catheter and examine the uterine cavity
trade name femara. Letrozole belongs to a on a nearby monitor using an x-ray camera. If
class of medication known as aromatase blockage is determined, and it is located on one or
inhibitor. Aromatase is an enzyme that is both fallopian tubes, thread a small catheter
Artificial Insemination (Therapeutic Insemination ang
responsible for the production of estrogen in the through the first catheter and then into the fallopian
nakaput sa ako book)
body. It works by inhibiting aromatase, thereby tube to clear the blockage.
suppressing estrogen production. ● Adhesiolysis
The instillation of sperm into the female reproductive tract
■ Clomiphene citrate on the other hand, blocks ○ Adhesions can form from any type of trauma to the
to aid conception. The sperm is instilled into the cervix
estrogen receptors. In both cases, the result is abdomen. However, they’re most commonly a side
(intracervical insemination) or directly into the uterus
that the pituitary gland produces more hormone effect of abdominal surgery. In adhesiolysis, this is
(intrauterine insemination). Either the husband’s sperm
needed to stimulate the ovaries. the removal of adhesions in any part of the
(artificial insemination by husband) or donor sperm
■ These hormones, FSH and LH, can cause the abdominal cavity. In fertility adhesion can cause
(artificial insemination by donor or therapeutic donor
development of ovulation in women who are female reproductive organ problems by obstructing
insemination) can be used.
anovulatory or increase the number of eggs ovaries or fallopian tubes. They can also be a
developing in the ovaries of women who cause of painful intercourse for some people. So if
Used if the man has an adequate sperm count or a woman
already ovulates. a doctor suspects adhesions are causing the
has a vaginal or cervical factor that interferes with sperm
■ Bromocriptine belongs to the group of medicine reproductive issue, they may recommend surgery
motility.
also known as ergot alkaloids. It blocks the to remove them. As for how it is done, a
release of a hormone called prolactin from the laparoscope is a long thin tube that contains a
Donor insemination can be used if a man has a known
pituitary gland. Prolactin affects the menstrual camera and light is inserted into an incision which
genetic disorder that he does not want transmitted to
cycle and milk production. Bromocriptine is helps the surgeon find the adhesion to remove
children or if a woman has no male partner.
used to treat certain menstrual problems like them.
It is a useful procedure for men who, feeling their family
amenorrhea in women and stop milk production
was complete, underwent a vasectomy but now wish to
in some men and women who have abnormal
have children.
milk leakage. It is also used to treat infertility in
both men and women that occurs because the
body is making too much prolactin.
MCN WEEK 6 NOTES
In the past, men who underwent chemotherapy or radiation assess the number and size of developing ovarian follicles.
for testicular cancer had to accept being child free Some couples have religious or ethical beliefs that prohibit When a follicle appears to be mature, a woman is given an
afterward as they were no longer able to produce sperm. them from using artificial insemination. Some states have injection of hCG, which causes ovulation in 38-42 hours.
specific laws regarding inheritance, child support, and
Today, sperm can be cryopreserved (frozen) in a sperm responsibility concerning children conceived by artificial In the harvesting procedure, a needle is introduced
bank before radiation or chemotherapy and then used for insemination. Artificial insemination takes an average of 6 intravaginally, guided by ultrasound and the oocyte is
insemination afterward (cryopreserved sperm: sperm months to achieve conception, it may be a discouraging aspirated from its follicle. Many oocytes may ripen at once
placed in a sperm bank before radiation or chemotherapy). process for couples to have to wait this long to see results. and perhaps as many as 3 to 12 can be removed. The
oocytes are incubated for at least 8 hours to ensure
One disadvantage of using frozen sperm is that it tends to In Vitro Fertilization viability. In the meantime, the husband or donor supplies
have slower motility than unfrozen specimens/sperm. One or more mature oocytes are removed from a woman’s fresh semen specimens. The sperm cells and oocyte are
However, although the rate of conception may be lower ovary by laparoscopy and fertilized by exposure to sperm mixed and allowed to incubate in a growth medium.
from this source, there appears to be no increase in the under laboratory conditions outside a woman’s body. About
incidence of congenital anomalies in children conceived by 40 hours after fertilization, the laboratory grown fertilized After sterilization of the chosen oocyte occurs, the zygotes
this method. ova are inserted into a woman’s uterus, where ideally one formed almost immediately begin to divide and grow. By 40
or more of them will implant and grow. hours after fertilization, they will have undergone their first
An advantage of cryopreserved sperm is that it can be cell division. The fertilized eggs are then examined if it is
used even after years of storage. Most often used for couples who have not been able to normal, it is transferred back to the uterine cavity through
conceive because a woman has a blocked or damaged the cervix by means of a urinary catheter.
To prepare for artificial insemination, a woman must record fallopian tube. It is also used when a man has oligospermia
her Basal Body Temperature (BBT), assess her cervical (very low sperm count). IVF may be useful to help couples In some instances, progesterone may be given to a woman
mucus, or use an ovulation predictor kit to predict her when an absence of cervical mucus prevents sperm from if it is believed that she will not produce enough on her
likely day or involution. travelling to or entering the cervix, or antisperm antibodies own to support implantation.
cause immobilization of sperm. In addition, couples who
On the day after involution, the selected sperm are instilled have unexplained infertility of long duration may be helped Once a pregnancy has been successfully established, a
into the cervix using a device similar to a cervical cap or by IVF. woman’s prenatal care is the same as that for any
diaphragm, or they are injected directly into the uterus pregnancy.
using a flexible catheter. A donor ovum, rather than a woman’s own ovum, also can
be used for a woman who does not ovulate (genetic Part of the nursing consideration, we nurses need to
If therapeutic donor insemination is selected, the donors disorder) or carries a sex linked disease that she does not supply support and counseling to sustain the couple
are volunteers who have no history of disease or no family want to pass on to her children (these are the indications). through this process. Also couples need emphatic support
history of possible inheritable disorder. The blood type, or from the health care providers through these difficult times.
at least the Rh factor, can be matched with the woman’s to Before the procedure, a woman is given an
prevent incompatibility. Sperm from sperm banks can be ovulation-stimulating agent such as Clomiphene citrate
selected according to the desired physical or mental (Clomid). Beginning about the 10th day of the menstrual
characteristics. cycle, the ovaries are examined daily by ultrasound to
MCN WEEK 6 NOTES
Infertility (Subfertility) Client Education: Sexual Dysfunction - This can happen at any phase of
Nursing Management: 1. Provide information of the different tests and sexual response cycle, and it prevents an individual from
● Educate couples on a variety of tests. procedures and possible outcomes. experiencing satisfaction from sexual activity.
○ As we all know couples have to undergo diagnostic 2. Self care awareness regarding fertility:
testing procedures in order to determine problems ● Avoid douching 1. Desire disorders
of infertility. Prior to availing those tests, we need to ○ Can alter the pH of vaginal secretion ● Lack of sexual desire or interest in sex
inform this couple how these procedures are being ● Promote retention of sperm after coitus ● The decrease in the sexual desire can also be the
performed and what is expected of that. ○ Right positioning effect of the medicine or chronic disease such as
● Allow couples to express thoughts on subfertility of ● Maximize the potential for fertilization peptic ulcer or chronic pulmonary disorder that
sterility. ○ Intervention: Monitoring of ovulation and right causes frequent pain and discomfort. This may
○ Infertility causes anxiety and emotional stress to timing of coitus. interfere with the man and women’s overall
individuals or couples. ● Avoid anxiety and stress. wellbeing and interest in sexual activity.
● Listen to them. ● Maintain adequate nutrition. 2. Arousal disorders
● Express their concerns. 3. Empowering realistic expectations. ● Inability to become physically aroused or excited
● Let them ventilate their feelings and anxiety. ● Most infertility interventions have advantages and during sexual activity.
○ This way it relieves tension and airs out feelings of disadvantages and not all of the outcomes favors ● Can be caused by physical or psychological factors
frustrations and disappointments. the couple’s desires. Help them set realistic goals or both. Needs careful assessment to help clarify
● Reinforce options on alternative childbirth techniques. to prevent devastations. the cause of the problem.
○ Surrogate mothers 4. Provide emotional support. 3. Orgasm disorders
■ Women who agrees to carry a pregnancy to ● With all of the anxiety and stress they are going ● Delay of absence of orgasm
term for a infertile couple through, we uplift them, offer genuine ● The failure of women to achieve orgasm can be a
○ Adoption encouragement, reassurance and compassion. result of poor sexual technique, or concentrating
■ Once a ready alternative for infertile couple 5. Create or refer to support groups. too hard on achievement or negative attitude
○ Child-free Living ● Couples with infertility are described to be toward sexual relationships. Treatment is aimed to
■ An alternative lifestyle available for both fertile extremely isolating. They may feel like they are the relieve the underlying cause and it may include
and infertile couple couples who have been only couple going through this. To help them, let instruction and counseling for the couple about
through rigors and frustrations of subfertility them talk to others who are in similar situation sexual feelings and needs. Like the arousal
testing and unsuccessful treatment regimens, 6. Promote a positive self image disorder, disorder of orgasm occurs in both men
child free living may emerge as the option they ● We help them recognize their own assets and and women.
finally wish to pursue. potential while being realistic liabilities and 4. Pain disorders
limitations. Negative self-image focuses on faults, ● Pain during intercourse (dyspareunia)
Advantages: distorting image and imperfections. A positive self ● Because the reproductive system has sensitive
● Pursue careers image can boost our physical, mental, social, nerve supply when pain occurs in response to
● Travel more spiritual well being. sexual activities it can be acute or severe and
● More time for hobbies impairs a person’s ability to enjoy this segment of
● May continue their education life.
MCN WEEK 6 NOTES
● Examples of a condition under pain disorder: ○ Such as vaginal vacuum, these are mechanical
Slides 15-21
○ Vaginismus aids in helping relieve pain during sexual
■ Involuntary contraction of muscles at the Etiology: intercourse and maybe penile implant.
● Urologic problem
outlet of vagina when coitus is attempted. ● Psychotherapy
● Chronic conditions
This muscle contraction prohibits penile
○ Such as pulmonary disease
penetration. This can occur in women who Nursing Considerations:
○ Peptic ulcer can also lead to sexual dysfunction.
have been raped and also a result of early ● Educate on preventing sexual dysfunction.
○ For example, pulmonary disease, if an individual
learning pattern in which sexual relations ○ How to prevent: We need to understand the
has chronic pulmonary disease he/she has the
are viewed as bad and sinful. In other underlying cause then we can be able to help them
tendency to cannot perform, maybe the individual
sexual problems, psychological counseling abstain or prevent from having sexual dysfunction.
will experience difficulty in breathing. He/She will be
is needed to reduce this response ● Diet modification
deprived of air so the individual cannot reach or an
○ Vestibulitis ○ Obesity could be a cause in sexual dysfunction. A
individual has a sexual disorder.
■ Inflammation of the vestibule. This condition diabetic individual can also experience sexual
○ Example: A diabetic individual has decreased libido
occurs due to endometriosis or abnormal dysfunction.
because of the hormone and overweight individuals
placement of endometrial tissue, vaginal ● Control health if comorbidities are present.
can also be one of the etiology of sexual
infection, hormonal changes that occur with ○ Health conditions like chronic conditions. We need
dysfunction.
menopause and causes vaginal drying. to inform them that they need to see a doctor to
● Hormonal imbalance
■ A psychological condition may be present, have a maintenance medication so that they may
● Alcohol and drugs
treatment is aimed at the underlying cause, be able to do some of the activities that they
● Nerve damage
encouraging open communication between wanted to do, especially activities for couples.
● Psychological in origin
the sexual partners is necessary.

Signs and Symptoms: INFECTIONS

● Premature Ejaculation
● Lack of sexual desire 1. Vaginitis
○ Ejaculation before penile-vaginal contact
○ Lack of interest into coitus - An inflammation of the vagina that can result in
○ This term is also used to mean ejaculation before
● Difficulty in arousal discharges, itching and pain.
the sexual partner achieved satisfaction.
○ Problems like erectile dysfunction or impotence - The cause is usually a change in the normal
○ This can be unsatisfactory and frustrating to both
● Pain during intercourse balance of the vaginal bacteria or an infection.
partners.
○ Other reasons suggest: doubt of muscularity and - Reduced estrogen level after menopause and
Management: some skin disorders can also cause vaginitis.
fear of impregnating the woman, which prevents
● Counseling, behavior modification
the men from sustaining an erection.
● Sildenafil (viagra) Etiology:
○ Sexual counseling to both partners may be helpful
○ Problems of impotence ● Yeast infection
to reduce stress in alleviating the problem.
○ It can be prescribed to this individual to correct ○ This occurs when there is overgrowth of fungal
● Persistent Sexual Arousal Syndrome
○ Excessive sexual arousal in the absence of desire. some sexual dysfunction. organisms, usually caused by candida albicans in
● Mechanical aids the vagina.
MCN WEEK 6 NOTES
○ Candida albicans also causes infection in other Signs and Symptoms: ovary, uterine wall, uterine serosa, broad ligaments
moist areas of the body such as in the mouth in the ● Discharges and the pelvic peritoneum.
form of oral thrush, skin folds and nail beds. The ○ Changes in the color, odor and amount of
fungus can also cause diaper rash. discharges from the vagina.
Slides 22-28
○ Antibiotics, hormone therapy, diabetes ● Redness, swelling, itching, pain during intercourse
● Bacterial vaginosis - STI ● Odor Signs and Symptoms:
○ The common cause of vaginitis results from a ● Dysuria ● Pain in your lower abdomen and pelvis
change of the normal bacteria found in the vagina. ○ Painful urination ● Heavy vaginal discharge with an unpleasant odor
The overgrowth of one of the several organisms ● Light vaginal bleeding or spotting ● Abnormal uterine bleeding, especially during or after
usually bacteria normally found in the vagina like ● Pain or bleeding upon sex intercourse, or between menstrual cycles
lactobacilli are outnumbered by other bacteria such ● Pain or bleeding during intercourse
as anaerobes . If anaerobic bacteria becomes too Nursing Considerations: ● Fever, sometimes with chills
numerous they accept the balance causing ● Explain the importance of complete course of antibiotic ● Painful or difficult urination
bacterial vaginosis. therapy to prevent resistance to the drug.
○ This type of vaginitis seems to be linked to sexual ● Avoid douching. Etiology:
intercourse especially if a person has multiple ● Avoid irritants. ● STDs (gonorrhea and chlamydia)
sexual partners or a new sex partner. It also occurs ○ This includes scented tampons, pads, douching, ○ Many types of bacteria can cause PID but
in women who aren’t sexually active. scented soap. gonorrhea and chlamydia are the most common
● Trichomoniasis ○ Rinse soap from the outer genital area after a one.
○ This common sexually transmitted infection is shower and dry the area well to prevent irritation. ○ These bacteria are usually acquired during
caused by a microscopic one celled parasite called ○ Do not use harsh soaps such as those with unprotected sex. Less commonly, bacteria can
trichomonas vaginalis. deodorant and antibacterial action or bubble bath. enter the reproductive tract anytime.
○ Trichonomas vaginalis ● Avoid tampons. Regularly change sanitary pads. ● Childbirth, miscarriage and abortion
■ This organism spread through sexual ● Practice protected sex. ○ The normal value created by the cervix is disturbed.
intercourse with some who have the infection. ○ The use of latex condoms. Both male and female ○ This can happen during menstruation and
In men, the organism usually infects the urinary latex condoms may help you avoid infections childbirth, or miscarriage or abortion.
tract that often causes no symptoms. spread by sexual contact. ○ Rarely bacteria can also enter the reproductive
○ In women, trichomoniasis usually infects the vagina tract during the insertion of IUD, a form of long term
and might cause symptoms also increases a 2. Pelvic Inflammatory Disease (PID) birth control or any medical procedure that involves
woman’s risk of getting sexually transmitted - Infection of the female reproductive organ inserting instruments to the uterus.
infection. spreading from the vagina to the uterus, fallopian
tubes or ovaries. Risk Factors:
Atrophic Vaginitis - the thinning of tissues and less - This is an ascending infection in the upper genital ● Sexually active, more than one sexual partner
moisture due to menopause tract caused by poly microbial organisms. ○ Women younger than 25 years old having multiple
- This may include infection of any of the following sexual partners or being in a sexual relationship
anatomical structures: endometrium, oviduct,
MCN WEEK 6 NOTES
with a person who has more than one sexual ○ The use of condom every time an individual engage pain after sex. And the typical sign of infection such as
partner. into sex with a new partner protects STI. fever. These symptoms can have a significant impact on
● Unprotected sex ● Avoid douching. the quality of life but in most cases they gradually improve
○ Sex without condom ○ Douching upsets the balance of bacteria in the every time and with treatment.
● Douching regularly vagina.
○ Which upset the balance of good versus harmful
bacteria in the vagina. Treatment:
● History of PID or STD ● Antibiotics (same with partner)
● Temporary abstinence

Prostatitis
- This is an inflammation or swelling of the prostate
gland. It can be very painful and distressing but will
often get better eventually.
- Can come at any age but usually between the age Epididymitis
30-50 years old. - Where a tube or the epididymis at the back of the
- Prostate is a small gland that lies between the penis testicle becomes swollen and painful.
Diagnosis: and the bladder. It produces fluid that mixes with sperm - It is often caused by an infection and is usually treated
● Pap smear (Papanicolaou smear) to create semen. with antibiotics.
● Culture and sensitivity testing - If the testicles is also affected, if maybe called
○ Of vaginal secretion Signs and Symptoms: epididymo-orchitis
● UTZ (ultrasound) ● Dysuria, nocturia, hematuria
○ Pain when peeing
Nursing Considerations: ○ There is frequency, urgency or the need to pee
● Encourage to practice safe sex and use of particularly at night or stop-start peeing.
contraception. ● Pain in the abdomen, groin or lower back
○ The use of condoms every time an individual ● Pain in the area between the scrotum and rectum
engage into sex and the limitation of numbers of ● Pain or discomfort of the penis or testicles
partner and ask about potential partner sexual ● Painful ejaculation
history. ● Fever
○ The use of birth control pills do not protect against
the development of PID. Pain is also present in and around the penis, testicles,
○ Using barrier methods such as condoms helps to anus, lower back or lower abdomen. There is also
reduce the risk even if you are taking birth control enlargement or tenderness of the prostate on rectal Signs and Symptoms:
pills. examination. Sexual problem could also be present such ● A swollen, red or warm scrotum
as erectile dysfunction, pain when ejaculating or pelvic ● Testicle pain and tenderness
MCN WEEK 6 NOTES
● Dysuria - Young boys may not need treatment, unless it makes (Left: Phimosis; Right: Normal Retracted Foreskin)
○ Pain upon urination urination difficult or causes other symptoms.
● Discharge from the penis - Tight foreskin is common in baby boys who are not Hypospadias
● Pain or discomfort in the lower abdomen or pelvis circumcised (usually stops by 3-years-old). - Abnormal ventral placement of urethral opening on the
● Blood in the semen underside of the penis.
● Fever Balanitis - Birth defect or congenital condition in which the
○ Typical sign of infection - Inflammation of the phimotic foreskin (glans/head of opening of the urethra is on the underside instead of at
the penis). the tip.
Etiology: - Due to infection or other causes. - Urethra: Tube through which urine drains from the
● Current UTI - Can be uncomfortable and sometimes painful but is not bladder and exit to the body.
○ Less common in men usually serious. - Common and does not cause difficulty caring for this
● STI (chlamydia or gonorrhea) - Relieved with topical medication. infant.
○ More likely in younger men under 35-years-old - Surgery usually restores the normal appearance of the
● Groin injury (epididymitis) Nursing Considerations: child’s penis.
○ Undergone surgery to the groin, prostate and ● Encourage proper hygiene.
bladder ● Instruct not to forcibly retract the skin. Signs and Symptoms:
○ Paraphimosis may occur. ● Opening of the urethra other than the tip of the penis
Treatment: ○ A urologic emergency in which the retracted ● Chordee
● Antibiotic foreskin of an uncircumcised male cannot be ○ Downwards curvature of the penis
Nursing Considerations: returned back to its normal anatomical position; ● Hooded appearance of the penis (only the top half of
● Lie down with elevated scrotum. recognize condition promptly, can lead to gangrene the penis is covered by foreskin)
● Cold packs over scrotum (hypogastric area) to relieve and amputation of the glans penis. ● Normal (spraying?) during urination
pain and discomfort.
● Avoid lifting heavy objects. Treatment: Nursing Considerations:
● Abstinence ● Steroid cream ● No circumcision
● Avoid alcohol, caffeine, spicy and acidic foods that ● Circumcision ● Catheter care (in surgery)
irritate the bladder. ● Urinary diversion
● Encourage increase in water intake. ○ Position drainage bag at lower level to facilitate
continuous flow of urine.
● Avoid tub baths, straddle toys, sandboxes, swimming
Slides 29-35
and rough activities.
INFANTS ● Encourage quiet play after the first few weeks of
Phimosis surgery. Avoid contact sports while the catheter is in
- The inability to retract the foreskin from the glans of the place.
penis.
- Can occur naturally or be the result of scarring.
MCN WEEK 6 NOTES
Pharmacological Management: born prematurely. The undescended testicle moves
● Anticholinergic (Oxybutynin) into proper position on its own within the first few
○ Used to treat bladder spasm months of life. If your son has undescended testes
that doesn’t correct itself, then surgery can relocate
Treatment: the testicle into the scrotum.
● Surgical correction: 6-12 months of age Sign & Symptoms
● Testosterone (pre-op) - Absence of testes in the scrotum. Testicle
○ To increase the size of the penis formed in the abdomen during fetal development.
● Goal: To improve the physical appearance, to be able During the last couple of months of normal fetal
to void in a standing position and sexually adequate development, the testicle gradually descends from
organ. the abdomen through a tube-like passageway in
the groin or inguinal cavity into the scrotum.
Bladder Exstrophy (How Bladder Exstrophy looks like with Epispadias: Male) - Acquired undescended testes
- Severe defect involving the musculoskeletal system - Retractile testes on warm baths
and urinary, reproductive and intestinal in some cases. Slides 36-42
- Congenital abnormality that occurs whenever the skin Treatment
Cryptorchidism
over the lower abdomen does not form properly—the - Spontaneous descend within 6 months of life
bladder is open and exposed on the outside of the - Surgery 12-18 months of life
abdomen. - Orchiopexy (a procedure to move testicle that has
- “Exstrophy” = turned inside out not descended or moved down to its proper place
in the scrotum. Done 6-24 months of life)
Epispadias
- Failure of urethra to close; opening at the dorsal of the Nursing Consideration
penis. - Pain management
- The urethra does not form properly. - Keep post-op site free from stool and urine. Take
- So all boys with bladder exstrophy also have note of the anatomical position of the site and the
epispadias, but it can occur on its own. possibility of contaminating urine
- Avoid rough sports and straddling
Nursing Considerations: - Teach child TSE starting puberty
● Clamp cord with soft umbilical tape or silk suture.
● Parental support - Failure of one or both testes to design through the Hydrocele
inguinal canal into the scrotum. Another term for - Presence of peritoneal fluid in the scrotum between
Treatment: this is undescended testicle. Usually one testicle is the parietal and visceral layers of the tunica
● Surgery affected but about 10% of the time, both testicles vaginalis. Most common painless scrotal swelling in
are undescended. An undescended testicle is children.
uncommon in general but common among babies
MCN WEEK 6 NOTES
- Swelling in scrotum that occurs when fluid collects Nursing Consideration of the day and relieved when the person lay down on
in the thin sheet surrounding the testicle. - Swelling and discoloration are temporary his back. This causes impaired infertility.
- Common in newborns and usually disappear - Change dressing everyday and bathe after 3 days ● Physical Appearance:
without treatment by age 1. Other boys and adult - Avoid straddle toys for 2-4 weeks ○ Wormlike mass above the testes
men can develop hydrocele due to inflammation or ○ Decrease testes
injury within the scrotum. ○ Decrease dihydrotestosterone
Slides 43-49 ADOLESCENTS
- Is not usually painful or harmful and might not need
any treatment Varicocele Treatment:
2 types of hydrocele ● Varicocelectomy
Communicating Hydrocele ○ A surgery performed to remove those enlarged
- Open process vaginalis veins and it is done to restore proper blood flow to
- Has an opening into the abdominal cavity. The the reproductive organ.
opening allows abdominal fluid to pass into the
scrotum. ADULT WOMEN
Noncommunicating Breast Cancer
- Less serious
- Usually remains the same size or has a very slow
growth. No connection with peritoneum or due to
secondary to trauma, infection, torsion.
If the communicating hydrocele does not go away on its - Elongation, dilation and tortuosity of the veins of the
own, and is not treated, it can lead to an inguinal hernia. spermatic cord or rather this is an enlargement of the
vein within the loose bag of skin that holds the testicle
or the scrotum.
- Similar to varicose vein that you may seen in the legs
- Common cause of low sperm production and decrease
sperm quality which can cause infertility
- Can cause testicle to fail to develop normally or shrink - Cancer that forms into the cells of the breast , after skin
- Most varicocele develop overtime or most varicocele is cancer breast cancer is the most common diagnosis in
easy to diagnose and may not need treatment women.
- If it causes symptoms is often can be repaired - Occurs both in men and women, but far more common
surgically in women.
- Survival rates have increased and the number of
Treatment
Signs and Symptoms: deaths associated with this disease is steadily
Surgery - for communicating hydrocele, this is corrected
● Rarely it might cause pain (sharp to dull discomfort). declining.
within 1 year
● There is increased pain when standing or physical
exertion over long periods. It worsened over the course
MCN WEEK 6 NOTES
- Largely due to factors such as early detection, new ○ Is most often used to treat cancer, since cancer ○ All of which have an impact on overall quality of life
personalized approach to treatment and better cells grow and multiply more quickly than most cells particularly body image perception.
understanding of the disease. in the body.
○ Many different chemotherapeutic drugs are Fibrocystic Breast
Signs and Symptoms: available, chemotherapy drugs can be used alone - Nodular or glandular breast tissue or these are
● A breast lump or thickening that feels different from the or in combination to treat a wide variety of cancer. composed of tissues that feel lumpy or ropelike in
surrounding tissue ● Radiation Therapy texture.
● Changes in the size, shape or appearance of a breast ○ A type of cancer treatment that uses a beam of - More than half of women experienced fibrocystic breast
particularly during physical and breast examination intense energy to kill cancer cells. changes at some point of their life.
● Changes to the skin over the breast, such as dimpling ○ Most often used x-rays but proton or other types of - In fact medical professionals have stopped using the
● A newly inverted nipple energy can be used. term fibrocystic breast disease and now simply refer to
● Peeling, scaling, crusting or flaking of the pigmented ○ Most often refers to external beam radiation fibrocystic breast. Fibrocystic breast changes because
area of the skin surrounding the nipple (areole) or therapy. having fibrocystic breast is not really a disease.
breast skin ○ Damages cells by destroying genetic material that - Breast changes categorized as fibrocystic are
● Redness or pitting of the skin over your breast like the controls how cells grow and divide. While both considered normal. Although many women with
skin of an orange health and cancerous cells are damaged by fibrocystic breasts do not have symptoms, some
radiation therapy. women experience breast pain, tenderness and
Treatment: ○ The goal is to destroy as few normal cells, healthy lumpiness especially in the upper outer area of the
● Lumpectomy cells as possible. Normal cells can often repair breast.
○ A surgery to remove cancer or other abnormal much of the damage caused by radiation. - Breast symptoms tend to be most bothersome just
tissue from the breast. before menstruation. Simple self-are measures can
○ Also called breast conserving surgery or wide Nursing Considerations: relieve discomfort associated with fibrocystic breasts.
location incision because only portion of the ● Chemotherapy support
breast is removed. ○ Helps aids in the overall health and well-being of an Etiology:
○ During lumpectomy, a small amount of tissue individual. So support from family, friends and ● Related to estrogen
around the lump is taken to help ensure that all healthcare providers has value to participate as to
cancer or other abnormal tissue is removed. deal with the disease and treatment. Signs and Symptoms:
● Mastectomy ● Hydration ● Breast lumps with fluctuation size especially during or
○ A surgery to remove all breast tissues from a breast ○ Providing adequate hydration can counter the effect nearing menstruation
as a way to treat or prevent breast cancer. of dehydration for significant planned visits to ● Generalized breast pain or tenderness
○ With those early stages of cancer mastectomy, cancer clinics, proper hydration of the patient. ● Green or dark brown nonbloody nipple (secretion is
maybe one treatment option. ● Address body image concerns. present)
● Chemotherapy ○ The body image concerns in women have been ● Monthly increase in breast pain or lumpiness from mid
○ Drug treatment that uses powerful chemicals to kill attributed to loss of breast from surgery, this result cycle (ovulation) to menstruation
fast growing cells in the body. scarring, physical changes resulting from adjuvant
treatment.
MCN WEEK 6 NOTES
- Cause is unknown Fine-needle aspiration
Slides 50-56
- Occurs more often during the reproductive years
...continuation (picture only, no audio in this slide) - Becomes bigger during pregnancy or hormone
therapy
- May shrink after menopause
S/S:
● Firm, smooth, rubbery or hard and has a
well-defined shaped lump
● Painless, moveable
● Complex fibroadenomas - this contains changes
such as an overgrowth of cells or hyperplasia that
can grow rapidly; diagnosed after reviewing the - May collapse the cyst and resolve the discomfort
Fibrocystic Breast
Diagnosis: tissue from a biopsy
● Juvenile fibroadenomas - most common; found in Treatment
● Detected through:
adolescent girls (10-18 y.o.). It can grow large but ● Monitoring to detect changes in the size (can shrink
○ Clinical & self-breast exam - the doctor
shrinks overtime and some may disappear or disappear on their own)
checks the breast and lump modules by the
● Giant fibroadenomas - can grow larger than 2 in. or ● Biopsy - to evaluate the lump
lower neck and underarm areas; if normal
5 cm; might need to remove because they can ● Surgery - to remove the lump
breast changes = no need for additional
press on or replace other breast tissue ○ Lumpectomy
tests
● Phyllodes tumor - usually benign; some can ○ Cryoablation
○ Mammogram - 45 yrs & above; to take
annually. Focuses on a specific area of become cancerous or malignant. Doctors
recommend removing the tumor. Nursing Consideration
concern in the breast.
● Instruct to wear firm support bra
○ Ultrasound - uses soundwaves to produce
● Avoid caffeine and fats
image of the breast and often performed
● Warm pack for discomfort
with mammogram; better use for younger
women; can help the doctor distinguish fluid
Dysmenorrhea
filled cyst and solid mass
- Pain at the suprapubic area or lower abdomen
Treatment
during or shortly after menstruation
● Fine-needle aspiration
Two Types
● Surgical incision
● Primary dysmenorrhea - due to prostaglandin
release. 8-48 hrs.
Fibroadenoma of the Breast
○ Occurs at menarche and continues
- Solid, non cancerous breast lumps that occur most
throughout life
often in women between the ages of 15 and 35.
○ Commonly first 3 to 5 years after menarche
Hormonal in nature.
or after ovulation is established
MCN WEEK 6 NOTES
○ Usually life-long Most girls have a small crescent or donut-shaped opening Different Types of Hymen:
○ Can cause frequent and severe menstrual in their hymen. This opening allows for access to the ● Normal
cramping for severe and abnormal uterine vagina and approximately 1 in 1,000 girls are born with ● Imperforate
contraction what is called imperforate hymen. ● Microperforate
● Secondary dysmenorrhea - due to pathologic ● Cribriform
condition. Dull pain that radiates to buttocks and Imperforate hymen is a hymen in which no opening to the ● Septate
thighs vagina is present. Many girls will not even be aware that
○ Usually starts later in life which may be they have an imperforate hymen until they begin their
because of another medical condition such menstrual period and experience complications due to
as PID and endometriosis blood pooling in the vagina.
Slides 57-62
Signs and Symptoms:
Dysmenorrhea ● Abdominal pain and swelling which often come and go
Risk Factors: each month
● Obese, Smoking ● Back pain
● Drinking alcohol during period tends to prolong ● Lack of a menstrual cycle despite having other signs
menstrual pain of sexual maturity (developing breast and pubic hair) Treatment:
● Early menarche (before the age of 11), nulliparity ● Dysuria and unable to void ● Hymenotomy
○ Surgically cut away part of the hymen using a
Nursing Considerations: Diagnosis: scalpel or laser
● Heating pad or hot baths ● Gynecologic exam
● Massage on lower back to relieve cramping ● Vaginal or Pelvic Ultrasound Nursing Considerations:
● Yoga, acupuncture, aromatherapy ○ Rule out transverse vaginal septum or mass ● NSAIDS, antibiotics as ordered
● TENS or transcutaneous electrical nerve stimulation ■ Imperforate hymen diagnosed in girls younger ● Dilator-application
● Diet modifications: low salt and sugar than 10 years old are often found by chance.
● NSAIDS or Nonsteroidal Anti-Inflammatory Drugs ■ In some cases, doctors may suspect an Premenstrual Syndrome
imperforate hymen following a routine newborn 3 of every 4 menstruating women have experienced
Imperforated Hymen check. So if the doctor suspects an imperforate premenstrual syndrome. Symptoms may occur in
Most females are born with hymen. A hymen is a thin hymen, they can order vaginal or pelvic predictable patterns but the physical and emotional
membrane that stretches across the vagina. It generally ultrasound. changes women experience with PMS may vary from just
has a ring-like appearance with a small opening. There is ■ Can also be mistaken for other pelvic conditions slightly noticeable to all the way to intense.
no real medical purpose for the hymen although some such as transverse vaginal septum. This is a
think it may have evolved over time to help protect vagina thick mass blocking the vagina and ultrasound We do not let this problem control our life. Treatment and
from infection. can help confirm the diagnosis. lifestyle adjustment can help reduce or manage the signs
and symptoms of premenstrual syndrome. Signs and
symptoms could be behavioral, physical, or emotional.
MCN WEEK 6 NOTES
Causes: - A natural, biological process but the physical
Signs and Symptoms: Unknown, but there are some factors that may contribute: symptoms such as hot flashes, emotional symptoms of
● Abdominal bloating ● Cyclic change in hormones or hormonal fluctuation menopause may disrupt sleep, lower the energy, or
● Pelvic fullness ○ Disappears in pregnancy and menopause affect emotional health.
● Joint muscle pain ● Chemical change in the brain
● Breast tenderness ○ Neurotransmitters: serotonin. This is thought to play Etiology:
● Weight gain due to fluid retention a crucial role in mood state. With the fluctuation of ● Decline of hormones
● Premenstrual cravings or appetite changes serotonin, this could trigger PMS symptoms. ● Hysterectomy
● Headache, fatigue ○ Insufficient amounts of serotonin may contribute to ● Chemotherapy and radiation
● Constipation, Diarrhea premenstrual depression as well as fatigue, food ● Primary ovarian insufficiency
● Alcohol Intolerance, Acne flares cravings and sleep problems. ○ Is said to be genetic
● Depression, crying spells, irritability, panic attacks, ● Depression
anger (mood swings) ○ Some women with severe premenstrual syndrome Signs and Symptoms:
● Insomnia, social withdrawal, change in libido, poor have undiagnosed depression although depression ● Irregular periods
concentration alone does not cause all the symptoms. ● Vaginal dryness
○ Generally, these will disappear 4 days after the ● Hot flashes
start of the menstruation. Treatment: ● Chills
● Advise women to have regular exercise and enough ● Night sweats
Premenstrual Dysphoric Disorder (PMDD) - Significant sleep ● Sleep problems
physical and behavioral symptoms that interfere with daily ● Avoid smoking, limit sugar, salt, alcohol and caffeine. ● Mood changes
living. ● Yoga, acupuncture, hypnosis, massage ● Weight gain and slowed metabolism
● Stress reduction techniques ● Thinning hair and dry skin
Signs and Symptoms: ● NSAIDs ● Loss of breast fullness
● Irritability or anger that may affect other people
● Feeling of sadness or despair
Slides 63-68
● Thoughts of suicide, Feeling out of control
● Feeling of tension or anxiety, panic attacks, mood Menopausal Syndrome
swings or crying - The stage of life after you have not had a period for 12
● Often lack of interest in daily activities and relationships months or longer.
● Trouble thinking or focusing - This is the time that marks the end of the menstrual
● Tiredness or low energy cycle.
● Food craving or binge eating and insomnia - It is diagnosed after 12 months without a menstrual
● Bloating, breast tenderness, headache and joint or period.
muscle pain - This can happen to women in their 40s or 50s, but the
average age is 51.
MCN WEEK 6 NOTES
○ Prevent osteoporosis
Slides 69-74

Nursing Considerations: (Key focus is more on a

symptomatic approach)
● Dress lightly
○ To counter the effects of hot flashes
● Increase cold fluids. Minimize hot beverages, spicy
foods, smoking, alcohol, stress, hot weather, and warm
room
● Use water-based vaginal lubricants
○ For vaginal dryness
● Sleep and exercise
● Kegel exercises
○ For the muscle tone in the lower pelvic area
Complications:
● Osteoporosis
The specific disturbance in adult men includes: This slide will help us compare a normal and enlarged
○ Due to loss of estrogen in the body
1. Benign Prostatic Hyperplasia (BPH) prostate gland. Prostate gland is located beneath the
○ Will lose up to 25% of our bone density following
- Also called prostate gland enlargement bladder. The tube that transports urine from the bladder out
menopause up to the age of 60
- Common condition in men as they get older of the penis and passes through the center of the prostate,
○ Makes a woman susceptible to bone fractures
- An enlarged prostate gland can cause that tube is called the urethra. When the prostate
particularly in the hips, spine, and wrists
uncomfortable urinary symptoms such as blocking enlarges, it begins to block the urine flow. Most men have
● Cardiovascular diseases
the flow of urine out of the bladder. So with the continued prostate growth throughout life, and with the
● Obesity
blockage, it causes stasis, urinary tract and kidney enlarged prostate, this can cause urinary symptoms or
○ Due to slowed metabolism
problems. significant blocked urine.
● Vaginal dryness
● Risk Factors:
● Urinary incontinence
○ Aging The one with the yellow picture is the normal prostate, and
■ 60-years-old and above there is no obstruction in the urethra.
Treatment:
○ Family history of BPH
● Hormone therapy
○ Diabetes and heart diseases On the other hand, the enlarged prostate, it pushes
○ Replacement of declined hormones
■ Because of the use of beta blockers through the urethra causing blockage. There is little
● Gabapentin
○ Obesity amount of urine passed through the urethra because of the
○ For hot flashes
increased size of the prostate. The compressed urethra, a
○ Is said to be an anticonvulsant drug but it is used to
possibility of stasis of urine in the bladder.
treat vasomotor symptoms in premenstrual women
with contraindications to hormonal therapy
● Vitamin D and calcium supplements
MCN WEEK 6 NOTES
The severity of symptoms in people who have prostate ○ Bladder stones can cause infection, bladder ○ Wherein an instrument called a cystoscope is
gland enlargement varies, but they tend to gradually irritation, blood in the urine, and obstruction of inserted to the urethra, allowing the doctor to see
worsen over time. urine. the inside of the urethra and the bladder.
● Damaged bladder ○ A local anesthesia is given before the test
Signs and Symptoms: ○ Is also a complication of BPH.
● Frequent or urgent need to urinate ○ A bladder that hasn’t emptied completely, can Treatment:
● Increased frequency of urination at night (nocturia) stretch and weaken over time. As a result, the For the treatment of BPH, this could either be minimally
● Difficulty starting urination muscular wall of the bladder no longer contracts invasive therapy like drug therapy or surgery.
● Weak urine stream or a stream that stops and starts properly and makes it hard to fully empty the
● Dribbling at the end of urination bladder. For medication or drug therapy, this is the most common
● Inability to completely empty the bladder ● Kidney damage treatment for mild to moderate symptoms of prostate
○ Pressure in the kidney from urinary retention can enlargement. This drug includes alpha blockers and
The less common signs or symptoms are urinary tract directly damage the kidneys and allow bladder 5-alpha reductase inhibitor:
infections, inability to urinate, and blood in the urine. infection to reach the kidney or ascending infection. ● Alpha-blockers (Tamsulosin, Alfuzosin, Doxazosin)
○ A medication that relaxes the bladder neck
The size of the prostate doesn’t necessarily determine the Diagnosis: muscle and muscle fiber in the prostate making
severity of the symptoms. Some men with only slightly ● DRE (Direct Rectal Exam) urination easier.
enlarged prostate can have significant symptoms, while ○ This is when the doctor inserts a finger into the ● 5-alpha reductase inhibitor (Finasteride,
other men with very large prostate can only have minor rectum to check the prostate for enlargement. Dutasteride)
urinary symptoms. Symptoms usually stabilize or might ● PSA Test (Prostate Specific Antigen) ○ This medication shrinks the prostate by
even improve over time. ○ Blood test preventing hormonal changes that cause
○ A substance produced in the prostate, an increased prostate growth.
Complications: level of which is seen in large prostate. However, ● Transurethral Resection of the Prostate (TURP)
● Urinary retention elevated PSA level can also be due to recent ○ Surgical management
○ Sudden inability to urinate, the need to have a procedure, infection, surgery, and prostate cancer. ○ Done using a lighted scope inserted into the
catheter inserted into the bladder to drain the urine. ● UTZ, Bx (Ultrasound and Biopsy) urethra, then the surgeon removes all but the
○ In some men with larger prostate, they need ○ Transrectal ultrasound outer part of the prostate.
surgery to relieve the retention. ○ An ultrasound probe is inserted in the rectum to ○ Generally relieves the symptoms quickly and
● UTI (Urinary Tract Infection) measure and evaluate the prostate. most men have a strong urine flow soon after
○ The inability to fully empty the bladder can increase ○ Prostate biopsy, this is an examination wherein a the procedure. After TURP catheter is inserted
the risk of infection in the urinary tract. tissue sample is taken to help the doctor diagnose temporarily to drain the bladder
○ If UTI occurs frequently, the need for surgery to and rule out prostate gland cancer. ● Transurethral incision of the prostate (TUIP)
remove part of the prostate. ○ A transrectal ultrasound guides the needle and ○ Same with TURP; a lighted scope into the
● Bladder stones and damage takes tissue samples for biopsy. urethra and the surgeon makes one or two cuts
○ Generally caused by inability to empty the bladder. ● Cystoscopy in the prostate gland, making it easier for urine
to pass through the urethra.
MCN WEEK 6 NOTES
○ This surgery might be an option if the man has
a small to moderate enlarged prostate gland,
especially if the man has health problems that
make other surgeries too risky.
● Transurethral Microwave Thermotherapy (TUMT)
○ The doctor inserts special electrodes through
the urethra into the prostate area. The
microwave energy from the electrodes destroy
the inner portion of the enlarged prostate gland,
shrinking it and easing the urine flow.
○ Only partly relieves symptoms and it might take
some time before a man notices the result.

Nursing Considerations:
● Instruct the patient to spread the fluid intake throughout
the day.
● Limit beverages at night, caffeine and alcohol.
○ To prevent nocturia
○ This increases the needs to urinate
● Bladder care
○ Take plenty of time to urinate and try to relax.
○ Read or think of other things while waiting.
○ For dribbling (?) problems, wash penis daily to
avoid skin irritation and infection.
● Healthy diet, minimize obesity.
MCN Week 7 NOTES
● Children at this stage tend to be egocentric and like being susceptible to chickenpox because they did
NURSING CARE OF A FAMILY WITH AN ILL CHILD
struggle to see things from the perspective of not get the vaccine.
Slides 1-9 others. ● By 4th grade, they are generally aware of the role
3. Concrete-Operational Stage (7 to 11-years-old) germs play in illness.
The quality of life of an individual is closely related to the ● During this stage, children begin to think ● ­By 8th grade, they are able to voice an understanding
quality of life to those around them. Like if one of the family logically about concrete events. that illness can occur from several causes.
members gets sick, the rest or wide variety of aspects of ● They begin to understand the concept of
family members' lives can be affected also. Including conservation that the amount of liquid in a short Knowing how children of each age view illnesses affects
emotional, financial, family relationship, education and wide cup is equal to that in a tall skinny glass. the planning of nursing care and influences how it should
work, leisure time, and social activities. Many of these are ● The egocentrism of the previous stage begins be worded:
linked to one another including financial impact, social to disappear as kids become better at thinking ● An example for this, stick for blood work. Stick, this can
impact, being linked to emotional impact. There are some about how other people might view a situation. be misinterpreted as putting an actual stick on the arm.
positive aspects that were also identified from the 4. Formal Operational Stage (12 and up) Another is receiving a die, the child might misinterpret it
literature, this includes family relationships growing ● The adolescent or young adult begins to think as the child will die during the procedure. We need to
stronger. This topic, we will be able to enhance our abstractly and reason about hypothetical be very careful in using words with double meaning.
knowledge on the different needs of the children when they problems. Abstract thoughts emerge at this We have to explain more further to the child what you
become ill. This is very important because this will serve as point. really mean and how the procedure will be done.
the basis for our nursing care and health teaching. Helping ● Teen begins to think more about moral,
a child and family prepare and adjust to the experience is a philosophical, ethical, social, and political Differences in Responses of Children and Adults to
fundamental nursing role. This role goes well beyond just issues that require theoretical and abstract Illness
providing information on what to expect throughout the reasoning. ● Inability to communicate
illness. ● They also begin to use deductive logic or ● Inability to Monitor Own Care and Manage Fear
reasoning from a general principle to specific ● Nutritional Needs
The Meaning of Illness to Children information. ● Fluid and Electrolyte Balance
● Depends on: ● The final stage of Piaget’s theory involves an ● Systemic Response to illness
○ ­Cognitive ability increase in logic, the ability to use deductive ● Age-specific Diseases
○ ­Past experiences reasoning, and understanding of abstract ideas.
○ ­Level of knowledge Inability to Communicate
● All of these can be related to Piaget’s cognitive Early school-age children ● Very young children
development wherein the focus of this theory is more ● Generally know quite a bit about the workings of their ○ Do not have the vocabulary to describe symptoms,
on understanding how children acquire knowledge, and major body parts. like when they have a headache, or they are dizzy
also understanding their nature of intelligence. If we ● ­Able to name the function of heart, lungs, and stomach. or nauseated.
recall the four stages, we have: ● ­Not able to see the body as a system until the age of ○ They cannot express what they are feeling because
1. Sensory Motor Stage (Birth to 2-years-old) 10 to 11 years. of lack of vocabulary.
● Infant uses senses and motor skills. ○ They may intend to minimize or intensify
● They also know items by its use and object Younger children symptoms.
prominence. ● ­May think the cause of illness is magical or a ○ It is important to evaluate by observation, like when
2. Pre-operational Stage (2 to 7-years-old) consequence of breaking a rule. They think they get the baby is crying, she probably has symptoms but
● The child becomes a symbolic thinker. They well after they follow another set of rules (e.g. staying she cannot describe so we need to observe or
begin to think symbolically and begin to use in bed or taking medicine). Because of this, children show guarding behavior.
words and pictures to represent them. may see a passive role for themselves in getting well ● School age
MCN Week 7 NOTES
○ Most can describe symptoms with accuracy. ● Newborn: Extracellular water is closer to 40%. This these parents requires patience because parents under
means that an infant does not have as much as water stress can have difficulty comprehending instruction.
Inability to Monitor Own Care and Manage Fear stores in their cells like an adult does. They are more
● Adults often ask questions about medications and likely to lose a devastating amount of body water in The Effect of Hospital Separation on Children:
procedures. If the nurse is late in giving the medication, diarrhea and vomiting. Because of this, there’s no such Decreasing Separation Anxiety
the adults would often follow-up. thing as “only diarrhea or simple diarrhea” in a child ● These are the ways of decreasing separation anxiety to
● School age and younger children cannot monitor their younger than 1 year old. them.
own care. They may not know which medicine or ● Infants of age 5-9 months - We all know that they are
procedures they have to receive. If they do know, they attached to their parents or caregivers. To reduce
Slides 10-18
may be confused about time. separation anxiety, we need to establish a primary
● Children have fears: Systemic Response to Illness nurse.
○ 8-9 months ● Because children have immature bodies, younger ● Toddlers and preschoolers - The effects of separation
■ Fear of separation; if they are taken away from children tend to respond to disease systemically rather become especially intense in young children before
their mother or their primary care provider. than locally. they understand time. We need to establish a primary
○ Toddler and preschoolers ● Example: When a child has pneumonia, supposed to nurse.
■ Fear of separation, the dark, intrusive be the presenting symptoms for pneumonia is cough, ○ Primary nurse - The nurse will care for them for
procedures, and mutilation of body parts but children will be admitted not because of the cough the entire course of their hospitalization and
○ School age child and adolescent but because of the other accompanying systemic establish trust to the child and reduce separation
■ Loss of body parts, loss of life, and loss of symptoms such as fever, vomiting, and diarrhea. anxiety.
friends. ● Systemic reactions can delay diagnosis and therapy ● School-age children and adolescent - Reacts better
and can cause increased fluid and nutrient loss. than younger children to the separation
Nutritional Needs
According to CDC or Center for Disease Control and Age-Specific Diseases Preparing the Ill Child and Family for Hospitalization
Prevention (2015), ● Most adults have achieved immunity to common ● The preparation the parents make for their child varies
● Children have greater metabolic demand infectious diseases and children are very susceptible to according to the child’s age and individual experience
● Children breathe in more air per pound of body weight illnesses such as measles, mumps, and chicken pox. no matter what the child’s age. However, the parents
● Higher surface to body mass ratio ● Because of the growth requirements and their are encouraged to convey a good positive attitude
immaturity, they are susceptible to some diseases that towards hospitalization.
In other words, children need more nutrients like calories, do not affect the adults. ● Children between 2 to 7-years-old should be told about
proteins, minerals or vitamins per pound of body weight. ● Example: Rickets, lack of vitamin D in children and it the scheduled ambulatory or in-patient hospitalization
Because their metabolic rate is faster, intake must only be may lead to skeletal deformities, the adult does not as many days before the procedure as the child ages
encouraged for tissue repair but also enough to allow for affect them. in years.
growth. An example to this, an infant needs 120 kcal per ● Another example is febrile seizure at age 5-10 years ● Example: A child who is 2 years old, they should be
kg whereas an adult needs only 30-35 kcal per kg of body old. Children with high temperature may respond to informed 2 days before hospitalization. For 4 years old,
weight per day. generalized seizure but they do not have any problems 4 days before.
in the brain only specific to their age. ● Children older than 7 years of age can be told, as soon
Fluid and Electrolyte Balance Care of the Ill Child and Family in the Hospital as the parents are aware of it.
● Adults: Extracellular water (plasma and outside body The parents of children admitted in the ICU are predicted
cells) represents approximately 23% of total body to experience a high degree of stress during their child’s Admitting the Ill Child and Family
water. hospitalization. Due to the severity of the child’s illness and Assessment on Admission:
of course the hightech setting of the ICU. Dealing with
MCN Week 7 NOTES
● Chief concern - Determine what are the parents’ In children, play is important so one way of promoting a facing illness or treatment that interferes with adequate
understanding of the illness of the child or what are positive hospital stay is to incorporate therapeutic play as intake. To correct nutritional deficiency, we need to help
their reasons for admission. part of their treatment and setting limits on behavior. and aid these children and families to follow nutritional care
● Family profile - We need to obtain the profile and plans. In planning for nutrition for these ill children, there
include pets if there are any, educational level, primary Discharge Planning are areas of concern that we need to look into or we need
caregiver or if the parents are divorced, who is staying Discharge planning is not only an important link between to take note.
with the child and who is often assigned for medical the hospital and the home, but it is also a final way to
permission. create a satisfying hospital experience. As part of our Areas of concern when planning nutrition for ill children:
● Past experience with illness or separation - This discharge plan, we need to include information like ● Meaning of food - In children, early in their life
would include how the child feels on previous tantrums and nightmares after returning home from (infancy), they learn to associate feeding with being
hospitalization, or does any recent hospitalization in the hospital stay for school-age children may manifest these held and being loved just like when breastfeeding. If
family. We have to consider for bad outcomes if there behaviors to a lesser extent. You can assure the parents they cannot eat for some reason when undergoing
are any, or has the child been away before like that these behaviors are part of the child’s normal surgery and they are placed in NPO temporarily, they
overnight with grandparents, does the child take response to hospitalization. These behaviors do not may view this restriction as punishment or restriction of
medication, is the child able to swallow a pill, or any happen because the child has been spoiled by the staff or love.
allergie. These need to be documented with exact by the parents during the illness but because of the ● Opportunity for socialization - Mealtime is often the
symptoms and happening. experience that was too intense for the child to handle. time of the day where children socialize with other
● Daily routines - This would include any bedtime sleep members of the family. In the hospital they may feel
routines, does the child need help in toothbrushing or Promoting Growth and Development of the Ill Child lonely eating alone and consequently, may have a poor
climbing the hair or does the child can do Children often fall behind in the growth and development appetite.
independently with the routine activity of daily living. because of their illness. Mostly, we would often see ● Level of stress - Children under stress may either feel
● Developmental survey - This would include if the child nursing problems like risk for delayed growth and a loss of appetite or experience a need to snack
feeds herself or does the child use a spoon, can use development related to the effects of illness. To counter frequently. Planning is necessary to see that children
cups, bottles, can dress herself, and what grade is the this, we need to promote growth and development. maintain adequate intake if not hungry. And that their
child. ● For ill infants, maintain their at-home schedule when snacks should be nutritious if they need to eat snack
● Special Information - This determines what the possible. Example would be the feeding schedule. frequently
parents think would make the child more comfortable in ● For ill toddler and preschooler, promote both autonomy ● Custom and culture - There are some children who
the hospital. in toddler and initiative in preschool. Example would be want their food to be separated and not mixed up. In a
to urge the parents to encourage their children to make hospital setting, we need to ask the parents to bring
Promoting A Positive Hospital Stay choices about their care whenever possible; coloring favorite food treats to stimulate the child's appetite.
This is very important for the health of both children and the medication schedule, it is the kind of task that helps ● Environment - Hunger is associated with sight and
their families like providing continuity of care or primary initiative in preschool. smell of food. Many children are normally in the kitchen
nursing. This ensures that children are exposed to a few ● For ill school-age children, they need to work on a while meals are being prepared. They may not be
substitute care people as possible to maintain consistency sense of industry or learning more about how and why hungry when food is served to them without them
and quality care. Nursing assignments should be made. things are done. seeing or smelling as the food is being prepared.
One nurse gives as much care to the same child as Encourage Fluid Intake
possible. ● Offer small, full glasses frequently rather than larger
Slides 19-27
half-full glasses.
Providing Adequate Play Facilities (Therapeutic Play) Promoting Nutritional Health of the Ill Child ● Determine the child’s favorite fluid and then offer it, if
As nurses, it is part of our responsibility to monitor and appropriate.
maintain optimal nutritional status of children in the hospital ● Popsicles and Jell-O count as fluids.
MCN Week 7 NOTES
● Children can drink more clear fluid than a thicker fluid. ● Be careful of the placement of television or call cords ○ NREM Stage II
● Suggest soothing beverages such as milk or Pedialyte or window blind cords so they cannot lead to ■ Sleep deepens, temperature and HR decrease
popsicles for children with mouth lesions. strangulations. slightly more. It is more difficult to awake a child
● Ice melts one half its volume. ● Never leave a child alone in the bathtub because even
from sleep when this point has been reached.
● Encourage breastfeeding whenever possible. a small amount of water can drown a baby or child.
● Introduce a game. ● Adhere to all fire precaution measures. ○ NREM Stage III
● Closely follow standard infection precautions. ■ Sleep deepens still further, temperature and HR
Encourage Food Intake decrease further. It is very difficult to awake the
● Calorie counting Promoting Adequate Sleep for the Ill Child child from stage 3 sleep. Use patience to awake
○ Record all the foods that a child eats during each Children need adequate rest and sleep so their body and a child fully to offer medicine.
24-hour period. ○ NREM stage IV
tissue can effectively use nutrients for repair and normal
○ Includes snacks, candy, gum
growth to continue. Children may not sleep well when they ■ Approximately 20-30 minutes after beginning to
○ A dietician then will analyse the list and determine
the calorie intake of the child. are ill because of the discomfort, pain or the administration fall asleep. A child enters stage 4 sleep where
of the medications or intensified symptoms of chronic sleep respiration is slow and deep. Temperature and
Promoting Safety for the Ill Child problems. Another factor is the strange hospital setting. HR slows even more and BP decreases. A child
It is our prime consideration as nurses to keep a child safe Also procedures that the child has to undergo. This has to remains at this stage for approx.. 30 mins then
during illness care. do with deprivation of nap or rest as much during the day progresses back to stage 3 and stage 2 until
● Always be sure of the location of all children in your he/she passes into a phase of REM.
as compared to their usual. We encourage the parents to
care to ensure safety, we need to be sure of the
stay with the children for support and comfort. ○ Rapid Eye Movement (REM)
location and the whereabouts and we need to account
for all the children in our care. ■ Eyes move in rapid, involuntary motions. This is
● Ensure that doors or gates are provided near stairways Sleep Patterns involuntary motion where respiration is irregular.
or elevators to prevent falls. ● Influenced by: in this stage. a child can be confused and
● Ensure that doors of healthcare facilities have working ○ Apprehension level unable to orient himself readily if awakened
alarms to prevent children from going out and to ○ State of health from stage 4 sleep. Use patience until a child is
prevent strangers from coming in.
○ Habit fully awake particularly if asking questions.
● Be sure windows are covered by screens or guards so
children cannot climb up on sills and fall out. ○ Medication REM is when involuntary motion occurs like
● Check that the side rails of beds and beds are in good ○ Environment at the time of sleep respiration is irregular, there is body turning.
condition, raised appropriately and locked. ● Stages: This will last 10-30 ins. And then a new sleep
● Test crib rail after it is raised to ensure the lock is ○ Non-Rapid Eye Movement (NREM) Stage I cycle with NREM begins. Dreaming occurs
caught. ■ A feeling of drifting or falling. This type of sleep during REM sleep although the child appears to
● Push bedside tables or stands away from cribs so as a be close to waking because of the active eye
occurs up to 80% of the total sleep time. Often
child cannot climb over the railing and use the stand as
described as “twilight sleep” at this time, a movement, he/she is very sound asleep. A child
a step down.
● Ensure that electrical cords or appliances such as hair child can be aroused easily from the early sleep may awake afraid and crying disturbed by a
dryers are not used in bathrooms to prevent by the slightest noise or even the silent frightened dream.
electrocution. presence of another person in the room. In
order to promote sleep, we need to reduce Sleep Deprivation
noise level during this stage.
MCN Week 7 NOTES
Children who don't receive enough sleep can suffer sleep ● Child support programs
deprivation just like adults do. ● Therapeutic Play (3 Types) Safe Storage of Drugs
● Infants are dependent on sleep to promote brain ○ Energy Release - Pounding, hitting, running, ● Adolescents can deliberately take extra doses of drugs
punching and shouting such as: Steroids or Pain medicine hoping for an
development.
○ Dramatic Play - Acting out an anxiety producing added effect.
● If sleep loss is mainly REM deprivation, children show situation ● Children like adults, may hoard drugs and then use
symptoms of irritability and difficulty concentrating. ○ Creative Play - Example: Drawing them in a suicide attempt.
● If Stage IV NREM sleep is lacking, tends to cause
apathy, physical and depression and can slow
NURSING CARE OF THE CHILD UNDERGOING Slides 36-43
recovery. MEDICATION ADMINISTRATION & INTRAVENOUS
THERAPY In hospitals:
Sleep is very important for ill children. We need to take ● Always be certain that medicines are stored in a safe
Variety of Routes
special step to ensure that this children is able to sleep place.
● Orally
during illness. Make certain that they are free from pain ● Intranasally ○ In the nursing unit, there’s a particular unit there for
and worry as possible. We try to let them maintain normal ● Transdermally medication wherein only the medication nurse can
bedtime routine as possible. We need to provide an ● Topically enter and prepare and store all the medication in
atmosphere conducive to sleep like turning off the light, ● Rectally that unit.
● Injection ● On a children’s unit, leaving a cart in the hallway is
quiet surrounding, reassuring people around. Children who
● Inhalation inappropriate.
are bored with bedrest may cut nap constantly, providing
more interesting activity for them during the day can help ○ As medication nurses, we always look after all the
Safe medication administration is a priority in child
reduce their nap and increase nighttime sleep health nursing. Each dose of a drug must be calculated medication that we prepared to prevent tampering,
individually. switching medication or even stealing.
● Never leave medicine on a bedside table for a child to
Slides 28-35 Pharmacokinetics in Children take later. As soon as you enter the room always offer
Promoting Adequate Stimulation for the Ill Child The four basic processes: a glass of water and make sure that the medicine is
1. Sensory Deprivation 1. Absorption taken by the child right away before leaving the room.
● The condition of being deprived of, or lacking 2. Distribution
adequate sensory, social, physical or cognitive 3. Metabolism
4. Excretion At home:
stimulation.
2. Sensory Overload ● Medication should be kept in a locked medicine cabinet
● Occurs when children receive more stimulation The immaturity of body systems in children plays a major above the height of the child so that the children could
than they can tolerate or process. role in drug action throughout each of these processes. not reach the cabinet and gain access to it easily.
● Remind parents that most childhood poisoning occurs
Promoting Play for the Ill Child Adverse Drug Effects in Children
when a family is under stress. During stress we tend to
● Assessing child health through play. ● Children may experience unique or exaggerated side
effects. forget procedures such as locking away a drug.
● Providing play in ambulatory settings.
● Providing play in the hospital. ● Newborns may suffer from adverse effects from drugs Reenforce the need to take special precautions, to
● Providing play for children on bedrest. taken by the mother prenatally or from drugs taken lock away medications at all times.
● Safety with play. during breast-feeding.
MCN Week 7 NOTES
● Tell parents they should never take medicine in front of slowly in the side of the child’s mouth. The end of the
their children because children can imitate this action drying or dropper should resist on the side of the mouth
with the parents taking medication. Also they should to help prevent aspiration.
never pour or prepare medicine in the dark, because ● Oral medication may also be given through a small
almost all medicine bottles look the same and feel the glass or spoon, allowing fluid to flow a little at a time so
same so it is easy to pour a wrong liquid or get a wrong the child has time to swallow between small sips.
pill or read medicine bottle instructions incorrectly ● Because firm pressure was used to give the medicine
without adequate lighting. to the infant, he or she may be frightened, so take time
to sit and comfort.
Safe Administration of Drugs ● Preschoolers and Early school-age: Responds well to
● Administering drugs safely to the children, we should rewards each time they take their medicine like giving
determine that we are giving the right drug to the right of stickers so they can paste it in a book each time they
child, in the right dosage and by the right route, at the take a medicine.
right time. ● Older children:
● Also we need to ensure that parents or children have ○ Hand them a glass of medicine as if they are
the right information about the medicine they are expected to take it.
taking. In giving this medication we always remember ○ Offer a “chaser” if necessary and not
the golden rules of drug administration. contraindicated. Chaser like oranges or any juice
available and accessible.
● If a child is having difficulty in swallowing a tablet, they
Oral Administration can be crushed and added to a teaspoonful of
● Children younger than 9 years old often have difficulty applesauce or a flavored syrup.
swallowing tablets. ● Let the child practice on small bits of ice before
● Most oral medication is furnished in liquid form. teaching them to swallow tablets.
● In infants:
○ Oral medication can be given with a medicine Slides 44-51
dropper or a unit dose syringe (without needle)
● Another technique to help a child swallow pills is to
○ Gently restrain the child’s arm and head
push them into a teaspoon of ice cream or pudding.
○ Never give medicine with the child lying completely
○ The intent is not to hide the pill but to help the child
flat for the risk of aspiration
learn to swallow medicine. So ice cream or pudding
● It is easy to administer oral medication when the child
has a slippery texture that can easily slide through
is crying as the mouth is already open, or gently open
and be swallowed as the child takes the pills.
the mouth by pressing on the child’s chin.
● In administering oral medication using a dropper or
Intranasal Administration
syringe, gently press the bulb on the medicine dropper
● Place the child on his or her back.
or use the plunger of the syringe so that the fluid flows
MCN Week 7 NOTES
● Extend the head over the side of the bed. ● Eye medications - Most often dropped into the transferring infected mucus from one eye to the
● Preschoolers are too frightened by this strange conjunctival sac of the eye. other. Eye medicine should be individually
position. Place them a pillow under their shoulders ● Infants and preschoolers must be restrained in a prescribed and not used by other children, because
instead. mummy restraint. if the tip of the dropper or tube touches the
● An infant may need to be restrained in a mummy ○ Place the child on the back conjunctival sac it is contaminated with body fluid.
restraint, where you wrap the baby from the neck ○ Open the eyes of infants and preschoolers gently
down to the feet, where the feet and the hands cannot by firmly pressing on the lower lid with the thumbs
Slides 52-59
move, and easy administration of the drug is and on the upper lid with the index finger.
performed. ● You may need to rest a hand on the eyelid to keep the Otic Administration
● Instill the appropriate number of drops into one nostril. eye open long enough and allow the eyelid to close ● Refers to administering medicine into the ear canal.
● Turn the child’s head to the side—to the left after the after. ● Remind the child that ear drops can feel funny.
left nostril, to the right after the right nostril—so that the ● Ear drops must always be used at room temperature or
medicine stays in the nose longer. warmed slightly.
● If the child is a preschooler or older, ask him or her to ○ Fluids stored in the fridge and are used can cause
further “sniff” the medicine. pain and severe vertigo once it touches the
● Have the child remain in a head flat position for at least tympanic membrane.
1 minute to let the medicine come in contact with the ● Place the child on the back in a mummy restraint if
mucous membrane of the nose. necessary.
● Give children high praise even if they did not cooperate ● Turn head to one side to expose the ear.
well. Praise tells children you understand how hard it ● Avoid placing the drops directly on the cornea because ● For a child younger than 3, straighten the ear canal by
was to stay still. this can be painful and to prevent the conjunctiva from pulling the pinna down and back.
● If using spray bottles, let the patient stand or sit upright, drying. ● For a child older than 3 years, pull the pinna of the ear
hold the spray bottle upright with the tip just inside the ● Do not hold the eyelids apart any longer than up and back.
nose, and gently squeeze the spray bottle. necessary. ● Instill the specified number of drops into the ear canal.
● After the child has blinked two or three times, allow the ● Hold the child’s head in the sideways position for at
child to get up. least 1 minute to ensure that the medication fills the
● Praise the child for his or her cooperation even if entire ear canal.
cooperation was not evident. He or she accomplished ● Praise the child for his or her cooperation after the
a major feat by allowing to touch and invade the eye procedure.
this way.
● To instill ophthalmic ointment: Rectal Administration
○ Apply a fine line of the ointment along the inside rim ● This allows the medication to be absorbed across the
of the conjunctival sac, working from the inner to mucous membrane of the intestine.
the outer eye canthus. ● Medications are given by rectal suppository or by
○ If the eye is pus-filled, apply from the medical retention enema.
Ophthalmic Administration
aspect to the outer core. This is to prevent
MCN Week 7 NOTES
● Suppositories are supplied already lubricated. If not, ■ Using the gluteal muscle in children younger Intravenous Therapy
add a drop of water-based lubricant to the tip. than 1 year is extremely hazardous. ● The quickest and most effective means of
● Use a glove and insert the suppository gently but administering fluid or medicine
Continuous Subcutaneous Pump Infusion ● Used to:
quickly beyond the rectal sphincters.
● The administration of medication by constant infusion ○ Maintain fluid and electrolyte balance.
○ Approximately ½ inch or as far as the first knuckle of a medication into the subcutaneous tissue using a ○ To produce therapeutic levels of drugs in the body
of the little finger for infants, and 1 inch or as far as medication pump. quickly.
the first knuckle of the index finger for older ● Disadvantage: The child must be careful to protect the ○ To provide rehydration and nutritional support.
children. pump from damage. ● IV fluid may be infused into a peripheral vein, a central
● Withdraw your finger and press the buttocks together ● Site Chosen: Abdomen venous access device, or a peripherally inserted
firmly until the child’s urge to evacuate the suppository ● Insulin and heparin are two drugs often prescribed for central venous catheter.
use with infusion pumps. ● The amount, type and rate of IV fluids for children are
passes.
● The syringe is filled with medicine and a small tube prescribed carefully.
with the needle attached at the distal end is attached to
Transdermal/Topical Administration the hub of the syringe. Determining Fluids and Caloric Needs of the Child
● Most children accept this type of application well ● The syringe is then clamped into the pump and the skin ● IV fluids administered to children and infants must be
because the medicine brings most immediate relief. is cleaned with alcohol and the needle inserted at a 45 isotonic.
● Be certain the child’s skin is dry and intact at the site. degree angle.
● Apply patches over the trunk or major muscle, not on
distal extremities, for best absorption.
● Assess and change the site every time a new patch is
applied.
● Put clothes on the young child immediately so that the
patch is out of site.
● Be certain patches applied to children wearing diapers (Picture above: Infusion Pump)
are not placed where a leaking diaper could wet the
patch. Nursing Considerations:
Slide 68-75
● The insertion site is changed every 1 to 2 days.
● If the child is not toilet trained, it is important to keep ● Example of isotonic: Lactated ringer’s and 0.9% normal
Slides 60-67 the pump and insertion away from an area that can be saline
Intramuscular and Subcutaneous Administration soiled with urine or stool. ● Example of hypotonic: Normal saline 0.45%
● Intramuscular (IM) injections are rarely prescribed in ● With small children cover the pump with clothing. ● Example of hypertonic: Dextrose 10% in 0.9% sodium
children because children do not have sufficient muscle chloride
mass for easy deposition of medication. ***to be continued kay wa pa nagupload sa video lecture si
○ For infants, the mandatory site is the vastus ms*** Obtaining Venous Access
lateralis muscle of the anterior thigh. ● The needle size for IV therapy varies depending on the
■ Use the lateral aspect rather than the medial NURSING CONSIDERATIONS IN ADMINISTERING solution and the rate at which it will be administered.
portion. INTRAVENOUS THERAPY TO PEDIATRIC CLIENTS ● Commonly used catheter sizes:
○ 22-gauge
MCN Week 7 NOTES
○ 24-gauge ● Medications may be added to an IV line as a small,
○ 25-gauge (in newborns) one-time administration (bolus) or piggyback for longer
● “Butterfly” needles or “scalp vein needles” are infusions.
metal needles with a flange of plastic added on both
○ Give more fluid than the usual IV medication, 10-20
sides of the needle hub.
● A length of narrow tubing leads from the needle to the cc syringe.
fluid administration tubing. ● Ensure that the drug to be injected is compatible with
○ This tubing must be flushed with IV solution before an IV fluid being infused.
the needle is inserted to avoid air embolus. ○ If incompatible, it will crystalize.
● Common sites: ● To administer medicine by a bolus technique.
○ The veins on the dorsal surface of the hand ○ IVTT medication should not be administered by
○ On the flexor surface of the wrist Determining Rate and Amount of Fluid Administration
nurses because it will lead to 30 day extension.
● Leg and foot veins may also be used. ● IV fluids must be infused at a slower rate than adults.
● Scalp vein over the temporal area ultimately causes ● Automatic rate-flow infusion pumps are useful when ○ Give slowly; veins are sensitive so if given fastly, it
the least discomfort for their child because needles do giving potent medications. Should be mandatory for may swell.
not infiltrate readily. small children. ○ Check for patency of the line by opening the flow
● Fluid chambers rate and bringing the solution down to the hand. If
○ Devices that allow only 50 to 100 mL of fluid into blood comes in the tubing, the site is patent.
the drip chamber at a time.
● Minidropper
○ Device that reduces the size of the drop in the
control chamber to 60 drops per mL.
● Keeping a careful record of both rate and amount of
fluid.
○ Signs of fluid overload are those of congestive
heart failure.

Slide 76-83
● It is difficult for children to lie still and wait for an
infusion to finish.
● Children who have IV infusions for long periods may ● Infants and preschoolers may need to have their other ● For piggyback infusion of medicine:
require the placement of an Intracath (a slim, pliable arm restrained. ○ Clean the medicine port on the IV line, and insert
catheter threaded into a vein). ○ Let parents know and understand.
○ Advantage: It cannot be dislodged as easily. the piggyback system into the port.
● Be sure parents understand the importance of the IV ○ Lower the level of the main (but ana si miss
● IV infusions must be secured in place with at least a
small armboard. therapy. piggyback daw so medj libog) infusion bag and
adjust the flow rate.
Intravenous Medication Administration ○ Elevate the maintenance bag (main) of fluid again
and regulate at the proper rate.
MCN Week 7 NOTES
Using Central Venous Access Catheters and Devices
● Venous access for long-term IV therapy
○ Obtained using a catheter inserted into the vena
cava just outside the right atrium.
● Typical catheters: Broviac, Hickman, Groshong
catheters
○ These catheters can be used to administer bolus or
continuous infusions of
medications and fluid.
● Advantage: Discomfort from further ● After skin cleansing, blood samples can be removed or
skin punctures is avoided. medication can be injected by a puncture through the
● Disadvantage: Catheter could chest/skin into the port.
become snagged on something ● This device requires a skin puncture, but no dressing is
and accidentally be pulled out. required. It allows a full range of activities like
○ Patients are not allowed to showering and swimming.
swim or take showers to avoid
infection, unless there is a
Using Intermittent Infusion Devices waterproof dressing.
● Heparin locks
○ Devices that maintain open venous access for
medicine administration while allowing children to Slide 84-91
be free out of bed. Vascular Access Ports (VAPs)
● Scalp vein tubing is used and capped at the end with ● Are small plastic devices that are implanted under the
a specially designed rubber stopper or a commercial skin, usually on the anterior chest just under the
trap. clavicle, for long term fluid or medication administration
● The tubing and stopper must be firmly secured to the via bolus or continuous administration.
wrist and an armboard taped in place to remind the ● Common brands: ● Children can also have Peripherally Inserted Central
child to protect the site from trauma. ○ Port-A-Cath Catheters (PICC lines).
● For hospitalized or receiving home care for a long time. ○ Infuse-a-Port ○ Advantage: Can remain in place for up to 4 months
● Can also be used if frequent venous blood samples are ○ Groshong Venous Port without being changed.
required (can extract blood through it). ○ These catheters are inserted into an arm vein
(usually at the antecubital space into the median,
cephalic, or basilic vein) and
advanced until the tip rests in
the superior vena cava.
MCN Week 7 NOTES
○ All central venous access systems have the ● Used for children with blood disorders who receive a
potential to cause thromboses because they medication to remove stored iron from their body.
partially occlude a vein. ● Sites used for hypodermoclysis generally include the
○ Dressing must be changed using strict aseptic pectoral region, the back, and the anterolateral aspects
techniques to prevent infection. of the thigh.

Administering an Intraosseous Infusion

● Infusion of fluid into the bone marrow, usually the distal
or proximal tibia, the distal femur, or the iliac crest.
● Fluid reaches the bloodstream
quickly as if it were administered
IV.
● Is used in an emergency when it
is difficult to establish usual IV
access.

● It is a temporary measure until a usual route of

administration.
● It must be initiated with sterile technique, and if
continued for an extended time, the infusion point is
rotated about every 2 to 3 days.

● Tubing must be changed every 48 hours and the

dressing over the site must be changed every 24
hours.
● Assess for a distal pulse and adequate temperature
and color of the leg every hour throughout the infusion.

Administering a Subcutaneous (Hypodermoclysis)

Infusion
UNIT 8 (Week 10)
INTRODUCTION TO GENETICS AND NURSING OF CLIENTS WITH • They are thread-like structures of nucleic acids and proteins, • For example, it is written in the DNA that if you reach 50-years-
GENETIC DISORDERS for example, there are DNAs inside and are tightly packed to old, you will become bald.
Understanding Genetics and Related Physiology form a chromosome. • Basically, a DNA is in form of letters encoded or imprinted.
• Genetics is the study of heredity, or the study of the way such
disorders occur.
• Heredity is a biological process where a parent passes certain
genes onto their children or offspring. Every child inherits
genes from both of their biological parents and these genes, in
turn, express specific traits.

Nature of Inheritance
• Deoxyribonucleic acid (DNA) is the cell’s hereditary material
and contains instructions for development, growth, and
reproduction of a human being. It is a molecule that encodes
an organism’s genetic blueprint. It contains all the information
required to build and maintain an organism’s body.
• Even before you were born, you already have DNA imprinted
in the cells of your body. If the DNA states that you have brown • In humans, each cell, with the exception of the sperm and
skin or black hair, then you are born, you will have brown skin • These chromosomes are found in the cells, specifically inside ovum, contains 46 chromosomes (44 autosomes and 2 sex
and black hair. the nucleus. In every cell, the center portion of it is the nucleus. chromosomes). Basically, we have 23 pairs of chromosomes in
These chromosomes carry genetic information in the form of a our body.
gene.
• One chromosome comes from the mother and the other is
from the father (23 + 23 = 46). Why 1 until 22? These are
autosomes. These are chromosomes that are not related to
gender, because chromosome 23 (the encircled one sa picture
below) is called the sex chromosome.

• Genes are the basic units of heredity that determine both the
physical and cognitive characteristics of people.
• DNA is located inside the chromosomes. They are thread-like • If you pull a thread from the chromosome, the DNA can be
structures located inside the nucleus of animal and plant cells, seen, or the book of instructions. A set of DNAs is called a gene.
or in a human being. It has a starting point and an end point.

majjyap ‘21
UNIT 8 (Week 10)
• In the 23rd pair of chromosome, this is where we determine the This is all the information that is found inside the individual’s
gender. If the 23rd pair of chromosome is XX, the gender is cells. It is everything that someone inherited from their
female. If it is XY, then it is male. parents. It depends on the hereditary information.
o For example, there is a person who has brown hair but
his cells contain one brown hair and one blonde hair
allele. The genotype includes all of this information,
even though this person does not have blonde hair.
• If the combination has two dominant alleles (both are capital
letters), the genotype is called homozygous (dominant). If the
combination has a dominant allele (capital letter) and a
recessive allele (small letter), it is a heterozygous. If the
combination has two recessive alleles (both are small letters),
the genotype is called homozygous (recessive).
• In a chromosome, there are certain areas where specific genes • Phenotype is the expression of the genotype that is visible to
are located for a specific characteristic or trait. It is called a other people and can be observed. Basically, it refers to one’s
• Gametes of the organism’s reproductive cells are haploid cells, gene locus. It is a specific physical location of a gene or other outward appearance or the expression of genes. That is, for
and each cell carries only one copy of each chromosome. DNA sequence on a chromosome, like a genetic street address. example, the color of the person’s eyes. It can be influenced by
o An example is the sperm cell and egg cell, these are The plural of locus is loci. the environment. Another example, the phenotype only
reproductive cells in our body. When these cells unite o For example, the gene locus for eye colors. There are includes information about brown hair because that is what we
and fertilize, it will form a zygote. Once the zygote is many variations or colors for our eyes. These observe when we look at a person.
formed, there are 23 pairs (22 chromosomes + 1 copy variations are called alleles, or the alternative o Phenotype is defined as all the observable
of each chromosome from the mother and father) or variations of a certain trait. If the mother has brown characteristics of an organism that result from the
46 chromosomes. After fertilization, it will form into eyes, she has an allele of the color brown. If the father interaction of its genotype (total genetic inheritance)
an embryo. It includes the 22 autosomes and 1 sex has blue eyes, he has an allele of the color blue. with the environment. Examples of observable
chromosome. o Another example is the gene locus for hair types. The characteristics include behavior, biochemical
alleles coming from the parents are either curly or properties, color, shape, and size.
straight hair. DNA are made up of letters. Instead of o Alleles are codes of the specific variations written in
writing these variations as curly and straight, they are the DNA. It cannot be seen. However, in phenotype,
written as H (represented as the dominant allele) and it is the traits or characteristics one has when they are
h (represented as the recessive allele). born, or your outward appearance.
• Punnett square is a graphical representation of the possible
genotypes of an offspring arising from a particular cross or
breeding event. It is a tool used by biologists to predict the
probability of possible genotypes of an offspring.
<– Father
• Normally, we have 46 pairs of chromosomes. The normal cells
are called diploid cells. From the syllable di which means two,
it has two chromosomes.
100% chance
Mother –>
of brown eyes
• Genotype refers to the genetic code of the individual, or the
particular combination of alleles for a particular gene or locus.
majjyap ‘21
UNIT 8 (Week 10)
Father affected individual, or ask for permission to obtain Diagnostic Testing
health records, if available. An extensive prenatal • Many diagnostic tests are available to provide important clues
history of an affected person should be obtained to about possible disorders.
75% chance of
straight hair;
determine whether there are environmental • Before pregnancy, karyotyping of both parents and an already
Mother conditions that could account for the condition, just affected child provides a picture of the chromosome pattern
25% chance of
the genetic or hereditary part of the disease. that can be used to predict occurrences in future children.
curly hair
• After gathering data from the history taking, make a o It is the process of pairing and ordering all the
genogram. It helps, not only to identify the possibility of a chromosomes of an organism, thus providing a
chromosomal disorder occurring in a couple’s child/ren, but genome-wide snapshot of an individual’s
also helps identify other family members who might benefit chromosomes.
Screening of Genetic Disorders and Genetic Counseling from genetic counseling. o Karyotypes are prepared using standardized staining
A genetic assessment begins with careful study of the pattern of • When a child is born dead, parents are advised to have procedures that reveal characteristic structural
inheritance in a family. A history, physical examination of family chromosomal analysis and autopsy performed on the infant. features for each chromosome.
members, and a laboratory analysis such as karyotyping or DNA analysis • If, at some future date, they wish genetic counseling, this o A sample of peripheral venous blood or excreting of
are performed to define the extent of the problem and the chance of would allow their genetic counselor to have additional medical cells from the buccal membrane is taken. Cells are
inheritance. information. This is one purpose of having a family genogram. allowed to grow until they reach the metaphase.
Metaphase is the most easily observed phase. Cells
History and Assessment / Family Genogram Physical Assessment are then stained, placed under a microscope, and
• Genetic disorders are often difficult because the facts detailed • Because genetic disorders often occur in varying degrees of photographed.
may evoke uncomfortable emotions such as sorrow, guilt, or expression, a careful physical assessment of any family o Chromosomes are identified according to size, shape,
inadequacy in parents. However, we should try to obtain member with a disorder, the child, siblings, and a couple taking stain, cut from the photograph, and arrangement.
information and document diseases in family members for a counseling is needed. o Any additional locking or abnormal chromosomes can
minimum of three generations. Remember to include the half- • During inspection, pay particular attention to certain body be visualized by this method.
brothers and sisters, or anyone related in any way as family. o A newer method of staining, Fluorescence in Situ
areas:
Document the mother’s age because some disorders increases Hybridization (FISH), is a laboratory technique for
o Space between the eyes
in incidence with age. detecting and locating a specific DNA sequence on a
o Height
o Documenting the family’s ethnic background can chromosome. It allows karyotyping to be done
o Contour and shape of ears
reveal risks for certain disorders that occur more immediately, rather than waiting for the cells to reach
o Number of fingers and toes
commonly in some ethnic groups than others. If the the metaphase. This makes it possible for a report to
o Presence of webbing
couple seeking counseling is unfamiliar with their be obtained in only 1 day.
Also known as syndactyly
family history, ask them to talk to their senior family o Aside from the cells in the buccal membrane, the fetal
It is a term used to describe webbing or
members about other relatives (grandparents, aunts, skin cells can also be used by obtaining through
conjoined digits of the fingers or toes.
and uncles) before an interview. Have them also ask o Note abnormal fingerprints or palmar creases as they amniocentesis. A few fetal cells circulate in the
the family and relatives for instances of spontaneous maternal bloodstream. Most noticeably, those
are present in some genetic disorders.
miscarriage or children in the family who died at birth. trophoblasts, lymphocytes, and granulocytes. They
o Abnormal hair whorls or hair color
In many instances, these children died of unknown
• Careful inspection of newborns is often sufficient to identify a are present but in a few number during the first and
chromosomal disorders or were miscarried because second trimester, but plentiful during the third or last
child with a potential chromosomal disorder. Infants with
of one of the 70 or more known chromosomal trimester. These cells can be cultured and used for
multiple congenital anomalies, those born at less than 35
disorders. Basically, some reasons why miscarriage genetic testing for such disorders such as trisomies.
weeks’ gestation, and those whose parents have had other
happens is because of chromosomal disorders.
children with chromosomal disorders need extremely close
o Attempt to obtain more information by asking the
assessment.
couple to describe the appearance or activities of the
majjyap ‘21
UNIT 8 (Week 10)
It is a prenatal test that is used to detect birth Has the advantage over the chorionic villi
defects, genetic diseases, and other sampling of carrying only 0.5% risk of
problems during pregnancy. spontaneous miscarriage. Unfortunately, it is
During the test, a small sample of cells called usually not done until the 14th to 16th week
the chorionic villi is taken from the placenta of pregnancy. At this time, this may prove to
where it attaches to the wall of the uterus. A be a difficult time because the woman is
catheter is inserted through the vaginal beginning to accept her pregnancy and has
canal into the uterus to get a sample villi already bonded with the fetus. In addition,
from the placenta. These cells are then the termination of pregnancy during the
submitted for analysis. The cells removed in second trimester is more difficult than
CVS are karyotyped, and then submitted for during the first trimester.
DNA analysis to reveal whether the fetus has Support the woman while she waits for the
a genetic disorder. test results, and to make a decision about
More fetal cells can be found earlier in the pregnancy.
pregnancy. Although this procedure may be After the procedure, all women needs to be
• Once a woman is pregnant, several other tests may be done as early as week 5 of pregnancy, it is observed for about 30 minutes to be certain
performed to help in the prenatal diagnosis of a genetic more commonly done at 8 to 10 weeks. that labor contractions are not beginning
disorder. These include: Is highly accurate and yields no more false and the fetal heart rate remains within
o Maternal serum alpha-fetoprotein (MSAFP) positive results than the amniocentesis. normal limit.
Alpha-fetoprotein (AFP) is a glycoprotein However, this test carries a small risk less o Percutaneous umbilical blood sampling (PUBS)
produced by the fetal liver that reaches peak than 1% of causing excessive bleeding Also called as cordocentesis
in maternal serum between the 13th and 32nd leading to pregnancy loss. The removal of blood from the fetal
week of pregnancy. After CVS, instruct the woman to report umbilical cord at about 17 weeks using an
During a baby’s development, some AFP chills or fever suggestive of infection, or amniocentesis technique, or basically just
passes through the placenta into the symptoms of threatened miscarriage such as the aspiration of blood from the umbilical
mother’s blood. uterine contractions or vaginal bleeding. vein for analysis.
An AFP test measures the level of alpha- o Amniocentesis After the umbilical cord is located through an
fetoprotein in pregnant women during the It is the withdrawal of amniotic fluid through ultrasound, a thin needle is inserted by
second trimester of pregnancy. Too much or the abdominal wall for analysis at the 14th to amniocentesis technique into the uterus and
too little of this protein in the mother’s blood 16th week of pregnancy. is guided by the ultrasound until it pierces
may be a sign of a birth defect or other Because amniotic fluid has reached about the umbilical vein.
conditions which includes a neural tube 200 mL at this point, enough fluid can be A sample of blood is then removed for blood
defect, Down syndrome, multiple births, withdrawn for karyotyping of skin cells found studies such as a complete blood count,
miscalculation of due date because AFP in the fluid as well as an analysis of the alpha- direct Coombs test, blood gases, and
levels change during pregnancy. It is used to fetoprotein. karyotyping.
check a developing fetus for risks of birth A packet of amniotic fluid is located through The fetus is monitored by a nonstress test
defects and genetic disorders. an ultrasound. A needle is then inserted before and after the procedure to be certain
Blood is withdrawn from the vein of the transabdominally, and about 20 mL of fluid is that uterine contractions are not present,
mother between the 16th to 18th week of aspirated. Skin cells in the fluid are and by ultrasound to see that no bleeding is
pregnancy. karyotyped for chromosomal number and evident.
o Chorionic villi sampling (CVS) structure. The level of the alpha-fetoprotein This procedure carries little additional risk to
is analyzed. the fetus and mother over amniocentesis
majjyap ‘21
UNIT 8 (Week 10)
and can yield information not available by woman to help sedate the fetus to avoid Treatment may include special formula, diet
any other means, especially about blood fetal injury by the scope and to allow better restrictions, supplements, medicines, and
dyscrasias. observation. close monitoring.
o Ultrasound o Preimplantation diagnosis
It is an imaging test that uses soundwaves to It is only possible for in vitro fertilization
create a picture (also known as sonogram) of procedures.
organs, tissues, and other structures inside It is the genetic profiling of embryo prior to
our body. implantation.
This diagnostic tool is used to assess a fetus It may be possible in the future for a
for general size, structural disorders of the naturally fertilized ovum to be removed from
internal organs, spine, and lips. Some genetic the uterus by lavage before implantation and
disorders are associated with physical studied for DNA analysis this same way. The
appearance. Usually, a congenital anomaly ovum would then be reinserted or not,
scan is usually done around 5 to 6 months of depending on the findings and the parents’
pregnancy because by that time, the body wishes. This would provide genetic
parts of the baby is formed. information extremely early in a pregnancy.
o Fetoscopy o Newborn Screening Test – after the delivery of the
The insertion of fiberoptic fetoscope through child
small incision in the mother’s abdomen into Is already a mandated law in the Philippines
the uterus and membranes to visually that every Filipino child should undergo.
inspect the fetus for gross abnormalities. It is a simple blood test that detects rare
It can be used to confirm an ultrasound genetic, hormone-related, and metabolic
finding to remove skin cells for DNA analysis conditions that can cause serious health
or to perform surgery for a congenital problems. It lets doctors diagnose babies
disorder. quickly and start treatment as soon as
If a photograph is taken through the possible.
fetoscope, it can document a problem or A small blood sample taken by pricking the
reassure parents that their infant is perfectly baby's heel is tested. This happens before Genetic Counseling
formed. the baby leaves the hospital, usually at 1 or 2 • It is the process of advising individuals and families affected by
The procedure is used to confirm the days of age. The blood sample should be or at risk of genetic disorders to help them understand and
intactness of the spinal column and obtain taken after the first 24 hours of life. adapt to the medical, psychological, and familial implications
biopsy samples of fetal tissue and fetal blood Often, parents will not hear about results if of genetic contributions to genetic diseases.
samples. screening tests were normal. They are • Any individual concerned about the possibility of transmitting
The earliest time in pregnancy that contacted if a test was positive for a a disease to their children should have access to genetic
fetoscope can be performed is about the 16th condition. A positive newborn screening test counseling for advice on the inheritance of a disease.
or 17th week. For the procedure, the mother does not mean a child definitely has the • It can serve to:
is prepared and draped as for amniocentesis. medical condition. Doctors order more tests o Provide concrete, accurate information about the
A local anesthesia is injected into the to confirm or rule out the diagnosis. process of inheritance and inherited disorders.
abdominal skin. The fetoscope is then If a diagnosis is confirmed, doctors might o Reassure people who are concerned that their child
inserted through a minor abdominal incision. refer the child to a specialist for more testing may inherit particular disorder that the disorder will
If the fetus is very active, meperidine and treatment. When treatment is needed, not occur.
(Demerol) may be administered to the it is important to start it as soon as possible.
majjyap ‘21
UNIT 8 (Week 10)
o Allow people who are affected by inherited disorders individuals who seek genetic counseling, and in helping with An option for couples if the genetic disorder
to make informed choices about future reproduction. reproductive genetic testing procedures. is one inherited by the male partner or is a
o Offer support to people who are affected by genetic • By such actions as: recessively inherited disorder carried by
disorders. o Explaining to a couple what procedures they can both partners. AID is available in all major
• Genetic counseling can result in making individuals feel “well” expect to undergo. communities and can permit the couple to
or free of guilt for the first time in their lives if they discover a o Explaining how different genetic screening tests are experience the satisfaction and enjoyment
disorder they were worried about is not an inherited one but done and when they are usually offered. of a usual pregnancy.
rather occurred by chance. o Supporting a couple during the wait for test results. If the inherited problem is one arising from
• In other instances, counseling can result in informing o Assisting couples in values clarification, planning, and the female partner, surrogate embryo
individuals they are carriers of a trait responsible for a child’s decision making based on test results. transfer is an assisted reproductive
condition. Even when people understand they had no control • A great deal of time may need to be spent offering support or technique that is a possibility. For this, an
over this, knowledge about passing a genetic disorder to a child a grieving couple confronted with the reality of how tragically oocyte is donated by a friend or relative or
can cause guilt and self-blame. Marriages and relationships can the laws of inheritance have affected their lives. Genetic provided by an anonymous donor, which is
end unless both partners receive adequate support. counseling is a role for nurses only if they are adequately then fertilized by the male partner’s sperm
• Couples who are most apt to benefit from a referral for genetic prepared in the study of genetics, however, because without in the laboratory and implanted into a
testing or counseling include: this background, genetic counseling can be dangerous and woman’s uterus. Like AID, donor embryo
o A couple who has a child with a congenital disorder or destructive. transfer offers the couple a chance to
an inborn error of metabolism. • Whether one is acting as the nurse member of a genetic experience a usual pregnancy.
o A couple whose close relatives have a child with a counseling team or as a genetic counselor, some common o Use of a surrogate mother
genetic disorder such as a chromosomal disorder or principles apply. A woman who agrees to be alternately
an inborn error of metabolism. o The individual or couple being counseled needs a inseminated, typically by the male partner’s
o Any individual who is a known carrier of a clear understanding of the information provided. sperm, and bear a child for the couple.
chromosomal disorder. o It is never appropriate for a healthcare provider to All of these procedures are expensive and,
o Any individual who has inborn error of metabolism or impose his or her own values or opinions on others. depending on individual circumstances, may
chromosomal disorder. Individuals with known inherited disease in their have disappointing success rates.
o A consanguineous (closely related) couple. family must face difficult decisions, such as how much o Adoption
o Any woman older than 35 years of age and any man genetic testing to undergo or whether to terminate a An alternative many couples can also find
older than 55 years of age. pregnancy that will result in a child with a specific rewarding. Choosing to remain child free
o Couples of ethnic backgrounds in which specific genetic disease. Be certain couples have been told all should not be discontinued as a viable
illnesses are known to occur. the options available to them and then leave them to option. Many couples who have every
For example, those with a Chinese ancestry think about the options and make their decision by reason to think they will have healthy
have a high incidence of glucose-6- themselves. Help them to understand that no one is children choose this alternative because
phosphate dehydrogenase (G6PD) judging their decision because they are the ones who they believe their existence is full and
deficiency, a blood disorder where must live with the decision in the years to come. rewarding without the presence of children.
destruction of red cells can occur. o Stem cell
Mediterranean people have a high incidence Reproductive Alternatives and Future Possibilities Is looking at the possibility immature cells
of thalassemia, a blood disorder. • Some couples are reluctant to seek genetic counseling because from a healthy embryo (stem cells) could be
they are afraid they will be told it would be unwise to have implanted into an embryo with a known
Nursing Responsibilities children. Helping them to realize viable alternatives for having abnormal genetic makeup, replacing the
• Nurses play important roles in assessing for signs and a family exist can allow them to seek the help they need. abnormal cells or righting the affected child’s
symptoms of genetic disorders, in offering support to o Artificial Insemination by donor (AID) genetic composition.

majjyap ‘21
UNIT 8 (Week 10)
Although presently possible, stem cell Mechanisms of Genetic Mutation and Inheritance Patterns • Mosaicism
research is costly ad produces some ethical Chromosomal Abnormalities (Cytogenic Disorders) o An abnormal condition that is present when the
questions. • Nondisjunction Abnormalities nondisjunction disorder occurs after fertilization of
• Help couples decide on a solution that is correct for them, not o The failure of homologous chromosomes to separate the ovum, as the structure begins mitotic (daughter-
one they sense you or a counselor feels would be best. They properly during meiosis. cell) division. If this occurs, there are different cells in
need to consider the ethical philosophy or beliefs of other the body that will have different chromosome counts.
family members when making their decision, although The extent of the disorder depends on the proportion
ultimately, they must do what they believe is best for them as of tissue with normal chromosome structure or
a couple. A useful place to start counseling is with values constitution.
clarification, to be certain a couple understands what is most o Usually, a nondisjunction abnormality occurs during
important to them. the meiosis phase of cell division.

Legal and Ethical Aspects of Genetic Screening and Counseling

• Nurses can be instrumental in making sure couples who seek
genetic counseling receive results in a timely manner and with
compassion about what the results may mean to future
childbearing. Always keep in mind several legal responsibilities • Deletion Abnormalities
of genetic testing, counseling, and therapy including: o It is a structural abnormality where a portion of the
o Participation by couples or individuals in genetic chromosome is missing or deleted.
screening must be elective. o Example: Cri cu Chat syndrome (Cat-cry syndrome)
o People desiring genetic screening must sign an
informed consent for the procedure.
o Results must be interpreted correctly yet provided to
the individuals as quickly as possible.
o The results must not be withheld from the individuals
and must be given only to those persons directly
involved.
o After genetic counseling, persons must not be • Translocation Abnormalities
coerced to undergo procedures such as abortion or o It is a structural abnormality where a portion of one
sterilization. Any procedure must be a free and chromosome is transferred to another chromosome.
individual selection. • Isochromosomes
• Failure to heed these guidelines could result in charges of o If a chromosome accidentally divides not by a vertical
invasion of privacy, breach of confidentiality, or psychological separation but by a horizontal one, a new
injury caused by “labeling” someone or imparting unwarranted chromosome with mismatched long and short arms
fear and worry about the significance of a disease or carrier can result. It has much the same effect as a
state. If couples are identified as being at risk for having a child translocation abnormally when an entire extra
with a genetic disorder and are not informed of the risk and chromosome exists.
offered an appropriate diagnostic procedure such as o Example: Turner syndrome (45XO)
amniocentesis during a pregnancy, they can bring a “wrongful
birth” lawsuit if their child is born with the unrevealed genetic
disorder.

majjyap ‘21
UNIT 8 (Week 10)
and flat. The eyelids have an extra fold of tissue at the
inner canthus (an epicanthal fold), and the palpebral
fissure (opening between the eyelids) tends to slant
laterally upward. The iris of the eye may have white
specks, called Brushfield spots. The tongue is apt to
protrude from the mouth because the oral cavity is
smaller than usual. The back of the head is flat, the
neck is short, and an extra pad of fat at the base of
the head causes the skin to be loose it can be lifted
easily and so thin it can be revealed on a fetal
sonogram.
o The ears may be low set. Muscle tone is poor, giving
the newborn a rag doll appearance. This muscle tone
can be so lax that the child’s toe can be touched
against the nose (not possible in the average mature
newborn). The fingers of many children with Down
syndrome are short and thick, and the little finger is
often curved inward. There may be a wide space
Classification of Common Genetic Disorder (Wala gi discuss ni Miss)
between the first and second toes and between the
• Autosomal Dominant Inheritance
first and second fingers. The palm of the hand shows
• Autosomal Recessive Inheritance
a peculiar crease (a simian line) or a single horizontal o Children with Down syndrome are usually cognitively
• X-Linked Dominant Inheritance crease rather than the usual three creases in the challenged to some degree. The challenge can range
• X-Linked Recessive Inheritance palm. from an IQ of 50 to 70 to a child who is profoundly
• Multifactorial (Polygenic) Inheritance
affected (IQ less than 20). The extent of the cognitive
• Mitochondrial Inheritance
challenge is not evident at birth, but the fact the brain
• Imprinting
is not developing well is usually evidenced by a head
• Autosomal Trisomies size smaller than the 10th or 20th percentile at well-
child healthcare visits.
Selected Genetic Disorders and their Nursing Management
o Internally, congenital heart disease, especially an
• Trisomy 21 or “Down” Syndrome atrioventricular defect, is common. Stenosis or atresia
o A genetic condition caused by an extra chromosome. of the duodenum, strabismus, and cataract disorders
Most babies inherit 23 chromosomes from each may also be present. In addition, the child’s immune
parent, for a total of 46 chromosomes. Babies with function may be altered because as these children
Down syndrome however, end up with three grow, they are prone to upper respiratory tract
chromosomes at position 21, instead of the usual pair. infections. Probably due to a second gene aberration,
o The most frequently occurring chromosomal they tend to develop acute lymphocytic leukemia
disorder, occurs in about 1 in 800 pregnancies. In about 20 times more frequently than the general
women who are older than 35 years of age, the population. Even if children are born without an
incidence is as high as 1 in 100 live births. accompanying disorder such as heart disease or do
o The physical features of children with Down not develop leukemia, their life span usually is limited
Syndrome are so marked that fetal diagnosis is to only 50 to 60 years because aging seems to occur
possible by sonography in utero. The nose is broad faster than usual.
majjyap ‘21
UNIT 8 (Week 10)
o It is important for children with Down syndrome to be Edwards’ syndrome has an impact on the
enrolled in early educational and play programs so baby’s movements as they get older, and
they can develop to their full capacity. Because they they may benefit from supportive treatment
are prone to infections, sensible precautions such as such as physiotherapy and occupational
using a good hand washing technique are important therapy.
when caring for them. The enlarged tongue may Depending on the baby’s specific symptoms,
interfere with swallowing and cause choking unless they may need specialist care in hospital or a
the child is fed slowly. Because their neck may not be hospice, or parents may be able to look after
fully stable, an x-ray to ensure stability is them at home with the right support.
recommended before they engage in strenuous • Trisomy 13 or “Patau’s” Syndrome
activities such as competitive sports or Special o A syndrome caused by a chromosomal abnormality,
Olympics. As with all newborns, these infants need a in which some or all of the cells of the body contain
physical examination at birth to enable the detection extra genetic material from chromosome 13. The
of the genetic disorder and the initiation of parental extra genetic maternal disrupts normal development,
counseling, support, and future planning. causing multiple and complex organ defects.
o Nursing Management: o In trisomy 13 (Patau syndrome), the child has an extra
Provide adequate nutrition chromosome 13 and is severely cognitively
Frequent consultations are a must challenged. The incidence of the syndrome is low,
Assess understanding of Down syndrome approximately 0.45 per 1,000 live births. Midline body
Provide emotional support and motivation disorders such as cleft lip and palate, heart disorders
• Trisomy 18 or “Edward’s” Syndrome (particularly ventricular septal defects), and abnormal
o A genetic condition in babies that causes severe genitalia are present. Other common findings include
disability. It is caused by an extra copy of microcephaly with disorders of the forebrain and
chromosome 18 and babies born with the condition forehead, eyes that are smaller than usual
usually do not survive for much longer than a week. (microphthalmos) or absent, and low-set ears. Most
o Children with trisomy 18 syndrome (Edwards of these children do not survive beyond early
syndrome) have three copies of chromosome 18. The childhood.
incidence is approximately 0.23 per 1,000 live births. o Defects that come with this syndrome:
These children are severely cognitively challenged Heart defects
and tend to be small for gestational age, have Brain or spinal cord abnormality
markedly low-set ears, a small jaw, congenital heart Small or poorly developed eyes
defects, and usually misshapen fingers and toes (the Extra fingers or toes
index finger deviates or crosses over other fingers). Cleft lip or palate
o Nursing Management:
Also, the soles of their feet are often rounded instead Weak muscles
There is no cure for Edwards’ syndrome.
of flat (rocker-bottom feet). As in trisomy 13
Treatment will focus on the symptoms of the
syndrome, most of these children do not survive
condition, such as heart conditions,
beyond infancy.
breathing difficulties, and infections.
Pediatric patients may also need to be fed
through a feeding tube, as they can often
have difficulty feeding.

majjyap ‘21
UNIT 8 (Week 10)
lack of estrogen during growing years may be
prevented. If females continue taking estrogen for 3
out of every 4 weeks, this produces withdrawal
bleeding which results in a menstrual flow. This flow,
however, does not correct the basic problem of
sterility; ovarian tissue is scant and inadequate for
ovulation because of the basic chromosomal
aberration. A woman with Turner syndrome could,
however, have IVF with surrogate oocyte transfer in
order to become pregnant.
o Clinical Features:
• Turner’s Syndrome
Grow more slowly than their peers during
o A condition that affects only females, results when
childhood and adolescents
one of the X chromosomes (sex chromosomes) is
Have delayed puberty and lack of growth
missing or partially missing.
spurts, resulting in an average adult height of
o The child with Turner syndrome (gonadal dysgenesis)
4 feet, 8 inches.
has only one functional X chromosome. The child is
Does not experience breast development.
short in stature and has only streak (small and
o Nursing Management: May not have menstrual periods.
nonfunctional) ovaries. She is sterile and, with the
There is no cure for trisomy 13, and Have small ovaries that may only function for
exception of pubic hair, secondary sex characteristics
treatments focus on the baby’s symptoms. a few years or not at all.
do not develop at puberty. The hairline at the nape of
These can include surgery and therapy. Typically does not go through puberty,
the neck is low set, and the neck may appear to be
Although, depending on the severity of the unless they get hormone therapy in late
webbed and short. A newborn may have appreciable
baby’s issues, some doctors may choose to childhood and early teens.
edema of the hands and feet and a number of
wait and consider any measures based on Does not make enough sex hormones.
congenital anomalies, most frequently coarctation
the chances of the baby’s survival. (stricture) of the aorta as well as kidney disorders. The
Trisomy 13 is not always fatal. But doctors incidence of the syndrome is approximately 1 per
cannot predict how long a baby might live if 10,000 live births. The disorder can be identified on a
they do not have any immediate life- sonogram during pregnancy (a nuchal translucency
threatening problems. However, babies born scan) because of the extra skin at the sides of the
with trisomy 13 rarely live into their teens. neck.
• Cri du Chat Syndrome o Although children with Turner syndrome may be
o Also known as 5p- (5p minus) syndrome severely cognitively challenged, difficulty in this area
o The result of a missing portion of chromosome 5. In is more commonly limited to learning disabilities.
addition to an abnormal cry, which sounds much Socioemotional adjustment problems may
more like the sound of a cat than a human infant’s cry, accompany the syndrome because of the lack of
children with cri-du-chat syndrome tend to have a fertility and if the nuchal folds are prominent.
small head, wide-set eyes, a downward slant to the o Human growth hormone administration can help
palpebral fissure of the eye, and a recessed mandible. children with Turner syndrome achieve additional
They are severely cognitively challenged. height. If treatment with estrogen is begun at
approximately 13 years of age, secondary sex
characteristics will appear, and osteoporosis from a

majjyap ‘21
UNIT 8 (Week 10)
o Nursing Management: o Before puberty, boys with fragile X syndrome may o A rare genetic disorder in which the body is not able
Hormone replacement therapy typically demonstrate maladaptive behaviors such as to break down complex sugars, which affects organs
They may also be given low doses of hyperactivity, aggression, or autism. They may have and tissues, particularly muscles.
androgen reduced intellectual functioning, with marked deficits o A genetically inherited condition caused by
• Klinefelter’s Syndrome in speech and arithmetic. On physical exam, frequent insufficient functioning of an enzyme called
o Children with Klinefelter syndrome are males with an findings identified are a large head, a long face with a lysosomal acid a-1,4-glucosidase or just acid alpha-
extra X chromosome. Characteristics of the syndrome high forehead, a prominent lower jaw, large glucosidase due to a mutation of the GAA gene. It can
may not be noticeable at birth. At puberty, secondary protruding ears, and obesity. Hyperextensive joints cause buildup of glycogen, eventually damages
sex characteristics do not develop; the child’s testes and cardiac disorders may also be present. After muscles and other cell types.
remain small and produce ineffective sperm. Affected puberty, enlarged testicles may become evident.
individuals tend to develop gynecomastia (increased Affected individuals are fertile and can reproduce.
breast size) and have an increased risk of male breast o Carrier females may show some evidence of the
cancer. The incidence of the syndrome is about 1 per physical and cognitive characteristics. Although
1,000 live births. Karyotyping can be used to reveal intellectual function from the syndrome cannot be
the additional X chromosome. improved, a combination of stimulants, a agonists,
atypical antipsychotics, and serotonin reuptake
inhibitors may improve symptoms of poor
concentration and impulsivity.

o Nursing Management:
Provide education, resources, and support.
Counseling about infertility, marriage, and o Glucose is used for energy by most cells of the body,
relationships. and it is stored inside the cells as a compact, branch-
Ideally, patients should begin testosterone shaped molecule called glycogen. When a cell needs
treatment as they enter puberty. A regular energy, it uses enzymes to remove glucose molecules
schedule of testosterone injections will from the branches. One of the organelles within the
increase strength and muscle size and cell is the lysosome, which function a bit like a tiny
promote the growth of facial and body hair. recycling plant. The lysosome contains enzymes that
o Behavioral Features:
• Fragile X Syndrome break down cellular substances so that they can be
Hypersensitivity
o The most common cause of cognitive challenge in recycled.
Intolerance to change in routine
males. It is an X-linked disorder in which one long arm o Small amounts of glycogen ends up in the lysosomes,
o Nursing Management:
of an X chromosome is defective which results in where it is broken down by an enzyme called acid
Protein replacement and gene therapy
inadequate protein synaptic responses. The incidence alpha-glucosidase, to release glucose from the
Referral to early intervention program
of the syndrome is about 1 in 4,000 males. glycogen chain.
Prognosis: Expected to live normal life span
• Pompe Disease
majjyap ‘21
UNIT 8 (Week 10)
o In Pompe disease, a mutation of the GAA gene
prevents the production of enough functional acid
alpha-glucosidase, and lysosomes cannot break down
glycogen. This leads to a buildup of glycogen within
the cytoplasm and lysosomes, and that leads to
cellular damage and destruction.
o Normally, glycogen is found in the largest amounts in
the cytoplasm of liver cells and all three types of
muscle cell. In individuals with Pompe, glycogen
mostly accumulates in the lysosomes of those cells.
Skeletal muscles include various muscles of the body o Nursing Management:
as well as the diaphragm which is the primary
breathing muscle. Cardiac muscle makes up the
majority of a healthy heart, and smooth muscle is
found in the walls of blood vessels and many other
organs.

o This results in progressive symptoms of central

nervous system or CNS degeneration, like decreased
muscle tone, visual difficulties and seizures, which
usually begin by 3 to 6 months of age, proceeding to
death by age 4.
o Depending on age of onset, TSD can be infantile, with
onset at 3 to 6 months; juvenile, with onset at 2-5
• Tay-Sachs Disease years; chronic, with onset in the first or second
o A rare disorder passed from parents to child. It is decade of life; and late-onset, with the first indication
caused by the absence of an enzyme that helps break of symptoms in the second or third decade of life.
down fatty substances. These fatty substances, called o Common signs for the first three forms are signs of
gangliosides, build up to toxic levels in the child’s CNS degeneration, like decreased muscle tone,
brain and affect the function of the nerve cells. As the abnormally increased reflexes, seizures and visual
disease progresses, the child loses muscle control. disturbances. For adult-onset, there may be motor
Eventually, this leads to blindness, paralysis, and difficulties and some adults may manifest bipolar type
death. psychological symptoms.
o Clinical Features:
o A lysosomal storage disorder caused by a mutation in o Ophthalmologists may be the first to consider TSD by
a gene on chromosome 15, which codes for a finding a “cherry red spot” in the macula of the eye,
lysosomal enzyme called beta-hexosaminidase A, or which results from GM2 buildup in the retinal cells
HEX-A for short. This enzyme normally breaks down a around the central macular area.
lipid called GM2 ganglioside. GM2 is found mainly in
neurons, so without HEX-A, it accumulates inside
lysosomes.

majjyap ‘21
UNIT 8 (Week 10)
amniocentesis and chorionic villus sampling Psychiatric symptoms can vary for mild
as well as artificial insemination, ovum depression to full-blown psychosis and the
donation, and in-vitro fertilization to have underlying cause of Wilson's disease is often
children who do not have Tay-Sachs disease missed and treatment is delayed.
or related GM2 disorders. Kizer flescher rings are found in the cornea
• Wilson Disease of the eye and they are deposits in decimates
o A rare inherited disorder that causes copper to corneal membrane. These are small circular
accumulate in your liver, brain, and other vital organs. brown rings that present around the eye in
o A rare inherited disorder, when your body takes in patients with Wilson's disease and these
and absorbs too much copper. Normally, copper from brownish circles surrounding the iris can
the diet is filtered out by the liver and released into usually be seen by the naked eye, but proper
bile, which flows out of the body. People who have assessment requires a slit-lamp
o Clinical Features: Wilson disease cannot release copper from the liver. examination.
Loss of learned skills When the copper storage capacity of the liver is There are a few other features. You get a
Loss of smile, crawl, grab exceeded, copper is released into the bloodstream hemolytic anemia where the red blood cells
Blindness, deafness, paralysis and travels to other organs including the brain, are being broken down too quickly, you can
Dementia kidney, and eyes. get renal tubular damage which leads to
Unable to swallow o Clinical Features: renal tubular acidosis, and you can get
Muscle atrophy Most people with Wilson's disease present osteopenia which is a loss of the bone
o Nursing Management: with one or more of these three different mineral density.
There is no cure for TSD or its variants. systems: hepatic problems or liver problems o Nursing Management:
Treatment for the infantile and juvenile form which occur in 40% of people, neurological
involves supportive care to manage problems or problems with the brain which
symptoms. Usually this involves many occur in 50% of people, or psychiatric
specialists including neurologists to manage problems which occur in 10% of people.
seizures, gastroenterologists, surgeons, and Copper deposition in the liver leads to
nutritionists to manage feeding, as well as chronic hepatitis so, inflammation of those
occupational and physical therapists to assist liver cells that have excessive copper in them
with the tasks of daily living and mobility. and eventually this leads to liver cirrhosis.
Management of symptoms in later onset Copper deposition in the nervous system
forms is also primarily supportive, dealing leads to neurological and psychiatric • Heredity Hemochromatosis
with the slower, but progressive nature of problems. The neurological symptoms can o Caused by a mutation in a gene that controls the
the degeneration in these related be subtle and range from concentration or amount of iron your body absorbs from the food you
conditions. Enzyme replacement or gene coordination difficulties to dysarthria eat. These mutations are passed from parents to
therapy continue to be areas of research, but (speech difficulties) and dystonia (abnormal children. A gene called HFE is most often the cause of
until they are in hand, genetic counselling for muscle tone). heredity hemochromatosis. You inherit one HFE gene
individuals at high risk can help prevent Copper deposits in the basal ganglia and the from each parent.
passing on the mutations associated with brain leads to something called o An iron storage disorder that results in excessive total
TSD. Parkinsonism and this is where you get body iron and the deposition of iron in tissues.
More specifically, couples at risk of having an tremors, bradykinesia (small movements), o The human hemochromatosis protein which is
affected child have options like and rigidity. abbreviated to HFE is encoded by a gene that is
located on the chromosome 6, and the majority of
majjyap ‘21
UNIT 8 (Week 10)
cases of hemochromatosis relate to mutations in this from the body and along with that blood properly. The condition gets its name from the
gene. comes the extra iron. distinctive sweet odor of affected infants’ urine.
o The hemochromatosis genetic mutation is inherited Carefully monitor the serum ferritin.
in an autosomal recessive way and the gene is Monitor and treat any complications of the
important in regulating iron metabolism in the body, condition.
which is why it causes an iron storage disorder. • Alkaptonuria
o Clinical Features: o A rare inherited disorder. It occurs when your body
Hemochromatosis usually takes a bit of time cannot produce enough of an enzyme called
before enough iron builds up in the body for homogentisic dioxygenase (HGD). This enzyme is
it to become symptomatic. It usually used to break down a toxic substance called
presents after the age of 40. homogentisic acid, a product of tyrosine and
Can present with chronic tiredness, joint phenylalanine metabolism.
pain because of iron deposits in the joints o When you do not produce enough HGD, homogentisic
causing arthritis. They can present with acid builds up in your body. The buildup of
pigmentation or a bronze discoloration of homogentisic acid causes your bones and cartilage to
their skin because of the iron deposits in the become discolored and brittle.
skin, hair loss, sexual problems such as an o This typically leads to osteoarthritis, especially in your o Clinical Features:
erectile dysfunction or amenorrhea, and spine and large joints. People with alkaptonuria also Sleepiness or irritability
cognitive problems like problems with have urine that turns dark brown or black when it is Coma or brain damage
memory and mood disturbance. exposed to air. Symptoms may develop at a later stage
o Clinical Features: Vomiting
Black spots in the eyes Poor feeding
Early onset osteoarthritis (especially in the Urine smells like maple syrup or burnt sugar
spine) Psychomotor delay
Kidney and prostate stones Intellectual disability
Blue or grey tinge (or darkening) to the ears Death
Hardening of blood vessels in the heart
Black urine

o Nursing Management:
Need to get rid of all of that excess iron in the
• Maple Syrup Urine Disease
body, and we do this through venesection
o An inherited disorder in which the body is unable to
which is a weekly protocol of removing blood
process certain protein building blocks (amino acids)
majjyap ‘21
UNIT 8 (Week 10)
have been described. The degree of enzyme function patients, but can have serious side effects in
can vary. some patients.
o When untreated, people with PKU develop symptoms • Galactosemia
such as severe intellectual disability, psychiatric o Which means “galactose in the blood,” refers to a
disorders, and seizures. group of inherited disorders that impair the body’s
o A pregnant woman with PKU must pay special ability to process and produce energy from a sugar
attention to her phenylalanine levels to reduce the called galactose. When people with galactosemia
risk of Maternal PKU Syndrome that can result in ingest foods or liquids containing galactose,
heart defects, microcephaly, and developmental undigested sugars build up in the blood.
disability in her baby.
o Testing for PKU is typically done as part of routine
newborn screening approximately 24 hours after
birth.
o First line therapy for PKU is the low phenylalanine
diet. This includes medical foods such as low or no
phenylalanine medical formulas that are a synthetic
o Nursing Management: form of protein and foods modified to be low in
Diet – whole proteins restricted diet; special protein.
metabolic formula o All high protein foods such as meat, fish, eggs, and
Regular blood testing dairy are eliminated from the diet. Measured
Small amounts of breast milk or standard amounts of some grains, vegetables and fruit are
infant formula allowed depending upon the individual patient’s
o The treatment for Galactosemia is the removal of
Avoid foods high in protein tolerance of small amounts of phenylalanine.
galactose from your diet. All lactose products must be
Dietitian will help determine diet routine o Each patient will need to customize the amount of
totally avoided. Milk and milk products contain the
Your clinic will teach you how to track and phenylalanine dietary intake with medical
most amount of lactose; however, it is also present in
limit BCAA professionals according to their individual needs.
other foods such as legumes, organ meats, and
Height and weight measurements o In addition to the low phenylalanine diet, two FDA
processed meats.
Review and make potential dietary approved pharmaceutical treatments are now
o Infants will need to be fed with food that is lactose
adjustments available.
free such as soy formulas, meat-base formula, or
Kuvan is a cofactor for phenylalanine
Nutramigen (a protein hydrolysate formula).
Inborn Errors on Metabolism (detected by Conventional Newborn hydroxylase which helps improve the PKU
o There is no definite cure for Galactosemia, the
Screening) patient’s innate PAH enzyme activity and
condition is life long and it can only be controlled.
increase their phenylalanine tolerance. It
• Phenylketonuria Doctors advise a calcium supplement for patients
must be used in conjunction with the low
o An inborn error of metabolism that results in with Galactosemia as milk is an important source of
phenylalanine diet.
decreased metabolism of the amino acid calcium for a growing child.
Palynziq can be used in adults with PKU. It is
phenylalanine. Untreated, PKU can lead to
an enzyme, injected under the skin every day • Congenital Adrenal Hyperplasia
intellectual disability, seizures, behavioral problems, o A collection of inherited conditions that affect the
by the patient that circulates in the blood,
and mental disorders. body’s adrenal glands, which are the cone-shaped
metabolizing phenylalanine, and substitutes
o An autosomal recessive genetic disorder that affects organs that sit on top of the kidneys. In a person with
for the defective phenylalanine hydroxylase
function of the phenylalanine hydroxylase enzyme. It CAH, the adrenal glands are very large and are unable
enzyme. It works well for many adult PKU
is located on chromosome 12 and over 600 mutations to produce certain chemicals, including cortisol, a

majjyap ‘21
UNIT 8 (Week 10)
chemical that helps protect the body during stress or Cognitive deficits • Interrupted family
illness and helps the body regulate the amount of Clumsiness processes related to having
sugar in the blood. Diminished fine motor skills a child with cognitive
o Treatment: impairment
Levothyroxine is either in tablet or liquid • Delayed growth and
form. In tablet form, it can be crushed and development related to
given with liquid formula to ensure safe impaired ability to achieve
swallowing. developmental tasks
• Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency • Self-care deficit: bathing and
o Occurs when a person is missing or does not have hygiene, dressing, feeding,
enough of an enzyme called glucose-6-phosphate toileting related to cognitive
dehydrogenase. This enzyme helps red blood cells impairment
work properly. • Impaired verbal
o Too little G6PD leads to the destruction of red blood communication related to
cells. This process is called hemolysis. When this impaired receptive or
process is actively occurring, it is called a hemolytic expressive skills
episode. The episodes are most often brief. This is • Potential for low self-
o Clinical Features: because the body continues to produce new red esteem related to body not
Low blood salt and sugar levels blood cells, which have normal activity. developing secondary sex
Change in the genitalia o Symptoms: characteristics as peers of
Early puberty Asymptomatic until exposed to an oxidative same age
Irregular periods stressor • Disturbed body image
o Nursing Management: Jaundice related to differences in
Replace missing corticosteroids Dark tea-colored urine physical characteristics as
Back pain (kidney damage)
• Congenital Hypothyroidism evidenced by webbed neck,
Anemia symptoms (fatigue, hypotension, shield chest, and short
o Previously known as cretinism, is a severe deficiency
tachycardia, confusion, and others) stature
of thyroid hormone in newborns. It causes impaired
o Treatment: Outcomes Child will achieve optimum:
neurological function, stunted growth, and physical
Removal of triggering agent and avoiding • Growth and development
deformities. The condition may occur because of a
exposure potential
problem with the baby’s thyroid gland, or a lack of
Supportive therapy (blood transfusion and • Socialization
iodine in the mother’s body during pregnancy.
o Almost all cases identified through neonatal folic acid supplements)
screening. Treatment of infection Family will:
Genetic counseling
o Clinical Features: • Receive adequate
Constipation • Maple Syrup Urine Disease (gi discuss na ni Miss sa previous information and support
slides)
Hypotonia (decreased muscle tone) • Be prepared for long-term
Hoarse cry care of the child
Nursing Management…
Macroglossia (unusual enlargement of the Nursing Interventions • Perform a physical and
tongue) Nursing Diagnoses • Delayed growth and developmental assessment
o Delayed treatment can lead to: development related to
• Assist with and explain
Learning disabilities impaired cognitive
diagnostic tests
functioning
majjyap ‘21
UNIT 8 (Week 10)
• Educate child and family o Special devices needed
o Managing stimulations (braces, equipment,
o Providing simple, one- etc.)
step instructions o Routines, unusual
o Motivation and positive behaviors
reinforcement o Nutrition and eating,
o Early intervention elimination
program available in o Play, special toys, and
area activities
• Teach child self-care skills • Explain procedures and
• Promote child’s optimal treatments at child’s
development cognitive level
• Encourage play and exercise • Work in partnership with
• Provide means of parents
communication • Opportunity to learn and
• Establish discipline grow in areas of self-care
• Encourage socialization and socialization
o Inclusion
o Camps
o Special Olympics
• Provide information on
sexuality
• Help family adjust to future
care needs
o At home
o Daycare
o Long-term care
• Teach prevention to families
or parents
o Reduce risk factors
(smoking, drugs,
alcohol)
o Prenatal care
o Early screening
Care During Hospitalization • Mutual participation model:
working with parents to
share child’s care
• Obtain a thorough
assessment
o Self-care abilities

majjyap ‘21
UNIT 9 (Week 11)
● Diaphragm - skeletal muscle of respiration ● So the process of breathing in air rich in oxygen is called
OVERVIEW AND ASSESSMENT OF RESPIRATORY inhalation, after the contraction of the muscular
FUNCTIONS AND PEDIATRIC VARIATIONS AND NURSING diaphragm the lungs expand and the air rushes in
CARE OF THE CHILD WITH A RESPIRATORY DISORDER Video Transcript:
resulting in the inflammation of the alveoli. During
Respiratory System exhalation, the diaphragm moves up and the lungs
Slides 1 - 7 (Sophia)
● To understand the process of breathing contract thus the alveoli deflate causing the air to be
● Respiratory disorders are among the most common ● In humans, the main organs responsible for respiration forced out. This exhaled air is rich in CO2.
causes of illness and hospitalizations in children. are present in the thoracic cavity ● This process of inhalation and exhalation is known as
● Overall respiratory dysfunctions in children tend to be ● In the thorax region, the rib cage and the dome-shaped respiration, which occurs approximately 20 times per
more serious than in adults, because the lumens of a fibrous tissue known as the diaphragm are observed minute.
child’s respiratory tract are smaller and therefore more ● Present within the rib cage are the pleural membranes
likely to become obstructed. which includes the lungs
DIFFERENCES BETWEEN THE RESPIRATORY SYSTEM
● The right lungs is divided into three lobes, the right
OF ADULTS AND CHILDREN
superior, right middle and the right inferior lobe
ANATOMY AND PHYSIOLOGY OVERVIEW OF THE
● The left lung is smaller and has only two lobes the left
RESPIRATORY SYSTEM
superior and the left inferior lobe
● Both the lungs are associated externally with small
tubular bronchi which unite and extend into the trachea
● The trachea has incomplete c-shaped rings of cartilage
which prevents the tracheal wall from collapsing
● The trachea leads into the pharynx which is connected
to the nostrils
● As we breathe an air the oxygen molecules enter the
nostrils and travel downwards through the pharynx and
trachea to finally reach the bronchi
● From each bronchus, oxygen travels into the lungs,
within the lungs the bronchus divides repeatedly to form
bronchioles.
● Because the respiratory tract continues to mature during
● Oxygen travels through these bronchioles and reaches
The upper respiratory tract is composed of: childhood, children have several important differences in
the alveoli. Each of which is surrounded by a network of
● Nose - serves as the passageway of air respiratory anatomy and physiology than adults
capillaries.
● Mouth - passageway of food and air ● Nasopharynx - usually smaller and is easily occluded
● A section of one alveolus shows the presence of
● Epiglottis - covers the larynx during swallowing during infections
numerous alveolar chambers with pores. Blood
● Nasal cavity - filters, warms, and moistens the air ● Lymph tissue (tonsils, adenoids ) - grows rapidly in early
containing RBCs is seen flowing through the capillaries
● Pharynx (Throat) - common passageway for air, food, childhood, atrophies after age 12
● The oxygen molecules from the alveolus diffuse into the
and liquid ○ Children 12 years old below - enlarged tonsils
capillary and then get absorbed by bluish purple RBCs,
● Larynx (Voice box) - production of sound and adenoids because of the lymph tissue that
this causes oxygenation of the RBCs and the transition
The lower respiratory tract is composed of: is rapidly growing
of their color from bluish purple into red is observed.
● Pleural membranes - cover the lungs and line the chest ● Smaller nares - easily occluded
● The blood moving into the alveolus contains RBCs and
cavity ● Small oral cavity and large tongue increases risk of
carbon dioxide molecules. These molecules are
● Trachea (Windpipe) - main airway obstruction
released into the alveolus, the CO2 collects from the
● Lung - organ of gas exchange ● Long, floppy epiglottis - vulnerable to swelling with
alveolar chamber and then from the alveolus it travels
● Bronchi - branching airways resulting obstruction
through the bronchioles, then into the bronchus, which
● Intercostal muscle - moves ribs during respiration ● Larynx and glottis are higher in neck - increases risk of
finally reaches the trachea and it is breath out through
● Alveoli - air sacs for gas exchange aspiration
the nostrils
● Rib
UNIT 9 (Week 11)
● Because thyroid, cricoid, and tracheal cartilages are Chest or Respiratory System
immature they may easily collapse when neck is flexed ● Infants are considered Obligate nasal breathers (until 4 Chest or Respiratory System
● Because fewer muscles are functional in airway - less – 6 weeks) because they are dependent on the patency ● Smaller lung capacity and underdeveloped intercostal
able to compensate for edema, spasm, and trauma of their nasal airway for ventilation muscles, poor chest musculature
● The large amounts of soft tissue and loosely anchored ● Short neck ○ less pulmonary reserve, lung damage w/o
mucous membranes lining the airway- increases risk of ● Tongue is larger in proportion to the mouth fracture
edema and obstruction ○ more likely to obstruct airway in unconscious ● Children rely on diaphragm breathing
child ○ high risk for resp. failure if the diaphragm unable
to contract
RESPIRATORY TRACT DIFFERENCES IN CHILDREN
Smaller, shorter, narrower airways more susceptible to airway Diaphragm breathing is basically just using abdominal muscles
● Changes until age 12 - child respiratory illness is risk obstruction and respiratory distress to assist in inhalation. Infant’s chest muscle man gud is not yet
greater than adult fully developed until the age of 12, so they use their abdominal
● Upper airway more prone to obstruction - smaller airway muscles instead. The change to thoracic breathing begins at 2-3
= greater resistance. years of age, and is complete at 7 years; therefore, children 2
● Children have less alveolar surface area - reduced area years below, are obligate diaphragm breathers
for gas exchange compared to adults
● More diaphragmatic breathing - flexible chest reduces air
ASSESSING RESPIRATORY ILLNESS IN CHILDREN
intake
Assessment of respiratory illness in children includes an
interview, physical examination assessment, laboratory testing. If
RESPIRATORY DEVELOPMENT
the child is in acute distress, the interview and the health history
may only cover the most important details. That includes when
the child became ill, and what symptoms are present. It is
Newborn (pic sa babaw)= 4 mm ra ang lumen sa iya airway, that
important to get the accurate picture as possible.
is the normal. Then if mag swell, 2 mm nalang. Compared to
adults, dagko na ug lumen. Therefor, children are susceptible to
HISTORY
airway obstruction
● Chief concern: Cough (characteristics, when it started),
rapid respirations, noisy breathing, rhinitis, reddened
sore throat, lethargy, cyanosis, difficulty, sucking, fever.
These are common chief concerns
PAST MEDICAL HISTORY
● Poor weight gain, difficulty with respirations at birth,
prematurity
PHYSICAL EXAMINATION
● We have to check for fever, auscultate abnormal breath
● Respiratory structures grow in size and distance from sounds, monitor respirations (rate, depth quality, note
each other - as the child matures in age the respiratory any dyspnea), percussing for dullness which indicate
structure still grows until they reach the age of 12 fluid. Inspect also if there is presence in color changes,
● Immature infant respiratory and neurologic system offers For the position of trachea, the bifurcation (division of something especially cyanosis. Observe for alertness and change
less efficient response to hypoxia and elevated PCO2 into two parts) of trachea in children is at T3 level, while in in mental status. Intercostal, suprasternal, sternal and
(partial CO2) adults, its at T6. The right mainstem bronchus in children, has a substernal retractions could indicate respiratory distress.
● Chest will stiffen with age - less retraction with distress steeper slope than the adults. In children, trachea is shorter and
the angle of the bronchus in the bifurcation is more acute than in
Slides 8 - 14 (Mygel) adults.
Changes in chest wall shape as the children matures (right side)
RESPIRATORY TRACT DIFFERENCES IN CHILDREN
UNIT 9 (Week 11)
> Also known as Fious sounds. They are caused by pathologic
conditions and can be heard on lung assessment on children
and respiratory disorders
- Fine crackles
- Wheezes
- Rhonchi (coarse crackles)
- Stridor
● Cough
○ One rule of coughing in children is NEVER TO
SUPPRESS IT AT FIRST. Don’t encourage
parents to use cough suppressants during the
early stage.
○ Coughing is a reflex. It is initiated by the
stimulation of nerves in the respiratory tract. If
INSPECTION there is presence of dust, chemicals, mucous or
LUNG SOUNDS / ADVENTITIOUS BREATH SOUNDS
● Chest inflammation, when detected by the nerves in
❖ Crackles
○ Size, symmetry movement. Because with the respiratory tract (mucosa), the body will
- High pitched
chronic obstructive lunch disease, children may cough.
- Heard during inspiration
be unable to exhale quickly, allowing air to be ○ Infants don’t know how to expectorate yet and
- Not cleared by a cough
chronically trapped in the lung.. This condition they are predispose to inflammation in the lower
- It happens when the alveoli becomes fluid-filled
produces an (innogated??) anterior-posterior respiratory tract infection like pneumonia
- Discontinuous
diameter of the chest. Sometimes termed as because there will be pooling of secretions in the
❖ Rhonchi
pigeon breast. There is an accompanying lower respiratory tract
- Rumbling coarse sounds like that of a snore
tympanic sound heard over the lungs. ○ Coughing is a useful procedure to clear excess
- During inspiration or expiration
○ Infancy shape is almost circular mucous in the respiratory tract.
- May clear with coughing or suctioning
○ < 6-7 years respiratory movement primarily ○ Coughing only becomes harmful and needs
- Continuous
abdominal or diaphragmatic suppression when there is no mucous or debris
- If the obstruction is in the nose or pharynx. The
● Respirations to be expelled already to the point the child is
noise is produced like snoring sounds.
○ Rate, rhythm, depth, quality, effort already exhausted and the amount of coughing
Obstructions like mucous
○ > 60 /min in small children = significant is exhausting to the part of the patient or there is
❖ Wheeze
respiratory distress; tachypnea- increased already stomach or chest pain due to coughing,
- Musical noise
respiratory rate. Often an indicator of first that’s the time cough suppressants are
- During inspiration or expiration
obstruction in young children. When we assess indicated.
- Usually louder during expiration
the respiratory rate in infants, try to count it - Continuous
before waking them because crying distorts the - Happens if there is an obstruction in the lower
respiratory rates. trachea or bronchioles
- Most noticeable on expiration
Slides 15 - 21 (Hannah) ❖ Stridor
- Happens if the obstruction is at the base of the
❏ AUSCULTATION tongue or in the larynx.
● Listen comparing one areas to the other - You can hear a harsh strident sound during
- Equality of breath sounds inspiration
- Diminished - It is often most marked when the child is on a
- Poor air exchange supine position and less marked when a child
● Abnormal breath sounds sits upright
UNIT 9 (Week 11)
❖ Diminished / absence of breath sounds Types of retractions:
- can occur when the alveoli are so fluid-filled that 1. Supraclavicular
little or no air can enter that. 2. Suprasternal retractions
3. Intercostal retractions
RESPIRATORY PATTERNS 4. Substernal retractions
5. Subcostal retractions

Highlighted information:
● Infants <2 years old are diaphragmatic breather meaning
they use their abdomen rather than thoracic cavity upon
breathing. Their chest cavity is not yet fully mature. Their
chest is very flexible having small lung capacity that’s
why they cannot fully expand their chest
Examples of Respiratory Distress: ● Diaphragmatic breathing (see image for normal
● Left side upper photo – with intercostal and sternal respiration) when the child inhales, chest and abdomen
❏ COLOR retractions. The center part between the ribs has rises together. If there is deviation from normal or if
- Mucous membranes indentions (retractions) there’s a sign of airway obstruction if the chest will draw
- Nailbeds (for presence of clubbing) ● Left side lower photo – intercostal retractions (in inward or retract, there’s more force will be used to
- Skin between the ribs). The chest draw inward in between the inhale.
- Cyanosis (bluish skin which indicates hypoxia or ribs ● In children and young infants, adventitious breath
decreased oxygen in the tissues) ● Right side upper photo – sternal retractions with sounds cannot be heard yet because their respiratory
❏ TEMPERATURE indentions structures are not mature yet.
● Febrile state increases oxygen consumption ● First thing to look if there is respiratory illness in an infant
- children with fever has increased respiratory ➢ Normal Respiration – chest and abdomen rises together is to check their respiratory rate. Tachypnea or
rate. Hyperthermia can occur in respiratory with inspiration increased RR is the first symptom that is indicative of
infections ➢ Retraction – chest wall retracts and abdomen rises with airway obstruction.
❏ RETRACTIONS inspirations. Chest draw inward while abdomen rises ● >60 RR regardless of having a cough or adventitious
● A sign of respiratory distress called “Seesaw inspiration” or presence of retractions breath sounds, that could already be an indicative of
● when children must inspire more forceful than in respiratory distress airway obstruction. Airway obstruction like mucous or
normal to inflate their lungs because of an secretions or foreign body that is ingested by patient.
airway obstruction or stiffness, an intrapleural Most common is secretions or pooling that can cause
pressure is decreased to the point that no rigid airway obstruction
parts of the chest draw inwards creating ● Children and young infants shifts to thoracic breathing
retractions (chest) when they reach >2 years old and their chest
● these retractions occur more commonly in cavity becomes mature at 7-12 years old
newborn and infants than in older children
because the intercostal tissues are weaker and
less developed in younger children COMMON LABORATORY AND DIAGNOSTIC TESTS
● retractions of upper chest muscles specifically ❏ Blood Gas Analysis
the suprasternal and supraclavicular (higher ❏ Allen Test
than suprasternal) suggest upper airway ❏ Pulse Oximetry
obstruction. ❏ Sputum Analysis
● retractions of the intercostal and subcostal ❏ Chest Radiography
muscles suggest lower airway obstruction ❏ Pulmonary Function Test
UNIT 9 (Week 11)
22-28 *23 Arterial Blood Gas Normal Values 1.) Determine if values interpret Acidosis or Alkalosis by
Respiratory Determinants of Acid-Base Imbalance & their looking at the pH value
Normal Values 2.) Determine if values define Metabolic or Respiratory
PaO2- shows adequacy of the gas exchange between alveoli Acidosis through PaCO2 (respi) and HCO3 (meta)
and the external environment (alveolar ventilation); CO2 cannot 3.) Determine the compensation:
escape when there is damage in the alveoli Fully, Partially or Uncompensated
Excess CO2 + Water = Carbonic Acid > Acidotic State There are 8 steps to interpret the arterial blood gas
(Mahimong Bicarbonate- a buffer system; compensatory results using the “Tic-Tac Toe Method”:
mechanism of the body if there is an increase of CO2 in the 1. Memorize the normal values
alveoli) (Draw the arrow diagram to guide)
Remember:
<35 PaCO2= alkalosis
>45 PaCO2=acidosis
<22 HCO3=acidosis
>26 HCO3=alkalosis
(*pH same interpretation sa HCO3)
< pH value = acidosis
-To determine acid-base imbalance, you need to know and
> pH value = alkalosis
memorize these values to recognize what deviates from normal.
2. Create your tic-tac-toe grid
-The normal range for ABGs is used as a guide, and the
-Based on their values, determine in which
determination of disorders is often based on pH
column we will place the pH, PaCO2 and HCO3
*If the blood is basic the HCO3 level is considered because the
3. Determine if pH is under normal, acidosis or
kidneys regulate bicarbonate ion levels.
Alkalosis
*If the blood is acidic, The PaCO2 or partial pressure of CO2 in
1st example: 7.35 - 7.39- slightly acidosis >> pH
arterial blood is assessed because the lungs regulate the
under normal but put an arrow leading to
majority of acid.
acidosis
2nd example: 7.41 - 7.45- normal, arrow towards
alkalosis
3rd example: any blood pH below 7.35- Acidosis
4th example : any blood pH 7.45 above-
Alkalosis
PaCO2- it is increased if a child cannot expire adequately, since
there is trapping of Co2 in the alveoli. H= Hydrogen Ion, ion
concentration of the blood determines also acidity or alkalinity of
the body fluids.
pH - important in the results of the ABG
HCO3 - remember as “metabolic determinant” it is an alkaline
substance that comprises over half of the total buffer base in the
blood. deficit=indicates metabolic acidosis
excess= metabolic alkalosis
O2 - measured in percentage, basically the amount of O2 in the Interpreting Arterial Blood Gas-used to detect Respiratory
blood that combines with hemoglobin. Acidosis or Alkalosis / Metabolic Acidosis or Alkalosis
To determine the type of Arterial Blood gas, the key components
are checked, that’s why we have to memorize the values.
We have 3 GOALS OF ABG ANALYSIS
UNIT 9 (Week 11)

7. Solve for Goal #2- Metabolic or Respiratory?

● If pH is under the same column as

4. Determine if PaCO2 is under normal, acidosis or PaCO2= Respiratory
alkalosis ● If pH is under the same column as
1st example: above 45- acidosis HCO3= Metabolic
2nd example: 45-35- normal ● If pH is under the normal value
3rd example: below 35-alkalosis determine where it is leaning to and
5. Determine if HCO3 is under normal, acidosis or interpret accordingly
alkalosis
1st example: below 22 - acidosis Solve for Goal #3- Type of Compensation?
2nd example: 22-26 - normal Normal pH= Fully Compensated
3rd example: above 26 - alkalosis All 3 values are abnormal= Partially
PaCO2 or HCO3 is normal and the other is
abnormal= Uncompensated

6. Solve for Goal #1- Acidosis or Alkalosis?

1- Leaning to acidosis = Acidosis Slides 29 - 35 (Cloy)
2-Leaning to alkalosis = Alkalosis
UNIT 9 (Week 11)
- Hyperventilation therefore the findings of our patients
are rapid deep breathing, confusion, and
unconsciousness. pH is increased and decreased
PaCO2

pH = 7.1 which is ABNORMAL = ACIDOSIS

pH = 7.26 which is ABNORMAL = ACIDOSIS PaCO3 = 40 which is NORMAL = NORMAL
PaCO2 = 32 which is ABNORMAL = ALKALOSIS HCO3 = 18 which is ABNORMAL = ACIDOSIS
HCO3 which is ABNORMAL = ACIDOSIS ✓ ACIDOSIS
✓ ACIDOSIS Metabolic Acidosis
✓ RESPIRATORY
✓ METABOLIC - Findings of patients usually altered level of
✓ FULLY COMPENSATED ABG
✓ PARTIALLY COMPENSATED ABG consciousness, disorientation, lack of appetite,
METABOLIC ACIDOSIS, UNCOMPENSATED
METABOLIC ACIDOSIS, PARTIALLY COMPENSATED coma, and jaundice.
- Can be seen in patients with diabetic ketoacidosis,
chronic renal failure, dehydration (bec. Of electrolyte
imbalances).

Metabolic Alkalosis
- Findings of patients kay edema, disorientation and
patients with excessive vomiting (bec. The loss of
gastric secretions specifically the hydrochloric acid; kung
mawa si hydrogen ions class, if mo excrete na sya, kay
ang bicarbonate ions kay adto na sya mo shift sa
extracellular tissues sa body).

Respiratory Acidosis
Slides 36 - 42 (Shannen)
(Discussion)
- Managhan si PaCO2 kay di man ma excrete si carbon 2. ALLEN TEST
pH = 7.44 which is NORMAL -> ALKALOSIS = ALKALOSIS dioxide. - used to assess collateral blood flow to the hands
PaCO3 = 30 which is ABNORMAL = ALKALOSIS - Basically, in respiratory acidosis, a hypoventilation
HCO3 = 21 which is ABNORMAL = ACIDOSIS trapping carbon dioxide in the alveoli therefore ang pH is
✓ ALKALOSIS decreased and increased ang PaCO2.
✓ RESPIRATORY - Findings of patients usually kay shallow breathing,
✓ FULLY COMPENSATED ABG inability to expire freely, confusion, and
RESPIRATORY ALKALOSIS, FULLY COMPENSATED disorientation.

Respiratory Alkalosis
UNIT 9 (Week 11)
- Because children cannot raise sputum with a cough sputum Even though they inspire the same amount of air as the average
collection is not feasible in children younger than school age. child, they expire it over a longer period.
(because they are not receptive to instructions, there is a specific • Restrictive – This is when the lungs tissue and/or chest
way to collect sputum) muscle can’t expand enough. This creates problems with air
- Instruct children to breathe in and out several times, cough flow, mostly due to lower lung volumes.
deeply and spit mucus into the sterile sputum cup. ( proper way - Children with restrictive ventilatory disorders such as
of collecting the specimen) neuromuscular disorders have equal difficulty with inspiration
- also known as sputum culture (tan awon ang organism and expiration.
present sa sputum. Ex. Mycobacterium tuberculosis – causative
org for TB) 6. PULMONARY FUNCTION TEST
2 Methods ( they can be used together and perform different
5. CHEST RADIOGRAPHY tests depending on the information that the doctor is looking for)
- an imaging test that uses small amounts of radiation to produce 1. Spirometry. A spirometer is a device with a mouthpiece
-Before obtaining an ABG from the radial artery, it is important to
pictures of the organs, tissues, and bones of the body. When hooked up to a small electronic machine.
establish that the child has collateral circulation to the hand.
focused on the chest, it can help spot abnormalities or diseases 2. Plethysmography. You sit or stand inside an air-tight
Otherwise, the needle puncture may block the artery and block
of the airways, blood vessels, bones, heart, and lungs. Chest box that looks like a short, square telephone booth to do the
blood flow to the hand.
x-rays can also determine if you have fluid in your lungs, or fluid tests.
-To prove that there is collateral circulation, we need to perform
or air surrounding your lungs. -Children younger than 4 years of age are unusually unable to
ALLEN TEST. By doing so, we have to compress both radial and
- Chest x-ray films will show areas of infiltration or consolidation participate in pulmonary function tests, because this test requires
ulnar arteries on the inner side of the wrist and elevate the hand
in the lungs. If a foreign body is present(?), a chest x-ray study their cooperation. All children need preparation and teaching for
until the color disappears (pallor)(muluspad). Release the
will show its exact location. With the help of a doctor, we can this test because they must breathe forcedly into the mouth on
pressure over the ulnar artery first, and observe for a color
identify asa nga part of specific lobes in the lungs ang affected the mouthpiece at cue (?). Some test require for the nose to be
change in the hand. If the hand does not turn into pink which is a
sa disorder. closed with a clip/clump/ assistant hand, this can be frightening
proof that there is a blood flow, the radial artery on that wrist
-Chest x-ray films are more difficult to obtain in infants than in feeling for children with respi disease. They may need some trial
should not be used for catheter insertion because that indicates
older children, because infants cannot take a breath and hold it runs to ensure themselves that they can breathe with the clump
clotting in the radial artery (occluded).
when instructed. It is therefore difficult to picture the lungs in its in place. Without good orientation to the equipment, they may
most expanded position. (px are encouraged to inhale aron mas become so anxious that they may develop tachypnea and they
3. PULSE OXIMETRY
maklaro siya tan awon sa x ray) may not be able to inhale or exhale with their full capacity. So the
- is a noninvasive and painless test that measures oxygen
6. PULMONARY FUNCTION TEST test results are altered. The result pulmonary function studies
saturation level, or the oxygen level in your blood. It can rapidly
- are non-invasive tests that show how well the lungs are help determine nature and extent of the child’s respiratory
detect even small changes in how efficiently oxygen is being
working. The tests measure lung volume, capacity, rates of flow, problem and the best method of achieving more effective
carried to the extremities furthest from the heart, including the
and gas exchange. ventilation.
legs and the arms.
- indicated to patients who already have respiratory illness,
- For measurement, a sensor and a photodetector are placed
specifically chronic respiratory illness. Because nanay
around a vascular bed, most often a finger in a child and a foot THERAPEUTIC TECHNIQUES USED IN THE TREATMENT
dysfunction sa ilang system nya e test na siya how well their
in an infant. Infrared light is directed into the finger from the OF RESPIRATORY ILLNESS IN CHILDREN
lungs are still working.
sensor to the photodetector because hemoglobin absorbs
There are 2 types of disorders that cause problems with air
lightweights differently when it is bound to oxygen than not. So Slides 43 - 49 (Brian)
moving in and out of the lungs:
the oximeter can detect the degree of oxygen saturation in the
• Obstructive – this is when air has trouble flowing out of the EXPECTORANT THERAPY
hemoglobin.
lungs due to airway resistance. This causes a decreased flow in • Liquefying agents
- To those px with respiratory illness, automatic apil najud na ang
air. ➔ Pharmacologic agents
O2 Saturation, nig kuha vital signs.
- Children with obstructive lung diseases such as asthma (expectorants) – ex. Guaifenesin(Robitussin) is given orally
4. SPUTUM ANALYSIS
and bronchiolitis have some difficulty moving air into the lungs and designed to liquefy a mucus in the trachea and bronchi
- is a test that checks for bacteria or another type of organism
but they have even more difficulty moving air out of the lungs.
that may be causing an infection in your lungs or the airways
leading to the lungs
UNIT 9 (Week 11)
➔ Instilling saline nose drops or using saline nasal sprays hand against a child’s chest during exhalation. Like - Most children do not like nasal prongs or catheters
can be effective in moistening and loosening dried percussion, it mechanically loosens and helps move because they are intrusive.
mucus in the nose. tenacious secretions upward, deep breathing, and - Assess their nostrils carefully when using these as the
• Nebulizers huffing or coughing. pressure of prongs can cause areas of necrosis,
- mechanical devices that provide a stream of moistened Nursing Considerations: particularly on the nasal septum.
air directly into the respiratory tract. - Before performing CPT we have to auscultate first the - Snug-fitting oxygen mask (non-rebreather mask)
- Serve as an important means for the delivery of lung fields of the patients so that we will know that lobe - a method for supplying nearly 100% oxygen and is
respiratory tract medication, drugs such as antibiotics or lung field is affected. With that, we can determine frequently used in emergencies
are bronchodilators that can be combined with nebulized what position to be done to the patient. - Masks, like prongs or catheters, are often not well
mist and sprayed into the lungs. - Upon position of the child so that the lobe of the lungs tolerated by children because they tend to slip and
- It is indicated to patients having acute asthma attack affected or to be brained in a superior position. obstruct their view, and if necessary let them hold the
- Some of these medications also can cause drying of - After each position ask the child to cough mask.
mucous membranes. - Simply changing a child’s position helps mucus to move - Oxygen must be administered warm and moistened, and
- Many children find nebulizer treatment uncomfortable so it initiates a cough reflex and is expelled, and to without proper humidification, oxygen dries mucous
because the feeling of the mist in the upper respiratory prevent mucus from pooling certain lung areas. membranes and thickens secretions, compounding
tract is irritating. Assure them that aerosol administration - If a child has a localized mucus problem, lying breathing difficulty.
is the most effective route. predominantly in one position can encourage drainage of Nursing Considerations:
• Coughing that lung segment. - When caring for a child with any form of oxygen
- Encourage coughing rather than suppress it in children - When the child is repositioned and the mucus drains into equipment, follow safety rules. Because oxygen
because it is an effective method of raising mucus. new bronchi, this will often result in a cough from supports combustion, keep open flames away from
- Changing a child's position and suggesting mild exercise irritation caused by this new drainage. oxygen and minimize the risk of sparks. Because oxygen
or deep breathing are helpful techniques to initiate - Chest Physiotherapy is best scheduled before meals or is humidified, the equipment is a good source of
coughing. an hour after meal so that the subsequent coughing microbial contaminants and so should be changed
- Cough and child preparations are not recommended in does not cause vomiting according to your agency’s policy at least once a week
children less than 6 years of age because both the lack - Limit the chest physiotherapy for at least 30 minutes to keep bacterial counts within safe limits.
of evidence of their effectiveness and their potential because this technique is tiring. - Monitor and record child's oxygen saturation level via
harmful side effects pulse oximeter
• Mucus - Clearing Devices THERAPY TO IMPROVE OXYGENATION - Also, the importance of monitoring the 02 saturation to
- A flutter device that can be used to aid in the removal of - Improving oxygenation almost automatically relieves know whether effective ang oxygen administration. But,
mucus. breathing distress initially we should take the baseline oxygen sat of the
- This device looks like a small plastic pipe. A • Oxygen administration patient para after administering oxygen administration
stainless-steel ball inside the device moves when - elevates the arterial oxygen saturation level by supplying we check again the oxygen level or flow rate.
children breathe out, causing vibration in the lungs. more oxygen to red blood cells through the respiratory - Obtain ABG measurements with any changes of oxygen
- This vibration helps loosen mucus so that it can be tract. or otherwise ordered by the physician.
moved up the airway and expectorated. - Oxygen may be delivered to an infant by flooding an
- This device is used most frequently with children who incubator using a plastic hoods mask or a cannula. • Metered - dose inhalers
have cystic fibrosis or pneumonia to help remove mucus - Plastic Oxygen hoods - is a handheld device that provides a route for medication
from the lungs - are tight fitting enclosures that can keep oxygen administration directly to the respiratory tract. (ex. of
concentration at nearly at a 100%. meds: bronchodilators, corticosteroids)
• Chest Physiotherapy - Always check that the hood fits snugly in the infant's - Corticosteroids are first administered because the
- is an airway clearance technique (ACT) to drain the head making sure that it does not rub the infant's neck, mechanism of action of steroids is to reduce the
lungs, and may include percussion involves striking a chin or shoulders. inflammation of the airway, then Bronchodilators are
cupped or curved palm against the chest to determine - Nasal catheter or Nasal Prongs administered which dilates the airway of the patient.
the consistency of tissue beneath the surface area - can be used in infants, but they usually reserve for - The child inhales while depressing a trigger on the
(clapping), vibration is done by pressing a vibrating older children. apparatus.
UNIT 9 (Week 11)
- For successful use of MDI, children need to follow five - is an opening into the trachea to create an artificial 2. As soon as children’s respirations are even and
general rules: shake the canister, exhale deeply, airway to relieve respiratory obstruction that has they are no longer experiencing acute
activate the inhaler and place it in their mouth as they occurred above that point. respiratory distress, show them how, by placing
begin to inhale, take a long slow inhalation, and then - Tracheotomy = the procedure to create an a finger over the tracheostomy tube opening, air
hold their breath for 5 to 10 seconds. They should only airway will again flow past the larynx and they can
take one puff at time, with a 1 minute wait between puffs. - Tracheostomy = the resultant artificial airway speak.
But if it is two medications like bronchodilators and - It also may be used as a route for suctioning mucus when 3. If this causes a child to become short of breath,
corticosteroids they have to wait for 3-5 minutes in accumulating mucus causes lower airway obstruction. supply a paper and pencil or chalkboard for
between the puffs - Few medical emergencies are as frightening to a child or communication.
- Coordinating inhalation with MDI use can be difficult; parents as an acute obstruction of a child’s upper airway 4. Be certain parents understand why the tube is in
therefore, use of an aerochamber (spacer) is generally requiring a tracheostomy or endotracheal intubation. place and how important it is that it remain
recommended to prevent deposition on the posterior Indication: patent.
pharynx. The child suddenly becomes limp and breathless, with color 5. Assure parents that it is a temporary measure to
- Younger children can use an MDI attached to an changing quickly to systemic cyanosis. provide oxygen
aerochamber with a mask. Procedure: ➔ Suctioning technique
- All children using inhaled corticosteroids need an 1. The cricoid cartilage of the trachea is swabbed with an -Most tracheostomy tubes used with children today are
aerochamber to prevent deposition of the medication in antiseptic. plastic. They do not include an inner cannula that would
the mucous membranes of the mouth and pharynx, 2. If readily available, a local anesthetic may be injected require removal and regular cleaning.
which can contribute to the development of thrush. into the cartilage ring. -Most children, however, do require frequent suctioning
• Incentive spirometry 3. An incision is made just under the ring of cartilage. to keep their airway free of mucus.
- Devices that encourage children to inhale deeply to 4. A tracheostomy tube with its obturator in place is -Use sterile technique to prevent introducing
aerate the lungs fully or move mucus. inserted into the opening. microorganisms, and suction gently yet thoroughly.
- Common type consist of a hollow plastic tube containing 5. When the obturator is removed, the child can breathe
a brightly colored ball or dome-shaped disk that will rise through the hollow tracheostomy tube.
in the tube when a child inhales through the attached 6. Have suction equipment available for immediate use to
mouthpiece and tubing. clear any blood caused by the incision and any
- The deeper the inhalation, the higher the ball rises in the obstructing mucus from the trachea.
tube. - The color change in children after tracheostomy is usually
- Children need instruction on how to use this type of dramatic. They inhale deeply several times through the tube, and
device because their first impression is that they should color returns to normal.
blow out against the mouthpiece rather than inhale. - A few sutures may be necessary at the tube insertion site to Slides 50 - 56 (Mira)
- Incentive spirometry can be very effective with children halt the bleeding or to reduce the size of the incision so the tube ● Lung Transplantation
because the device and procedure resemble a game fits snugly. ○ A possibility for children with a chronic
more than an actual treatment. - As the children begin to breathe normally and, if unconscious, respiratory illness such as cystic fibrosis. The
• Breathing Techniques regain consciousness, they often thrash and push at people transplant may involve a single lung, or it can be
- blowing a piece of cotton or a plastic ball across a table, around them, both from oxygen deficit and from fright. They call done in conjunction with heart transplantation if
blowing through a straw or blowing out with the lips for a parent but can make no sound, adding To their fright. chronic respiratory disease has caused
pursed are effective techniques for better emptying Nursing Management: ventricular hypertrophy of the heart.
alveoli. 1. Assure children that everything is alright, even ○ As with any organ transplantation, children need
- Can be used if there is no incentive spirometry though they cannot speak. A school-age child continued immunosuppression therapy with
- For best results, make these activities a game or contest can understand a simple explanation such as “ drugs such as cyclosporine or azathioprine
rather than exercise. You can’t speak right now because of the tube in (Imuran) following a lung transplant to decrease
• Tracheostomy your throat”. cell-mediated immunity.
○ Although this level of immunosuppression is the
key to successful transplantation, it also makes
UNIT 9 (Week 11)
post-transplant children susceptible to fungal, closed. Their color improves when they open their mouths. Following surgery,
bacterial, and viral lung infections. their mouth to cry. children have no further difficulty
○ In addition, families experience a tremendous ○ Atresia is also suggested if infants struggle and or symptoms.
psychosocial toll as they wait to see whether the
become cyanotic at feedings because they 2. Acute Nasopharyngitis
new transplant will be rejected.
○ Children may need to have chest physiotherapy cannot suck and breathe through the mouth ○ Caused by one of several viruses, most
or use a portable spirometry device daily to help simultaneously. predominantly by rhinovirus, coxsackievirus,
mobilize secretions resulting from loss of nerve ■ Congenital Disorder RSV, adenovirus, and influenza viruses.
innervation or a reaction to accumulating mucus ■ Unilateral Choanal Atresia ○ The common cold is the most frequent infectious
in the transplanted lung. ● Only one nasal passage disease in children—in fact, toddlers have an
affected average of 10 to 12 colds a year. School-age
RESPIRATORY DISORDERS AND THEIR NURSING ■ Bilateral Choanal Atresia children and adolescents have as many as four
MANAGEMENT ● Both nasal passages affected or five yearly. The incubation period is typically 2
○ Symptoms: to 3 days.
UPPER RESPIRATORY DISORDERS ○ Children are exposed to colds at school or while
Unilateral Bilateral
The upper respiratory tract warms, humidifies, and filters the air playing with other children. If they are in ill health
that enters the body. As such, the structures of the upper Difficulty Breathing Difficulty Breathing from some other cause, or if their immune
respiratory tract constantly come into contact with a barrage of Persistent Nasal Drainage Respiratory Distress system is compromised, they are more
foreign organisms, including pathogens, that can lead to airway Recurrent Sinus infections Cyanosis susceptible than others to the cold viruses.
irritation and illness. Congenital malformations of respiratory ○ Diagnosis: ○ Symptoms:
structures also cause some upper respiratory tract disorders. ■ Medical History and Physical ■ begin with nasal congestion, a watery
1. Choanal Atresia Examination rhinitis, and a low-grade fever. The
○ Nasal Passages are blocked or narrowed by soft ■ Test for nasal airflow mucous membrane of the nose
tissue or bone ■ CT scan becomes edematous and inflamed,
○ A congenital obstruction of the posterior nares ○ Treatment: constricting airway space and causing
by an obstructing membrane or bony growth, ■ Transnasal Endoscopic Surgery difficulty breathing. Posterior rhinitis,
preventing a newborn from drawing air through ● treatment for choanal atresia is plus local irritation, leads to pharyngitis
the nose and down into the nasopharynx . It may either local piercing of the (sore throat). Upper airway secretions
be either unilateral or bilateral. Newborns up to obstructing membrane or that drain into the trachea lead to a
approximately 3 months of age are naturally surgical removal of the bony cough. Cervical lymph nodes may be
nose-breathers. Infants with choanal atresia, growth. swollen and palpable. The process lasts
therefore develop signs of respiratory distress at ● Because infants with choanal about a week and then symptoms fade.
birth or immediately after they quiet for the first atresia have such difficulty with In some children, a thick, purulent nasal
time and attempt to breathe through their nose. feeding, they may receive discharge occurs because bacteria such
○ Choanal atresia can also be assessed by intravenous fluid to maintain as streptococci invade the irritated nasal
holding the newborn’s mouth closed, then gently their glucose and fluid level until mucous membrane and cause a
compressing first one nostril, then the other. If surgery can be performed. secondary purulent infection.
atresia is present, infants will struggle as they Some infants may need an oral ○ Management:
experience air hunger when their mouth is airway inserted so they can ○ There is no specific treatment for a common
continue to breathe through cold. Although many parents ask to have
UNIT 9 (Week 11)
antibiotics prescribed, because colds are caused ● To loosen secretions ■ Because children’s throats feel so sore,
by a virus, antibiotics are not effective unless a ■ Cool mist vaporizer to help loosen nasal they often prefer liquids to solid food.
secondary bacterial invasion has occurred. If a secretions Infants, especially, must be observed
child has a fever, it can be controlled by an 3. Pharyngitis closely until the inflammation and
antipyretic such as acetaminophen (Tylenol) or ○ Pharyngitis is infection and inflammation of the tenderness diminish to be certain that
children’s ibuprofen (Motrin). Help parents throat. The peak incidence occurs between 4 they take in sufficient fluid to prevent
understand that these drugs are effective only in and 7 years of age. It may be either bacterial or dehydration.
controlling fever symptoms; they do not reduce viral in origin. 5. Streptococcal Pharyngitis
congestion or “cure” the cold. ○ It may occur as a result of a chronic allergy in ○ Group A beta-hemolytic streptococcus is the
○ Therefore, they should not be given unless the which there is constant post nasal discharge that organism most frequently involved in bacterial
child has a fever. If infants have difficulty nursing results in secondary irritation. At least a slight pharyngitis in children. All streptococcal
because of nasal congestion, saline nose drops pharyngitis usually accompanies all common infections must be taken seriously because they
or nasal spray may be prescribed to liquefy upper respiratory infections. can lead to cardiac and kidney damage from the
nasal secretions and help them drain. Removing 4. Viral Pharyngitis accompanying autoimmune process.
nasal mucus via a bulb syringe before feedings ○ The causative agent of pharyngitis is usually an ○ Symptoms:
also allows infants to breathe more freely and be adenovirus. ■ Streptococcal infections are generally
able to suck more efficiently. ○ Symptoms: more severe than viral infections. The
○ Caution parents that if they use a bulb syringe, ■ Generally mild: a sore throat, fever, and fact that symptoms are mild, however,
they must compress the bulb first, then insert it general malaise. On physical does not rule out streptococcal infection.
into the child’s nostril. If they insert the bulb assessment, regional lymph nodes may ■ With a streptococcal pharyngitis, the
syringe first, then depress the bulb, they will be noticeably enlarged. Erythema will be back of the throat and palatine tonsils
actually push secretions further back into the present in the back of the pharynx and are usually markedly erythematous
nose, causing increased obstruction. the palatine arch. Laboratory studies will (bright red); the tonsils are enlarged and
○ There is little proof that oral decongestants indicate an increased white blood cell there may be a white exudate in the
relieve congestion to an appreciable degree with count. tonsillar crypts. Petechiae may be
the common cold. Cough suppressants are not ○ Therapeutic Management: present on the palate.
necessary either as coughing raises secretions, ■ If the inflammation is mild, children ■ A child typically appears ill with a high
preventing pooling of secretions and the danger rarely need more than an oral analgesic fever, an extremely sore throat, difficulty
of consequent lower respiratory infection. such as acetaminophen or ibuprofen for swallowing, and overall lethargy.
Guaifenesin is an example of a drug that comfort. Temperature is usually elevated to as
loosens secretions but does not suppress a ■ Warm heat applied to the external neck high as 104° F (40° C). The child often
cough so is safe to use. Parents may use a cool area using a warm towel or heating pad has a headache. Swollen abdominal
mist vaporizer to help loosen nasal secretions if also can be soothing. By school age, lymph nodes may cause abdominal
they wish. children are capable of gargling with a pain. A throat culture, often completed
■ Antipyretic for fever solution such as warm water to help as a quick office procedure, confirms the
■ Saline nasal drops or spray reduce the pain. Before this age, presence of the Streptococcus bacteria.
■ Removal of nasal mucus via a bulb children tend to swallow the solution ○ Therapeutic Management:
syringe unless the procedure is well explained ■ Treatment consists of a full 10- day
■ Guaifenesin and demonstrated to them. course of an oral antibiotic such as
UNIT 9 (Week 11)
penicillin G or clindamycin. school-age children, the organism is generally a
● Oral analgesics such as enlarged, petechiae on
Cephalosporins or broad-spectrum acetaminophen or the palate, high fever, group A beta hemolytic streptococcus
macrolides such as erythromycin may ibuprofen extremely sore throat, ○ Management:
be prescribed if resistant organisms are ● Warm heat applied to dysphagia and lethargy. ■ Antipyretic - for fever
known to be in the community. Help external neck area ■ Analgesics - for pain
parents understand the importance of ● Gargling with warm water Management: ■ Antibiotics (penicillin or amoxicillin;
completing the full prescribed days of to reduce pain ● Penicillin, G or 10-day course) - If the cause is viral, no
Clindamycin for bacterial
therapy. therapy other than comfort or fever
infection
■ The recommended treatment days are ● Measures for rest reduction strategies is necessary.
necessary to ensure the streptococci ● Maintaining hydration Although the pain of the infection will
are eradicated completely. If they are subside a day or two after the antibiotic
not, the child may develop a administration is begun, remind parents
hypersensitivity or autoimmune reaction Slides 57 - 63 (Joash) that children need the full 10-day course
to group A streptococci that can result in 4. Tonsillitis of antibiotic to eradicate streptococci
rheumatic fever (although the chance of ○ refers to infection and inflammation of the completely from the back of the throat.
rheumatic fever occurring is probably as palatine tonsils. ■ Tonsillectomy - removal of the palatine
low as 1%) or glomerulonephritis. ○ Tonsillar tissue is lymphoid tissue that filters tonsils. In the past, tonsillectomy was a
■ In addition, instruct them about pathogenic organisms from the head and neck common procedure following an episode
measures for rest, relief of throat pain, area. The palatine tonsils are located on both of tonsillitis, but today it is not
and maintaining hydration, the same sides of the pharynx; the adenoids are in the recommended unless all other
actions as for a common cold. Because nasopharynx. measures to prevent frequent infections
it is impossible for parents to ○ Infection of the palatine tonsils presents with all prove ineffective. Tonsillar tissue is
discriminate between a pharyngitis of the symptoms of severe pharyngitis. Children removed by ligating the tonsil or by laser
caused by a virus (and needing no drool because their throat is too sore for them to surgery. Because sutures are not
therapy other than comfort measures) swallow saliva. placed, the chance for hemorrhage after
and a streptococcal pharyngitis (needing ○ They may describe swallowing as so painful it this type of surgery is higher than after
definite therapy to prevent feels as if they are swallowing bits of metal or surgery involving a closed incision. The
life-threatening illnesses), a child with glass. danger of aspiration of blood at the time
pharyngitis always should be examined ○ In addition, they usually have a high fever and of surgery and the danger of a general
by health care personnel. are lethargic. anesthetic compound the risk. After
○ Tonsillar tissue appears bright red and may be surgery we usually put children or any
Viral Bacterial
so enlarged the two areas of palatine tonsillar other patient, place them in a prone
Causative Agent: Causative Agent: tissue meet in the midline. position to prevent aspiration and
● Adenovirus ● Group A beta-hemolytic ○ Pus can be detected on or expelled from the secretions. In younger children we place
streptococcus crypts of the tonsils (whitish exudates). a pillow under their chest to help
Symptoms: ○ Tonsillitis occurs most commonly in school-age secretions flow out of the mouth.
● Mild sore, throat, fever Symptoms: ■ Chronic tonsillitis is about the only
children. The responsible organism is identified
and general malaise ● Back of the throat and
by a throat culture. In children younger than 3 reason for removal of palatine tonsils.
palatine tonsils are
Management: erythematous, tonsils are years of age, the cause is often viral. In
UNIT 9 (Week 11)
Tonsillectomy is indicated for chronic blood should run down the back of the Encourage: drink a lot of fluids, saltwater nasal
tonsillitis. nasopharynx. irrigation, steam humidifier. Warm compresses
■ Tonsillectomy or adenoidectomy is ○ Management: to the sinus area may also encourage drainage
and relieve pain.
never done while the organs are ■ Keep children with nosebleeds in an
○ Oxymetazoline hydrochloride (Afrin), supplied
infected, because an operation at such upright position with their head tilted as nose drops or a nasal spray, shrinks the
a time might spread pathogenic slightly forward to minimize the edematous mucous membranes and allows
organisms into the bloodstream, causing amount of blood pressure in nasal infected material to drain from the sinuses and
septicemia. Parents often ask why an vessels and to keep blood moving relieve pain. To avoid a rebound effect, this type
operation to remove tonsils must be forward, not back into the nasopharynx. of nasal spray should be used for only 3 days at
delayed until the child is well again. ■ Apply pressure to the sides of the a time; otherwise, it actually causes more nasal
congestion than was present originally.
They think that as long as the tonsils are nose with your fingers. Make every
○ Sinusitis is considered by many adults to be a
sore, they should be immediately effort to quiet the child and to help stop minor illness. It needs to be treated, however,
removed. crying, because crying increases because it can have serious complications if the
■ Help them understand why it is safer to pressure in the blood vessels of the infection spreads from the sinuses to invade the
schedule surgery for a later date. Most head and prolongs bleeding. facial bone (osteomyelitis) or the middle ear
parents report an improvement in their ■ If these simple measures do not control (otitis media). Chronic sinusitis can also interfere
child’s general health and performance the bleeding, epinephrine (1:1000) may with school and social interactions because of
the constant pain.
after tonsillectomy surgery, as this ends be applied to the bleeding site to
7. Laryngitis - inflammation of the larynx.
the chronic infections. constrict blood vessels. A nasal pack ○ Symptoms include sore throat, loss of voice,
5. Epistaxis (Nosebleed) may be necessary to provide continued voice change.
○ Extremely common in children and usually pressure. ○ It results in brassy, hoarse voice sounds or
occurs from trauma, such as picking at the nose, ○ Every child has an occasional nosebleed. inability to make audible voice sounds. It may
from falling, or from being hit on the nose by Chronic nasal bleeding, however, should be occur as a complication of pharyngitis or from
excessive use of the voice, as in shouting or
another child. investigated to rule out a systemic disease or
loud cheering. Laryngitis is as annoying for
○ In homes that lack humidification, the hot dry blood disorder. children as it is for adults.
environment causes children’s mucous 6. Sinusitis - infection and inflammation of the sinus ○ Treatments include:
membranes to dry, feel uncomfortable, and be cavities ■ Sips of fluid (either warm or cold,
susceptible to cracking and bleeding. ○ It is rare in children younger than 6 years of age whichever feels best) offer relief from
because the frontal sinuses do not develop fully the annoying tickling sensation often
○ In all children, epistaxis tends to occur during
until age 6. It can occur as a primary infection or present.
respiratory illnesses. It also may occur after a secondary one in older children when ■ The most effective measure, however, is
strenuous exercise, and it is associated with streptococcal, staphylococcal, or H. influenzae for the child to rest the voice for at least
several systemic diseases, such as rheumatic organisms spread from the nasal cavity 24 hours, until inflammation subsides.
fever, scarlet fever, measles, or varicella ○ Children develop a fever, a purulent nasal ■ Use of humidifier
infection (chickenpox). discharge, headache, and tenderness over the ■ Gargling salt water
○ It can occur with nasal polyps, sinusitis, or affected sinus. A nose and throat culture will ■ Encouraging oral fluids
identify the infectious organism. 8. Allergic Rhinitis
allergic rhinitis. Some families show a familial
○ Treatment for acute sinusitis consists of an ○ Results from a local defense mechanism in the
predisposition. antipyretic for fever, an analgesic for pain, and nasal airways that attempts to prevent irritants
○ Nosebleeds are always frightening because of an antibiotic for the specific organism involved. and allergens from entering the lungs.
the visible bleeding and a choking sensation if Hot shower is also encouraged to relieve pain,
promote drainage and open up the sinus cavity.
UNIT 9 (Week 11)
○ In children, it is often caused by sensitization to ○ Most children with congenital laryngomalacia ○ Management:
animal dander, house dust, pollens and molds. need no routine therapy other than to have ■ One emergency method of relieving
○ It is often associated with different symptoms in parents feed them slowly, providing rest periods croup symptoms is for a parent to run
the upper respiratory tract that includes: as needed. The condition improves as infants the shower or hot water tap in a
■ Runny nose mature and cartilage in the larynx becomes bathroom until the room fills with steam,
■ Sneeze stronger at about 1 year of age. then keep the child in this warm, moist
■ Stuffy nose ○ Be certain parents know the importance of environment.
■ Itchy eyes bringing the child for early care if signs of an ■ If this does not relieve symptoms,
■ Headache upper respiratory tract infection develop. If not, parents should bring the child to an
■ Sinus pain (upon percussing) laryngeal collapse will be even more intense emergency department for further
○ Management: during these times, and complete obstruction of evaluation and care.
■ Antihistamine & Cetirizine (not advisable the trachea could occur. If stridor becomes more ■ When a child is seen at an emergency
to be always used. The body tends to be intense, advise parents to have the infant seen room, cool moist air with a corticosteroid
dependent on this.) by their primary care provider, because such as dexamethasone, or racemic
■ Steroids - most common medication generally this indicates beginning obstruction epinephrine, given by nebulizer,
given and probably the beginning of an upper reduces inflammation and produces
■ Avoidance of allergens or environmental respiratory tract infection. effective bronchodilation to open the
controls. 10. Croup (Laryngotracheobronchitis) - inflammation of airway.
■ For severe cases: Allergen-specific the larynx, trachea, and major bronchi ■ Other managements include
immunotherapy (sublingual or allergy ○ one of the most frightening diseases of early antipyretic, fluid intake, decreasing
shot) childhood for both parents and children. In anxiety, and vital signs monitoring
○ Immune system hypersensitivity is the cause for children between 6 months and 3 years of age,
this allergic reaction, no pathogens involved. It is the cause of croup is usually a viral infection
Slides 64 - 70 (Mary)
just that patients with allergic rhinitis are such as parainfluenza virus. In previous years,
hypersensitive to these allergens. the most common cause was H. influenzae. 11. Epiglottitis
9. Congenital Laryngomalacia/Tracheomalacia ○ However, since immunization against this ○ Inflammation and swelling of the epiglottis,
○ means that an infant’s laryngeal structure is organism has been included in a routine which is the flap of cartilage that covers the
weaker than normal and collapses more than immunization series, the incidence of croup from opening to the larynx to keep out food and fluid
usual on inspiration this cause has declined by 90% during swallowing. Although it is rare,
○ This produces laryngeal stridor (a high-pitched ○ Assessment: inflammation of the epiglottis is an emergency
crowing sound on inspiration) present from birth, ■ Children typically have only a mild upper because the swollen epiglottis cannot rise and
possibly intensified when the infant is in a supine respiratory tract infection at bedtime. allow the airway to open. It occurs most
position or when sucking Temperature is normal or only mildly frequently in children from 2 to about 8 years of
○ Symptoms include noisy breathing in inspiration, elevated. During the night, they develop age.
stridor may be louder in exertion, crying or a barking cough (croupy cough), ○ Epiglottitis can be either bacterial or viral in
feeding. inspiratory stridor, and marked origin. Haemophilus influenzae type B has
○ The infant’s sternum and intercostal spaces may retractions. They wake in extreme been replaced as the most common bacterial
retract on inspiration because of the increased respiratory distress. cause of the disorder followed by pneumococci,
effort needed to pull air into the trachea past the ■ The larynx, trachea, and major bronchi streptococci, or staphylococci. Echovirus and
collapsed cartilage rings. Many infants with this are all inflamed. These severe RSV also can cause the disorder. The incidence
condition must stop sucking frequently during a symptoms typically last several hours of epiglottitis has greatly decreased with the
feeding to maintain adequate ventilation and to and then, except for a rattling cough, introduction of the H. influenzae type B vaccine.
rest from their respiratory effort, which is subside by morning. ○ Assessment:
exhausting. ■ Symptoms may recur the following ■ Symptoms begin as those of a mild
night. upper respiratory tract infection. After 1
UNIT 9 (Week 11)
or 2 days, as inflammation spreads to
the epiglottis, the child suddenly
develops severe inspiratory stridor, a
high fever, hoarseness, and a very sore
throat. Children may have such difficulty
swallowing that they drool saliva. They
may protrude their tongue to increase
free movement in the pharynx.
■ If a child’s gag reflex is stimulated with a
tongue blade, the swollen and inflamed
epiglottis can be seen to rise in the back
of the throat as a cherry-red structure. It
can be so edematous, however, that the
gagging procedure causes complete 13. Bronchial Obstruction
obstruction of the glottis and shuts off ○ The right main bronchus is straighter and has a
the ability of the child to inhale. larger lumen than the left bronchus in children
Therefore, in children with symptoms of older than 2 years of age. For this reason, an
epiglottitis (e.g. dysphagia, inspiratory aspirated foreign object that is not large enough
stridor, cough, fever, and hoarseness), to obstruct the trachea may lodge in the right
never attempt to visualize the epiglottis 12. Aspiration bronchus, obstructing a portion or all of the right
directly with a tongue blade or obtain a ○ Inhalation of a foreign object into the airway, lung. The alveoli distal to the obstruction will
throat culture unless a means of occurs most frequently in infants and toddlers. collapse as the air remaining in them becomes
providing an artificial airway, such as When a child aspirates a foreign object such as absorbed (atelectasis), or hyperinflation and
tracheostomy or endotracheal a coin or a peanut, the immediate reaction is pneumothorax may occur if the foreign body
intubation, is immediately available. This choking and hard, forceful coughing. Usually, serves as a ball valve, allowing air to enter but
is especially important for the nurse who this dislodges the object. However, if the airway not leave the alveoli.
functions in an expanded role and becomes so obstructed and no coughing or ○ Assessment:
performs physical assessments and speech is possible, intervention is essential. A ■ After aspirating a small foreign body, the
routinely elicits gag reflexes. series of back blows or subdiaphragmatic child generally coughs violently and may
○ Clinical Presentation: abdominal thrusts may be used with children. become dyspneic. If the article is not
■ Drooling ○ Symptoms: expelled, hemoptysis, fever, purulent
■ Holding neck in hyperextended position ■ Choking, coughing, or gagging while sputum, and leukocytosis will generally
■ Tripod position eating result as infection develops. Localized
■ Stridor is a late finding! ■ Weak sucking wheezing (a high whistling sound on
■ Not usually associated with cough ■ Fast or stopped breathing while feeding expiration made by air passing through
■ Hoarse voice or cry the narrowed lumen) may occur.
■ Noisy breathing or wheezing Because this is localized, it is different
■ Chest discomfort or complaints of food from the generalized wheezing of a child
coming back up or feeling stuck with asthma.
■ Apnea, bradycardia, or cyanosis ■ A chest x-ray will reveal the presence of
■ Excessive salivation an object if it is radiopaque. Objects
○ Management: most frequently aspirated include
buttons, bones, popcorn, nuts, and
coins. Because objects such as those
made of plastic, nuts, or popcorn cannot
be visualized well on x-ray film, an x-ray
UNIT 9 (Week 11)
study may be inconclusive. Foreign some people refer to it as “the kissing was touched by an infected person, and then
bodies may also lodge in the esophagus disease.” touching his or her mouth, nose, or eyes.
and cause respiratory distress because ○ Many people develop EBV infections as children ○ People are most contagious with the flu 24
of compression on the trachea. Care after age 1. In very young children, symptoms hours before symptoms start, continuing while
must be taken when feeding young are usually nonexistent or so mild that they symptoms are most active.
children to avoid potential choking or aren’t recognized as mono. ○ Symptoms:
aspiration hazards. Popcorn, grapes, ○ Once you have an EBV infection, you aren’t ■ Sore throat
nuts, etc. can pose hazards. likely to get another one. Any child who gets ■ Dry cough
Additionally, children may aspirate on EBV will probably be immune to mono for the ■ Rhinitis
nonfood items such as toys, coins, and rest of their life. ■ Fever
etc. ○ Symptoms: ■ Chills
○ Symptoms: ■ High fever ■ Headache
■ Coughs violently ■ Swollen lymph glands in the neck and ■ In some cases, your child may also
■ Dyspnea armpits have symptoms such as nausea,
■ Hemoptysis, fever, purulent sputum and ■ Sore throat vomiting, and diarrhea.
leukocytosis may develop as a result of ■ Headache ■ Most children recover from the flu within
infection ■ Fatigue a week. But they may still feel very tired
■ Localized wheezing ■ Muscle weakness for as long as 3 to 4 weeks.
○ Management: ■ A rash consisting of flat pink or purple ■ It is important to note that a cold and the
■ A bronchoscopy may be necessary to spots on skin or mouth flu have different symptoms:
remove the foreign body in the operating ■ Swollen tonsils
Cold Symptoms Flu Symptoms
room. After a bronchoscopy, assess the ■ Night sweats
child closely for signs of bronchial ○ Management:
Low or no fever High fever
edema and airway obstruction that ■ Getting plenty of rest
occur from mucus accumulation ■ Drinking lots of fluids
Sometimes a headache Headache in most cases
because of the bronchus manipulation. ■ Antipyretic for fever
Obtain frequent vital signs (increasing ■ Analgesics for headache
Stuffy, runny nose Clear nose, or stuffy nose in
pulse and respiratory rates suggest ■ In some cases, corticosteroids, a type of
some cases
increased edema and obstruction). steroid medication, can reduce swelling
■ Keep a child nothing by mouth (NPO) of the throat and tonsils.
Sneezing Sneezing in some cases
for at least an hour. Once a gag reflex is 15. Influenza
present, offer the first fluid cautiously to ○ Or flu, is a very contagious viral infection that Mild, hacking cough Cough, often turning severe
prevent additional aspiration. Cool fluid affects the air passages of the lungs
may feel more soothing than warm fluid ○ Caused by influenza virus Mild body aches Severe body aches
and also can help reduce the soreness ○ A flu virus is often passed from child to child
in the throat. Breathing cool, moist air or through sneezing or coughing. Mild tiredness Extreme tiredness that can
having an ice collar applied may further ○ A flu virus is often passed from child to child last weeks
reduce edema. through sneezing or coughing. The virus can
14. Infectious Mononucleosis also live for a short time on surfaces. This Sore throat Sore throat in some cases
○ Mono, or infectious mononucleosis, refers to a includes doorknobs, toys, pens or pencils,
group of symptoms usually caused by the keyboards, phones and tablets, and ○ Management:
Epstein-Barr virus (EBV). It typically occurs in countertops. It can also be passed through ■ Treatment will depend on your child’s
teenagers, but you can get it at any age. The shared eating utensils and drinking. Your child symptoms, age, and general health. It
virus is spread through saliva, which is why can get a flu virus by touching something that will also depend on how severe the
UNIT 9 (Week 11)
condition is. The goal of treatment is to ● Applying a warm compress to Inflammation and infection of the lungs or bronchi is particularly
help prevent or ease symptoms. the ear to relieve pain troublesome. It occurs in various forms and is caused by several
■ Acetaminophen. This is to help lessen ● Applying a cool compress to the organisms.
body aches and fever. Do not give forehead to relieve fever 1. Bronchitis
aspirin to a child with a fever. ● Keeping up their fluid intake to ● Inflammation of the major bronchi and trachea
■ Cough medicine. This may be avoid dehydration ● One of the more common illnesses affecting pre-school
prescribed by your child’s healthcare ■ Antibiotics and school-age children.
provider. ● Patients younger than 6 months ● Characterized by fever and cough and usually a
■ Antiviral medicine. This may help to of age conjunction with nasal congestion.
ease symptoms, and shorten the length ● They are unwell ● Usually viral (influenza virus, adenovirus
of illness. This medicine does not cure ● Who have been treated with ● May develop after a cold or other viral infection in the
the flu. The medicine must be started pain relievers and self-care nose, mouth, throat, or upper respiratory tract. Such
within 2 days after symptoms begin. measures and are getting worse illness can spread easily from direct contact by the
■ Antibiotics are not effective against viral or not improving after 2 days. person who is sick.
infections, so they are not prescribed. 17. Acute Otitis Externa Symptoms:
Instead, treatment focuses on helping ○ Also known as “swimmer’s ear,” is a common ● Starts with mild upper respiratory tract infections for 1-2
ease your child’s symptoms until the disease of children. It is defined by diffuse days. May begin as rhinitis or nasal congestion
illness passes. inflammation of the external ear canal. It can be ● Fever
■ Get lots of rest in bed caused by many different types of bacteria or ● Productive cough (may be purulent) with increased
■ Drink plenty of fluids fungi. mucus. May contain pus.
■ Prevention: Emphasize the importance ○ Symptoms: ● These symptoms may last for a week with full recovery
of yearly flu vaccine to the parents. ■ Ear pain sometimes taking as long as 2 weeks
16. Otitis Media ■ Itching ● Upon auscultation bronchi and (coarse/horse??? haha)
○ An infection of recent onset, and is associated ■ Hearing loss crackles can be heard
with a build-up of fluid in the middle ear. ■ The outer ear may look red or swollen. ● Chest radiograph would reveal diffuse alveolar
○ Middle ear infections can be caused by viruses ■ Lymph nodes around the ear can get hyperinflation and some marking in the lungs
or bacteria. enlarged and tender. Management:
○ Most children who develop a middle ear ■ Discharge from the ear canal–this might ● Therapy is aimed at relieving symptoms, reducing fever
infection have a viral infection (such as a cold), be clear at first and then turn cloudy, and maintaining adequate hydration
which causes inflammation and swelling in the yellowish, and pus-like. ● Increase fluids
nasal passages and eustachian tube. ○ Management: ● Assess VS, secretions, respiratory effort
○ Symptoms: Ear Pain ■ Analgesia ● Antipyretics for fever
■ Irritability and crying in young children ■ Topical antibiotic or steroid drops ● Quiet activities for diversion
who are unable to tell you that they have ■ If the canal is very swollen and ● Expectorant may be given if mucus is viscid to help
a sore ear installation of drops is not possible, child raise sputum.
■ Tiredness consider referral to ENT for wick ● It is important that children with bronchitis to cough to
■ Disrupted sleep insertion. raise the accumulating sputum
■ Fever 2. Bronchiolitis
■ Reduced appetite ● Inflammation of the fine bronchioles and small bronchi
RESPIRATORY DISORDERS AND THEIR NURSING
■ Vomiting that can eventually congest the smaller airways.
MANAGEMENT (LOWER RESPIRATORY DISEASES)
○ Management: ● This time, smaller airways are affected which are the fine
■ Pain relievers bronchioles and smaller bronchi. Unlike bronchitis, which
Slides 1 - 4 (Mygel)
■ Self-care measures only affects the major bronchi.
● Rest The structures of the lower respiratory tract are subject to
infection basing pathogens that attack the upper respiratory tract.
UNIT 9 (Week 11)
● Most common lower respiratory illness in children tachypnic already and has mark retractions, has ● inflammation of bronchial mucosa / mucosal edema
younger than 2 years. Peak incidence at 6 months of history of poor fluid intake ● increased bronchial secretions / increased mucous
age. ● If symptoms is sever, children need Humidified secretions
● Many children who develop asthma later in life have O2 to counteract hypoxemia and adequate
numerous instances of bronchiolitis during the first year hydration to keep respiratory membranes moist. all 3 processes act to reduce the size of the airway lumen
of life. ● Nebulize bronchodilators leading to acute respiratory distress
● Viruses such as adenovirus, influenza virus, RSV in ● Some children need ventilatory assistance to
particular appear to be the common pathogen achieve adequate ventilation (severe) - Bronchial constriction occurs because of the stimulation
SYMPTOMS: ● All infants with bronchiolitis needs to be carefully of the parasympathetic nervous system which initiates
● Starts with mild upper respiratory tract infections observed because if RSV is the cause or the smooth muscle constriction
for 1-2 days pathogenic agent, apnea may occur or periodic - Inflammation in the mucous production can occur
● It starts with a nasal congestion then suddenly cessation of breathing. because of mast cell activation to release leukotrienes,
begins to demonstrate nasal flaring. ● Feeding is also a problem because infants tire prostaglandin and histamine
● Intercostal and subcostal retractions on easily and therefor cannot finish a feeding. Thus - In patients with asthma, the bronchi and bronchioles are
inspiration and there will be an increased intravenous fluids may be given for the first 1 or chronically inflamed and can become so inflamed that it
respiratory rate. 2 days of illness to eliminate the need for oral leads to an asthma attack (wheezing, chest tightness,
● Fever because of infection. feeding. shortness of breath, coughing), which is usually due to a
● Leukocytosis and increased erythrocytes rate ● HOB elevated trigger of some type.
indicating the amount of bronchial inflammation ● Antibiotic not given unless secondary bacterial
present. Both accumulating and mucous and infection
inflammation block the small bronchioles. Air
Slides 5 - 8 (Hannah)
can no longer enter or leave the alveoli freely.
● Hyperinflation of the lungs on X-ray because air
enters more easily than it leaves the inflamed ASTHMA
narrow bronchioles.
● This increases the expiratory phase of - A chronic inflammatory lung disease that causes airway
respiration and can create Wheezing. After initial hyperresponsiveness. It is an immediate hypersensitivity
hyperinflation areas (inaudible..) in alveoli may response to a triggering factor. There is no pathogen causing the
occur. So, nay parts na mag lung collapse or disorder, instead the immune system of the patient is
alveoli collapse because air cannot be expired hypersensitive to a triggering factor.
but instead it is absorbed.
● Tachycardia and cyanosis develop from hypoxia. - It is the most common chronic illness in children accounting
Infants soon become more exhausted from rapid from a large number of days of absenteeism in school and many
respirations. A chest radiograph may also show hospitalization admissions each year, very common in pediatric
pulmonary infiltrates caused by a secondary ward
infection or collapse of alveoli.
● Pulse oximeter shows low oxygen saturation - It tends to occur initially before 5 years of age
MANAGEMENT:
● If mild, treated at home - Tends to occur in children with atopy or those who tend to be
○ Antipyretics, hydration hypersensitive to allergens With an asthma attack:(see image)
● Maintaining a watchful eye for progression to
more serious illness is necessary. - It primarily affects the small airways and involves 3 separate ● there will be tightened muscles because of the
● Hospitalization is waranteed?? For children in processes (triad of inflammation): constriction (triad of inflammation), that is how our
severe distress such as when an infant is immune system works if there are triggering factors
● Bronchospasm
UNIT 9 (Week 11)
especially to patients with hypersensitive immune ❏ Because bronchioles are normally larger in lumen on Prevention:
system inspiration than expiration even with bronchoconstriction
● There will be excess mucous, pooling of exudates in that children may inhale normally or have little difficulty. ● Allergens
certain area because of inflammation ❏ However in asthma, they develop increasing difficulty in - Allergens, either seasonal or perennial, can be
● There will be hyperinflation of the alveoli, because of the exhaling. However, as it becomes more and more prevented through avoiding contact with them
trapping of the air since air cannot be expired because of difficult to force air through the narrowed lumen of the whenever possible.
the constriction due to the inflammation inflamed bronchioles filed with mucous, this causes ● Knowledge
atypical dyspnea and wheezing (the sound caused by air - Knowledge is the key to quality asthma care. We
Increased immune system sensitivity causes the lungs and being pushed forcibly tasked obstructed bronchioles should encourage, instruct and educate the
airway to swell, and produce mucous when exposed to certain typically associated with asthma) parents about the disease especially in
triggers. Triggers vary from child to child and can include: ❏ Wheezing is heard primarily on expiration. Lumen of identifying the allergens of the patient to
bronchioles is bigger upon inspiration so there will be no minimize recurrence of the attack
Triggering factors: problem. However, when it is very severe, it maybe ● Evaluation
heard on inspiration as well. Hearing it during inspiration, - Evaluation of impairment and risk are key in the
- Pet dander means a child is having extreme breathing difficulty. If a control. Since asthma is recurring, it has to be
- Exercise (physical activity) child coughs up mucous, it is generally copious and may manages well. The child should have a check up
- Pollen contain white cast bearing a shape of the bronchi from regularly to check the progress of the disease or
- Insects in the home which it was dislodged. how their body receives or react to the
- Chemical fumes medications. The doctor will evaluate if there is a
- Cold air (weather changes) need to change or reduce or increase the dose
- Smoke (air pollutants) Assessment: of medicine depending on the clients condition
- Pollution
- Stress ● Positive family history There is no cure for asthma but it can only be prevented and
- Viral infection - Asthma is a hereditary disease, and can be managed the relief of symptoms through pharmacological
- Allergies to dust mites possibly acquired by any member of the family therapy or agents:
- Mold who has asthma within their clan.
● Environmental factors Pharmacologic therapy:
When an individual is exposed to these triggers, an immediate - Seasonal changes, high pollen counts, mold, pet
inflammatory response with bronchospasm happens. This dander, climate changes, and air pollution are ● Corticosteroids. – mild persistent asthma
inflammatory process leads to recurrent episodes of asthmatic primarily associated with asthma. ❏ Fluticasone (Flovent) – inhaled
symptoms - After the attack or if the attack subsides, we anti-inflammatory corticosteroid
should ask the parent or the child to describe ● Bronchodilators – moderate persistent asthma,
Symptoms: their home environment including their pets, the children are prescribed a long acting bronchodilator at
child’s bedroom, outdoor pace based?, the bedtime in addition to the inhaled anti-inflammatory daily
- Coughing classroom environment and the eating to see corticosteroids
- Chest tightness whether there are more environmental control to
- Wheezing reduce occurrences of the attack • Anticholinergics
- Shortness of breath (dyspnea) ● Hx of child’s symptoms
- Increased mucous production - Assessment should include a thorough history of o Ipratropium (common)
- the development of a child’s symptoms. For
❏ Typically after exposure to certain allergen, an episode example what the child was doing during the • Short-acting beta2 – adrenergic
begins with a dry cough often at night as attack and what actions were taken by the agonists.
bronchoconstriction begins. parents or child to decrease or stop the
symptoms. o Albuterol, terbutaline, salbutamol
UNIT 9 (Week 11)
● Mast cell stabilizers Symptoms: - Wheezing or stridor
- Cyanosis
• Cromolyn sodium – given by a nebulizer - Short, shallow breaths - Clubbing of fingers
or a meter dose inhaler. This can prevent - Wheezing - Easy fatigability
bronchoconstriction and thereby prevent - Coughing - Physical growth may be restricted
symptoms of asthma. It is not effective once - Difficulty breathing - Enlarged chest
symptoms have begin. - Heavy sweating
- Trouble speaking Management:
● Leukotriene modifiers. - Fatigue and weakness
- Abdominal, back or neck muscle pain ● Mucolytic agent
• Montelukast – this medication is used - Panic or confusion ● Bronchodilators
for prophylaxis and chronic treatment of asthma - Blue-tinted lips or skin ● Chest Physiotherapy
in children over 6 years of age. They are not - Loss of consciousness (due to deprivation of O2 in the ● Antibiotic if infection is present
effective in an acute attack. brain)

Management:
PNEUMONIA
➢ Cough suppressants are contraindicated with asthma ● Higher doses of inhaled bronchodilators
because as a rule again, as long as a child can continue - Affects the lower respiratory system and is due to an
to cough up mucous they are not in serious danger. -such as Albuterol or Levalbuterol to open up your infection caused by either bacteria, virus, or fungi that
Coughing up mucous take plugs form that may lead to airways causes inflammation of the alveoli sacs
pneumonia, atelectasis and further acidosis.
➢ Steroids – it decreases the swelling and the ● Oral, Injected, or inhaled corticosteroids -The lung parenchyma are affected which are the alveolar ducts,
inflammation of the bronchus specifically in asthma bronchioles, and alveoli.
➢ Bronchodilators – acts to dilate the airway -to reduce inflammation
➢ Children who have severe persistent asthma symptoms
take a high dose of both an oral and an inhaled ● Ipratropium Bromide
corticosteroids daily as well as long acting
bronchodilators at bedtime -another type of bronchodilator different than albuterol

● An epinephrine shot
Slides 9 - 12 (Cybelle) ● Temporary ventilation support
● Oxygen administration via face mask

STATUS ASTHMATICUS BRONCHIECTASIS

-it refers to an asthma attack that doesn’t improve with traditional - a condition where the bronchial tubes of the lungs are Slides 13 - 16 (Joash)
treatments. These attacks can last for several minutes or even permanently damaged, widened and thickened
hours. This is an extreme emergency because if the attack - is a chronic dilatation and plugging of bronchi. It may
cannot be relieved, a child may die because of heart failure due follow pneumonia, aspiration of foreign body, pertussis Symptoms Signs
to the combination of exhaustion, atelectasis and respiratory or asthma
acidosis from bronchial clogging. ● Fever (Infection) ● Tachypnea
Symptoms: ● Chest Retraction
● Fast and difficult
● Grunting and stridor
- Chronic cough with mucopurulent sputum
UNIT 9 (Week 11)
3. Amoxicillin-clavulanate
breathing ● Nasal flaring CAP CHLAMYDIAL
(Augmentin) - may be
● Cyanosis PNEUMONIA
● Cough prescribed for penicillin-resistant
● Dullness on organisms
● Chest pain
percussion CLASSIFICATION - according to their specific causative ○ Reposition child frequently - to avoid
● Abdominal pain ● Diminished breath agent pooling of secretions
sounds, wheeze, ○ Intravenous therapy - to supply fluids
● Poor feeding
crackles on 1. Pneumococcal Pneumonia especially in infants, because infants tire
● Irritability ● Caused by bacteria called streptococcus so readily with sucking they may not be
auscultation able to achieve a good oral intake.
pneumoniae
● Localized in a single lobe ○ Antipyretic
IMPORTANT POINT TO ASSESS ● In infants, pneumonia tends to remain ○ Humidified oxygen - to alleviate
WHO respiratory rate thresholds for identifying children bronchopneumonia with poor consolidation labored breathing and prevent
with pneumonia: (infiltration of exudate into the alveoli). hypoxemia
● In older children, pneumonia may localize in a ○ Chest physiotherapy - encourages the
● Children younger than 2 months >= 60 breaths/min single lobe, and consolidation may occur. movement of mucus and prevents
● Children aged 2-11 months >= 50 breaths/min ● With this, children may have blood-tinged obstruction. Older children may need to
● Children aged 12-59 months >= 40 breaths/min sputum as exudative serum and red blood cells be encouraged to cough so that
invade the alveoli. secretions do not pool and become
*Wheezing and crackles are almost never heard in infants that’s ● After 24 to 48 hours, the alveoli are no longer further infected.
why it is important to note the respiratory rate* filled with red blood cells and serum but fibrin,
Slides 17 - 20 (Mira)
leukocytes, and pneumococci.
CLASSIFICATION ● At this point, the child’s cough no longer raises CHLAMYDIAL PNEUMONIA
bloodtinged sputum but thick purulent material. ● Caused by bacteria called Chlamydia trachomatis
● The fever with pneumococcal pneumonia may ● Can be contacted from the mother’s vagina duri
Community Ventilator-Associat Hospital-Acquired rise so high and fast a child has a febrile seizure
Acquired ed (VAP) (HAP) ■ Elevated level of IgG and IgM antibodies
● Children with pneumococcal pneumonia appear
(CAP) acutely ill. Tachypnea and tachycardia and specific antibody of C.trachomatis
develop. Because the lung space is filled with Management:
exudate, respiratory function will be diminished. ■ Macrolide- erythromycin
Breath sounds become bronchial (sound
transmitted from the trachea) because air no
longer or only poorly enters fluid-filled
alveoli. Crackles (rales) may be present as a
result of the fluid. Dullness on percussion
over a lobe indicates that total consolidation
has occurred. Chest radiographs will usually
show this type of lung consolidation in older
children but only patchy diffusion in young
- Pneumonia that - Pneumonia that - Pneumonia that children. Laboratory studies will indicate
develops outside develops 48-72 hrs develops 48 hours leukocytosis.
the hospital after endo tracheal after admission ● Management
intubation - This type of ○ Antibiotics
- This type is pneumonia VIRAL PNEUMONIA
1. Ampicillin
harder to treat than causes 2. Third generation cephalosporin ● Caused by viruses called Respiratory Syncytial Virus
(RSV), myxovirus or adenovirus
UNIT 9 (Week 11)
● Viral pneumonia is generally caused by the viruses of ● An inflammatory response occurs when lung lipases act exhibit gastrointestinal symptoms such
upper respiratory tract infection: the RSVs, myxoviruses, on the aspirated oil. as nausea and vomiting. Next, they
or adenoviruses. Symptoms begin as an upper ● Lipid pneumonia is caused by the aspiration of an oily or become drowsy and develop a cough
respiratory tract infection. After a day or two, additional lipid substance. It is much less common than it once was from inhalation as vapors from the
symptoms such as a low grade fever, nonproductive because children are not given oil-based tonics, such as stomach rise and are inhaled. As
cough, and tachypnea begin. There may be diminished castor oil or cod liver oil anymore, as they were in the bronchial edema occurs from irritation
breath sounds and fine rales on chest auscultation. RSV past. Today it is most often caused by aspirated oily and inflammation, respirations become
may cause apnea. Chest radiographs will show diffuse foreign bodies such as peanuts or popcorn. increased and dyspneic.
infiltrated areas. ● A proliferative inflammatory response occurs when lung ■ Physical assessment shows an
● Because this is a viral infection, antibiotic therapy usually lipases act on the aspirated oil. This is then followed by increased percussion sound caused by
is not effective. The child needs rest and, possibly, an diffuse fibrosis of the bronchi or alveoli. The area then the presence of air trapped in the alveoli
antipyretic for the fever; intravenous fluid may be becomes secondarily infected. A child may have an beyond the point of inflammation. Rales
necessary if a child becomes exhausted or is dehydrated initial coughing spell at the time of aspiration. A period may be heard as air passes through
and refusing fluids. follows during which the child is symptomless; then a collecting mucus. Because air cannot
● After recovery from the acute phase of illness, a child will chronic cough, dyspnea, and general respiratory distress reach and inflate the alveoli fully, breath
have a week or two of lethargy or lack of energy, the occur. sounds may be diminished.
same as occurs with bacterial pneumonia. Parents may ● A chest radiograph shows densities at the affected site. ○ SYMPTOMS:
be confused because their child is not receiving an Antibiotic therapy is ineffective unless a secondary ■ Nausea & vomiting
antibiotic, despite the diagnosis of pneumonia. Explain bacterial infection has occurred. Surgical resection of a ■ Drowsy
the difference between viral and bacterial infections so lung portion may be necessary to remove a lung ■ Cough
they can better understand their child’s therapy and plan segment if the pneumonitis does not heal by itself. ■ Increased RR and dyspnea
of care ○ SYMPTOMS: ■ Rales
○ Symptoms: ■ Initially coughing spell Chronic cough ○ MANAGEMENT:
■ Begin as an upper respiratory tract Dyspnea General respiratory distress ■ Irritation from fumes of hydrocarbon
infection Chest xray reveal densities on the ingestion may occur when children
■ Low grade fever affected area initially swallow the fluid. If they are
■ Non productive cough ○ MANAGEMENT: given an emetic to induce vomiting, it
■ Tachypnea ■ Antibiotic therapy is ineffective unless a can cause them to aspirate vomitus or
■ Diminished breath sounds secondary infection is noted Surgical cause additional irritation.
■ Fine crackles resection of a lung portion ■ In the emergency room, gastric lavage
■ RSV may cause apnea HYDROCARBON PNEUMONIA may be done by health care personnel
○ Management:: ● Several common household products such as furniture with great care to remove the substance
■ Adequate rest polish, cleaning fluids, kerosene, gasoline, lighter fluid from the stomach and help prevent
■ Antipyretic and insects sprays have hydrocarbon. inhalation. The child is usually admitted
■ Intravenous fluid ● These products are a common cause of childhood to a hospital observation unit for a short
LIPID PNEUMONIA poisoning and result to hydrocarbon pneumonia time. Obtain vital signs and observe the
● Caused by the aspiration of an oily or lipid substance ○ ASSESSMENT child’s general appearance carefully for
such as oily foreign bodies (peanuts or popcorn). ■ Children who swallow a evidence of increased respiratory tract
hydrocarbon-based product usually obstruction or increasing drowsiness or
UNIT 9 (Week 11)
other symptoms of CNS involvement atelectasis must be established, however, so that
-newborns respiration is ○ Symptoms:
from CNS intoxication. therapy directed to the specific cause can be initiated.
irregular, with nasal flaring -asymmetry of chest,
■ Cool, moist air administered by a
SECONDARY ATELECTASIS and apnea. Cyanosis and decreased breath sounds,
nebulizer with supplemental oxygen
respiratory grunt may occur. tachypnea, cyanosis
may be prescribed to decrease lung ●Secondary atelectasis occurs in children when they have
inflammation. If febrile, a child needs an a respiratory tract obstruction that prevents air from
antipyretic. Frequent changes of entering a portion of the alveoli. As the residual air in the
position will prevent pooling of alveoli is absorbed, the alveoli collapse. Slides 21 - 23 (Sophia)
secretions, which could lead to a ● The causes of obstruction in children include mucus
21st slide
secondary infection. Chest plugs that may occur with chronic respiratory disease or
physiotherapy will help to move aspiration of foreign objects. In some children, 7. Atelactasis
secretions and reduce areas of stasis. atelectasis occurs because of pressure on lung tissue - is the collapse of lung alveoli
■ Do not induce vomiting Gastric lavage from outside forces, such as compression from a - If caused by a mucus plug, will be resolved when the
Obtain V/S Monitor sx of CNS diaphragmatic hernia, scoliosis, or enlarged thoracic plug dissolves, or is moved or expectorated
involvement Cool, moist air through lymph nodes.
Management:
nebulizer Supplemental O2 ● The signs of secondary atelectasis depend on the
7. Atelectasis degree of collapse. Asymmetry of the chest may be ○ Children may need oxygen and assisted
● Atelectasis is the collapse of lung alveoli. It may occur in noticed. Breath sounds on the affected side are ventilation to maintain adequate respiratory
children as a primary or secondary condition. It must be decreased. If the process is extensive, tachypnea and function until this time
considered as a possibility in all children with respiratory cyanosis will be present. A chest radiograph will show ○ Make certain also that the chest of the child with
distress. the collapsed alveoli (a “whiteout”). Children with atelactasis is kept free from pressure so that the
atelectasis are prone to secondary infection because lung expansion is as full as possible, to allow as
PRIMARY ATELECTASIS much breathing space as possible
mucus, which provides a good medium for bacteria,
○ Check the clothing to be certain if it is loose and
● This is seen most commonly in immature infants or in becomes stagnant without air exchange. non binding
infants with CNS damage. It may occur if infants have SUMMARY ○ Make certain also that the child’s arms are not
mucus or meconium plugs in the trachea. When positioned across the chest where their weight
PRIMARY ATELECTASIS SECONDARY ATELECTASIS
atelectasis occurs, the newborn’s respirations become could interfere with deep inspiration
irregular, with nasal flaring and apnea. After a few ○ Position px on semi fowlers to generally allow for
● Occurs on newborns ● Occurs in children the best lung expansion because it lowers
minutes, a respiratory grunt and cyanosis may occur. who do not breathe when they have a abdominal contents and increases chest space
● The sound of a respiratory grunt is caused by the with enough respiratory tract ○ Increase the humidity of the child’s environment
newborn’s glottis closing on expiration. At first, this is a respiratory strength at obstruction to prevent further bronchial plugging
helpful action because it increases pressure in the birth to inflate lung ● In some children, it ○ Suction and chest physiotherapy may be
respiratory tract, keeps alveoli from collapsing, and tissue or whose occurs because of necessary to keep the respiratory tract clear and
allows for better alveoli exchange surfaces. This action free of mucus
alveoli are so pressure on lung
is also tiring, however, and as the infant tires, hypoxemia ○ Observe closely for increase respirations or
immature or lacking tissue from outside cyanosis as this indicates filling oxygenation
will increase, and the infant will become hypotonic and in surfactant that forces such as 8. Pneumothorax
flaccid. alveoli cannot diaphragmatic hernia, - Is the presence of atmospheric air in the pleural space;
● The Apgar score will invariably be low. As infants cry or expand. scoliosis or enlarged its presence cause the alveoli to collapse ( basically
are administered oxygen, more alveoli become aerated ○ Symptoms: thoracic lymph nodes. naay tear sa pleural space)
and cyanosis may decrease. The cause of the
UNIT 9 (Week 11)
- Pneumothorax in children usually occurs when air exit - the condition most often occurs in infants who received
Slides 24 - 26 (Brian)
from ruptured alveoli and collects in the pleural cavity mechanical ventilation for respiratory distress syndrome
- They can also occur with external puncture wound that at birth 10. Tuberculosis
allows air to enter the chest such as pneumo trauma or - The condition is thought to occur from a combination of ● Highly contagious pulmonary disease that affects the
sharp objects that can penetrate the chest cavity can surfactant deficiency, barotrauma, lung damage from lungs
also cause pneumothorax ventilator pressure, oxygen toxicity from high levels ● Causative agents: Mycobacterium tuberculosis
- Occurs in approx. 1% of newborns because of the needed to counteract the original respiratory distress ● Mode of transmission: inhalation of infected droplets
rupture of alveoli from the extreme intrathoracic pressure and continuing inflammation ● Tb spreads from person to person by airborne
needed to initiate first inspiration - It occurs more often in infants born weighing less than transmission an infected person releases a droplet
Symptoms: 1,000 grams, basically pre-mature infants. They can’t nuclei of the bacteria through talking, coughing,
○ Tachypnea produce enough surfactants pa man sa ila body also laughing, singing or sneezing.
○ Grunting respiration mao nang ig gawas nila naay assistive ventilators upon ● Larger droplets can settle however smaller droplet
○ Nasal flaring birth remains suspended in the air and are inhaled by the
○ Cyanosis - Oxygen toxicity- not allowed to give high rates of oxygen susceptible person.
○ Auscultation reveals absent or decreased breath to pediatric clients because their alveoli is not receptive
sounds to oxygen which will possibly collapse Risk factors:
○ The chest film will show the darkened area of Symptoms: ➔ Close contact with someone who has active TB
the air filled pleural space ○ Tachypnea ➔ Children who are homeless or severely impoverished
Management: ○ Retractions ➔ Any person without adequate health care
○ Oxygen therapy - to relieve respiratory distress ○ Nasal flaring ➔ Immunocompromised status
○ Thoracotomy catheter or needle - may be placed ○ Tachycardia ➔ Who have chronic illnesses
in the pleural space and atmospheric air ○ Oxygen dependence - since premature infants ➔ Pre Existing Medical conditions or special treatment
aspirated or low pressure suction with water pa man but in a low rate ➔ Living in overcrowded, substandard housing (High risk)
sealed drainage applied to remove aspirated air. ○ Abnormal radiograph findings that show areas of
In most children with pneumothorax symptoms overinflation, inflammation and atelactasis ASSESSMENT/ DIAGNOSTIC TESTS
are relieved after suction has begun ○ As inflamed surfaces heal they are left with ● All children should have a tuberculosis test as a part of
○ If the air in the pleural space is from a puncture fibrotic scarring basic preventive healthcare screening at 9 to 12 months
wound such as stab wound - cover the chest ○ Upon auscultation there will be decreased air of age and yearly thereafter.
wound immediately with impervious material ( movement that can be detected
e.g., petroleum gauze) to prevent further air ○ Infants who already have respiratory system
from entering and help decrease the possibility defects are more at risk for BPD
of atelactasis. Management:
○ In emergency cases, an impervious object can ○ Administration of corticosteroid to reduce
be your gloved hand ( as much as possible inflammation
tabunan with pressure para way air mo sud) ○ Bronchodilator by nebulizer greatly improves
○ Pneumothorax is always a potential serious respiratory function
respiratory problem, the extent of the symptoms ○ Infants need to be monitored carefully for
and the outcome will depend on the cause of nutrition and fluid intake especially if ventilator
inhaled air in the pleural space whether it can be dependent
moved ○ Emphasize long hospitalization until the child is
9. Bronchopulmonary Dysplasia ( BPD) independently breathing and doesn’t need
- is a chronic pulmonary involvement that occurs in 10% supplemental oxygen, so that’s the time na they ● Mantoux test - or tuberculin test (purified protein
to 40% of infants who are treated for acute respiratory are allowed to wean from ventilation machine derivative (PPD) test)
distress in the first days of life ➔ It determines if a person has been infected or exposed
with TB
UNIT 9 (Week 11)
➔ A standard procedure should only be performed by a ➔ Hemoptysis also may occur
trained by the organization ➔ Anorexia
➔ 5 units of protein derivative vaccine is Injected ➔ Night sweats
intradermally at left lower arm, then 0.1 ml of protein ➔ Low grade fever
derivatives is injected creating an elevation in the skin ➔ Finger clubbing, a late sign of poor oxygenation, may
and a wheeler of a blood is formed occur
➔ A healthcare professional inspects the area 72 hours ➔ The inflamed parenchyma may cause pleuritic chest
after administration is necessary to evaluate the level of pain
reaction Severe cases:
➔ After 3 days reaction on the site is noted ➔ Dyspnea
➔ Positive reaction – 5-15mm of reddened induration
(hardening, nagtuyok nga gahi) , indicates the child has MANAGEMENT:
been exposed to tuberculosis or has developed ➔ Pulmonary TB is treated primarily with anti-tuberculosis
antibodies to the foreign products of the tuberculosis agents for 6 to 12 months.
organism For prevention:
➔ Children with positive reactions need a follow up chest ➔ BCG vaccine is given at birth to prevent it Health teaching, tell patient nga normal ni siya nga effect sa
radiograph to ascertain the reaction. tambal, pero dili nimo e reason nila nga to stop, sultii kung unsay
Note: further complication if ila e stop
- Skin testing should not be done on children who
have a history of tuberculosis diagnosis because OTHER MGT STRATEGIES​
Slides 27 - 29 (Shannen) · Nutritional therapy​
of the risk of intense reaction at the testing site.
- Tuberculosis screening test should not be done - well balanced diet
immediately after administration of the measles, 10. Tuberculosis · Lifestyle modification​
mumps, and rubella (MMR) vaccine because of - Esp. if smoker ang patient, we need to educate
the possibility of a false-negative result The World health Organization has a recommended strategy to stop smoking kay it can further complicate the
● X Ray will show cloudiness in the inflamed area, and it through TB DOTS Project which means Directly Observed condition
may not be Treatment, Short-Course for those px that has tuberculosis. This · Cough hygiene​
evident on chest management includes first line drugs or anti tubercular drugs - TB is Highly contagious, teach client about
radiography. As given to the patient. So with DOTS, nay partner habang ga take proper cough etiquette
local inflammation sa medication because usually 6-12 months ang treatment (long · Regular follow-up​
occurs, term) and dapat everyday imnon to prevent multidrug resistance. - Even if patient is treated with tuberculosis, we
calcification and have to encourage this because possible nga mu
cloudiness in the Good thing nga ma detect nimo early para ma prevent ang reccur ang disease.
flamed area will transmission since highly contagious kayo. · Prevention of complications​
be noticeable
Antitubercular drugs include: 11. Cystic Fibrosis
● Sputum analysis (Sputum Culture) - for confirmatory dx, FIRST LINE DRUGS
- Isoniazid (H) - Autosomal recessive disorder​that has a defect on the long arm
SYMPTOMS: - Rifampicin (R ) of chromosome 7. Two genes are needed one gene from each
When mycobacterium tuberculosis invades a child’s lungs there - Pyrazinamide (Z) parent is needed to manifest the disease. (so if one gene, carrier
is primary inflammation, the child develops a - Ethambutol ( E) lang ang patient, if ang two parents are carriers then the child will
➔ slight cough - Streptomycin (S) have 100 percent acquisition of the disease)
➔ Fatigue - This disorder s characterized by abnormalities affecting certain
As disease progresses there will be: Naa lang juy factor nga dili kayo mu comply ang patient sa gland of the body especially those that produce certain mucus,
➔ Weight loss tambal because of the series of adverse effects : particularly a dysfunction of the exocrine glands. Exocrine gland
UNIT 9 (Week 11)
excretes substances through ducts either internally (glands in the - Meconium ileus = bowel obstruction that occurs when the ○ Diagnostic:
lungs) or externally ( though the sweat glands) meconium in the child’s intestine is even thicker and stickier than ■ Chromosome Analysis or
- What happen in cystic fibrosis, mucus secretions in the body the normal meconium creating a blockage in the part of small Karyotyping - to detect the defected
particularly in the pancreas and in the lungs are so tenacious intestine, so it can be usually seen at birth. And with this, there genes, specifically, the chromosome 7
that they have difficulty flowing through the gland ducts causing will be abdominal distension in newborn. ■ Sweat testing - time-honored method
obstruction caused by the thick viscous mucus and leads to 2.Salty-tasting skin -when newborn is kissed ​ to detect the abnormal concentration in
irreversible lung damage. It can cause complex disorders also - this is the first symptom nga manotice sa parents. Because of sweat in children
that affects multiple organ systems especially the respiratory and the dysfunction of sweat gland nga ang concentration sa chloride ■ Duodenal Analysis - analysis of the
GI. kay daghan (2-5 times than normal) duodenal secretions for detection of
- The body produces thick sticky mucus in the lungs that could 3.Steatorrhea • Greasy, large, bulky and foul smelling ​ pancreatic enzymes. It reveals the
clog the lungs, it can obstruct the pancreas therefore producing - fat in the stool extent of pancreatic involvements
malabsorption and malnutrition. -when the intestinal flora increase because of the undigested ■ Stool Analysis - maybe collected and
- What happen with cystic fibrosis, if nay dysfunction sa food in the patient’s stomach, when combined with fat in the analyzed for fat content and lack of
pancreas (we all know pancreas secretes enzymes that are stool gives the stool an extremely foul odor compared to that of a trypsin.
responsible for digesting fat , protein and some sugars). Without cat’s stool. ■ Pulmonary Testing - part of the
those pancreatic enzymes , children cannot digest those, 4.Poor growth/weight gain in spite of good appetite ​ pulmonary function test, a chest
therefore there will be malabsorption and malnutrition - because of the malabsorption that is happening sa radiograph, generally confirms the
· Dysfunction of exocrine glands ​ gastrointestinal tract sa patient extent of the pulmonary involvement.
· Obstruction caused by thick, 5.Chronic coughing, at times with phlegm ​ May be done to determine atelectasis
viscous mucous ​ - because of the viscous mucus pulling in the airway and emphysema are present.
· Leads to irreversible lung damage ​ 6.Frequent lung infections​ ○ Management:
· Complex disorder: affects multiple - because of the high rate of sodium absorption and low rate of ■ Therapy for children with CF consist of
organ systems, especially respiratory & GI​ chloride secretion reduces salt and water content in mucus measures to reduce involvement of the
· Clogs the lungs- stagnant mucus​ depleting the periciliary liquid in the airway. The mucus adheres pancreas, lungs, and sweat glands.
· Obstruct the pancreas – malabsorption to airway surfaces leads to decreased mucus clearing. With ■ Humidified oxygen - oxygen is
and malnutrition​ mucus nga naa ra sa airway can predispose for the patient to supplied to children by masks,
acquire secondary infection ( specifically bacterial infection) ventilators or nebulizers. Mist can be
supplied by an ultrasonic compressor
and delivered through a nebulizer mask
which makes the droplet size so small
that the mist reaches the smallest
bronchioles spaces.
■ Aerosol Therapy - 3 or 4 times a day,
children may be given aerosol therapy
by means of embolization to provide
antibiotics or bronchodilators. Antibiotics
are given specifically if there is
secondary bacterial infection.
■ Mucolytic - can be given specifically
acetylcysteine mucomyst can be added
to the mist to aid in diluting and liquifying
secretion. Children’s coughs will
SYMPTOMS:​ become loose and productive after
1.Meconium ileus – seen at birth ​ Slides 30 - 32 (Cloy) using aerosol therapy.
11. Cystic Fibrosis
UNIT 9 (Week 11)
■ Chest physiotherapy - because the to go and swells up in the affected lung. When this
bronchioles secretions with CF are so occurs over the period of 4-5 weeks, the long expands
tenacious even with liquefaction by mist and its functions appear to be improved. So this type of
are aerosol therapy, children may be blockage can be achieved through a temporarily
unable to raise them. To aid drainage blocking the fetal windpipe or trachea with a balloon over
and secretions, children need this a period of time. So this is done by performing operative
therapy approx. 3-4 times a day. fetoscopy.
■ Encourage exercise. To keep mucus ➔ Fetal surveillance and delivery planning - There is a high
from moving. Children with CF need to possibility that a baby with cdh will get worse before the
maintain their usual activity as much as anticipated due date. part of a comprehensive treatment
possible. When in bed, they need plan will involve close fetal and maternal monitoring to
frequent position changes so that at avoid severe fetal deterioration .
various times of the day, all lobes of
their lungs will be encouraged to drain
by being in a superior position. Be The presence of these abdominal organs in the chest
certain they sit a part of each day to limits the space of the lungs and can result in respiratory
drain the upper lobes. complications because CDH forces the lungs to grow in a
■ Respiratory hygiene. The sputum that compressed state, several aspects of their function may not
a child coughs may have a disagreeable develop normally until after the birth of the baby. So before birth,
taste or odor do offer frequent mouth the placenta takes over all the functions of the lungs so that a
care, toothbrushing and a good fetus can grow in a womb without suffering low oxygen levels or
mouthwash to make a child’s hypoxemia. However, after birth, the baby depends on the
mouthfresh. function of the lungs and if their development is severe, artificial
■ Lung Transplantation - As children ventilation techniques may be necessary.
with CF reach adolescents, they are SYMPTOMS:
now candidates for lung transplant. ➔ difficulty breathing.
Some of these are done as lower lobe ➔ fast breathing.
transplants from a living donor. People ➔ fast heart rate. Most people infected with covid-19 virus will experience
who donate a single lobe in this manner, ➔ cyanosis (blue color of the skin) mild respiratory illness and recover without special treatment.
report that they feel a little lost lung ➔ abnormal chest development, with one side being larger Older people and those with underlying medical problem like
capacity afterward. A lung transplant is than the other. cardiovascular disease, diabetes, chronic respiratory disease
advantageous for children with CF ➔ abdomen that appears caved in. and cancer are more likely to develop serious illness.
because the new lung does not possess MANAGEMENT MODE OF TRANSMISSION
the defective gene that causes mucus to Following a delivery, a baby with CDH may undergo:
be so thick therefore lifespan can be ➔ Surgery - to close the defect. However, surgery after ● Virus is spread through DROPLETS when an infected person
greatly improved. delivery does not address the lung damage since it has speaks, coughs, or sneezes, and these can land on:
already occurred. For this reason, fetal therapeutic ○ mouths or noses of people up to one (1) meter away
procedures are recommended in some pregnancies ○ surfaces up to one (1) meter away, and survives for at
which may help decrease the amount of lung damage least three (3) days.
that can occur during pregnancy. The goal of fetal
treatment is to reverse some of the lung damage that ● AIRBORNE transmission may be possible in may be possible
results from the compression of the lungs. in healthcare settings, during aerosol-generating procedures,
➔ Fetoscopic tracheal occlusion (FETO) - The fetal lungs fand areas with poor ventilation
produce fluid that leaves the body through the babies
mouth. If this outflow of fluid is blocked, It has nowhere
UNIT 9 (Week 11)
younger, 35 or older, those with
Slides 33 - 35 (Mary)
pre-existing conditions) show
13. Corona Virus Disease of 2019 (COVID-19) symptoms, but they are infected
○ Symptoms of Intubation: and can transmit the virus.
■ Symptoms can take up to 14 days from ○ Prevention:
infection to show. ■ Avoid crowded places and limit time in
■ The most common symptoms are: enclosed spaces
● Fever (not necessarily high ■ Maintain at least 1 meter distance from
fever) others
● Dry cough ■ When possible, open windows and
● Tiredness or fatigue doors for ventilation
● Shortness of breath or difficulty ■ Keep hands clean and cover coughs
breathing and sneezes
● Patients may experience aches ■ Wear a mask
and pains, nasal congestion, ○ Management:
and sore throat ■ Tocilizumab belongs to a class of drugs
● Some would say they known as Interleukin-6 (IL-6) blockers.
experience body or muscle pain, It works by blocking IL-6, a substance
severe fatigue, diarrhea, loss of made by the body that causes swelling
smell and taste (mostly in mild (inflammation).
cases). ■ Antiviral medication
■ Severe symptoms include: ● Remdesivir
● Difficulty breathing or
breathlessness while speaking
● Constant pain or pressure in the
chest
● Paleness
● Confusion, or changes in mental
state because of deprivation of
oxygen.
■ Some people are asymptomatic—they
do not show symptoms, but they are
infected and can transmit the virus.
○ People At Risk (Vulnerable Groups):
■ People of all ages can catch COVID-19
■ People at risk of severe illness if they
catch the virus:
● The elderly
● Persons with pre-existing Slides 64 - 70 (Mary)
medical conditions (heart or
lung disease, diabetes, asthma,
etc.)
● Persons who smoke
● Women with high-risk
pregnancies (aged 17 or
UNIT 10 (Week 12)
OVERVIEW AND ASSESSMENT OF CARDIOVASCULAR FUNCTION After flowing through an extensive network of capillaries, blood from ● Closure of shunts: Minimum of 3 to 10 days and maximum of
AND PEDIATRIC VARIATIONS AND NURSING OF THE CHILD WITH A the coronary arteries drain into the cardiac veins. The veins follow into 3 months
CARDIOVASCULAR DISORDER the great cardiac vein and coronary sinus. Blood empties from the ● Lungs have greater resistance because it is fluid filled so there
Fetal Circulation coronary sinus into the right atrium. is little blood passing through there. When the baby is born,
Video Transcript (Basic Cardiac Anatomy and Physiology): the resistance decreases which allows blood to pass through.
Normal Cardiac Anatomy Cardiac Conduction System
The right side of the heart receives venous blood from the body Electrical impulses originate in the sinoatrial node located at the Cardiac Assessment in Children
through the superior and inferior vena cava, which enter the right junction of the right atrium and superior vena cava. Each electrical The assessment in heart disease in children begins with:
atrium. Blood flows through the tricuspid valve into the right ventricle. impulse generated from the SA node travels through the right and left ● Health History
Blood leaves the right ventricle through the pulmonary valve into the atrium, causing the atria to contract. The impulse then travels to the o Should indicate a thorough pregnancy history of the
main pulmonary artery. The pulmonary artery divides into right and atrioventricular node, AV node, then to the bundle of His, and finally mother to determine whether an intrauterine
left pulmonary arteries to transport deoxygenated blood from the right through the right and left bundle branches of the ventricles, causing problem could have led to poor fetal formation.
side of the heart to the right and left lungs. The pulmonary arteries the ventricles to contract. Cardiac anomalies can occur as a result of
branch further into the pulmonary capillary bed where oxygen and intrauterine infections such as toxoplasmosis (can
carbon dioxide exchange occurs. The four pulmonary veins, two from Electrocardiogram sometimes cause miscarriage) and cytomegalovirus
the right lung and two from the left lung, carry oxygenated blood from The P-wave of electrocardiogram represents atrial contraction. The PR or rubella (can cause congenital disorders to the
the lungs to the left side of the heart. The oxygenated blood flows interval is a measure of time from the onset of atrial contraction to the baby). Ask whether the mother took any medications
from the left atrium through the mitral valve (bicuspid valve) and into onset of ventricular contraction. The QRS complex represents the during pregnancy, whether nutrition was adequate,
the left ventricle and out through the aortic valve and into the aorta complete depolarization of the ventricles. The ST segment represents or whether she was exposed to any radiation (this
and to the body. the complete repolarization of the ventricles. Elevation or depression may also contribute to congenital heart disorders).
of this segment may indicate heart muscle ischemia. The QT interval o Child’s activity. A mark of older children with heart
Cardiac Valves represents the complete depolarization and repolarization of the disease is that they become easily fatigued. Ask how
The heart valve openings are protected by flaps of tissue called leaflets ventricles. A prolonged QT interval is a risk factor for ventricular much activities it takes before a child becomes tired
or cusps that are attached to the papillary muscles by the chordae arrhythmias and sudden death. (e.g. an hour of strenuous play, a short walk). Be sure
tendineae. The papillary muscles are extensions of the heart muscle that parents are not confusing sedentary activities
that pull the cusps together and downward at the onset of ventricular Intracardiac Pressures (e.g. sit and read) with activities that result in fatigue
contraction. As the pressure increases in the ventricles, the valves Pressures on the left side of the heart are usually three times greater (e.g. coming home from school and falling asleep day
close, and the papillary muscles prevent the valves from opening. than the right side of the heart. A normal right atrial pressure is usually after day).
around 3, with a range of 2 to 8. And left atrial pressure is usually 8, o Ask about the child’s usual position when resting.
Coronary Arteries with a range of 6 to 12 millimeters of mercury (mmHg). Some infants with congenital heart disease prefer a
The branch of circulation that supplies oxygen and other nutrients to knee-chest position whereas older children often
the cells of the heart is called the coronary circulation. The major Remember: voluntarily squat. These positions are unusual in
coronary arteries are the right coronary artery and the left coronary ● Left side of the heart has greater pressure because it pumps children but drop blood in the lower extremities
artery. The left coronary artery originates from a single opening behind blood throughout the entire body (systemic circulation). The because of the sharp bend at the knee, allowing the
the left cusp of the aortic valve and divides into the left anterior right side of the heart only pumps blood to the lungs so it child to oxygenate blood remaining in the upper
descending artery and the circumflex artery. The right coronary artery does not need that much pressure (pulmonary circulation). body more fully and easily.
originates from an opening behind the right cusp of the aortic valve ● Veins carry blood towards the heart. o Ask about frequency of infections because children
and divides into three major branches: the conus, the marginal–the ● Arteries carry blood away from the heart. with heart disease have higher incidence of lower
right marginal branch, and the posterior descending branch. ● Right side of the heart: Bicuspid respiratory tract infections, probably due to less than
● Left side of the heart: Tricuspid usual pulmonary circulation.
Coronary Veins ● Decreasing prostaglandin stimulates the closure of ductus o Ask if the infant is wetting diapers or if an older child
arteriosus. is voiding normally. Urine is produced only when
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
cardiac function is adequate to perfused kidneys. Ask o Inspection: ▪ Assess the central pulses. In infants, the best
how many times the infant voided or how many ▪ Look for any signs and symptoms of place to assess the central pulse is the
times did the mother change the infant’s diapers in a diminished cardiac output or poor cardiac brachial artery (upper or medial part of the
day. Edema from retained fluids is a late sign of function. You will be able to tell by color, arm). You can also palpate for femoral pulse
heart disease in children because there is a decrease perfusion, and general overall appearance. which is located in the groin. In older
in urine output with edema. The color of your patient should be pink and children, feel for a carotid pulse that is in
o Ask the history of nosebleeds and headaches. well-perfused. If the child looks incredibly the neck. It is imperative to note that the
Children with coarctation of the aorta and high pale, this could indicate a number of things absence of a central pulse indicates the
blood pressure in the head and upper extremities from anemia to poor cardiac output or need for an immediate CPR and call for an
have a history of nosebleeds and headaches. narrowing of your patient’s blood vessels emergency response.
Because of corresponding low blood pressure in the and response to shock. ▪ Feel for the child’s peripheral pulses. It can
lower extremities, such children may have pain in the ▪ See if the patient has the presence of be palpated on the radial artery which is
legs when running; reported as growing pain. clubbing which is the expansion of the found on the wrist; compare both sides. You
● General Assessment patient’s fingernails or fingertips. This is can feel in their feet, the dorsalis pedis and
o Take a look at the overall appearance of the patient. often caused by prolonged and long-term posterior tibial pulses. Note whether these
What is the color of their skin? How alert are they? hypoxemia or low oxygen levels in the pulses are strong, normal, weak, or
What is their nutritional status? Do the parents blood, and is typically seen in children with threading. They are graded from 0 to +4
report that the child is taking a normal amount of PO congenital heart defects. basis. It is important to note because a
intake? ▪ Look for edema or swelling. Edema can bounding pulse (+3 to +4) can be an
either be in a generalized capacity or overall indicative of a hyperdynamic state of the
body of the patient (meaning the patient as patient, which would be indicative for warm
a whole looks puffy) and fluid overload. shock.
Perhaps it is more localized to certain
regions such as their lower extremities.
Lower extremity edema is often associated
with congestive heart failure. It is also
important to note whether the edema is
pitting in which, if you pushed on the
edema, you would see an indention and
may remain for some time. It is graded from
0 (no pitting) to +4 (severe pitting).
▪ Look for any visible (distention) pulsations.
The most important one to look for is in the ▪ Feel the overall temperature of the patient.
neck. You look for a jugular vein distention. Do they feel hot, cold, or warm? Warm and
● Physical Examination In some babies, this is normal but to some dry is usually normal. If they are cold and
o It is best if the child is relaxed and not crying. Provide patients who are laying at a 30 to 45 degree clammy, this may be indicative that
age-appropriate toys that can distract a child readily. angle, you should see no extra pulsations in something is going on with their vasculature
A bottle of formula or breast milk, or asking the their neck. If you see this, this could be an and warrants for their investigation.
mother to breastfeed, can help comfort the infant. indicative of some sort of a blockage or ▪ Test the patient’s capillary refill time. This
Play with both children and infants, if possible, obstruction for a certain heart problem. can be judged by pressing on either a finger
before an examination so that they are acquainted o Palpation: or toe until it turns white or blanched.
and are not afraid of you. Watch for spontaneous return of the color.
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
Normal time for the color to return is less pericardial effusion. It could o It cannot tell us how severe or the extent of the
than 2 seconds. If it reaches 3 to 4 seconds, develop after a pericardiotomy. damage of the heart.
this is described as a delayed capillary refill. ▪ The first thing you want to be aware of is a 2. Laboratory Testing
Anything more than 5 seconds is indicative murmur. o Children with heart disease usually undergo a
for a serious problem; requires immediate - This often indicates there is some number of blood tests to support the diagnosis of
intervention. sort of an opening or (abnormal) heart disease or to rule out anemia.
o Auscultation: connection between heart o Check for hematocrit or hemoglobin.
▪ Normally, anyone will be able to hear the S1 chambers, indicating abnormal - It is usually obtained to assess the rate of
and S2 or “lub-dub.” valve function. It should be brought erythrocytes or the RBCs production, which
- S1 indicates the closing of the AV to the attention of the physician in may increase in an attempt to produce more
valve order to best diagnose and treat oxygen carrying red blood cells.
- S2 is the closing of the semilunar the problem. - If the increase in the number of RBC is
valve. extreme (polycythemia), there will be an
- They are the two normal heart increase in the blood volume.
sounds and we have to be sure that - Newborns are normally slightly
we hear these noises. polycythemic, having a hemoglobin level
▪ However, as we move forward, you might over 25 grams per 100 mL or a hematocrit
hear an S3 and S4. level over 70%.
- S3 can be normal but should be - In an older child, they have a hemoglobin
reported to the physician. It is level over 16 grams per 100 mL or
sometimes heard in small children. hematocrit level over 55%.
This is usually heard at the apex of o Elevated erythrocyte sedimentation rate is taken if it
the heart and it can also be denotes inflammation. It is useful in documenting
identified as a gallop. This may be that an inflammatory process such as rheumatic
normal but report to a physician if *Check urine and cardiac output sad. Note lack of central pulse which fever, Kawasaki disease, or myocarditis occurs or is
this is a new finding. indicates immediate need for CPR and chest compressions. present.
- S4 is a concerning finding and it is o Blood gas levels are also determined.
usually identified at the atrial ● Tachycardia: One of the first indicators that the child is more - To test for this, a child is given 100% oxygen
contraction portion of the heart ill; Fast HR for about 15 minutes.
pumping cycle. It is a low frequency ● Decreased perfusion: Poor color, pallor, mottling or poor - If the child’s PO2 is less than 150 mmHg
sound that can often indicate white spots in the body after this time, a shunt directing
severe hypertension and potential ● No cardiac output = blood flow to kidneys decrease = deoxygenated blood into oxygenated blood
cardiomyopathy. decrease urine output is suspected.
▪ Some other abnormal heart sounds that we ● Flaccidity: Low muscle tone o Before cardiac catheterization or surgery, blood
want to be aware of is the pericardial clotting must be assessed. Expect prothrombin,
friction rub. Common Diagnostic and Therapeutic Procedures partial thromboplastin, and platelet count studies to
- This may sound sort of like when 1. Chest X-ray be completed before the procedure. Some children
you pull out a piece of hair and rub o Can show an accurate picture of the heart size, the with polycythemia from heart disease, have an
it between your fingers. contour or anatomic changes, and even the size of associated reduced platelet count or
- This is concerning as well as it the heart chambers. It can also reveal fluid collecting thrombocytopenia. Because platelet formation is
could indicate that there is in the lungs or pulmonary artery from cardiac failure. necessary for blood coagulation, the platelet count
o Used to confirm the placement of pacemaker leads. must be corrected before cardiac surgery.
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
o In children with heart failure, serum sodium may be o Records patient ECG tracing non-stop for 24 hours or o MRI: complementary role to ECG
obtained to ensure that an increased sodium level is longer o Purpose:
not causing edema. o Not invasive ▪ Evaluate the structure of the heart and
o All children receiving diuretics, such as furosemide, o The child’s regular activities will not be altered. surrounding blood vessels
should have serum potassium levels determined o Purpose: Detects arrhythmias and checks other signs ▪ Assess causes of arrhythmia (abnormal
periodically because diuretics tend to deplete the and symptoms that may be heart-related such as heart rhythm)
body potassium. Low serum potassium levels fatigue, shortness of breath, dizziness, or fainting ▪ Evaluate infections
potentiate or increase the effect of cardiac glycosides o Event monitor does not record until the patient feels ▪ Assess blood flow to the heart muscle
such as digoxin. For this reason, serum potassium symptoms. The patient must trigger the monitor to ▪ Evaluate findings following cardiovascular
levels are usually obtained in children receiving these record the ECG tracing at the time the symptoms surgery
medications. Hypokalemia increases risk for digoxin occur 7. Exercise Stress Testing
toxicity. 5. Echocardiogram o uses treadmill walking
3. Electrocardiogram o Or ultrasound cardiography o Can give information about how the heart responds
o Written record of the electrical voltages generated by o Primary diagnostic test for heart disease to the extra demands of activity.
the contracting heart. It provides information on o Uses high frequency sound waves to make detailed o The test is done on children who are able to walk and
heart rate, rhythm, state of the myocardium, pictures of the heart run on a treadmill and are mature enough to
presence or absence of hypertrophy (thickening of o Used to locate and study the movement and understand what is being asked of them, usually ages
the heart), ischemia (necrosis due to inadequate dimensions of the cardiac structures such as the size 5 and up.
cardiac circulation), and abnormal conduction of the of chambers, thickness of walls, relationship of major o Patient’s ECG and blood pressure will be taken while
heart. vessels to chambers, and the thickness, motion, and they exercise on a treadmill. The patient will be
o P wave: Atrial contraction pressure gradients of the box continuously monitored. Make sure there are no
o T wave: Recovery or relaxation o Can be done in Transthoracic echo (TTE) wherein a problems as the exercise level increases. Although
o Abnormal Results: hand-held wand called the transducer is used across the exercise is not harmful, it checks the child’s heart
▪ Longer P wave: Suggests atrial hypertrophy the chest over the area where the heart is, then the as it works to its highest level so some shortness of
and is taking longer than usual for the transducer sends and receives sound waves that are breathing and fatigue is expected. However with
electrical conduction to spread over the changed into images. children who have heart defects that obstruct the
atrium o Types: blood flow to the lungs (such as those with
▪ Lengthened PR interval: Difficulty in ▪ Two-dimensional: Reveals chambers and pulmonary stenosis), exercise is not possible because
coordination between the SA and AV nodes vessel size it can cause extreme exertion of dyspnea to the
▪ Heightened R wave: Ventricular ▪ Doppler: Reveals velocity of the blood patient.
hypertrophy o Can reveal heart anomalies as early as 18 weeks into o This test is difficult to perform successfully with
▪ Decreased R wave height: Ventricles cannot a pregnancy. This can alert the staff to be prepared young children because this requires their
fully contract as it happens when they are with immediate resuscitation or other needed cooperation.
surrounded by fluid equipment for the baby’s birth. 8. Cardiac Catheterization
▪ Elongated T wave: Hyperkalemia o Remind the parents that this does not use x-ray so it o gold standard for cardiac imaging
▪ Depressed Y wave: Anoxia can be repeated at frequent intervals without o Invasive outpatient procedure
▪ Depressed ST segment: Abnormal calcium exposing children to possible risks of radiation. o A procedure in which a small radiopaque catheter is
levels 6. Computed Tomography or Magnetic Resonance Imaging passed through a major vein in the arm, leg, and
4. Holter or Event Monitor o Both are non-invasive and used to capture images neck into the heart to secure blood samples or inject
o Continuous ambulatory ECG within the body. dye which helps to evaluate cardiac function
o Gives us a diagnostic information over a period of o The biggest difference is that MRIs use radio waves
time and CT scans use x-rays.
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
o allows for direct measurements of pressure as well as ● Four classifications: This classification has been established to resulting in right ventricular hypertrophy, an
visualization of the heart and all blood vessels with address the hemodynamic and blood flow patterns of the increased pressure in the pulmonary artery.
the aid of a contrast medium/dye disorders rather than the effect allowing a more uniform and ● There will be an extra blood nga mu congest sa right
o Can be diagnostic cardiac catheterization (used to predictable signs and symptoms. ventricles. Supposedly kaning blood coming from the
help diagnose specific heart disorders and lugs nga muenter sa left side of the heart should
anticipation of surgery) or interventional cardiac Disorders With Increased Pulmonary Blood Flow normally pass through the aorta, to be distributed
catheterization (used to correct an abnormality). ● Increase in pulmonary flow occurs as blood shunts from left throughout our body. However, with a hole in the
Both types can evaluate the pressure of blood flow in to right at either the atrial level or a ventricular level through septum, nay mga extra blood na oxygenated na unta
all heart chambers and total cardiac output. a hole in the septum and recirculated back to the lungs. This will get mixed sa non-oxygenated blood because of
o many corrective procedures can also be performed in shunting of the blood causes the volume overload on the the hole that is present. Eventually it can cause
the catheterization lab, such as atrial and ve heart and the lungs. The pressures on the right side are lower pulmonary infection/pulmonary problems.
o Ambulatory or one day surgery with conscious from the pressures of the left side of the heart. ● Since the right ventricle is pumping too much extra
sedation ● In defects, which causes opening between the chambers in blood to the lungs, sometimes the lungs cannot
o Before the procedure: the heart, blood will flow between the openings from the left handle it, specifically the arteries connecting the
▪ Children must have a recent radiograph, side of the heart to the right side. Blood will flow the path of lungs will become damaged and narrow. Narrowing
ECG, electrolyte levels, and blood must be the least resistance going from the area with the highest of arteries in the lungs can cause pulmonary
typed and crossmatched. pressure (left side), to an area of lower pressure (right side). hypertension and can cause several breathing
▪ Take baseline pedal pulses. problems in the infants.
▪ Measure height and weight for catheter size These are problems in the heart’s structure that are present at birth. ● With that pulmonary hypertension, since arteries are
and amount of sedation. The four classifications are: already narrow in the lungs, the right ventricles have
▪ Do not draw blood specimens from the 1. Ventricular Septal Defect to exert a lot of effort/pressure to pump those extra
projected catheterization entry site. ● The most common type of congenital heart disease. blood nga nag congest sa right side of the heart.
▪ NPO for 2 to 4 hours to reduce the danger It occurs about 25% of all congenital heart disease ● Left ventricle normally has higher pressure because it
of vomiting and expiration during the (about 2 in 1000 live births). has to pump the blood throughout the body, while
procedure. ● Occurs when there is an opening in the ventricular the right ventricle only has to pump the
○ Risks: septum, the wall between the two lower chambers non-oxygenated blood only to the lungs.
▪ Arrhythmias as catheter or dye is passed of the heart known as the right and left ventricles. ● With extra congested blood in the right side of the
through; may be transient ● A VSD allows the oxygen rich red blood that is heart, eventually it's going to have hypertrophy
▪ Inadvertent perforation of the heart coming from the lungs to pass from the left ventricle because of the exertion of a lot of pressure
▪ Bleeding to the septum and get mixed with oxygen poor blue ● It is found approximately 25% of all CHD.
▪ Thrombophlebitis blood in the right ventricle. ● The size of the defect can be small or large.
● The blood flows from the left side of the heart thru ● Cause is unknown
Congenital Heart Disorders the abnormal opening the right side of the heart. ● Risk Factors:
● These are problems in the heart’s structure that are present at Because the pressure on the left side is higher than ○ VSD appears to run in families and
birth. the right. sometimes occurs with other genetic
● Approximately 1 in every 100 newborns have congenital heart ● VSD occurs during fetal development when the problems, such as Down syndrome
defects which can range from mild to severe. separating process that forms the septum is not ○ Having the following conditions during
● It happens because of incomplete or abnormal development of completed. pregnancy can also increase the risk of
the fetus’ heart during the early weeks of pregnancy ● Impairs the effort of the heart because the blood having heart defect:
● Some are associated with genetic disorders, but the cause of most that should go into the aorta and out of the blood is ■ Rubella infection- that’s why during
congenital heart defects is unknown. shunted back into the pulmonary circulation history taking we ask the mother if
she had measles during pregnancy
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
■ Poorly controlled diabetes become infected or cause endocarditis because of discovered until infection from circulating
■ Drug or alcohol use or exposure to recirculating blood flow. blood occurs.
certain substances ○ Small-closed with a stitch o Signs and Symptoms:
● Signs and Symptoms: “HOLE” ○ Larger-Dacron or Silastic patch is applied ▪ Shortness of breath, especially when
○ The size of the ventricular opening will ● Post-Op interventions: Alert for arrhythmias (because edema exercising
affect the type of symptoms noted. in the septum can interfere with ventricular contraction), ▪ Fatigue
○ Heart Failure and pulmonary hypertension: prophylactic antibiotic given to prevent bacterial endocarditis ▪ Swelling or edema of legs, feet, or abdomen
Dyspnea, fatigue, swelling extremities, for 6 months afterwards. ▪ Heart palpitations or skipped beats
crackles, sweating, clammy with activity ● Adequate nutrition- prevent failure to thrive ▪ Frequent lung infection
○ Often experiences lung infection: With the ● Infection control- prevent lung and heart infection ▪ Stroke
narrowed arteries, it can cause possible ● Medications: ▪ Heart murmur: Heard over the 2nd or 3rd
secondary bacterial infection. ○ Digoxin makes contraction of the heart strong but at interspace (pulmonic area)
○ Low growth rate and loss of weight: It ties the same time at slow rate para di ma-stress o A harsh systolic murmur is heard over the second or
back to the heart and breathing problems ○ Furosemide: To get the excess fluid that are third interspace (the pulmonic area) because of the
burning a lot of energy to maintain the life congesting extra amount of shunted blood that crosses the
of the patient. The heart has to pump ○ ACE inhibitors increase blood pressure, especially the pulmonic valve. As the volume of the blood crossing
harder. left ventricle. it causes the pulmonic valve to close consistently
○ Extra heart sounds: Murmurs heard at the 2. Atrial Septal Defect later than the aortic valve, the second heart sound
left sternal border, at the 3rdor o An abnormal communication between the two atria, will be auscultated as split (fixed splitting). Such a
4thinterspace. Typically one of the major allowing blood to shift from the left to the right sound is almost always diagnostic of ASD.
signs of ventricular septal defect (Murmurs). atrium. o Diagnostic Tests:
Happens because of the turbulent radiant o A “hole” in the wall that separates the top two ▪ Echocardiogram with color flow Doppler will
blood crossing over the septum during chambers (atria) of the heart. generally reveal the enlarged right side of
systole. A small defect will cause a large o This defect allows oxygen-rich blood to leak into the the heart and increased pulmonary
amount of resistance to blood flow and oxygen-poor blood chambers in the heart. circulation.
result in a loud murmur. o This defect allows oxygen-rich blood to leak into the ▪ Cardiac Catheterization: Although rarely
● Diagnostic Tests: oxygen-poor blood chambers in the heart. needed for diagnosis. Would reveal the
○ Echocardiogram o Female predominance (more common in girls than separation in the atrial septum and the
○ MRI reveals right ventricular hypertrophy in possibly boys) increased oxygen saturation in the right
pulmonary artery dilatation from the increased blood o Occurs 5-10% of all children born with congenital atrium.
flow. heart disease. ▪ ECG
○ ECG reveals right ventricular hypertrophy. o This causes an increase in volume in the right side of o Management:
● Management: the heart and generally results in ventricular ▪ Surgery to close the defect is done electively
○ In small VSD usually no medical management is hypertrophy and increased pulmonary artery blood at 1 to 3 years of age. Closure is important
required because up to 85% of VSD are so small that flow, the same as with a VSD (ventricular septal because without it, a child is at risk for
they close spontaneously. defect). infectious endocarditis and eventual heart
○ Surgical repair may be indicated in some cases. o Two Types: failure or hypertension.
○ Especially in large VSD (over 3 mm) requires open ▪ Ostium primum (ASD 1): Where the ▪ It is particularly important that ASD be
heart surgery. Scheduled before 2 years of age to opening is at the lower end of the septum. repaired in girls, because they can cause
prevent pulmonary artery hypertension. Closure is ▪ Ostium secundum (ASD 2): Where the emboli during pregnancy.
important because if left open, cardiac failure from opening is near the center of the septum. ▪ Surgery in which the edges of the opening in
the artery hypertension can result. Heart can ASD2 defects may be asymptomatic and not the septum are approximated and sutured
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
may be completed with cardiac impulse conduction is halted before the AV o PDA is common in preterm infants.
catheterization technique if only the defect node. In the first degree heart block, there o It is a more common type in female babies.
is small. is no electrical blocking rather there is a o A small PDA may cause no symptoms, but a large one
▪ Large defects may still require open heart slowing or delay of the electrical activity of may cause poor eating, failure to thrive or
surgery and cardiopulmonary bypass. the heart. breathlessness.
▪ As with VSDs, if the defect is very large, a ▪ Echocardiography: Confirm the diagnosis o Ductus arteriosus is a vessel that connects the aorta
Silastic or Dacron patch may be sutured into o Management: and the pulmonary artery in the fetus. It carries
place to occlude the space. ▪ Pulmonary artery banding: This increases blood from the right side of the heart to the rest of
▪ Postoperatively, carefully observe the child pressure in the pulmonary artery and right the body bypassing the nonfunctional lungs. After
for arrhythmias because edema of the right side of the heart, reducing the amount of birth it should close because it is no longer needed.
atrium could interfere with SA node shunting. o Patent: Wala ni close
function. With uncomplicated surgery, ▪ Surgery: Necessary for final repair because o In this defect there will be an increase in pulmonary
children can expect a normal quality and these defects are too large to close blood flow in the lungs. How? Normally, the
length of life. spontaneously. Because surgery may involve oxygenated blood coming from the lungs enters into
3. Atrioventricular Canal Defect a valve repair as well as a septal repair, the left ventricle then to the aorta then to be
o Also called endocardial cushion defect mitral and tricuspid insufficiency from poor pumped out to the rest of the body. But because of
o Caused by a poorly formed central area of the heart. valve function may occur at a later date. the increase pressure in the aorta because ductus
Typically there is a large hole in the upper chamber ▪ Post-Op: Observe for jaundice, Prophylactic arteriosus did not close, some oxygenated blood will
of the heart(atria) and an additional hole in the anticoagulant, Antibiotic therapy enter into the ductus arteriosus then will go to the
lower chambers of the heart (ventricles). ▪ Postoperatively, closely observe children for pulmonary artery going back to the lungs, therefore
o Instead of having 2 separate valves (tricuspid and jaundice resulting from red blood cell there will be an increase blood flow to the lungs, this
mitral valve) there is one large common valve which destruction as red cells are destroyed by results to right ventricular hypertrophy and
is quite malformed the newly constructed valves. Both ineffective heart function.
o There is low ASD continuous with VSD and distortion prophylactic anticoagulation and the o IMPORTANT TO NOTE: Full closure may not occur
of the mitral valve and tricuspid valve. antibiotic therapy may be necessary until 3 months of age.
o Blood may flow between all four heart chambers. postoperatively, but with these drugs, the o Signs & Symptoms: CALL
o Commonly seen in trisomy 21 (although rare in the artificial valve should help ensure the child ▪ Cardiac
general population, as many as 50% of children with can lead an active life. ● Continuous “machine-like” murmur:
trisomy 21 (Down syndrome) who have heart disease 4. Patent Ductus Arteriosus Hallmark sign; The heart sound that
have this type of congenital heart defect. o It is a persistent vascular connection between the is unique. Continuous meaning
o Signs and Symptoms: pulmonary artery and the aorta that persist after you're gonna hear in both diastole
▪ The same symptoms of ASDs birth. and systole and you are gonna hear
▪ Right ventricular hypertrophy o Normally closes between birth and first 2 weeks of it in the left upper sternal border.
▪ Increased pulmonary blood flow life as the vessel is filled with fibrin. Murmurs can be heard because of
▪ Fixed S2 splitting (fixed second heart sound o Functionally the closure of the ductus arteriosus the strong pressure or turbulence of
splitting) occurs soon after birth. the blood flow that is happening in
▪ Caused by closure of the aortic and o Delayed closure is common in premature infants. It the affected area.
pulmonary valve are not synchronized accounts about 12 percent of congenital heart ● Risk for endocarditis: If there is
during inspiration. diseases and it is more common in females. increased pulmonary blood flow,
o Diagnostic Tests: o When ductus arteriosus remains patent and open there will be a hypertrophy of the
▪ ECG: Reveal first degree heart block. An ECG after pulmonary artery due to higher pressure in the right ventricle since the RV has to
often will reveal first degree heart block as aorta. put a lot of force and exertion to
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
pump the extra blood to the lungs oftentimes they do not have energy ■ Severe: cyanosis (if narrowing is severe;
because of the resistance. Over time anymore to feed. because of the inability of adequate blood
there will be a damage in the heart’s ● Infants cannot feed simultaneously to reach the lungs for oxygenation or right
lining that will occur and eventually while they are experiencing air to left shunting across the foramen ovale
predispose any infection. hunger. because of the increased right sided heart
● Increased heart rate: Due to the o Management: pressure)
right ventricle that is pumping so o Indomethacin 0.1 to 0.25mg/kg/IV over 30 ■ systolic ejection murmur (grade 5,
hard so the heart rate will increase mins very slowly is administered every 12 to crescendo decrescendo murmur) heard at
and also because of the narrowed 24 hours for 3 doses. (Since 1 reason that upper left sternal border (because of the
arteries that the RV is pumping so the ductus arteriosus remains open in fetal turbulence of the blood flow), S2 splitting
hard. life is because of the stimulation of (because of the late closure of the
● Wide pulse pressure: This is where prostaglandin from the placenta and low pulmonary valve)
you take the systolic BP and you can oxygen level of fetal blood; medication is ○ Diagnostic Test
subtract it to the diastolic and you given if ductus arteriosus does not close) ■ ECG will reveal right ventricular hypertrophy
get the number that would o Supportive care is provided with rest, ■ Cardiac catheterization: Rarely necessary for
represent the force that is needed adequate intake of calorie for weight gain diagnosis but is used for interventional
for the heart to contract; high due to and promotion of growth and development. enlargement of the stenosis valve
the blood flow to the ductus o Surgery-Transaction or ligation of patent ○ Management
● Heart Failure: Crackles and dyspnea ductus arteriosus is performed via lateral ■ Balloon angiography is a catheter with an
is not normal for a baby to have a thoracotomy, a closed heart intervention. If un-inflated balloon at its tip inserted and
heart failure; because of the surgery is not done, the child is at risk for passed through the heart into the stenosed
pulmonary infiltrates. heart failure. valve. As the balloon is inflated, it breaks
▪ Activity Intolerance valve adhesions and releases the stenosis.
● Fatigues easily due to the Disorders With Obstruction to Blood Flow Following the procedure, although children
happenings of the lungs and heart. ● Because vessel or valve narrows may have residual heart murmur, you can
Any kind of activity can cause them ● Prohibit enough blood from reaching intended site expect a normal life span.
to fatigue ● Threaten to overwhelm the heart due to the pressure 2. Aortic Stenosis
● Sweating or diaphoresis ○ Stenosis or stricture of the aortic valve prevents
▪ Lungs 1. Pulmonary Stenosis blood from passing freely from the left ventricle of
● Pulmonary hypertension happens ○ It is a narrowing of the pulmonary valve or the heart into the aorta
when there is too much flow pulmonary artery just distal to the valve. ○ Because the heart must work harder to pass blood
towards the lungs. Over time, the ○ pulmonary valve does not open properly through the narrowed area, increased pressure and
arteries feeding the lungs will ○ Inability of the right ventricle to evacuate blood by hypertrophy occur in the left. If this pressure
narrow causing increased way of the pulmonary artery because of the becomes severe, pressure in the left atrium will
hypertension in the lungs and obstruction leads to right ventricular hypertrophy increase, resulting in back pressure through the
predisposing the risk of infection. ○ If mild, pulmonary stenosis may never require any pulmonary veins to the lungs, possibly causing
● Risk for infection treatment. pulmonary edema.
▪ Loss of weight ○ Signs and Symptoms ○ There will be increased pressure and hypertrophy of
■ Mild: asymptomatic (Infants with PS may be the left ventricle
● Generally because of the problem of
asymptomatic or have signs of mild right ■ Back-pressure in pulmonary veins
feeding. These infants are burning a
sided heart failure ■ Pulmonary edema
lot of calories in order to breathe so
○ Signs and Symptoms:
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
■ Most children with aortic stenosis are ● An antibiotic prophylaxis is given with children can occur from this
asymptotic, a physical assessment generally to fight or prevent endocarditis. dangerously elevated blood
reveals a typical murmur, a rough systolic ● In addition, children need exercise pressure.
sound heard loudest in second and third testing before participating in ○ Decreased blood pressure in the lower parts of the
beat in the interspace or aortic space. competitive sports if an artificial body, there will be:
Murmur may be transmitted to the right valve is in place. ■ Absence or decreased femoral pulses
shoulder, clavicle and up to the vessels and 3. Coarctation of the Aorta ■ Cool extremities
even at the apex of the heart. ○ The narrowing of a portion of lumen of the aorta due ■ Lower BP in lower extremities
■ In severe cases, there will be decreased to a constricting band and it often seriously ○ As children with coarctation of aorta grow older they
cardiac output as evidenced by: decreases blood flow from the heart out to the may experience leg pain on exertion because of the
● Faint pulses upper portion of the body. diminished blood supply to the lower extremities,
● Hypotension ○ It occurs more frequently in boys and in girls and it is because collateral circulation is necessary to allow
● Tachycardia the leading cause of congestive heart failure in the blood to flow around the constriction.
○ Inability to suck for long periods first few months of life. ○ Collateral arteries are enlarged and may be seen
■ When the child is active there will be chest ○ There are two locations in which this commonly under ribs as obvious nodules such as the child grows
pain similar to angina because the coronary occurs: older.
arteries receive inadequate blood. ■ Preductal: The constriction occurs between ○ Diagnostic Tests:
■ Sudden death can occur when the amount the subclavian artery and the ductus ■ History and physical assessment
of oxygen needed by the heart muscle on arteriosus. ■ Upon examination, the BP in the arms will
excoriation far exceeds what is available ■ Postductal: The constriction is distal to the be at least 20 mmHg higher than in the legs,
■ An ECG or echocardiogram will reveal left ductus arteriosus. a reversal of the normal pattern.
ventricular hypertrophy. ○ Signs and Symptoms: ■ ECG, Echocardiogram, MRI, X-ray
○ Management: ■ Because it is difficult for blood to pass examinations of older children will reveal
■ Stabilization of beta-blocker or calcium through the narrowed lumen of the aorta, the left sided heart enlargement from back
channel blocker may be necessary to reduce blood pressure increases proximal to the pressure and also notching the ribs for the
cardiac hypertrophy before the defect is coarctation and decreases distal to it. So this large collateral vessels.
corrected. results in an increased blood pressure in the ○ Management:
■ Balloon valvuloplasty is a surgical treatment heart and upper portion of the body as ■ Interventional angioplasty (balloon
of choice. It is a surgery that involves pressure in the subclavian artery increases. catheter): With this procedure, a catheter
dividing the stenotic valve or dilating Elevated upper body blood pressure with an inflated balloon at its tip is inserted
constrictive aortic ring for severe defects. produces: and passed through the heart and into the
Such repair may lead to aortic valve ● Headache aorta. As the balloon is inflated it breaks the
insufficiency in later life at which time ● Vertigo adhesions and reveals the stenosis.
further surgery may be needed. ● Because a child under 3 years of ■ The narrowed portion of the aorta is
■ Artificial valve replacement age has difficulty describing these removed and the new ends of the aorta are
● Some children will need artificial sensations, exceptional irritability anastomosed, a graft of transplanted
valve replacement for correction as may be the main clue that these subclavian artery may be necessary if the
well. If there is a prosthetic valve symptoms are present. narrowed section is so expensive and an
used, children generally continue ● Epistaxis or nose bleeding can anastomosis is not accomplished readily.
anticoagulation or antiplatelet occur. ■ Many infants with coarctation of aorta
therapy. ● Cerebrovascular accident (CVA): In require therapy of digoxin and diuretics in
an event not generally associated the time before surgery can be performed.
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
This drug aims to reduce the severity of ■ Pulmonary artery arises at the left ventricle oxygen but it does not happen because
congestive heart failure. however in this condition, it arises at the there is no connection between right and
■ Surgical repair is usually scheduled by 2 right ventricle. left side of heart)
years of age, if the surgery is successful the ○ ASD and AVD occur in connection with this ● Poor feeding lead to decreased growth rate
child can expect to live a normal life. After transposition. ● Cool extremities
surgery the abdominal vessels receive more ○ ASD, VSD, and PDA permit mixing of two circulations. ■ Watch heart rate, rhythm, and O2 saturation levels
blood than they did previously, this may ○ Fetus survive in utero ● Give O2
result in abdominal pain or generalized ○ Once they are born, present signs and symptoms. ● Prepares for intervention
abdominal discomfort, but this is just a ○ Structures or shunts needs to be open until surgery ■ Alprostadil (Prostaglandin E): Keep connection
short term problem. to have oxygenated blood to be circulating in the between aorta and pulmonary artery (PDA); Keep
■ Some children continue to have elevated system ductus arteriosus open; Buys us some time until
upper body hypertension after the repair, ○ have some type of other congenital defects which surgery
they need continued treatment with allows a little bit of mixing of the blood ■ Procedures to correct
antihypertensive agents. ● Balloon atrial septal pull-through
■ Some children also require repeated balloon ○ Enlarged Septal Opening
angioplasty if adolescent to enlarge the ○ Temporary
aortic lumen and help reduce the upper ○ first few days of infants
body hypertension. ○ done by cardiac catheterization
wherein balloon is passed from
Angiography: Imaging and diagnostic tests foramen ovale through right atrium
Angioplasty: Repair ○ creates artificial ASD
● Arterial Switch Procedure
Disorders With Mixed Blood Flow ○ Permanent
Are cardiac anomalies that involve mixing of blood from the pulmonary ○ Done to 1 week to 3 months of age
artery and systemic circulation in the heart chambers. This mixing ○ major vessels are switched in
results in a relative deoxygenation of systemic blood flow. Although position
cyanosis is not always visible, mix defects include: ○ Survival heart of 95%
1. Transposition of the Great Arteries 2. Total Anomalous Pulmonary Venous Return
○ The great arteries such as the aorta and pulmonary ○ A birth defect of the heart in a baby with TAPVR,
artery are switched (transposed; swapped position in oxygen-rich blood does not return from the lungs to
the heart). ○ Diagnostic Tests: the left atrium or to a vein flowing to the right atrium
○ Normal heart: left side deals with systemic ■ Echocardiogram: Reveals enlarged heart or SVC . Instead, the oxygen-rich blood returns to the
circulation; aorta arise in left ventricle; right side ■ ECG - may not reveal heart changes right side of the heart via the superior vena caviar
deals with pulmonary circulation) ■ Cardiac Catheterization - reveal low oxygen the right atrium. Thus, oxygen-rich blood mixes with
○ Each side of the heart has its own circulation without saturation oxygen-poor blood.
communication. ○ Signs and Symptoms: “SWAP” ○ For the infant to live, an atrial septal defect (ASD) or
■ Pulmonary Circulation (left side of the ■ Severe Cyanosis patent foramen ovale (the passage between the left
heart) ● Will not resolve without treatment and right atria) must exist to allow oxygenated blood
■ Systemic Circulation (right side of the heart) ● Degree vary if CHD is present (worst as to flow to the left side of the heart and the rest of
■ Aorta arises on the right ventricle. structures close normally) the body.
● Low oxygen: Increased HR & RR (body’s way ○ pressure build ups in the pathway and pulmonary
of trying to compensate to pump more veins
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
○ Signs and Symptoms: ● Management: Disorders With Decreased Pulmonary Blood Flow
■ Tire easily ○ Repair involves restructuring the common As the category implies, the disorders will decrease pulmonary blood
■ Trouble breathing trunk to create 2 separate vessel flow, involves some type of obstruction to blood flow in the pulmonary
■ Mildly cyanotic ■ Some children need a 2nd surgical artery because of the obstruction, pressure increase sin the right side
■ If the ductus arteriosus closes or the septal procedure during school age as the of the heart and if an ASD or VSD is present, the oxygenated blood
defect is small, cyanosis increases. graft inserted to separate the aorta shunts from right to left. This results in deoxygenated blood invading
■ Right sided heart failure develops as & pulmonary artery may be large the systemic circulation. Common disorders include:
complication (permanent correction) 1. Tricuspid Atresia
○ Management: ■ Done for the first 2 weeks
■ Continuous infusion of prostaglandin to help ■ Digoxin, diuretics and ACE
keep the ductus arteriosus open inhibitors decrease pressure in the
■ Balloon atrial septal pull-through procedure pulmonary arteries: Given before
to enlarge a small foramen ovale surgery; Goal is to decrease the
■ Continuous IV infusion with prostaglandin to stress of the heart while increasing
help keep ductus arteriosus open the contraction.
■ Surgery: Reimplanting the pulmonary veins 4. Hypoplastic Left Heart Syndrome
into the left atrium (permanent correction) ○ It is a severe congenital heart defect in w/c the left
3. Truncus Arteriosus side of the heart is underdeveloped.
○ A rare type of heart disease in which a single blood ○ Left ventricles not functioning or is too small
vessel (trunk) comes out of the right & left ventricles, ○ Absence of mitral and aortic valve.
instead of the normal 2 vessels (pulmonary artery & ○ Aorta(main artery leaving the heart) smaller than
aorta). normal ○ Blood normally flows from the right atrium to the
○ There are holes in the ventricles associated with this ○ The left side of the heart can’t effectively pump right ventricle through the tricuspid valve. In
defect. blood to the body. Instead, the right side of the heart tricuspid atresia the valve is replaced by a plate or
○ There is usually an accompanying VSD must pump blood to the lungs and to the rest of the membrane that does not open.
○ There will be mixing of oxygenated and body. ○ An extremely serious disorder because the tricuspid
deoxygenated blood. ○ Signs and Symptoms: valve is completely closed.
○ Complications include pulmonary hypertension and ○ Blue or purple tint to lips, skin and nails (cyanosis) ○ No blood flow from the right atrium to the right
heart failure. ○ Difficulty breathing ventricle.
○ single artery comes out of the two ventricles which ○ Difficulty feeding ○ Instead, blood crosses through the patent foramen
allows oxygenated and deoxygenated blood mixes ○ Lethargy (sleepy or unresponsive) ovale into the left atrium bypassing the lungs and the
○ causes extra fluid to build up ○ Management: step of oxygenation. It reaches the lungs for
● Signs & Symptoms: ■ Prostaglandin therapy: To maintain PDA oxygenation by being shunted back through a Patent
○ Cyanotic: Decreased O2 blood in the system ■ Inhaled nitrogen combined with oxygen: To ductus arteriosus.
○ Increased RR: Compensatory mechanism of decrease PO2 ○ Signs and Symptoms:
the lungs ■ Surgery (restructuring of the heart) ■ As long as the foramen ovale and DA remain
○ Extreme fatigue ● Limited success in this syndrome open, the child can obtain adequate
○ Poor feeding ● Norwood procedure oxygenation.
○ Decreased cardiac output-activity ■ Heart transplantation: Ultimate answer for ■ As foramen ovale and ductus arteriosus
intolerance, cold, clammy skin prolonging the child’s life; donor hearts for close, extreme cyanosis, tachycardia and
○ May have a typical VSD murmur: Usually newborns is limited. tachypnea will develop.
heard at the upper sternal border ○ Management:
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
■ IV infusion of prostaglandin to ensure that ■ Aorta Displacement
ductus arteriosus remains open. ● Aorta is the main artery leading out
■ Surgery: Restricting the right side of the to the body branches out to the left
heart ventricle. In the tetralogy of fallot,
■ Fontan Procedure: Construction of a vena the aorta is shifted slightly to the
cava to pulmonary atresia which deflects right and lies directly above to the
more blood to the lungs. It restructures the ventricular septal defect. In this
RS of heart. position, the aorta both receives
2. Tetralogy of Fallot blood from the right and left
ventricles which normally the aorta ■ Pulmonary Stenosis
should only receive oxygenated ● Pulmonary valve is a valve that
blood from the left ventricle to be separates the lower right chamber
pumped through the body. In this of the heart from the main blood
condition, the aorta both received vessel leading to the lungs which is
the oxygenated and the pulmonary artery.
non-oxygenated blood. The right ● Stenosis is the narrowing of the
ventricular hypertrophy, when the pulmonary valve. The constriction
heart's pumping action is reduces the blood flow to the lungs
overworked, it causes the muscular affecting the muscles beneath the
wall of the right ventricle to thicken pulmonary valve. In some severe
overtime this may cause the heart cases the pulmonary valve does
to stiffen, become weak and not form properly when there is
eventually fail. Like in pulmonary pulmonary atresia and causes
○ A rare condition caused by a combination of 4 heart valve stenosis, there is narrowing. reduced blood flow to the lungs. As
defects present at birth, these defects which affect If there is a consistent resistance, we all know the blood coming from
the structure of the cause oxygen poor blood to flow overtime it can hypertrophied the the right ventricle will be pumped
out of the heart and to the rest of the body. Infants ventricle. There will be a right through the pulmonary valve to the
and children with this condition usually have blue ventricular hypertrophy with pulmonary artery to be oxygenated
tinged skin because their blood does not carry tetralogy of fallot. in the lungs. However, with
enough oxygen. stenosis or narrowing, there is a
○ Occurs during fetal growth. resistance only little blood will
○ termed as “Blue Baby” due to severe cyanosis enter the lungs.
○ Most common complex congenital heart defect. ■ Septal Defect (Ventricle)
○ Occurs when the baby is developing in the womb. ● A hole that separates the two
○ Factors the increases the risk of this condition: lower chambers of the heart (right
■ Poor maternal nutrition and left ventricle). The hole allows
■ Viral illness the oxygenated blood in the right
■ Genetic condition ventricle to mix with the
○ In most cases, the cause of tetralogy of fallot is oxygenated blood on the left
unknown. ventricle. The blood that has
○ Four anomalies are present: “RAPS” circulated to the body and is
■ Right Ventricular Hypertrophy returning to the lungs to replenish
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
oxygen supply will be mixed to flow the right to left shunting which is creating ductus arteriosus
to the left ventricle and mix with going to improve the blood flow to allow blood to leave
the oxygenated blood fresh from and help increase the oxygen level. the aorta and enter the
the lungs. ● Inability to grow: Children will be Pulmonary artery,
○ Signs and Symptoms: “AFFLICT” usually smaller for their age. oxygenate the lungs and
■ Because there will be decreased pulmonary ● Cardiac sound-systolic murmur: A return to the left side of
blood flow, there will be less oxygenation of harsh systolic murmur will be heard the heart, the aorta and
the systemic circulation. The signs and in the left of the sternal border in body. Because the
symptoms of this condition will be due to the second intercostal space subclavian artery is used
poor oxygenation. because it is where the pulmonary in the blalock taussig
■ Activity. Like crying, feeding or playing could valve is located. Definitely if there procedure, the child will
put a lot of stress and demand on the heart. is stenosis, you can hear a systolic not have a palpable pulse
With all those structural changes, it does murmur. in the right arm after this
not for the heart to work correctly and ● Trouble feeding and thriving: There procedure. For this
properly so it cannot replenish the blood will be delay in meeting their reason, blood pressure
with oxygen. Any activity that could stress developmental milestones and venipuncture should
the heart out could lead to Tet Spell. In compared to their peers because of be avoided in the affected
remembering the tetralogy of fallot, you the chronic poor oxygen in the arm.
have to remember Tet Spell and the need of body. ● Full-repair
knee chest position or squatting. ■ Management: ○ Brock procedure relieves
■ “Tet Spell” ● Surgery: Correct the heart defects. the pulmonary stenosis,
● Cyanosis Usually done at 1 to 2 years of age. TSD and overriding if aorta
● SOB (shortness of breath) Parents need to try to keep is scheduled.
● Increased RR hypercyanotic episodes (tet spell) ○ Postoperatively: Observe
■ Fingernail Changes: Clubbing. Chronic low to have a minimum during this for arrhythmias which may
oxygen in the blood causes those nails to waiting time. result in any ventricular
have an abnormal appearance. You may ● During hypoxic episode: septal repair, edema,
notice this around 6 months of age. ○ Administer oxygen conduction interference.
■ Chronic Hypoxia ○ Place baby in knee-chest
● Fatigue or faints easily: Related to position can help trap the Acquired Heart Disease
the chronic low oxygen in the blood in the lower A. Congestive Heart Failure
blood especially during Tet Spell, extremities keeping the o It is a common pediatric emergency.
the patient can faint easily leading heart from being o It indicates inadequate cardiac output.
to activity intolerance. overwhelmed o Heart failure (HF) results from structural or
● Lift knee to chest or squats: ○ Propranolol (Inderal): A functional cardiac disorders that impair the ability of
Anytime the patient is having a Tet beta-blocker to aid in the ventricle(s) to fill with and/or eject blood.
Spell, you need to put the patient pulmonary artery dilation o Clinical condition in which the heart fails to meet the
in a knee chest position or ● Temporary palliative surgical repair metabolic and circulatory demands of the body.
squatting for older children, give ○ Blalock Taussig procedure o Pulmonary and/or systemic congestion may develop
oxygen and calm the patient. can create a shunt as a consequence of heart failure, resulting in
Squatting increases the systemic between the aorta and Congestive Heart Failure (CHF).
vascular resistance, it decreases the pulmonary artery
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
o Congestive Heart Failure (CHF) usually occurs as a ▪ Inflammation of heart muscle (myocarditis) o The infant becomes breathless from rapid
result of a congenital heart disorder or a disease such o Signs and Symptoms: respirations, tires easily, and has difficulty feeding
as rheumatic fever, Kawasaki disease, or infectious ▪ Tachycardia: Early sign because of the exhaustion and dyspnea present.
endocarditis. This occurs when the myocardium of ▪ Tachypnea Often an infant becomes diaphoretic from the effort
the heart cannot pump and circulate enough blood ▪ Right heart failure: Increased venous of feeding.
to supply oxygen and nutrients to body cells. pressure, Hepatomegaly, Irritability, Restless o If edema is present, it is generalized rather than
o Blood pools in the heart (excessive preload) or in the from abdominal pain caused by liver dependent and often is first noticed as periorbital
pulmonary or venous systems. This may result from a distention, Lower extremity edema-late sign edema. An abrupt gain in weight may be the most
congenital disorder that lessens the effectiveness of ▪ Left heart failure: Dyspnea, Orthopnea, obvious indication that extra fluid is accumulating.
the heart’s pumping action, or it may occur after Rales, Bloody sputum on coughing, Cyanosis o Diagnostic Tests:
cardiac surgery or rheumatic fever, when the ▪ In infants: Breathless, Tires easily, Difficulty ■ Detail history of illness
myocardium is weakened. feeding, Diaphoresis, Generalized edema ■ Physical Examination
o CHF is most apt to occur in children under 1 year of o One of the first signs of CHF is tachycardia as the ● Palpation of weak peripheral pulse
age. heart attempts to beat faster to move blood forward with cold extremities
o The heart can compensate in several ways to move more effectively; this is quickly followed by ● Auscultation of heart sound
blood forward and attempt to increase cardiac tachypnea or rapid breathing. ● Auscultation of lungs
output. The muscle fibers can lengthen, causing the o When a child has primary right heart failure, ■ Chest X-ray
ventricles to enlarge in an attempt to handle more increased venous pressure and hepatomegaly ■ ECG
blood with each heart stroke (ventricular (enlarged liver) occur from back-pressure in the ■ ECHO
hypertrophy). The heart can also increase the portal circulation. ■ Cardiac catheterization
number of beats per minute. As long as these o The child may feel irritable and restless from the ■ On physical examination, an infant will have
mechanisms allow for adequate cardiac output, the abdominal pain caused by the liver distention. Lower an enlarged liver (a liver palpable more than
signs of heart failure are not apparent. However, the extremity edema, usually a primary sign in adults, is 2 cm below the right costal margin) and may
heart’s capacity for compensation is limited, often a late sign of heart failure in children. have ascites or fluid in the peritoneal space.
particularly in infants, an age group in which o With left-sided heart failure, back-pressure causes The apical heartbeat is displaced laterally
hypertrophy is restricted. Eventually, in children of all blood to accumulate in the pulmonary system. and downward.
ages, the heart can no longer compensate and Dyspnea is usually the dominant symptom, especially ■ As a rule, if the width of the heart is more
becomes overwhelmed by the amount of blood when a child lies flat (this is orthopnea or difficulty than half the width of the chest (in a child
present, which cannot be pushed forward effectively. breathing except in an upright position; it occurs due over 1 year of age), the heart is enlarged.
o Causes: to increased pulmonary congestion). ■ In addition, a galloping heart rhythm or an
▪ Various forms of congenital heart disease o A child may have rales and may produce bloody accentuated third heart sound may be
such as ventricular septal defect (VSD), sputum on coughing (from lung capillaries broken heard because of the sudden distention of
patent ductus arteriosus (PDA) or common under increased pulmonary blood pressure). the ventricle during the rapid filling phase.
AV canal o A child may appear cyanotic from interference with ■ Heart failure may be confirmed by
▪ Heart valve disease caused by Rheumatic gas exchange in the alveoli, which begin to fill with echocardiography, which reveals the
fever or other infections fluid (pulmonary edema). enlarged heart. Ventricular hypertrophy can
▪ Infections of the heart valves and/or heart o Left-sided heart failure can ultimately lead to be confirmed by ECG.
muscle (endocarditis) right-sided heart failure as extensive pressure in the ○ Management:
▪ Cardiac arrhythmias (irregular heartbeats) pulmonary system prevents blood from leaving the ■ Pharmacologic treatment:
▪ Cardiomyopathy or another primary disease right ventricle. In an infant, heart failure is often ● Diuretics: Furosemide
of the heart muscle difficult to detect because it presents with very ● Inotropic Agent: Digoxin
▪ Coronary artery disease subtle signs. ● Vasodilator: Hydralazine
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
● ACE Inhibitor: Captopril ● Babies are most comfortable in an ■ Continuous monitoring of child’s condition
● Calcium Channel Blocker: infant seat, which supports them in Maintenance of intake output and other
Nifedipine a semi-Fowler’s position. records.
■ Therapy for heart failure consists of ● Sedation with morphine may be ■ Emotional support and health education
reducing the workload of the heart by necessary to encourage bedrest in with necessary instruction should dietary
measures such as evacuating the some children. Most children with and activity restriction, drug intake,
accumulated fluid (reduces preload) with heart failure, however, prevention of complication, daily hygiene
diuretics, slowing the heart rate and automatically limit their activity, so care and measures of prevention of
strengthening cardiac function (increases the need for sedation must be infection.
contractility) by administering an inotropic considered on an individual basis B. Persistent Pulmonary Hypertension
(heart-strengthening) drug, and reducing ■ Provide oxygen as necessary ○ Results when the pulmonary vascular resistance
afterload with a vasodilator. ● If a child has dyspnea, hypoxemia, present at birth because of unopened alveoli fails to
■ Commonly used diuretics include or cyanosis, supplemental oxygen normal.
furosemide (Lasix) and spironolactone by way of hood, mask, or nasal ○ In fetal circulation, when there is an increase of
(Aldactone). The most common drug used prongs is usually necessary. vascular resistance in the lungs since it is filled with
to increase contractility and slow ● Assess the nostrils of the child fluid and not functioning in the utero.
tachycardia is digoxin. receiving oxygen with nasal prongs ○ Four blood flow that cannot enter to the lungs:
■ Drugs that decrease afterload include every 4 hours to prevent pressure ■ When the baby is born, this pressure
hydralazine, an arterial vasodilator; and subsequent irritation and normally subside or down as the lungs starts
nifedipine, a calcium channel blocker; breakdown of the interior nostrils to function, however with this condition,
nitroprusside, a direct-acting vasodilator; (this is a major problem in the hypopulmonary (?) resistance still
and captopril, an angiotensin converting newborns). persists does the name of this condition.
enzyme (ACE) inhibitor. ● For a child with heart failure, it is a ● Occurs most often in full-term
■ Provide for rest periods. strain to be submitted to strange, infants who have experienced
■ Put the patient in a semi-fowler's position. frightening equipment. Orient a perinatal asphyxia from conditions
■ Sedation with morphine child to oxygen equipment before it such as post term birth where
● Rest, a major aspect of care for a is brought to the bedside. Children there is a decrease of oxygenation
child with heart failure, reduces the generally experience such relief while the baby is still in the uterus.
metabolic rate, decreasing from dyspnea when they are ● PPH occurs because of hypoxia and
myocardial and body oxygen receiving oxygen that their acidosis from respir
demand. apprehension quickly disappears. ○ Signs and Symptoms: Infant develops tachypnea and
● Most children with heart failure ■ Maintaining proper nutrition pulse oximetry shows low PO2 from inability of blood
feel more comfortable in a ● Small frequent feeding (6 to 8 small to perfuse the lungs because of the pulmonary artery
semi-Fowler’s position than in a meals daily = less tiring). constriction.
supine position. ● Infants need to drink smaller ○ Management:
● This chest-elevated position lowers amounts of liquid frequently to ■ Supportive therapy:
the abdominal contents, enlarging have adequate daily intake or ● Oxygen administration
the thoracic cavity and allowing for receive a higher calorie formula. ● Assistive ventilation
easier, more comfortable lung ■ Diet should be planned with low salt for ● IV Glucose: Provides calories
expansion. sodium restriction and to be given in small ● Antibiotics: Combats infection
amounts frequently. ● Medication to reduce pulmonary
resistance such as low dose of
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
dopamine to elevate systemic it occurs in a late reaction of its response to
blood pressure infection.
● Sildenafil citrate: Vasodilation and ● Researchers believe that this is a cross reactivity
reduced resistance caused by antibodies binding to sites such as heart,
● Sodium bicarbonate: Relieve brain, and especially the joints.
acidosis and help reverse ● The name takes after “Rheumatism”
pulmonary vasoconstriction ● Signs and Symptoms:
● Inhaled nitric oxide: Promote ○ Fever
pulmonary vasodilation ○ Sydenham’s Chorea
● ECMO: For infants who does not ■ In 20-30% of cases, damage can
respond happen to the basal ganglia of the
C. Rheumatic Fever and Endocarditis brain, causing spastic movements
Rheumatic Fever of the head, face, and limbs.
● It is an inflammatory disease that can develop as a ■ This is known as chorea or St. Vitus’
complication of inadequately treated streptococcus dance.
infection. The disease often follows an attack of ■ Most cases resolve in 2 to 6
pharyngitis, tonsillitis, scarlet fever, impetigo because months, but extreme cases usually
the organism common to this infection is a group A need physical therapy.
beta hemolytic streptococcus. ○ Chest pain
● It is a diffuse inflammatory disease of connective ○ Erythema marginatum: A subcutaneous rash
tissue primarily involving heart, blood vessels, joints, that does not itch and forms rings that
subcutaneous tissue, and CNS. spread out overtime.
● Management:
● The heart damage and joint lesions of rheumatic ○ Carditis: In 50% of cases, the infection can
○ Encourage bedrest and decrease oxygen
fever are not infectious in the sense that these spread to the heart and form bacterial
demands by allowing the patient to rest.
tissues are not invaded and directly damaged by the vegetations. These usually target the valves
○ Monitor vital signs during the acute phase.
destructive organism, rather they present a and can cause life-long heart issues.
In obtaining apical pulse for a full minute is
sensitivity phenomenon or a reaction occurring in ○ Bacterial vegetations on tricuspid valve
preferred, it may be ordered if the child is
response to hemolytic streptococci. ○ Wrist inflammation
asleep as well as the child is awake to
● Common in children 6 to 15 years of age with a peak ○ Rheumatism. Inflammation occurs in the
measure the effect of activity on the pulse
incidence at 8 years. It is most seen in a poor joints making it painful to move. The joints
rate)
crowded urban area because children do not develop of the legs are usually affected first with the
○ Penicillin therapy: Benzathine penicillin is
immunity to streptococcal infections referring to inflammation migrating to upper joints.
used to eliminate group A beta-hemolytic
rheumatic fever.
streptococci.
● Children appear well again in 1 to 3 weeks however if
○ Oral Ibuprofen: Reduce inflammation and
the child is not treated with an appropriate antibiotic
joint pain
for the original infection the rheumatic fever’s
○ Corticosteroid: Reduce inflammation on
symptoms can begin.
children who are not responding to
● As nurses, we have to advise the parents to seek
ibuprofen therapy
healthcare and advise them to adhere to medicine
○ Phenobarbital and Diazepam: Reducing the
administration especially with antibiotics.
purpose less movement of the chorea
● Since rheumatic fever is an autoimmune disease
○ Digoxin and Diuretics: Reduce heart failure
where it occurs after streptococcal infection basically
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
Endocarditis complications such as renal occlusion or infectious agent. After the infection (perhaps an
● Inflammation and infection of the endocardium or cerebrovascular accident or stroke. upper respiratory infection), altered immune
valves of the heart. It may occur to children without function occurs. An increase in antibody production
heart disease but more commonly occur as a creates circulating immune (antibody–antigen)
complication of a congenital heart disease such as complexes that bind to the vascular endothelium and
ventricular septal effect. cause inflammation.
● It is caused by streptococci of the viridans type. The ● The inflammation of blood vessels leads to
streptococcal infection tends to invade the body aneurysms, platelet accumulation, and the formation
during oral surgery such as dental extractions, it also of thrombi or obstruction in the heart and blood
can enter from a urinary tract infection or a skin vessels.
infection such as impetigo. ● Signs and Symptoms:
● As the disease progresses, vegetation composed of ○ Acute Phase (Stage I)
bacteria, fibrin and blood appears on the ■ High fever (102° to 104° F [39.0° to
endocardium of the valves and heart chambers. This 40.0° C]) that does not respond to
tends to occur more commonly on the left side of the antipyretics.
heart although if a heart defect is present the ■ Child acts lethargic or irritable and
erosions begin at the site of the defect. Over a period may have reddened and swollen
of time, the invading process destroys the hands and feet.
endocardial lining of the heart so underline muscle ■ Conjunctivitis: Soon the bulbar
and also with valve. mucous membranes of the eyes
● Management: become inflamed and the child
○ Should have a prophylactic antibiotic develops a “strawberry” tongue
administration before ear, nose, throat, and red, cracked lips.
tonsil, or mouth surgery to prevent ■ A variety of rashes occur, often
D. Kawasaki Disease
infectious endocarditis. confined to the diaper area.
● Also known as mucocutaneous lymph node
○ If it does occur, these preventive measures ■ Cervical lymph nodes become
syndrome
therapy is directed toward the underlying enlarged. As internal lymph nodes
● It is an acute systemic vasculitis, or the inflammation
infection and also include supportive swell, children may develop
of the blood vessels, of unknown origin which occurs
measures to reduce heart failure. abdominal pain, anorexia, and
usually in children less than 5 years of age.
○ Maintain patient on bed rest if acute heart diarrhea.
● It is a febrile, multisystem disorder that occurs
failure is noted. Again, it is to decrease ■ Joints may swell and redden,
almost exclusively in children before the age of
oxygen demand simulating an arthritic process.
puberty. It has replaced rheumatic fever as the most
○ Antibiotics ○ Subacute Phase (10 days after the onset)
likely cause of acquired heart disease in children. The
■ Penicillin: Nafcillin (Unipen) ■ The skin desquamates, particularly
peak incidence is in boys under 4 years of age.
prescribed and given IV through on the palms and soles.
● Vasculitis (inflammation of blood vessels) is the
essential venous access devices. ■ The platelet count rises; this
principal (and life-threatening) finding because it can
○ Long term follow-up care to be certain that increases the possibility of clotting,
lead to formation of aneurysm and myocardial
the invading organism is eliminated and which could result in necrosis of
infarction.
disease process has stopped. distant body cells, particularly the
● The cause of Kawasaki disease is unknown, but it
○ Prognosis is good and less embolus from the fingertips, if they no longer receive
apparently develops in genetically predisposed
vegetation on the valve causes adequate blood.
individuals after exposure to an as-yet-unidentified

Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 10 (Week 12)
■ Aneurysms may form in coronary ○ Coronary artery bypass surgery: If the child different tests that may be used to diagnose
arteries, compromising heart is left with coronary artery disease from arrhythmias, including:
activity. stenosis of the coronary arteries. ● Electrocardiogram (EKG or ECG)
■ Sudden death from accumulating ● Stress test
thrombi or rupture of an aneurysm Dysrhythmias ● Exercise EKG
may occur, making this the most ● Can be used interchangeably with arrhythmias. ● Holter or event monitor
dangerous phase. ● Are disturbances in the normal cardiac rhythm of the heart ● Continuous recording
● Criteria for Diagnosis of Kawasaki Disease: which occurs as a result of alterations within the conduction ○ Management:
○ Fever of 5 or more days’ duration of electrical impulses. ■ Atropine: To counteract the vagal
○ Bilateral congestion of ocular conjunctivae ● The heart beats in response to electrical signals that are stimulation
○ Changes of the mucous membrane of the generated by the sino-atrial node. You can think of the Sino ■ Digoxin: Decreases and strengthens heart
upper respiratory tract, such as reddened atrial node as the heart’s pacemaker, found in the upper right rate
pharynx; red, dry, fissured lips; or part of the heart. These electrical impulses pass through the ■ Pacemaker: To maintain a steady heart
protuberance of tongue papillae right chamber of the heart or the atria then to the rhythm
(“strawberry” tongue) atrioventricular node. The specialized fibers allow the
○ Changes of the peripheral extremities, such electrical impulse to travel from the AV node to the lower
as peripheral edema, peripheral erythema, chambers of the heart or the ventricles. When any part of this
desquamation of palms and soles electrical signaling sequence is disrupted through the changes
○ Rash, primarily truncal and polymorphous in the heart tissue.
○ Cervical lymph node swelling ● Children have fewer cardiac dysrhythmias than adults.
○ To be diagnosed with Kawasaki disease, a ● Sinus arrhythmia is commonly found in children.
child must manifest fever and four of the ● Ventricular tachycardia and atrial fibrillation are syndromes
typical symptoms shown above, plus that occur because of multiple or abnormal initiation of the
echocardiographic confirmation of artery heartbeat and can occur following surgery for congenital
disease. heart disease.
○ Children are followed by sequential ● Ventricular Tachycardia is a fast abnormal heart rate and it
echocardiograms to monitor for starts in the ventricles.
development of aneurysms. ● Atrial Fibrillation is an irregular and often rapid heart rate
● Management: that occurs when the two upper chambers of the heart
○ Acetylsalicylic acid (aspirin) or ibuprofen experience chaotic electrical signals = fast irregular heart
decreases inflammation and blocks platelet rhythm.
aggregation. ● Signs and Symptoms:
○ Abciximab: A platelet receptor inhibitor ○ Some children with an arrhythmia have no
specific for Kawasaki disease. symptoms. When they do, symptoms can include:
○ IV immune globulin (IVIG): To reduce the ■ Fatigue
immune response ■ Rapid Breathing
■ Caution: patients should not ■ Palpitations
receive routine immunizations ■ Dizziness
while taking IVIG or the ■ Fainting
immunization will be ineffective. ○ Diagnosis:
○ Steroids, which may increase aneurysm ■ In addition to a complete medical history
formation, are contraindicated. and physical examination, there are several
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
OVERVIEW AND ASSESSMENT OF DIGESTIVE FUNCTION AND ● During the test, the child will be seated and awake. ENT ● Special consideration before the procedure, the child must
PEDIATRIC VARIATIONS AND NURSING CARE OF THE CHILD WITH A specialists will put the endoscope through the nose, and follow strict eating and drinking rules before the procedure.
GASTROINTESTINAL DISORDER down to the throat or pharynx. Child’s stomach must be empty before a general anesthesia.
Pediatric Variations of the GI Tract ● Child may feel mild discomfort with the scope in place. The ● Once the child is in the hospital for colonoscopy, he or she will
Gastrointestinal System endoscope allows the doctor to see parts of the voice box or take a second dose of bowel prep medication. At this point
● At birth, the resistance of the newborn’s intestinal tract to larynx, pharynx, and trachea on a video screen. the child must walk around and move as much as possible. He
bacterial and viral infection is incompletely developed. That is why ● The doctor will also look at the video screen to see how the or she must also drink plenty of fluid until 3 hours before the
they are very prone to different infections in the GI system. child swallows. They can see if the child is aspirating and the colonoscopy. The child’s bowel is clear once they pass several
● As children grow, they have higher nutritional, metabolic, and doctor can also see how well the saliva is swallowed. watery stools that are clear or yellow.
energy needs. ● They will also be able to see if there are problems in the ● If the bowel prep medication has not cleared the stools, the
● Children with nausea and vomiting dehydrate more quickly than shape or the anatomic changes in the child’s throat. child may need to receive an enema.
do adults with those symptoms. ● The child may swallow small amounts of food or liquid during C. Barium Enema
● The infant’s stomach is small and empties rapidly. the test. These may be dyed, so they can be seen on the ● A type of fluoroscopy procedure that allows us to see images
● Newborns produce little saliva until 3 months of age. screen. of the child’s colon.
● Swallowing is a reflex for the first 3 months. ● At the end of the test, the endoscope will be removed from ● It is done by using an x-ray machine and a contrasting agent
● Hepatic efficiency in the newborn is immature, sometimes causing the throat and nose. that is administered through the rectum.
jaundice. B. Colonoscopy ● In most cases, barium enema is performed to help us
● The infant’s fat absorption is poor because of a decreased pool of ● A procedure that allows visualization of the lower part of the diagnose why a child is having difficulty with bowel
bile acid. child’s digestive system. This includes the rectum and large movements.
intestine (the colon). ● Fluoroscopy procedure is an imaging technique that uses x-ray
Diagnostic and Therapeutic Techniques ● During a colonoscopy, a thin flexible tube with a camera on to create real time or moving images of the body. It helps us
Several typical procedures are used in the diagnosis and GI disorders. the end is inserted through the anus and up into the rectum to see how an organ or bowel system functions.
Common diagnostic procedures include fiberoptic endoscopy, and large intestine. The doctor will look for changes in how ● In most of these types of exams, the child will lie on the table
colonoscopy, barium enema, and fluid, Electrolyte, and Acid-Base the bowel (the inside of the intestine) looks, such as bleeding, while the x-ray machine called a fluoro tower is brought
Imbalance. Children need good preparations for these procedures inflammation, or polyps. They will also collect small samples overhead. The fluoro tower has a curtain in it, it is like being
because they are potentially frightening. Therapy may include of tissue (called biopsies) for testing. in a tent or a small car wash, so the doctor and the child will
alternative methods of feeding such as enteral, nasogastric tube be able to see the images on the television or the monitor in
feeding, or nutritional sources such as TPN (Total Parenteral Nutrition) the room.
and intravenous therapy through… A colostomy may be created to D. Fluid, Electrolyte, and Acid-Base Imbalance
further rest the GI tract. The GI system plays a major role in maintaining fluid, electrolyte,
and acid-base imbalance. It is the main route by which substances
A. Fiberoptic endoscopy are taken into the body and can be a major source of loss in
● A test used to see if a child has dysphagia (difficulty vomiting or diarrhea.
swallowing). When a person has dysphagia, it can lead to
serious problems such as trouble with feeding and breathing. Please keep in mind that retaining fluid is a greater importance in
Sometimes, it can lead to respiratory infections such as the body chemistry of infants and children than adults. This is
bronchiolitis or pneumonia. because fluid constitutes a greater fraction of the infants total
● During the test, a thin, flexible tool called an endoscope is put weight.
into the nose and down the back of the throat. Parts of the ● Fluid Balance
throat are viewed as the child swallows. ● Fluid Imbalance
● Isotonic Dehydration
● Hypertonic Dehydration
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
● Hypotonic Dehydration in the lungs which is an acid, the lungs will breathe a lot more of 12). Going back to the laboratory, the patient will become
● Overhydration rapidly or hyperventilate to expel this CO2. So lungs can, hopefully, alkalotic, pH is greater than 7.45 and bicarbonate will be
● Acid-Base Imbalance excrete that blood pH back to normal and increase the greater than 26. There will also be signs and symptoms of
● Metabolic Acidosis bicarbonate level. Therefore, there will be Kussmaul breathing or hypokalemia (reverse nga action sa acidosis; there will be
● Metabolic Alkalosis respiration, this is deep rapid breaths (compensatory shifting of ions intracellularly). Symptoms like tremors, muscle
hyperventilation). Hyperkalemia can also happen when the body cramps, tingling of fingers and toes, there will be cardiac
Acid- Base Imbalance detects acidosis, the potassium moves from cells intracellular to arrhythmias or dysrhythmias, the patient will become
extracellular fluid in the blood plasma in exchange for those lethargic or restless, confusion, decrease level of
hydrogen ions. There will be muscle twitching, decreased muscle consciousness, irritability and nausea and vomiting can occur.
tone, decreased reflexes, warm flushed skin, headache, decreased
blood pressure, nausea, and vomiting. Common GI Symptoms of Illness in Children
● Nursing Responsibilities for Metabolic Acidosis: A. Vomiting
○ Watch out for signs of respiratory distress because of ● Vomiting results from sudden contractions of diaphragm and
increased respiration, probably the patient will need assistive muscles of the stomach.
or mechanical ventilation. ● Many children with vomiting are suffering from a mild
○ Watch out for laboratory values, especially the potassium, gastroenteritis (infection) caused by viral or bacterial
BUN, creatinine which are signs for kidney failure. organisms.
○ Strict input and output (how much a patient drinks or pilay ● Persistent vomiting requires investigation because it results in
napagawas nga fluids, we have to take note of that). dehydration and electrolyte imbalance specifically metabolic
○ Some patients will undergo dialysis especially those nga nay alkalosis.
DKA, wherein and excess nga acids kay ipagawas na siya ○ Continuous loss of hydrochloric acid and sodium chloride
● These imbalances (metabolic acidosis and metabolic alkalosis) through dialysis. from the stomach can cause alkalosis. These are hydrogen
occur with severe diarrhea and vomiting. ○ Metabolic Alkalosis occurs when the blood becomes overly ions that are very abundant in the GI tract so with
● Recall in arterial blood gas interpretation wherein we can get alkaline wherein there is an increase in bicarbonate in the vomiting, il ana ipagawas, increase loss of those, there will
metabolic acidosis when there is a decrease in pH below 35 and a blood. This condition occurs when the body has experienced be an increase in bicarbonate causing alkalotic state of the
decrease of bicarbonate below 22. Remember, when there is too excessive loss of hydrogen ions of acids, which in turn body.
much acid in the body, the bicarbonate as a metabolic buffer increases all the bicarbonate in the body in cases with the use ○ Can result in death if left untreated.
system will drop. Causes of this condition develop when there is of diuretics wherein a patient starts urinating a lot and they ● Multiple causes of vomiting
too much acid produced in the body. It happens in diabetic are wasting all those hydrogen ions like chloride. Another ○ Improper feeding technique
ketoacidosis wherein substances called ketone bodies which are cause of loss of fluids, in conditions like vomiting and ○ Systemic illness such as increased intracranial pressure or
very acidic builds up in the body during uncontrolled diabetes. nasogastric suctioning, the fluids gikan ani are very rich in infection (swell of the tissues in the brain)
● Metabolic acidosis can also occur when the kidneys cannot hydrogen ions, when there is a decrease in hydrogen ions, the ○ Child at risk for aspiration pneumonia
remove enough acid from the body such as renal failure. Inability bicarbonate will increase. Another cause, it occurs when the ● In describing the symptoms of vomiting, be certain to
of the kidney to excrete those waste (specifically the acid). body has too many alkaline producing bicarbonate ions, in differentiate the various terms that are used. It is important
Another cause, it can happen also when there is loss of too much cases like sodium bicarbonate administration. Physicians that vomiting is described correctly because different
bicarbonate in the body (it happens in severe diarrhea). In order this to correct acidosis, however if super kadaghan ang conditions are marked by different forms of vomiting and
diarrhea, those fluids have a lot of bicarbonate in them and losing mahatag sa body then it will cause the body to be alkalotic. correct description of the child’s action can aid greatly in the
that in diarrhea kay like those alkaline fluids kay ma loss na siya sa ○ The body will compensate, starting with the lungs, the body child’s diagnosis.
body leaving the body in acidotic condition. will hypoventilate, because the lungs think that keeping these ● Nursing Management:
● For the signs and symptoms, let us go back to the laboratory carbon dioxide which is an acid will help balance the alkalotic ○ Withhold feeding (NPO may it be fluid or food). Take note
values. Whenever you have a metabolic acidosis, the respiratory state. So, it slows down the ventilation or what we call that other parents feed the baby dayun after vomiting
system tries to compensate. When there is a lot of carbon dioxide compensatory hypoventilation (decrease of respiratory rate because they do not want nga ma dehydrate. But this only
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
prolongs the vomiting and intensifies electrolyte ○ Episodes: 2 to 10 loose, watery bowel movements diarrhea dili na mudritso og give ang doctor og
imbalance, mag alkalosis na nuon si baby. It can also tire per day antibiotic, because and cause could be viral.
the baby. ○ Dry mucous membrane 2. Severe Diarrhea
○ Place the infant on their side after feeding to prevent ○ Warm skin, no change in skin turgor ● Signs and Symptoms:
aspiration, if vomiting occurs (let them also burp after ○ Rapid pulse ○ Fever of 39.5 to 40℃ (103 to 104℉)
feeding). ○ Urine output normal ○ Pulse and respirations are weak and rapid
○ When an older child vomits, turn head to one side and ● Management: ○ Cool, pale skin
offer an emesis basin. ○ Can be managed at home ○ Lethargic and listless
○ IV fluids may be ordered to replenish lost fluids. ○ Resting the GI tract ○ Depressed fontanelles
○ Slowly introduce foods to allow the stomach to rest. ○ After an hour, start giving an oral rehydration ○ Sunken eyes
● Documentation: solution or Pedialyte. ○ Poor skin turgor
○ Time, amount, color, consistency, force (projectile or not), ○ Antipyretic ○ BM of every few minutes
frequency, and whether vomiting was preceded by nausea ○ Zinc supplement ○ Stool in liquid green, may have mucus or blood
and feedings (especially the infants, kay pwede na sila ○ Probiotics ○ Concentrated and scanty urine output
musuka kay busog pa ang baby). ● Assessment: ○ Weight loss of 5-15% of body weight
○ Administration of antiemetic agents should also be ○ If diarrhea is mild, fever of 101 to 102℉ (38.4 to ● Management:
documented, including time given and if when vomiting 39.0℃) may be present. Children are usually ○ IV rehydration therapy of normal saline
subsided (withhold feeding for 2 hours; if 2 to 3 or more anorectic and irritable and appear unwell. ○ 125 ml/kg of body weight to replace fluid
hours na siya since last nisuka then we can resume ○ The mucous membrane of the mouth appears dry ○ Rapid administration for 3-6 hours
feeding). and the skin feels warm although skin turgor will noy ○ Resting the GI tract
B. Diarrhea yet be decreased. The pulse will be rapid and out of ○ Identifying causative agents through stool culture
● Diarrhea in infants is a sudden increase in stools from the proportion to the low-grade fever. Urine output is ○ ORS
infant’s normal pattern, with a fluid consistency and a color usually normal. ○ Antipyretic
that is green or contains mucus or blood. ● Therapeutic Management: ● Assessment:
● Normal frequency of stool is 1 to 3 times a day. ○ Diarrhea is not yet serious, and children can be cared ○ Severe diarrhea may result from progressive mild
● Diarrheal stool can be unlimited frequency. for at home. As with vomiting, treatment for diarrhea diarrhea, or it may begin in severe form. Infants with
● Normal color of stool is yellowish. must involve resting of the GI tract, but this is severe diarrhea are obviously ill. Rectal temperature
● Indicative of other conditions: green, mucus, blood. necessary for only a short time. At the end of is often as high as 103 to 104℉ (39.5 to 40℃). Both
○ Acute sudden diarrhea is most often caused by approximately 1 hour, parents can begin to offer an pulse and respirations are weak and rapid. The skin is
inflammation, infection, or a response to medications, oral rehydration solution such as Pedialyte in small pale and cool. Infants may appear apprehensive,
food or poisoning. amounts on a regimen similar to that for vomiting. listless, and lethargic. They have obvious signs of
○ Chronic diarrhea lasts more than 2 weeks and may ○ For breastfed infants, breastfeeding should continue. dehydration such as depressed fontanelle, sunken
indicate malabsorption problem, long-term inflammatory Again, it may be difficult for parents to restrict fluid eyes, and poor skin turgor. The episodes of diarrhea
diseases, or allergic responses. for a short time if they think they should overfeed usually consist of bowel movement every few
○ Infectious diarrhea caused by viral, bacterial, or parasitic children to make up for the fluid loss. Children also minutes. The stool is liquid green, perhaps mixed
infection usually involves gastroenteritis. need measures to reduce the elevated temperature. with mucus and blood, and it may be passed with
1. Mild Diarrhea In developing countries, where children may be zinc explosive force. Urine output will be scanty and
● Signs and Symptoms: deficient, zinc may be administered. Probiotics concentrated.
○ Fever of 38.4 to 39℃ (101 to 102℉) (dietary supplements containing potentially ○ Mild dehydration occurs with a loss of 2.5 to 5% of
○ Anorexia beneficial bacteria or yeasts) to change bacterial body weight.
○ Irritability flora of the intestine may be administered. For mild

Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
○ In contrast, severe diarrhea quickly causes a 5 to 15% C. Bacterial Infectious Diseases that Cause Diarrhea and Vomiting in ● Causative Agent: Organism of the genus Shigella
loss. Any infant who has lost 10% or more of body Children ● Period of Communicability: 1 to 4 weeks
weight requires immediate treatment. 1. Salmonella ● Mode of Transmission: Contaminated food, water, or milk
● Therapeutic Management: ● Causative Agent: Salmonella bacteria products
○ Treatment focuses on regulating electrolyte and fluid ● Period of Communicability: As long as organisms are being ● Confirmatory Test: Stool culture
balance by oral or IV rehydration therapy, initiating excreted (may be as long as 3 months) ● Signs and Symptoms: Severe diarrhea with blood and
rest for the GI tract, and discovering the organism ● Mode of Transmission: ingestion of contaminated food, mucus
responsible for diarrhea. especially chicken and raw eggs ● Incubation Period: 1 to 7 days
○ All children with severe diarrhea or diarrhea that ● Confirmatory Test: Stool culture ● Treatment:
persists longer than 24 hours should have a stool ● Signs and Symptoms: ○ Intense fluid and electrolyte replacement
culture taken so definite antibiotic therapy can b e ○ Diarrhea ○ Cephalosporin
prescribed. Stool cultures may be taken from the ○ Abdominal pain ○ Shigella organisms, like the Salmonella group, cause
rectum or stool culture in a diaper or a bedpan. ○ Vomiting extremely severe diarrhea that contains blood and
○ If a child can drink, the most effective way to replace ○ High fever mucus. As the organism becomes more resistant,
fluid is by offering oral rehydration therapy or ○ Headache ampicillin or trimethoprim-sulfamethoxazole, typical
Pedialyte (ORS – Oral Rehydration Solution). For a ● Treatment: drugs used for therapy in the past, are being replaced
child who will not drink, an IV solution such as ○ Fluid and electrolyte replacement by cephalosporins. The child needs intense fluid and
normal saline or 5% glucose in normal saline is ○ Ampicillin for systemic infection like high grade fever electrolyte replacement. Shigella infection can be
begun. The solution will provide replacement of or a 3rd generation of cephalosporin to be given prevented by safe food handling and cautioning
fluid, sodium and calories. Although infants usually ● Incubation Period: 6 to 72 hours for intraluminal type; 7 to families to drink only from the safe water sources.
have potassium depletion, potassium cannot be 14 days for extraluminal type 3. Staphylococcal Food Poisoning
given until established that they are not in renal ● Salmonella is the most common type of food poisoning in ● Causative Agent: Staphylococcus aureus
failure. Giving IV potassium when the body has no the United States and a major cause of diarrhea in ● Period of Communicability: Carriers may contaminate food
outlet for excessive potassium can lead to excessively children. The diagnosis of the infection can be made from as long as they harbour the organism.
high potassium levels and heart block. Be sure that stool culture. Children develop diarrhea, abdominal pain, ● Mode of Transmission: Ingestion of contaminate food such
the infant has voided. This is proof that kidneys are vomiting, high temperature, and headache. They are as poultry, creamed foods (e.g., potato salad), and
functioning. listless and drowsy. The diarrhea is severe and may contain inadequate cooking
○ Fluid must be given to replace the deficit that has blood and mucus. Salmonella infection may remain in the ● Confirmatory Test: Stool culture
occurred, for maintenance therapy, and to replace bowel as intraluminal disease. When it does, it is treated ● Signs and Symptoms:
the continuing loss until diarrhea improves. like severe diarrhea, with fluid and electrolyte ○ Severe vomiting and diarrhea
○ If infants have lost less than 5% of total body weight, replacement. Antibiotics are rarely prescribed as they may ○ Abdominal cramping
their fluid deficit is approximately 50 mL/kg of body actually prolong the length of the infection. If the infection ○ Excessive salivation and nausea within 2-6 hours of
weight. becomes systemic (extraluminal disease), it is treated with eating
○ If infants have lost 10% of body weight, they need the addition of antibiotics such as ampicillin or a third ● Treatment:
approximately 100 mL/kg of body weight to replace generation cephalosporin. ○ Intense fluid and electrolyte replacement
their fluid deficit. ● Complications such as meningitis, bronchitis, and ○ Cefotaxime
○ If the weight loss suggests a 12 to 15% loss of body osteomyelitis may occur. Because the source of Salmonella ○ The child needs intensive supportive therapy with
fluids, they require 125 mL/kg of body weight to generally iz infected food (contaminated chicken and eggs fluid and electrolyte replacement, and perhaps
replace the fluid lost. This fluid will be given rapidly are common sources), caution parents to wash utensils administration of Cefotaxime. Food poisoning from
in the first 3 to 6 hours, then it will be slowed to a used to prepare raw chicken such as cutting boards well the source could be prevented by proper
maintenance rate. and to cook eggs thoroughly. refrigeration of the foods.
○ Antipyretic can also be given to px with high fever. 2. Shigellosis (Dysentery)
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
 UNIT 11 (Week 13)
Disorders of the Mouth and Esophagus ○ Frenuloplasty
A. Ankyloglossia (Tongue-Tie) ■ More expensive and is done for if additional repair is
needed or lingual frenulum is too thick.
■ Done under general anesthesia with surgical tools
■ Surgical alteration of a frenulum when its presence
restricts range of motion between interconnected
tissues.
■ Possible Complications: Bleeding; Infection; Damage
to the tongue or salivary glands; Scarring is possible
due to the more intensive nature of the procedure as
a reaction to the anesthesia.
■ After the procedure, tongue exercises are ● Signs and Symptoms:
recommended to enhance tongue movement and ○ A small, soft, round lump in the center front of the neck
● It is a condition present at birth in which it restricts the reduce potential for tongue scarring. ○ Tenderness, redness, and swelling of the lump, if infected
tongue’s range of motion. B. Thyroglossal Cyst ○ Difficulty swallowing or breathing
● With tongue-tie, an unusually short, thick or tight band of ● It is a congenital disorder where the thyroglossal duct, which ● Management:
tissue (lingual frenulum) tethers or is tied to the bottom of the is a tiny canal connecting the thyroid gland with the tongue ○ Antibiotic – If there is an inflammation or infection
tongue's tip to the floor of the mouth, so it may interfere with during fetal development, grows in size and fills up with ○ Incision and drainage – Cutting into or draining of the cyst
breast-feeding. mucus, which forms a cyst. It is a pocket in the front part of especially if the antibiotic medicine does not get rid of
● Someone who has tongue-tie might have difficulty sticking out the neck that is filled with fluid. the infection.
his or her tongue. ● It is formed from leftover tissue from the development of the ○ Cutting out the cyst and some nearby tissue (surgical
● Tongue-tie can also affect the way a child eats, speaks and thyroid gland with an embryo forming. The thyroid gland is excision)
swallows. located in front of the neck.
● Signs and Symptoms: ● although the cyst is present at birth, it is usually not found
○ Difficulty lifting the tongue to the upper teeth or moving until a child is at least age 2. Often, a healthcare provider finds
the tongue from side to side a thyroglossal cyst when a child gets an upper respiratory
○ Trouble sticking out the tongue past the lower front teeth infection. What causes this condition, it forms during the early
○ A tongue that appears notched or heart shaped when stages of the development of an embryo. It begins at the base
stuck out of the tongue and moves down the neck through a channel or
● Management: tube called the thyroglossal duct. This duct normally goes
○ Tongue-tie’s management is controversial because some away once the thyroid reaches its final position in the neck.
doctors and lactation consultants recommend correcting it Sometimes part of the duct remains, this leaves a pocket C. Cleft Lip and Palate
right away even before the newborn is discharged from called a cyst. ● Openings or splits in the upper lip, the roof of the mouth
the hospital. Other is to wait because the lingual frenulum (palate) or both.
may loosen overtime in solving the condition ● Cleft lip and cleft palate result when facial structures that are
○ Frenotomy developing in an unborn baby do not close completely. These
■ A simple surgical procedure that can be done without are among the most common birth defects. They most
anesthesia commonly occur as isolated birth defects but also associated
■ Uses sterile scissors to snip the frenulum free with many inherited genetic conditions or syndromes.
■ After procedure the baby can breastfeed immediately ● Causes:
■ Possible Complications: Bleeding, Infection, damage
the tongue or salivary glands
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
● When tissue in the baby’s face and mouth do not fuse ● Types of Surgeries: happens, liquid gets into your baby’s lungs. This can cause
properly. Normally, the tissues that make up the lip and palate ○ Cleft lip repair – Within the first 3 to 6 months of age. It pneumonia and other problems.
fused together in the 2nd and 3rd months of pregnancy. In closes the separation. The surgeon makes an incision of ● It is caused by a failure of the tissues of the GI tract to separate
baby’s with this condition, fusion never occurs, only part way both sides of the cleft and creates flaps of tissue and properly in prenatal life.
leaving an opening also known as cleft. these flaps are stitched together including the lip ● TE fistula often happens with another birth defect called
● Researchers believe that most cases of this condition is muscles. The repair should create a more normal esophageal atresia which means that the baby’s esophagus
caused by an interaction of genetic and environmental appearance, structure and function. Initial nasal repair if does not develop properly during pregnancy. It forms in two
factors. In many babies, a definite cause is not discovered yet. needed is usually done at the same time. parts instead of one. One part connects to the throat and the
○ Cleft palate repair – By the age of 12 months, or earlier if other part connects to the stomach but the two parts do not
possible. Various procedures may be used to close the connect to each other since the esophagus is in two parts,
separation and rebuild the roof of the mouth. Depending liquid that the baby swallows does not pass as it should
on the child’s situation, the surgeon makes an incision on through the esophagus and reach the stomach. This means
both sides of the cleft and repositions the tissue and that the baby cannot digest milk and other fluids.
muscles. Then the repair is stitched and closed.
○ Follow-up surgeries – For surgery to reconstruct
appearance, additional surgeries may be needed to
improve appearance of the mouth, lip and nose. Usually
follow-up surgeries are done between age 2 and late teen
years. To improve speech and improve the appearance of
the nose and lip. ● Three Common Types of TEF:
1. (A) The upper esophagus ending in a blind pouch and the
lower esophagus ending in the trachea.
● Most cases of this condition are noticed right away at birth 2. (B) The upper esophagus and the lower esophagus ending
and do not require a special test for diagnosis. Increasingly, in a blind pouch (fetal swallowing is prevented, and the
cleft lip and cleft palate are seen in the ultrasound before the mother will develop polyhydramnios during pregnancy).
baby is born specifically congenital anomalies. 3. (C) Both the upper and lower esophagus end in the
● Usually a split in the lip or palate is immediately identifiable. trachea. In TEF, the newborn will have excessive mucous
● Signs and Symptoms: secretions (drooling) and may choke or vomit if fed.
D. Tracheoesophageal Atresia and Fistula
○ A split in the lip and roof of the mouth (palate) that
● Fistula – Abnormal connection
affects one or both sides of the face.
● Atresia – Abnormal development
○ A split in the lip that appears as only a small notch in the
● This condition happens because of a connection between the
lip or extends from the lip through the upper gum and
esophagus and the trachea. Esophagus is a tube that connects
palates into the bottom of the nose.
the throat to the stomach. Trachea is the tube that connects
○ A split in the roof of the mouth that does not affect the
the throat to the windpipe and the lungs.
appearance of the face.
● Normally, esophagus and trachea are 2 tubes that are not
● Management: This is a permanent repair. The goals of this
connected. This problem is also called TE fistula or TEF. It can
treatment are to improve the child’s ability to eat, speak and
happen in one or more places.
hear normally and achieve normal facial appearance.
● TE fistula is a birth defect. This means it is a problem that the
● Treatment:
baby is born with. It happens when the baby is still forming
○ Surgery – To repair the defect; To correct cleft lip and
during pregnancy.
palate is base on the child’s particular situation
● When a baby with TE fistula swallows, liquid can pass through ● Signs and Symptoms:
○ Therapies – To improve any related conditions ○ Frothy, white bubbles in the mouth
the connection between the esophagus and trachea. When this
Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
 UNIT 11 (Week 13)
○ Coughing or choking when feeding ○ Esophagomyotomy – Uses a large or small incision to
○ Vomiting access the sphincter and carefully alter it to allow better
○ Blue color of the skin, especially when the baby is feeding flow into the stomach. However, some people have
○ Trouble breathing problems afterward gastroesophageal reflux disease. If you
○ Very round, full stomach have GERD, the stomach acid backs up into the esophagus
● Nursing Management: and can cause heartburn.
○ Prevent pneumonia, choking and apnea in the newborn ○ Nitrates or calcium channel blockers – To relax the
○ Assessment of the newborn during the first feeding for sphincter
signs and symptoms of TEF is essential B. Pyloric Stenosis
○ Feeding, usually, is with clear water or colostrum to ● Obstruction of the lower end of the stomach caused by the
minimize seriousness of aspiration. overgrowth of the circular muscles of the pylorus or spasms of
○ Surgical repair is essential for survival. This surgery is the sphincter. If hypertrophy or hyperplasia of the muscles
almost done soon after birth. Both defects can often be surrounding the sphincter occurs, it is difficult for the stomach
repaired at the same time. The surgery may take place to empty.
when general anesthesia is given and the patient then a ● Commonly classified as a congenital anomaly
surgeon will make a cut between the ribs. The fistula ● No cure for achalasia. Once esophagus is paralyzed, the muscle ● Symptoms usually do not appear until the infant is 2 or 3 weeks
between the esophagus and windpipe where the trachea cannot work properly again but symptoms can usually be old.
is closed. The upper and lower portion of the esophagus managed with endoscopy, minimally invasive therapy or ● Most common surgical condition of GI tract in infancy.
are sewn together if possible surgery.
● The exact cause for this condition is poorly understood.
Researchers suspect it may be caused by a loss of nerve cells in
Disorders of the Stomach and Duodenum
the esophagus. Rarely, achalasia may be caused by genetic
A. Achalasia
disorder or infection.
● Rare disorder that makes it difficult for food and liquid to pass
● Signs and Symptoms:
from the esophagus down to the stomach.
○ Dysphagia (inability to swallow) – Which may feel like the
● This occurs when nerves in the esophagus become damaged.
food or drink is stuck in the throat
As a result, the esophagus becomes para;yzed and dilated over
○ Regurgitating food or saliva – Due to reflux
time and eventually loses the ability to squeeze food down into
○ Heartburn
the stomach.
○ Pneumonia (from aspiration of food into the lungs)
● Food then collects in the esophagus, sometimes, fermenting
○ Weight loss
and washing back up into the mouth which can taste bitter.
○ Vomiting
Some people mistake this for gastroesophageal reflux disease
● Management:
or GERD. However in achalasia, the food is coming from the
○ It focuses on relaxing or stretching upon the lower
esophagus whereas in GERD, the materials come from the ● Signs and Symptoms:
esophageal sphincter so that food and liquid can move
stomach. ○ With this condition, at 4 to 6 weeks of age, infants begin to
through easily into the digestive tract.
vomit almost immediately after each feeding. The
○ First line of therapy: Doctors can either dilate the sphincter
vomiting grows increasingly forceful until its projectile.
or alter it.
Possibly projecting as much as 3 to 4 feet. The vomitus
○ Pneumatic dilation – Inserting a balloon into your
contains mucus and ingested milk. Vomitus smells sour
esophagus and inflating it. This stretches out the sphincter
because it has reached the stomach and has been in
and helps the esophagus function better. However,
contact with stomach enzymes. However, there is never
sometimes, dilation tears the sphincter. If this happens,
bile in vomiting pyloric stenosis because the feeding has
there’s a need for additional surgery to repair it.

Aquino, Bacon, Gonzaga, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 11 (Week 13)
not reached the duodenum to become mixed with the ● Burped before and during feedings to remove any the surrounding muscles such as coughing, vomiting, straining
bile. gas accumulated in the stomach. during a bowel movement, exercising or lifting heavy objects.
○ Projectile vomiting is outstanding symptom from force or ● Place on the right side (preferably Fowler’s ● Signs and Symptoms:
pressure being exerted on the pylorus position) after feeding to facilitate stomach ○ Heartburn – Because of the acid reflux
■ Vomitus contains mucus and ingested milk. drainage into the intestines. If an infant vomits, ○ Regurgitation of food or liquids into the mouth
■ Infant is constantly hungry and will eat again the nurse is instructed to refer to the infant. ○ Backflow of stomach acid into the esophagus (acid reflux)
immediately after vomiting. ■ Postoperative Nursing Care ○ Difficulty swallowing
○ Dehydration – From vomiting when they are first seen. ● Monitor IV fluids, provide feedings as prescribed ○ Chest or abdominal pain
S&S includes lack of tears, dry mucous membrane of the by the surgeon, document intake and output, ○ Feeling full soon after eating
mouth, sunken fontanelles, fever, decreased urine output, monitor surgical site. (For surgical correction, the ○ Shortness of breath – It can occur by the compression of
poor skin turgor and weight loss. muscle of the pylorus is split down to the mucosa the ling space by the stomach.
○ Olive-shaped mass may be felt in the upper right quadrant allowing for larger lumen. Although the ○ Vomiting of blood or passing of black stools, which may
of the abdomen. Definitive diagnosis is made by watching procedure sounds simple, it is technically difficult indicate gastrointestinal bleeding.
the infant drink and palpate the right upper quadrant of to perform and there is a high risk for infection ○ Pain usually accompanies the vomiting
the abdomen of pyloric mass prior to drinking. If one is afterwards because the abdominal incision is near ● Diagnostic Tests:
present, it feels round and firm and approx. the size of the diaper area. Prognosis for infants with PS is ○ History
olive. As the infant drinks, observe for gastric peristaltic excellent if the condition is discovered before the ○ UTZ
waves passing from left to right across the abdomen. The electrolyte imbalance occurs. ○ Barium swallow
olive-sized lump becomes more prominent. The infant C. Hiatal Hernia ● Management:
vomits with projectile emesis. ● The intermittent protrusion of the stomach up through the ○ Keeping the baby in an upright position prevents the
esophageal opening in the diaphragm. condition from recurring.
● The volume of the stomach is suddenly restricted, leading to ○ Antacids that neutralize stomach acid – Medications can
periodic vomiting. Normally, a portion of the esophagus and all be given especially those that reduce acid secretions.
the stomach are situated on the abdominal cavity. However, in ○ H-2-receptor blockers – These are medications that reduce
this condition, part of the stomach moves up into the chest acid production. Examples include:
cavity through the weakened area of the diaphragm. ■ Cimetidine (Tagamet HB)
■ Famotidine (Pepcid AC)
■ Nizatidine (Acid AR)
○ Proton pump inhibitors – Medications that block acid
production and heal the esophagus, these are stronger
acid blockers then H-2 receptor blockers and allows time
for damaged esophageal tissue to heal. This includes:
■ Lansoprazole (Prevacid)
■ Omeprazole (Prilosec)
● Management: ○ Laparoscopic surgery – If the condition has not corrected
○ Surgery: Pyloromyotomy (It is performed before itself by the time the infant is 6 months old even with
electrolyte imbalance from the vomiting or hypoglycemia maintaining an upright position most of the day,
from the lack of food occurs. ● This occurs when weakened muscle tissue allows the stomach laparoscopic surgery may be performed. To reduce the
■ Preoperative Nursing Care to bulge up to the diaphragm. It’s not always clear when this stomach's ability to protrude into the diaphragm. What
● IV fluids to treat or prevent dehydration happens but a hiatal hernia might be caused by age-related happens in the surgery, it involves pulling the stomach
● Thickened feedings may be given by a teaspoon changes in the diaphragm, injury to the area, being born with down into the abdomen and making the opening in the
or through a nipple with a large hole. an unusually large hiatus, persistent and intense pressure in
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 UNIT 11 (Week 13)
diaphragm smaller or reconstructing the esophageal ○ Loss of consciousness in severe cases the portal vein and often stops bleeding from
sphincter. ○ Signs of liver disease, including: esophageal varices.
○ Some cases of hiatal hernia, surgery is combined with ■ Yellow coloration of your skin and eyes (jaundice) ■ Balloon Tamponade – Applying pressure at the
weight loss surgery such as sleeve gastrectomy but it is not ■ Easy bleeding or bruising esophageal varices, one way to stop bleeding is by
usually applicable in pediatric clients. ■ Fluid buildup in your abdomen (ascites) inflating a balloon to put pressure in the varices for up
D. Esophageal Varices ● Management: to 24 hours.
● These are abnormal, enlarged veins in the esophagus. ○ Primary aim in treating esophageal varices is to prevent ■ Restoring blood volume – The patient might be given
● These develop when normal blood flow to the liver is blocked bleeding. a transfusion to replace the lost blood and a clotting
by a clot or scar tissue in the liver. To go around the blockages, ○ Bleeding esophageal varices is life threatening so if it factor to stop bleeding.
blood flows into smaller blood vessels that aren’t designed to occurs treatments are available to try to prevent bleeding. ■ Preventing infection – There is an increased risk of
carry large volumes of blood. The vessels can leak blood or ● Treatment: infection with bleeding, patients might be given
even rupture, causing life-threatening bleeding. ○ Lowering the blood pressure in the portal vein, also may antibiotics to prevent infection.
reduce the risk of bleeding the esophageal varices, E. Hepatic Disorders
medications to reduce pressure in the portal vein is given. Hepatitis is an inflammation and an infection of the liver that is
Type of blood pressure called a beta blocker may help caused by the invasion of hepatitis A, B, C, D, E viruses.
reduce blood pressure in the portal vein. Decreasing the ● Hepatitis A
likelihood of bleeding these medications include ○ Mode of Transmission: Fecal-oral route
propranolol and nadolol. ○ In children ingestion of fecally contaminated water or
○ Endoscopic Band Ligation – Using elastic bands to tie off shellfish, it can spread from the contaminated changing
bleeding veins. If the esophageal varices appear to have a tables.
high risk of bleeding and also if the patient had episodes ○ Symptoms:
● This forms when blood flow to your liver is blocked, most often of bleeding before, the doctor might recommend a ■ Loss of appetite
by scar tissue in the liver caused by a liver disease. The blood procedure called endoscopic band ligation. Using an ■ Diarrhea
flow begins to back up increasing pressure within the large vein endoscope the doctor uses suction to pull the varices into ■ Fever
or specifically the portal vein that carries blood to the liver. This a chamber at the end of the scope and wraps them with ■ Nausea (sickness)
increased pressure portal pressure forces the blood to seek an elastic band which essentially strangles the veins so ■ Malaise (general discomfort)
other pathways through smaller veins such as those in the they can’t bleed. ■ Jaundice (yellow skin)
lowest part of the esophagus. These thin-walled veins balloons ○ Treatment During Bleeding: ■ An acute infection, these symptoms will last for
with the added blood and sometimes the veins ruptures and ■ An immediate treatment is essential to reverse the approximately a week and symptoms fade with full
bleed. bleeding recovery.
● Common causes of varices include severe liver scarring or ■ Octreotide (Sandostatin) and vasopressin (Vasostrict) ● Hepatitis B
cirrhosis in those patients with hepatitis infection. Also, a blood – Medications to slow blood flow into the portal vein ○ Unlike with hepatitis B, the symptoms of hepatitis B
clot can be a cause, specifically blood clot in the portal vein or can be given. This drug is usually continued for up to 5 especially the acute one are more marked, children can
a vein that feeds into the splenic vein or that can cause days after a bleeding episode. have generalized aching or right upper quadrant pain
esophageal varices. Also, a parasitic infection can be one of the ■ Diverting blood away from the portal vein is essential where liver is located and headache, they may also have
causes, specifically the schistosomiasis. if medication or endoscopy treatment do not stop low grade fever. Also, there will be jaundice for hepatitis B
● Signs and Symptoms: bleeding the doctor might recommend a procedure with acute onset.
○ Usually esophageal varices do not cause any symptoms called Transjugular Intrahepatic Portosystemic Shunt ○ Mode of Transmission:
unless they bleed (TIPS) – This shunt is an opening created between the ■ Sexual contact
○ Vomiting large amounts of blood portal vein and the hepatic vein, which carries blood ■ Contaminated needles
○ Black,tarry or bloody stools from the liver to heart. The shunt reduces pressure in ■ Also spread via infected tear/saliva
○ Lightheadedness
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UNIT 11 (Week 13)
■ Transfusion of contaminated blood and plasma, or ○ No matter which virus is involved, hepatitis is a generalized recover completely but 10% will develop chronic
semen, inoculation by contaminated syringe or needle body infection with specific intense liver effects. hepatitis and become hepatitis carriers. Hep. B is
through IV drug use ○ Type A occurs in children of all ages and accounts for always potentially serious because newborns
■ May be spread to fetus, if mother has infection in the approximately 30% of… di masabtan contract the disease at birth and have an increased
third trimester of pregnancy ○ Hepatitis B tends to occur in newborns from placental-fetal risk for liver carcinoma later in life.
○ It could possibly lead to cirrhosis of the liver and liver transfer. In adolescence, after intimate contact or the use
cancer of contaminated syringe or drug injections. Intestinal Disorders
○ Vaccines are already available for prevention ○ Management: A. Diaphragmatic Hernia
○ Although hep. A and hep.B are the viruses that most ○ Since it is a virus it is self limiting which means it ● A diaphragmatic hernia occurs when one or more of the
frequently cause hepatitis, hep. C, D, and E may also be does not have a definite cure abdominal organs move upward into the chest through a
involved. ○ Vaccines – Healthcare providers should receive defect (opening) in the diaphragm.
● Hepatitis C prophylaxis against hepatitis with the hepatitis ● This kind of defect can be present at birth or acquired later in
○ A single stranded RNA virus vaccines. life.
○ Mode of transmission: ○ Infants should also receive routine immunization ● Congenital diaphragmatic hernia can be diagnosed through
■ Blood-to-blood transmission against hepatitis B. fetal ultrasound.
■ IV drug use ○ All women should be screened during pregnancy for
■ Sexual contact hepatitis surface antigen (HbsAg).
○ The virus produces mild symptoms of disease but there is ○ Infants born to hepatitis positive mothers should
a higher incidence of chronic infection with the virus. receive both Hepatitis B immune globulin (HBIG)
Usually asymptomatic but if there are symptoms it will be and active immunization at birth to prevent them
flu-like symptoms. from contracting the disease.
● Hepatitis D ○ Hepatitis A vaccine is available for healthcare
○ Similar to hepatitis B in mode of transmission providers and included in routine immunization
○ Although it apparently requires a coexisting hepatitis B programs for infants beginning 1 year of age.
infection to be activated ○ Strict hand washing and infection control
○ Disease symptoms are mild but there is a high incidence of precautions are mandatory when caring with
fulminant hepatitis after the first infection children with hepatitis. Feces must be disposed
○ Resides inside hepatitis B so there is also greater risk of carefully because the type A virus can be cultured
liver failure and progression to liver cirrhosis from feces. Syringes and needles must be disposed of
● Hepatitis E with caution because the type B virus can be
○ Mode of Transmission: Fecal-oral route transmitted by blood. Contact should receive
○ Disease symptoms from the E virus are usually mild except immune globulin for hep.A and hep. B immune ● Signs and Symptoms:
in pregnant women. Pregnant women tend to have severe globulin as appropriate ○ Difficulty breathing
symptoms. ○ For hepatitis A – Increased rest and maintains a good ○ Tachypnea
○ 2 to 8 weeks duration calorie intake. A low fat diet is prescribed once it's ○ Cyanosis
○ Signs and Symptoms: recommended, it is not required and in any event it ○ Tachycardia
■ Jaundice is difficult to enforce especially in children. Children ○ Diminished or absent breath sounds
■ Nausea are generally hungrier at breakfast than later in the ○ Bowel sounds in the chest area Less full abdomen
■ Fatigue day, encouraging them to eat a healthy breakfast. ● Management:
○ Chronic Stage: Weak immune system especially in ○ For Hepatitis B – Lamivudine is an antiviral agent, ○ Surgery
pregnant women that’s why they are at greater risk for which may be effective in reducing viral replication ■ With a CDH, surgeons may perform surgery as early
fulminant liver failure and cirrhosis. with hep. B infection. Of those with type B, 90% will as 48 to 72 hours after the baby is delivered.
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 UNIT 11 (Week 13)
■ The first step is to stabilize the baby and increase its diseases), or bowel tumors. The point of the invagination is ■ Is the child ill in any other way? Yes. Vomits; refuses
oxygen levels. generally at the juncture of the distal ileum and proximal colon. food; states stomach feels “full.”
■ With an ADH, the patient typically needs to be ● Signs and Symptoms: ○ The presence of the intussusception is confirmed by
stabilized before surgery. Because most cases of ADH ○ Onset is usually sudden ultrasound or a CT scan
are due to injury, there might be other complications ■ May have a fever as high as 106° F (41.1° C) ○ Management:
such as internal bleeding. Therefore, the surgery ■ As it progresses, child may show signs of shock, ■ Diagnosis is determined by history and physical
should happen as soon as possible. sweating, weak pulse, shallow, grunting respirations; findings.
B. Intussusception abdomen is rigid ■ May feel a sausage-shaped mass in the right upper
● A slipping of one part of the intestine into another part just ○ In infants, severe pain in abdomen, loud cries, straining abdomen Barium enema is treatment of choice, with
below it efforts, and kicking and drawing of legs toward abdomen. surgery if reduction does not occur.
○ Often seen at the ileocecal valve ○ Child vomits green or greenish- yellow fluid (bilious). ■ The condition is a surgical emergency. Reduction of
○ The mesentery, a double fan-shaped fold of peritoneum ○ Bowel movements diminish, little flatus is passed. the intussusception must be done promptly by either
that covers most of intestine and is filled with blood ○ Blood and mucus with no feces are common about 12 instillation of a water-soluble solution, barium enema,
vessels and nerves, is also pulled along. hours after onset of obstruction, called currant jelly stools. or air (pneumatic insufflation) into the bowel or
● Edema occurs ○ Children with this disorder suddenly draw up their legs and surgery to reduce the invagination before necrosis of
● At first, intestinal obstruction occurs, but then strangulation of cry as if they are in severe pain; they may vomit. After the the affected portion of the bowel occurs.
the bowel occurs as peristalsis occurs peristaltic wave that caused the discomfort passes, they ■ If there is no lead point, just the pressure of these
● Affected portion may burst, leading to peritonitis are symptom-free and play happily. In approximately 15 nonsurgical techniques may reduce the
● Generally occurs in boys between 3 months and 6 years minutes, the same phenomenon of intense abdominal intussusception. After this type of reduction, children
● A “lead point” on the intestine likely cues the invagination such pain strikes again. Vomitus will begin to contain bile are observed for 24 hours because some children will
as Mickel’s diverticulum, hypertrophy of the Peyer's Patches, because the obstruction is invariably below the ampulla of have a recurrence of the intussusception within this
and bowel tumors. Vater, the point in the intestine where bile empties into time. If this occurs, children will be scheduled for an
the duodenum. additional reduction or surgery.
○ After approximately 12 hours, blood appears in the stool C. Volvulus
and possibly in vomitus, described as a “currant jelly” ● Refers to abnormal twisting of a part of the large or small
appearance. The abdomen becomes distended as the intestine.
bowel above the intussusception distends. If necrosis ● Leads to bowel obstruction
occurs, children generally have an elevated temperature, ● Occurs due to malrotation of small intestines during fetal
peritoneal irritation (their abdomen feels tender; they may development.
“guard” it by tightening their abdominal muscles), an ● It is a medical emergency that needs surgical treatment.
increased white blood cell count, and often a rapid pulse.
Diagnosis is suggested by history.
○ Any time a parent is describing a child who is crying, be
certain to ask enough questions to recognize the
● Intussusception, the invagination of one portion of the possibility of intussusception:
intestine into another, usually occurs in the second half of the ■ What is the duration of the pain? It lasts a short time,
first year of life. In infants younger than 1 year, intussusception with intervals of no crying in between.
generally occurs for idiopathic reasons. ■ What is the intensity? Severe
● In infants older than 1 year, a “lead point” on the intestine ■ What is the frequency? Approximately every 15 to 20
likely cues the invagination. Such a point might be a Meckel’s minutes
diverticulum, a polyp, hypertrophy of Peyer’s patches ■ What is the description? The child pulls up legs while
(lymphatic tissue of the bowel that increases in size with viral crying.
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UNIT 11 (Week 13)
■ This must be done promptly before necrosis of the ● The incidence of NEC is highest in immature infants, those who
intestine occurs from a lack of blood supply to the have suffered anoxia or shock, and those fed by enteral
involved loop of bowel. feedings. Infants with infections may develop it as a further
■ Preoperative and postoperative care will be the same complication of their already stressed state.
as for infants with intussusception. ● There is a lower incidence of the condition in infants who are
○ Relieve the volvulus and re-attach the bowel fed breast milk than in those who are fed formula because
○ Must be done promptly intestinal organisms grow more profusely with cow’s milk than
○ Stoma may be needed if necrosis of parts of the intestine breast milk (cow’s milk lacks antibodies). A response to the
is noted. foreign protein in cow’s milk may also be a mechanism that
D. Necrotizing Enterocolitis (NEC) starts the necrotic process. Therefore, encouraging
● The bowel develops necrotic patches, interfering with digestion breastfeeding may help prevent this disorder.
and may possibly lead to paralytic ileus. ● Signs and Symptoms:
● Necrosis results from ischemia of blood vessels in sections of ○ Abdominal distension
bowel. ○ Stomach does not fully empty by the next feeding time
● The twist leads to obstruction of the passage of feces and ● The entire bowel may be involved or it may be localized. ○ Occult blood in the stool
compromise of the blood supply to the loop of intestine ● Incidences are higher in immature infants. ○ Periods of Apnea
involved. This occurs most often because, in fetal life, a portion ○ Signs of blood loss
of the intestine first protrudes into the base of the umbilical ● Management:
cord at approximately 6 weeks of intrauterine life. ○ IV or total parenteral nutrition
● At approximately 10 weeks of intrauterine life, it returns to the ○ Enteral Probiotics
abdominal cavity. As the intestine returns to the abdominal ○ Antibiotic Therapy
cavity, it rotates to its permanent position. After the rotation, ○ Restrict Abdominal palpation
the mesentery becomes fixed in this position. In volvulus, this ○ Surgery to remove necrotic bowel
action is incomplete and the mesentery does not attach in a ○ Peritoneal drainage or laparotomy in cases of bowel
normal position. perforation
● The bowel is left free to move and twist. Usually, the symptoms ○ Temporary colostomy
are those of intestinal obstruction and occur during the first 6 E. Appendicitis
months of life. ● Inflammation of the appendix
● Signs and Symptoms: ● Most common reason for emergency abdominal surgery
○ Intense crying and pain ● Appendix may become obstructed with fecal matter or with
○ Pulling up the legs lymphoid tissue after a viral illness or with parasites
● Necrotizing enterocolitis (NEC) is a condition that develops in ● Stasis, increased swelling, edema, and growth of organisms
○ Abdominal distention approximately 5% of all infants in intensive care nurseries. The
○ Vomiting ● Initial pain usually in periumbilical and increases within a 4
bowel develops necrotic patches, interfering with digestion and hour period
● Diagnosis: possibly leading to a paralytic ileus. Perforation and peritonitis
○ History ● When inflammation spreads to peritoneum, pain localizes in
may follow. The necrosis appears to result from ischemia or RLQ of abdomen
○ Abdominal examination – Abdominal mass poor perfusion of blood vessels in sections of the bowel.
○ Ultrasound or barium enema reveals obstruction ● Appendix may become gangrenous or rupture
● The ischemic process may occur when, owing to shock or ● Can lead to peritonitis and septicemia
● Management: hypoxia, there is vasoconstriction of blood vessels to organs
○ Surgery ● Signs and Symptoms:
such as the bowel. The entire bowel may be involved, or it may ○ Anorexia
be a localized phenomenon. ○ Nausea and Vomiting
○ Tenderness in RLQ, known as McBurney’s point
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 UNIT 11 (Week 13)
○ Guarding ● Management: ○ Evaluate dietary and bowel habits – Some infants develop
○ Decreased Bowel sounds ○ Surgery-removal of the diverticulum constipation due to high iron content in formula
○ Leukocytosis ○ Nursing care is the same as for the patient undergoing ○ Note frequency, color, and consistency of stool
○ Fever exploration of the abdomen. ○ Document any medications child is taking
● Diagnosis: ○ Because this condition appears suddenly and bleeding ○ Dietary modifications include increasing roughage in diet
○ Blood tests causes parental anxiety, emotional support is of particular ■ Foods high in fiber include whole-grain breads and
○ Abdominal X-ray importance cereals, raw vegetables and fruits, bran, and popcorn
○ CT Scan G. Celiac Disease for older children.
○ Ultrasound ● Also known as gluten enteropathy and sprue ○ Stool softener may be prescribed.
● Management: ● Sensitivity or abnormal immunologic response to protein found B. Inguinal Hernia
○ Surgical Intervention (typically required) in grains, wheat, rye, oats, and barley ● A protrusion of a section of the bowel into the inguinal ring.
○ Nursing care is the same as with most other abdominal ● Leading malabsorption problem in children ● It usually occurs in boys (9:1) because, as the testes descend
surgery patients ● Repeated exposure to gluten damages the villi of intestines from the abdominal cavity into the scrotum late in fetal life, a
F. Meckel’s Diverticulum resulting in malabsorption especially fat fold of parietal peritoneum also descends, forming a tube from
● During fetal life the intestine is attached to the yolk sac by the ● Deficiency in fat-soluble vitamins (Vit. A,D,E,K) the abdomen to the scrotum.
vitelline duct. A small blind pouch may form if this duct fails to ● Signs and Symptoms: ● In most infants, this tube closes completely. If it fails to close,
disappear completely. ○ Steatorrhea intestinal descent into it (hernia) may occur at any time when
● With this structure there may be some misplaced gastric ○ Malnutrition there is an increase in intra-abdominal pressure.
mucosa that can irritate the bowel ○ Distended abdomen ● In girls, the round ligament extends from the uterus into the
● This disorder is the most common congenital malformation of ○ Anorexia inguinal canal to its attachment on the abdominal wall. In girls,
the GI tract. ○ Appears skinny, spindly extremities an inguinal hernia may occur because of a weakness of the
○ Irritable muscle surrounding the round ligament.
○ Infant presents with failure to thrive
○ Atrophy of buttocks
● Management:
○ Lifelong diet restricted in wheat, rye, barley, & oats.
○ Detailed parent teaching is essential.
■ A professional nutritionist or dietitian can aid in
identifying foods that are gluten-free.

Disorders of the Lower Bowel

A. Constipation
● Difficult or infrequent defecation with the passage of hard, dry
fecal matter
● Signs and Symptoms: ● Because passing a hardened stool is painful, a child represses
○ Painless bleeding from the rectum (most common sign) the next urge to defecate.
○ Bright red or dark red blood is more usual than tarry stools ● Returns gradually distended. ● Signs and Symptoms:
○ Abdominal pain may or may not be present ● May have episodes of encopresis (involuntary release of stool) ○ A hernia appears as a lump in the left or right groin. In
● Diagnosis: when rectum can hold no more. some instances, the hernia is apparent only in crying
○ Barium Enema and radionuclide scintigraphy ● Management: (when abdominal pressure increases) and not when
○ x-ray films are not helpful because the pouch is so small ○ Ask caregiver to define constipation children are less active. Inguinal hernias are painless. Pain
that it may not appear on the screen at the site implies that the bowel has become incarcerated
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UNIT 11 (Week 13)
in the sac, which is an emergency that requires immediate prophylactic measure, setting outcomes may be difficult ● Signs and Symptoms:
action to prevent bowel obstruction and ischemia. for parents as they weigh the value of surgical repair ○ Infants present in the first few days of life with failure to
○ The diagnosis is established by a history and physical against the risk of anesthesia and surgery. pass stools, abdominal distention, and vomiting.
appearance. When taking a history of a well child, be ○ After surgery, keep the suture line dry and free of urine or ○ Thick, inspissated, rubbery meconium forms a cast on the
certain to ask parents whether they have ever noticed any feces to prevent infection. Most indications in this area are colon, resulting in complete obstruction.
lumps in the child’s groin area. The hernia may not be closed by a tissue adhesive, which is waterproof and seals ● Management: Radiographic Contrast Edema — The
noticeable at the time of a healthcare visit, so, unless the incision from urine and feces. Even so, the infant will water-soluble contrast enema can be therapeutic by separating
asked specifically, parents may not mention it. If present, need frequent diaper changes and good diaper-area care. the plug from the intestinal wall and expelling it. Occasionally,
the herniated intestine can be palpated in the inguinal ring Assess circulation in the leg on the side of the surgical repeated enemas are required.
on physical examination. repair to be certain that edema of the groin is not D. Meconium Ileus
compressing blood vessels and obstructing blood flow to ● Obstruction of the intestinal lumen by hardened meconium
the leg. ● A specific phenomenon that occurs most exclusively in infants
C. Meconium Plug Syndrome with cystic fibrosis, resulting from the abnormal pancreatic
● Refers to a functional colonic obstruction in a newborn due to enzyme function seen with cystic fibrosis and reflects extreme
an obstructing meconium plug. meconium plugging.
● It is usually transient and affects the left colon with meconium ● The usual symptoms of bowel obstruction occur: no meconium
plugging the bowel distal to this segment. passage, abdominal distention, and vomiting of bile-stained
● Delayed passage (more than 24 to 48 hours) of meconium and fluid.
intestinal dilatation ● Meconium ileus is the only bowel obstruction that can present
with abdominal distention at birth. Unlike simple meconium
plugging, the obstruction point may be too high in the intestine
for enemas to reduce it; instead, the bowel must be incised
and the hardened meconium removed by laparotomy.
● Meconium ileus is so strongly associated with cystic fibrosis,
the infant needs close follow-up by an interprofessional cystic
fibrosis team in the following months.
E. Hirschsprung's Disease (Aganglionic Megacolon)
● Management: ● An absence of ganglionic innervation to the muscle of a section
○ Herniorrhaphy of the bowel—in most instances, the lower portion of the
○ Treatment of inguinal hernia is laparoscopic surgery. The sigmoid colon just above the anus. The absence of nerve cells
bowel is returned to the abdominal cavity and retained means there are no peristaltic waves (lack of normal
there by sealing the inguinal ring. Pneumoperitoneum peristalsis) in this section to move fecal material through the
(instillation of carbon dioxide into the perineal cavity) segment of intestine. This results in chronic constipation or
during surgery may be performed to reveal the presence ribbonlike stools (stools passing through such a small, narrow
of an enlarged inguinal ring on the opposite side. If this is segment look like ribbons). The portion of the bowel proximal
present, both sides may be repaired, and the child will to the obstruction dilates, thus distending the abdomen.
return from surgery with dressings on both groins. ● The incidence of aganglionic disease is higher in the siblings of
○ Formerly, surgery for inguinal hernia was delayed until the a child with the disorder than in other children. It also occurs
child was 3 or 4 years of age. Today, to prevent the more often in males than in females. It is caused by an
complication of bowel strangulation—a surgical abnormal gene on chromosome 10. The incidence is
emergency—infants with inguinal hernia may have surgery approximately 1 in 5,000 live births.
before 1 year of age. If surgery is proposed as a ○ Seen more often in children with Down syndrome.
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UNIT 11 (Week 13)
○ A barium enema or ultrasound with contrast medium is response by the immune system to an environmental trigger in a
generally prescribed to substantiate the diagnosis. The genetically susceptible individual.
contrast mediums will outline the narrow, nerveless
portion and the large proximal distended portion of the Psychological factors have not been supported as a primary
bowel. Enemas must be used cautiously, however, contributory factor to IBD, but psychological problems often occur
because children cannot expel this afterward any more secondary to the disease, possibly intensifying symptoms.
effectively than they can stool. ● Ulcerative Colitis
○ A definitive diagnosis is by a (rectal) biopsy of the affected ○ Affects only the mucosal lining of the colon.
segment to show the lack of innervation or by anorectal ○ Children with UC develop crampy abdominal pain, urgency,
manometry, a technique that tests the strength or tenesmus, and frequent bloody stools. Anemia and
innervation of the internal rectal sphincter by inserting a hypoalbuminemia due to losses in the stool may be
balloon catheter into the rectum and measuring the present. It is treated with oral and sometimes IV
pressure exerted against it. medications such as infliximab (Remicade). If it does not
● Management: respond to medical therapy, surgery to remove the colon is
○ Repair of aganglionic megacolon involves dissection and performed, which is curative for UC. There is an
removal of the affected section, with anastomosis of the association between UC and colon carcinoma if the
intestine (termed a pull-through operation). Because this is disease persists over 10 years. Yearly colonoscopy should
a technically difficult operation to perform in a small be performed once the patient has reached 8 to 10 years
abdomen, the condition is generally treated in infants by from the date of diagnosis.
two-stage surgery: ● Crohn Disease
● Signs and Symptoms: ■ First, a temporary colostomy is established, followed ○ Can affect any part of the GI tract from the mouth to the
○ Occasionally, infants are born with such an extensive by bowel repair at 12 to 18 months of age. anus. The area most commonly involved is the last part of
section of bowel involved that even meconium cannot ■ After the final surgery, children should have a the small intestine known as the terminal ileum. The
pass. Because newborn stools are normally soft, however, functioning, normal bowel. inflammation in CD can extend through the wall of the
symptoms of aganglionic megacolon generally do not ■ In the few instances in which the anus is deprived of intestine and cause abscesses and fistulae.
become apparent until 6 to 12 months of age. By this time, nerve endings, a permanent colostomy will need to be ○ Smoking has been shown to be a precipitating factor.
children appear thin and undernourished (sometimes established. ○ The symptoms of CD depend on the severity and location
deceptively so because their abdomen is large and ○ Nursing Care: of the inflammation. Abdominal pain, diarrhea with or
distended) and have a history of not having a bowel ■ In newborns, detection is high-priority. without blood, and weight loss may be present. The
movement more than once a week of ribbonlike or watery ■ As the child grows, careful attention to a history of inflamed area may become narrowed causing a stricture of
stools. constipation and diarrhea is important. the bowel, and a bowel obstruction may develop if this
○ Newborns — Failure to pass meconium stools within 24 to ■ Signs of undernutrition, abdominal distention, and goes untreated. Fistulae, small tunnels that run either
48 hours may be a symptom poor feedings from the bowel to the skin or to another organ, can
○ Infants — Constipation, ribbon-like stools, abdominal F. Inflammatory Bowel Diseases develop. These most commonly involve the perianal area.
distention, anorexia, vomiting, and failure to thrive Two conditions are categorized as inflammatory bowel disease CD is also treated with oral and IV medications depending
● Diagnostics: (IBD). These disorders have some separate as well as some on the severity of the disease. Remission has also been
○ The diagnosis is suggested by a rectal exam; if a gloved overlapping characteristics. Both involve the development of achieved with exclusive enteral feeding. Surgery may be
finger is inserted into the rectum of a child with true inflammation in the intestine. About 25% of IBD cases are necessary to remove strictures or repair fistulae, but the
constipation, the examining finger will touch hard, caked diagnosed in children younger than 20 years of age. The incidence disease can redevelop in other areas or the bowel. There
stool. With aganglionic colon disease, the rectum is empty in the United States has been increasing. The cause of IBD is are periods of exacerbations and remissions in both
because fecal material cannot pass into the rectum unknown but thought to be multifactorial and due to an abnormal disorders. As inflammation becomes acute, children
through the obstructed portion. develop abdominal pain. Because the inflamed areas do
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UNIT 11 (Week 13)
not absorb nutrients or fluid well, diarrhea and Management: (for both ulcerative colitis and crohn disease sad) ● The cause is unknown. The onset of loose stools can follow an
malnutrition develop. To reduce abdominal pain, which is ● In mild to moderate cases, oral medications are usually sufficient infection and may be due to an alteration in the intestinal flora.
most acute after eating, when the bowel becomes active, to control the symptoms. Vitamin and mineral deficiencies should Other studies have looked at intestinal bacterial overgrowth,
children begin to skip meals. This can cause them to be corrected. In more severe cases, bowel rest may be indicated to food sensitivities, visceral hyperalgesia (heightened sensitivity
become malnourished and develop a vitamin or iron allow the bowel to heal. Enteral or total parenteral nutrition, to bowel distention), and psychosocial factors.
deficiency. therefore, is usually provided for nutrition during the resting ● Antidepressants, anticholinergics, and antibiotics that work to
period. A child can remain home during this period as long as reduce bacteria in the gut such as rifaximin may be prescribed
Assessment: (for both ulcerative colitis and crohn disease) parents have thorough education about the child’s nutritional to treat the symptoms of IBS.
● In both disorders, diarrhea and steatorrhea develop from the needs. H. Imperforate Anus
irritation and the unabsorbed fluid. If inflamed portions ulcerate, ● When food is reintroduced after the resting period, a high-protein, ● The lower GI tract and the anus arise from two different
there will be blood in the stool. Weight loss occurs; in prepubertal high-carbohydrate, and high-vitamin diet is prescribed to replace tissues.
children, growth failure can occur. a recurring fever may be nutrients. Children may eat cautiously at first to avoid ● Early in fetal life, the two tissues meet and join; the tissue
present. reintroducing diarrhea, so assess intake and output carefully. The separating them then perforates, allowing a passageway
treatment regimen depends on the child’s condition. In more between the lower GI tract and the anus.
Comparison Factor Crohn Disease Ulcerative Colitis
severe cases, remission is usually achieved with corticosteroids or ● When this perforation does not take place, the lower end of
infliximab (Remicade), an antibody to the inflammatory cytokine the GI tract and the anus end in blind pouches. This is called
Part of bowel Ileum Colon and rectum
tumor necrosis factor alpha. Maintenance therapy may be with imperforate anus.
affected
infliximab or mercaptopurine (immunomodulator) or mesalamine ● Basically, there is no opening in the rectum.
Nature of lesions Intermittent Continuous alone or a combination of medications. If surgery for UC becomes
necessary, the procedure is performed in two stages. During the
Diarrhea Moderate Severe and bloody first stage, total colectomy is performed and an ileostomy created.
Several months later, an ileoanal pouch is created and the
Anorexia Severe Mild ileostomy is taken down. This allows the child to be continent of
stool.
Weight loss Severe Mild ● Bowel surgery is always a serious step, but because it reduces the
possibility of the child developing colon cancer in association with
Growth retardation Marked Mild UC, it may be necessary in children whose disease is running a
long-term, debilitating course that does not improve. Caution
Anal and perianal Common None parents, although they want their children to be independent with
lesions regard to bathroom use, to always report if change in the color or
consistency of bowel movements does occur so a relapse can be
Association with Rare Common detected.
carcinoma G. Irritable Bowel Syndrome (Chronic Nonspecific Diarrhea)
● A functional bowel disorder that typically causes symptoms of ● Signs and Symptoms:
● Diagnosis is established by endoscopy and colonoscopy. Small
abdominal pain and altered bowel habits with no underlying ○ No anal opening — Part of the routine newborn
biopsies with very low risk of bleeding are taken from multiple
organic cause. It should not be confused with IBD. It may be assessment is to determine the patency of the anus. It is
areas in the upper and lower GI tract. Inflammation, friability, and
either constipation or diarrhea predominant or there may be a important upon birth. Often, the first temperature of the
bleeding may be seen. The histology report shows chronic
mixed picture. Diagnosis is based on the Rome III Criteria. It is a newborn is taken rectally through a certain patency (mao
inflammation and sometimes granulomas in CD. A radiology study
common disorder in adolescents and adults and thought to ni atong buhatonon, almost always gyud sa DR after birth).
such as an MRI is usually obtained to examine the parts of the
affect 15% of the population with a 2:1 female to male ○ Distended abdomen — Because of failure to pass stool
small bowel that cannot be reached with an endoscope.
predominance. The symptoms can adversely affect quality of ○ Failure to pass meconium in the first 24 hours must be
life and cause children to miss school. reported.
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UNIT 11 (Week 13)
○ Infants should not be discharged to the home before a not exist. Assess abused or neglected children closely for nutritional hungry (starving) and will suck at any object offered to them,
meconium stool is passed because there are a lot of deficiencies, because they may not have been given adequate food. such as a finger or their clothing.
conditions that need to be ruled out, especially if there is A. Kwashiorkor ● Signs and Symptoms:
failure to pass meconium. ● Caused by protein deficiency, occurs most frequently in ○ Growth failure
● Diagnosis and Management: children ages 1 to 3 years, because this age group requires a ○ Muscle wasting
○ Once a diagnosis of imperforate anus is established, the high protein intake. ○ Irritability
infant is given nothing by mouth and is prepared for ● It tends to occur after weaning, when children change from ○ Iron-deficiency anemia
surgery. breast milk to a diet consisting mainly of carbohydrates. ○ Diarrhea
○ Diagnosis is confirmed by x-ray study or magnetic ● “...caused by inadequate amounts of proteins in the body. This ● Treatment: A diet rich in all nutrients.
resonance imaging (MRI). disease is usually found in countries where good food is not ● Two Types of Malnutrition:
○ The initial surgical procedure may be a colostomy. readily available.”
■ The type of corrective surgery will depend on the ● Signs and Symptoms:
specific effects of the patient, or how far the baby’s ○ Growth failure is a major symptom. Because edema is
rectum descends, or how it affects the nearby also a symptom, however, children may not appear light
muscles, or whether fistulas are involved. in weight until the edema is relieved.
■ There will be a repair in the perineum to close any ○ Muscle wasting — There is a severe wasting of muscles,
fistulas that are present in the rectum. but, again, this is masked by the edema.
■ A pull-through operation is done by allowing the ○ Edema results from hypoproteinemia, which causes a
physician to pull the rectum down and connect it to shift of body fluid from the intravascular compartments
the new anus. to the interstitial space, causing ascites. This is the same
■ To prevent the anus from narrowing, it may be phenomenon that causes extensive edema in children
necessary to stretch the anus periodically. This is with nephrosis. The edema tends to be dependent, so it
called anal dilation. The patient’s significant other is first noted in the lower extremities.
may need to repeat this periodically for a few months. ○ Irritable — Children are generally irritable and
The physician can teach the significant other to uninterested in their surroundings. They fall behind other
perform this at home. children of the same age in motor development.
C. Vitamin and Mineral Deficiencies
○ Subsequent surgery can reestablish the patency of the anal ○ Failure to thrive
Both vitamin and mineral deficiencies occur at a low rate in
canal. ● Management: Diet rich in protein — Without treatment,
children of the United States because so many foods are enriched
Kwashiorkor is fatal. For therapy, a diet rich in protein is
(restoration of ingredients removed by processing) or fortified
Disorders Caused By Food, Vitamin, and Mineral Deficiencies essential. Even so, there is evidence to suggest that protein
(additional vitamins and minerals not normally present have been
There are many underfed and malnourished children in every part of malnutrition early in life, even if corrected later, may result in
added). Milk, for example, is fortified with vitamins D and A.
the world. Although extreme diseases of food or vitamin deprivation failure of children to reach their full potential of intellectual
Orange juice is fortified with calcium. White bread is enriched with
are rare in the United States, they do exist. Such children need early and psychological development.
B vitamins. Vitamin deficiency diseases are summarized in Table
identification so they can receive better nutrition before permanent B. Nutritional Marasmus
below.
damage occurs. ● Caused by a deficiency of all food groups, basically a form of
starvation. Vitamin Cause of Deficiency Signs and Symptoms
The average child does not develop a deficient intake of essential ● These children are most commonly younger than 1 year of
nutrients because, even if the child is occasionally a fussy eater, over age. Vitamin A Lack of yellow vegetables in ● Tender tongue;
the space of a week, a child does ingest foods containing the necessary ● They have many of the same symptoms as children with diet cracks at corners of
nutrients. Carefully assess any child who has an interference in kwashiorkor. But children with kwashiorkor are anorectic (loss mouth
nutrition such as a GI illness or a child is receiving enteric feedings or of appetite), children with nutritional marasmus are invariably ● Night blindness
total parenteral nutrition to make sure that nutrient deficiencies do
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UNIT 11 (Week 13)
● Xerophthalmia (dry ● Bowed legs
and lusterless ● Tetany (muscle
conjunctivae) spasms)
● Keratomalacia
D. Iodine Deficiency
(necrosis of the
● Because iodine is not supplemented in food except as iodized
cornea with
salt, a diet deficient in iodine may lead to either
perforation, loss of
hypothyroidism or overgrowth (goiter) of the thyroid gland as
ocular fluid, and
the gland struggles to produce thyroxine in the face of
blindness)
deficient iodine.
● Goiter tends to occur most commonly in girls at puberty and
Vitamin B1 Most common in children ● Beriberi (tingling and
during pregnancy. It is potentially dangerous as an enlarged
who eat polished rice as numbness of
thyroid gland may lead to difficulty breathing
dietary staple, because B1 is extremities; heart
● Supplemental iodine or synthetic thyroxine (Synthroid) is
contained in hull of rice palpitations;
needed to correct the deficiency. Children must also be
exhaustion)
maintained on a diet adequate in iodine, found most
● Diarrhea and
abundantly in seafoods.
vomiting
● Aphonia (cry without
sound)
● Anesthesia of feet

Niacin Common in children who ● Pellagra (dermatitis;

eat corn as dietary staple, resembles a sunburn)
because corn is low in niacin ● Diarrhea
● Mental confusion
(dementia)

Vitamin C Lack of fresh fruits in diet Scurvy (muscle

tenderness; petechiae)

Vitamin D Lack of sunlight ● Poor muscle tone;

delayed tooth
formation
● Rickets (poor bone
formation)
● Craniotabes
(softening of the
skull)
● Swelling at joints,
particularly of wrists
and cartilage of ribs

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UNIT 13 (Week 14)
PEDIATRIC VARIATIONS AND NURSING CARE OF THE CHILD WITH A
NEUROLOGIC DISORDER

Anatomy and Physiology Overview of the Nervous System and

Pediatric Variations
● A wide array of problems, rooting from the disorders in your
neurological systems might be from congenital cause, infection, or
trauma.
● Prevention must be the highest priority for keeping the nervous
system healthy because in the future, stem cell research may offer
a cure for neurological disorders. For now, because neural tissues
do not degenerate like any other tissue or any other systems in
our body, we need to extend more of our nursing focuses in
preventing or measuring or making strategies for dealing with the ● Dura Mater - Outer layer of the meninges lying directly
association of loss in mental or physical functioning of our underneath the bones of the skull and vertebral column. This is
patients; making the child more comfortable especially in the thick, tough, and extensible.
hospital stay and providing an environment which is conducive for ● Arachnoid (mater) - Middle layer of the meninges lying directly
the child’s development and self esteem. underneath the dura mater. Underneath the arachnoid is a space
● It is really of great significance especially reviewing the diseases in called “subarachnoid space” which is the site for the lumbar
our neurological disorder in pediatrics to have an overview of our puncture. It contains cerebrospinal fluid which acts as a cushion of
anatomy and physiology of the nervous system. the brain.
● Nerve cells (neurons) are unique among body cells in that, instead ● Pia mater - Located under the desk of the arachnoid space. It is
of being compact, they consist of all cell nuclei and extensions: very thin, tightly adhered to the surface of the brain and spinal
one axon and several dendrites. The dendrite transmits impulses cord. It is the only covering to follow contours of the brain which
to the cell nucleus (listener); the axon transmits impulses away we call as “gyri” or tissue.
from the cell nucleus to body organs(talker).
● The nervous system is not fully functioning at birth; it continues to Cerebrospinal Fluid (CSF)
mature through the first 12 years of life. Two separate systems are ● A clear fluid that surrounds the brain and spinal cord. It serves
involved: the peripheral nervous system (PNS) and the central as a cushion to the brain and spinal cord from injuries
nervous system (CNS). The PNS consists of the cranial nerves, the ● serves as a nutrient delivery removal system of the brain
● Cell body - The cell’s life support system ● In the brain there are ventricles, it is important to know these
spinal nerves, and the somatic and visceral divisions. The CNS
● Neural impulse - Electrical signal travelling down the axon parts because the ventricle is one of the manufacturers of the
includes the brain and the spinal cord surrounded by the
● Myelin sheath - Covers the axon of some neurons and helps serum and H20.
cerebrospinal fluid (CSF), the skull, and three membranes or
speed neural impulses ● we need to know the normal properties to rule out different
meninges (the dura mater, a fibrous, connective tissue containing
● Terminal Branches of Axon - Form junctions with other cells diseases
many blood vessels; the arachnoid membrane, a delicate serous
● Dendrites - Receives messages from other cells
membrane; and the pia mater, a vascular membrane) that protect Normal Properties of Cerebrospinal Fluid
● Axon - Transmits impulses away from the cell or nucleus,
the brain and spinal cord from trauma.
termed as the tracker. It transmits different information from
Parameter Normal Findings Abnormal Findings: Possible
messages throughout your body.
Significance

Aquino, Bacon, Buhay, Gonzaga, Jalang, Literato, Luna, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 13 (Week 14)
him or her. Ask older children what they ate for breakfast to
Opening Newborns: 8-10 Lowered pressure usually Glucose 60%-80% of Bacterial meningitis causes a
test recent memory.
Pressure cm H2O; indicates there is serum glucose marked decrease in CSF
● Remote memory is long-term recall. Ask preschoolers what
Children: 10-18 subarachnoid obstruction in level glucose, invasion of fungi,
they ate for breakfast that morning or for dinner the night
cm H2O the spinal column above the yeast, tuberculosis, or
before because, for them, that was a long time ago; ask older
puncture site; Elevated protozoans into the CSF
children what was the name of their first-grade teacher
pressure suggests intracranial results in some decrease in
because most people remember this information their whole
compression (pressure), glucose level; Viral infections
life.
hemorrhage, and infection; do not cause a decrease in CSF
● Stereognosis refers to the ability of a child to recognize an
Pressure increases if a child glucose and may occasionally
object by touch; it is a test of sensory interpretation. For this,
coughs or pressure is applied cause a slight increase
ask a child to close his or her eyes and then place a familiar
to the external jugular vein
object, such as a key, a penny, or a bottle cap, in her hand and
(Valsalva Maneuver) Albumin/Glob 8:1 Increased level suggests
ask her to identify it. This is a skill even preschoolers are able
ulin (A/G) infection or an A/G ratio
to do successfully.
Appearance Clear and If cloudy, indicates possible Ratio neurologic disorder
● Graphethesia is the ability to recognize a shape that has been
colorless infection with an increased
traced on the skin. Ask a child to close his or her eyes; trace
number of white blood cells
Neurological Examinations first a circle then a square on the back of his or her hand.
(WBCs); If reddened, color is
● Kinesthesia is the ability to distinguish movement. Have a
probably because of red blood
1. Cerebral Function child close her eyes and extend her hands in front of her.
cells (RBCs)
Orientation Person, place, and time Raise one of her fingers and ask her whether it is up or down.
Cell Count 0-8/mm3 Granulocytes suggest 2. Cranial Nerve Function - Testing for cranial nerve function consists
cerebrospinal fluid (CSF) Immediate Recall Recent memory of assessing each pair of cranial nerves separately.
infection; Lymphocytes
suggest meningeal irritation Remote Memory Long-term recall
and inflammation; A few RBCs
and WBCs are normally Stereognosis Ability to recognize object by
present in the newborn CSF touch
due to the trauma of birth
Graphesthesia Ability to recognize shape that
Protein 15-45 mg/100 ml Elevated count (more than has been traced on the skin
45/100 ml) occurs if RBCs are
present; If both protein Kinesthesia Ability to distinguish movement
content and RBC count are ● Immediate recall is the ability to retain a concept for a short
elevated, meningitis or time, such as being able to remember a series of numbers and
subarachnoid hemorrhage is repeat them (a child of 4 years can usually repeat three digits;
suggested; If protein content a child older than 6 years can repeat five digits).
alone is elevated, it more ● Recent memory covers a slightly longer period of time. To 3. Cerebellar Nerve Function
likely suggests a degenerative measure this, show the preschool child an object such as a ● Tests for balance and coordination. To test these, observe the
process such as multiple key and ask the child to remember it because later you will child walk to assess whether the walk is natural (most children
sclerosis ask him or her to tell you what it was. After about 5 minutes, walk at least a little self-consciously when they know they are
ask whether the child remembers what object you showed being observed, so watch them also as they enter the exam
room and move around for other activities). Ask the child to
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UNIT 13 (Week 14)
attempt a tandem walk (walk a straight line, one foot directly ● Be sure to provide an explanation that includes a description of all pathogens into the CSF) or if there is a suspected
in front of the other, heel touching toe; walk three steps. of the sensory experiences the child might undergo—that is, not elevation of CSF pressure. In the latter instance, if fluid is
● Ask if the patient can already walk. only what will be done but also how the child might feel, or what removed, the higher pressure in the intracranial space
● A child as young as 4 years should be able to do this for as the child might see or hear or even smell or taste (if appropriate). could cause the brainstem to be drawn down into the
long as 5 seconds. ● Cerebrospinal fluid (CSF) is a fluid that circulates through the spinal cord space, compressing the medulla and
4. Motor Function - Measured by evaluating muscles size, strength, brain. Ventricles (chambers) inside the brain make the fluid. compromising the action of the cardiac and respiratory
and tone. Begin by comparing the size and symmetry of Normally, the fluid drains out of the brain through the ventricles centers.
extremities. If in doubt about either of these, measure the and into the spinal column. The body then absorbs the fluid. If CSF ■ EMLA or lidocaine cream can be applied to the puncture
circumference of the calves and thighs or upper and lower arms backs up into the brain, the problem is called hydrocephalus. The site 1 hour before the procedure to reduce pain.
with a tape measure. Palpate muscles for tone. Move the buildup causes the ventricles to swell and puts pressure on other Alternatively, the child may receive conscious sedation for
extremities through passive range of motion to evaluate for parts of the brain. The head may swell as fluid and pressure build. the procedure.
symmetry, spasticity, and flaccidity bilaterally. To test for strength, The pressure can damage brain tissue. In some cases, a healthcare ■ For a lumbar puncture, a newborn is seated upright with
ask the child to extend her arms in front of her and then resist provider drains the fluid and protects the brain. Common the head bent forward. You might describe the position
your action as you push down or up on her hands or push them treatments are: as “rolling into a ball” or “folding up like an astronaut in
out to the side. Do the same with the lower extremities. ○ Lumbar Puncture a small spaceship.”
5. Sensory Function ■ During a lumbar puncture, the needle will press against a
● If children’s sensory systems are intact, they should be able to dorsal nerve root and the child will experience a shooting
distinguish light touch, pain, vibration, hot, and cold. Have a pain down one leg. If this happens, reassure the child that
child close his or her eyes and then ask the child to point to this feeling passes quickly and does not indicate an injury.
the spot where you touch him or her with an object. Light ■ The older infant or child is placed on one side on the
touch is tested by using a wisp of cotton, deep pressure by examining table. The head is flexed forward, the knees
pressure of your finger, pain by a safety pin, temperature by are flexed on the abdomen, and the back is arched as
water bottle filled with hot or cold water. much as possible. This position opens the space between
● Vibration is tested by touching the child’s bony prominences the lumbar vertebrae, facilitating needle insertion.
(iliac crest, elbows, knees) with a vibrating tuning fork. Warn ■ When the insertion stylet is removed and CSF drips from
the child that on pin testing, he will feel a momentary prick. the end of the needle, the procedure has been
Otherwise, he may be unwilling to close his eyes again for successful. Lay down for 30 minutes and drink a glass of
further testing. water.
6. Reflex Testing ■ To confirm that the subarachnoid space in the cord is
● Full range of neurological function patent with that in the skull, the examiner may ask a child
● Deep tendon reflex testing, which is part of a primary physical who is older than 3 years of age to cough, or the
assessment, is also a basic part of a neurologic assessment. In examiner may ask you to press on the child’s external
newborns, reflex testing is especially important because the jugular vein during the procedure.
infant cannot perform tasks on command to demonstrate the ■ Either of these measures will cause an increase of CSF
■ Involves the introduction of a needle into the
full range of neurologic function. pressure if fluid is flowing freely through the
subarachnoid space (under the arachnoid membrane) at
subarachnoid space. Typically, three tubes of CSF,
Diagnostic Testing the level of L4 or L5 to withdraw CSF for analysis. The
containing 2 to 3 mL each, are collected, a closing
procedure is used most frequently to diagnose
● Many of these tests are invasive, so it is best to try to schedule the pressure reading is taken, and the needle is withdrawn.
hemorrhage or infection in the CNS or to diagnose an
least invasive procedures first, before the painful or more ■ If a child had minimally increased CSF pressure at the
obstruction of CSF flow.
frightening procedures are done, to help promote the child’s time of the puncture, closely observe the child after the
■ Lumbar puncture is contraindicated if the skin over the
cooperation. Lumbar puncture should be performed in the end.. procedure to prevent respiratory and cardiac difficulty
needle insertion site is infected (to avoid introducing
from medulla pressure. An increase in blood pressure or a
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UNIT 13 (Week 14)
decrease in pulse and respiration are important signs of procedure and prevents the infant from crying ● The diagnostic technique involves imaging after injection of
increased intracranial compression. Other important excessively, an action that could increase ICP. positron-emitting radiopharmaceuticals into a vein. These
signs include a change in consciousness, pupillary radioactive substances accumulate at diseased areas of the brain
changes, and a decrease in motor ability. or spinal cord. PET is extremely accurate in identifying seizure foci.
Radiographic Techniques
○ Ventricular Tap ● Uses a contrast; evaluates the metabolic activity of cells of body
Ventriculoperitoneal shunt - CSF fluid is drained out through the tissues.
peritoneum. Tube is connected to a catheter, a thin flexible tube then
takes the fluid from the brain to the stomach (abdomen). Echoencephalography - The ultrasound of the head and spinal cord.
High frequency sound waves above audible range towards the child’s
Myelography - The x-ray study of the spinal cord following the head and spinal cord, it outlines the ventricles of the brain. It
introduction of a contrast material into the CSF by lumbar puncture to determines the frequency of sound waves. Non-invasive; no
reveal the presence of space-occupying lesions of the spinal cord. After discomfort; no complications.
the procedure, keep the head of the child’s bed elevated
(High-Fowler’s) to prevent contrast medium from reaching the Electroencephalography (EEG)
meninges surrounding the brain and causing irritation.

Computed Tomography

■ In infants, CSF may be obtained by a subdural tap into a

ventricle through the coronal suture or anterior
fontanelle. A small space on the scalp over the insertion
site is shaved or clipped, and the area is prepared with an
antiseptic.
■ A ventricular tap may be done if the opening between the
ventricle and spinal cord is completely blocked. The
healthcare provider places a device similar to a rubber
stopper into your baby's skull. This allows access to the
ventricle. A healthcare provider can then draw fluid out ● Most common
of the ventricle with a needle. ● Involves the use of x-rays to reveal densities at multiple levels or ● Recommended for patients who have seizures. Electrodes are
■ The infant’s head must be held firmly in a supine position layers of the brain tissue and is helpful to confirm the presence of attached to the brain.
to prevent movement during the procedure, which could a brain tumor or other encroaching lesions. ● EEG readings reflect electrical patterns of the brain = physical and
cause the needle to strike and lacerate meningeal tissue. ● Diagnose brain tumors, lesions same as with the Magnetic chemical interactions at the time
■ Fluid must be removed from this site slowly, rather than Resonance Imaging (MRI). Magnet fields are used to show tissue ● Nursing Considerations (for infants):
suddenly, to prevent a sudden shift in pressure that could composition and rule out tumors and any injuries in the brain or ○ Instruct the mother nga ang goal is dapat makatulog siya
cause intracranial hemorrhage. hematoma. during the procedure, because, if luhag kaayo bati ang tracing
■ After the procedure, a pressure dressing is applied to the ○ Pag lecture sa E: Magnetic Resonance Imaging (MRI) uses sa EEG. So dapat stay put jud ang patient.
site, and the infant is placed in a semi-Fowler’s position magnetic fields to show differences in tissue composition, ○ Keep the infant up before the procedure so that matug jd sya
to prevent prolonged drainage from the puncture site. revealing normal versus abnormal brain tissue. during the procedure.
After the procedure, comfort the infant or allow the ● Patients are sometimes sedated.; Control Anxiety; Modify
parents to do so; this both reduces the stress of a painful Positron Emission Tomography (PET) behavior and movement
● Medications:
Aquino, Bacon, Buhay, Gonzaga, Jalang, Literato, Luna, Miranda, Mollaneda, Monleon, Olila, Racaza, Troyo, Yap
UNIT 13 (Week 14)
○ Chloral Hydrate - Increase fast activity brain damage which is a result from increased intracranial ● Seizures are a sign of increased ICP. So if there is a seizure in your
○ Thorazine - Increase the slow activity pressure. patient, the child’s ICP is becoming greatly compromised.
○ Chlorpromazine - Increase slow activity (Dili klaro ang tingog ○ Fontanelle changes
ni miss) ○ Vomiting (Projectile) Intracranial Pressure Monitoring
○ Vital Signs Changes
Increased Intracranial Pressure ○ Pain
● Not a disorder but a group of signs and symptoms that occur with ○ Mentation
many neurologic disorders
● Most common causes of increased ICP include the increase in CSF
volume, blood entering the CSF, cerebral edema, head trauma,
and infection. It could also be due to brain tumors, the
development of hydrocephalus, or Guillain-Barre syndrome.
● Symptoms develop which depend on the cause and the ability of
the child’s skull to expand to accommodate the increased
pressure. Three methods in monitoring ICP:
● With patients whose fontanelles are not fully closed, they are able ● An intraventricular catheter that is inserted through the anterior
to adapt with the pressure. But with patients who have closed fontanelle.
fontanelles, it can cause severe damage to the brain with ● A subdural screw or bolt that is inserted through a bore hole in
increased pressure. Children with open fontanelles can withstand the skull.
more pressure without brain damage than older children, whose ● A fiberoptic sensor that is implanted into the epidural space or the
suture lines and fontanelles are closed. anterior fontanelle in an infant.
● Assessment: Obtain vital signs, evaluate pupil response, determine ○ These methods in monitoring ICP are threaded into the lateral
levels of consciousness (motor, sensory function, or it may include ventricle filled with normal saline, and then connected to the
more elaborate electronic monitoring). external pressure monitoring. As pressure in the ventricles
● Signs and Symptoms (initial): fluctuate, it registers through the filled catheter into the
● Common manifestations of brain injury include decorticate
○ Headache oscilloscope screen plus a written printout. This method is
posturing and decerebrate posturing. These manifestations occur
○ Irritability advantageous over simple scanning because it also enables
in patients who are having infection.
○ Restlessness CSF drainage, and administration of medication through the
● During the final assessment in ICP, carefully observe the child’s
○ Pulse and respiratory rate will tend to slow down catheter.
resting posture because the motor control grows weaker because
○ Increased blood pressure ○ Normal ICP in Children: 1-10 mmHg; if it is more than
of loss of cell function. It is a characteristic posture of the patient,
○ Increased temperature 15mmHg, it needs further assessment, as blood pressure rises
or primitive reflexes that occur to the patient.
○ Diplopia (double vision) and falls with the influx of blood through the vessels.
● If there is a loss in the cerebral function (cerebral loss), it is shown
○ Papilledema ○ On a monitor, there are the A waves which are also referred
mainly by decorticate posturing. The child’s arms are adducted
○ Ocular Changes: Strabismus, nystagmus, and sunset eyes to as the ‘plateau waves.’ B waves are referred to as the
and flexed on the chest with wrist flexed, and the hands are fisted.
○ “Doll’s eye” reflex - Abnormal eye reflexes wherein a person’s ‘short duration waves.’ C waves are the ‘small rhythmic
The lower extremities are extended and internally rotated. The
eye will look to the right once the head of the person will turn burst’ on the monitor.
feet are plantar-flexed.
to the left side, and vice-versa. ○ If brain ischemia is present and there is no oxygen in the
● Decerebrate posturing occurs when the midbrain is not
○ Pulse Pressure - The gap between the systolic and diastolic brain, wave pattern changes even before there is a deviation
functional. It is characterized by rigid extension, adduction of the
blood pressure. in blood pressure or pulse rates.
arms, and pronation of the wrist with the fingers flexed. The legs
● Signs and Symptoms: ○ It is very important to determine these factors of your patient,
are held extended with the feet and plantar-flexed.
○ Increased head circumference - The fontanelles of children especially the checking of vital signs so as to monitor the
are usually closed, so the tendency of this is that there will be patient’s intracranial pressure.
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UNIT 13 (Week 14)
● Management: ● It really affects the infant cognitively because they are
○ Increased intracranial pressure must be identified first and cognitively challenged. And also this patient… (na putol)
remedied as quickly as possible to prevent brain injury or infected sila with a virus which is caused by anopheles?? (Not
compression to the brain stem, which could lead to both sure kay di ma klaro) mosquito that could really lead to
cardiac and respiratory failures. infantile microcephaly (infant’s lack of functioning of the brain
○ Actions such as coughing, sneezing, and vomiting, or rapid tissue), but do not... (na putol si ms)
administration of intravenous fluid increases the ICP. So when ● (Sige ka putol si ms nya di masabtan) is no brain premature
a parent is burping an infant after feeding, caution them to be fusion of the cranial sutures so wala ni fuse gyud ang (na putol
really careful not to put pressure on the tubular veins because napud) sutures or bone sa imohang brain, so with this one kay
this is another action that increases the ICP. (di masabtan)
○ Since an increase in intracranial pressure is a sign of an C. Spina Bifida Occulta
underlying disorder, after the pressure is reduced, the
underlying cause must be identified, or else, the pressure will
rise again from the original disorder. So it is important to
know the cause of the increased ICP of the patient. ● Absence of cerebral hemisphere
○ Decadron - A dexamethasone medication that treats or ● Affects the medulla
reduces cerebral edema (edematous brain). ● Upper end of neural tube fails to close early in intrauterine life
○ Mannitol - A diuretic that moves fluids from extravascular to ● Termination of pregnancy is most likely to occur
vascular spaces of the brain, from brain tissue to the blood B. Microcephaly
vessels. This medication is also used to treat cerebral edema.
It is important to monitor the urinary output of the patient.

Neural Tube Disorders (NTD)

● Malformation of the neural tube (forms in the utero as flat plate ● This is a mild form of your neural tube defect: posterior
then molds to form the brain and spinal cord) laminae of vertebrae fail to use.
● During pregnancy, it is important to acquire 600 mcg of folic acid ● Malformation caused by non-closure or incomplete closure of
since folic acid is proven to reduce the incidence of neural tube the posterior portion of the vertebrae (na putol)
defects. ● The spinal cord or the cerebrospinal fluid dili ra gyud siya
affected or wala ra gyud siya ni herniate.
A. Anencephaly ● Most affected gyud ani niya is the 5th lumbar and 1st sacral of
the spinal cord.
● Surface bone missing and spinal cord intact, missing bone lang
● From the word “micro” meaning gamay or slow gyud siya the problem of these patients.
● The fetal brain grows slowly and falls more than three
standard deviations below normal on a growth chart at birth.
As you can see there is a normal brain at the right, the left is
your microcephaly, gamay siya ug brain and the skull of the
brain is inside the cerebrum and cerebellum.
● The causes of this one are your rubella, cytomegalovirus or
toxoplasmosis and different infectious diseases.

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UNIT 13 (Week 14)
E. Myelomeningocele

● We can really differentiate spina bifida occulta which is ● A cranial meningocele, so with pediatrics these deal with
manageable ra siya of a minimal surgery. It could also be
● also commonly known as Meningomyelocele or Spina Bifida occipital where the affected area is the occipital area of the
managed if there is no affected na mga sensory sa patient or
● Most common birth defect affecting CNS and viewed as the skull may occur as nasal or nasopharyngeal disorder.
motor, non-surgical case ra sya or ma resolve ra siya ● Encephaloceles generally are covered fully by skin or may be
most complicated birth defect.
especially in the bifida but with your meningocele, as you can
● Meningoceles - Lesions associated with spina bifida open or covered only by the dura
see there is a herniation and your myelomeningocele mas ●
● Partial or complete paralysis of lower extremities, loss of Examinations that could assess via transillumination of the
heavy gyud siya na ni herniate affected ang... (na putol) patient if the disorder is encephalocele or more on the cranial
bowel and bladder function, club foot, hydrocephalus
D. Meningocele
● T6-T12: complete flaccid paralysis of the lower extremities; aspect of the brain. We also have the CT scan, MRI or
weakened abdominal and trunk musculature in higher lesions; ultrasound (maybe your EEGs) will reveal the size of the skull
kyphosis and scoliosis common; ambulation with maximal disorder and help predict the extent of surgery, which will be
support needed.
● L1-L2: hip flexion present; paraplegia; ambulation with ● Encephaloceles happens during intrauterine life: prenatal
maximal support ultrasound, fetoscopy, amniocentesis (increased AFP in
● L3-L4: hip flexion, adduction, and knee extension present; hip amniotic fluid) that is why some of the mothers kay kuhaan
dislocation common; some control of hip and knee movement og AFP to know if high or increased ba ang AFP in your
possible; ambulation with mod support amniotic fluid (mag get og sample ana with your
● L5: hip flexion, adduction, and varying degrees of abduction; amniocentesis), or analysis of MAFP.
knee extension and weak knee flexion; paralysis of the lower ● Infant should be delivered through cesarean section to avoid
legs and feet; ambulation with mod support pressure and injury to the spinal cord (especially ingani na
● S1-S2: ambulation with minimal support cases na cranial iyahang lesion so ma lessen ang injury to the
● S3: mild loss of intrinsic foot muscular function possible; infant).
ambulation without support ● “Always wet” - We call this disorder “always wet” because the
F. Encephalocele affected area is, especially meningocele, encephalocele, bifida
occulta, your bowels or bladder functions.
● Nursing Considerations:
● Membranes herniate through an unformed vertebrae, they ○ Need to observe spontaneous movement of lower
protrude as a circular mass about the size of an orange. extremities or lower motor function.
● Protrusion at the lower lumbar and lumbosacral region ○ Usual newborn appears always wet because the normal
although it might be present anywhere along the spinal cord. voiding of a newborn is 30 mL/day every 2 to 3 hours

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UNIT 13 (Week 14)
(that is why we should check the output of the patient) Arnold-Chiari Disorder If you see the actual patient with this syndrome, it’s more on skin
but with this disease, the diaper is always wet (you will ● Chiari Type I lesions or a skin disorder, but there is an underlying neurological case
not find it dry; there is always defecation). ○ Most common in adults with this disorder. Neurocutaneous syndromes are characterized by
○ Before voiding, we have to check the motor function or ○ Common symptom: Headache the presence of skin or pigment disorders with CNS dysfunction.
sphincter function of the patient. ○ Malformation involves the downward herniation of the caudal A. Sturge-Weber Syndrome (Encephalofacial Angiomatosis)
● Management: end of the cerebellar vermis through the foramen magnum. ● Ig tanaw nimo sa patient, you need to explain to the
○ Immediate Surgery: If you prolong the case and you will ○ Herniation of the lower part of the brain: Cerebellar tonsils significant other or the mother especially with Sturge-Weber
not do surgery, this will really affect the function of the ○ “Adult type,” Syringomyelia (common type) Syndrome so encephalofacial angiomatosis (?? word per word
patient. there will be cognitive challenge in the patient; ● Chiari Type II na gikan ni miss). Ig tanaw niya sa iyahang baby medyo naa
24 to 48 hours after birth so that dili mo further damage ○ Occurs with spina bifida ray angiomas or puwa puwa sa nawng, ingon siya, ah we can
and further increase the intracranial pressure in the brain ○ Caused by overgrowth of the neural tube in weeks 16 to 20 surgically revise that one or we can do a surgery so that
which leads to edema and this lowers BP, RR, and PR and fetal life murag facial deformity ra gae ang pagtanaw sa significant
then there will be anoxia in the brain of the patient ○ Cerebellum, medulla oblongata, and 4th ventricle project into other muthink siya nga dili ra serious ang ing ani na disorder.
○ Replace meninges close gap in the skin to prevent the spinal canal at the cervical level which obstructs CSF flow But with Sturge-Weber Syndrome, it affects your fifth cranial
infection ○ Common in patients with hydrocephalus nerve.
○ Large portion of the meninges must be removed by ○ Lumbar puncture should never be performed if there is ● Congenital port-wine birthmark on the skin of the upper part
surgery increased intracranial pressure and also with this disorder of the face following the distribution of the first division of the
○ Limit absorption of CSF which can lessen build-up of CSF because LP increases further increases ICP fifth cranial nerve (trigeminal nerve).
and hydrocephalus ○ Brain stem herniation if lumbar puncture is done; naa jud ● It is divided unilaterally, midline, extending inward at that
○ Fetoscopic Surgery downward projection to the medulla oblongata point of the meninges and your choroid plexus.
■ Performed intrauterinely ● Signs and Symptoms:
■ Insert catheter ○ Sluggish blood flow leading to anoxia (decreased
■ Not performed in the Philippines kay it needs broad oxygenation of the brain). Because of involvement of the
technology meningeal blood vessels, blood flow is sluggish, and
■ Surgically close up the compressed area especially anoxia may develop in some portions of the cerebral
with spina bifida cortex.
○ Hemiparesis - Half of the body might be paralyzed. The
child may have symptoms of hemiparesis (numbness) on
the side opposite the lesion from destruction of motor
neurons.
○ Intractable seizures
○ Be cognitively challenged (to be expected)
○ Develop blindness because of the glaucoma or the
pressure inside the brain of your patient
Comparing the normal brain from a brain with Chiari Type I
Malformation, you can clearly see the presence of the downward CT Scan or MRI
herniation. In the normal brain the cerebellum is intact, but in the
other picture kay ni project siya downwardly.

Neurocutaneous Syndromes
Neurocutaneous Syndrome can be seen on the surface of your patient.

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UNIT 13 (Week 14)
● Physically inig tanaw sa significant other, maka inggon sila nya kanang dghan kay syag skin lesions and ingon ko rare or
“very light ra guro na nga disorder, ma cure rana.” They will take it usahay ra kayko makakita ug inana and I was so curious and
lightly and not seriously, that is why, you have to explain the that disease is this one diay.” And also, it is not just the lesions
disorder to them. You should really have a nursing intervention in ang problem, but naa sd stay psychological or neuro case sd
how the significant other will emotionally accept the condition; diay siya. THE END HAHAHAH)
they need to adapt to the status of the patient. ● Autosomal dominant trait carried on the long arm of
● A child with Sturge-Weber Syndrome (Encephalofacial chromosome 17
Angiomatosis) has a congenital port-wine birthmark on the skin of ● Spots appear following paths of cutaneous nerve (>6 larger
the upper part of the face that extends inward to the meninges than 1 cm in dm are diagnostic)
and choroid plexus. ● Acoustic nerve or cranial nerve VIII = Hearing impairment
● The skin manifestation follows the distribution of the first division involvement of optic nerve lead to vision loss
of the fifth cranial nerve (trigeminal nerve). ● Cognitive challenge-cerebral brain tumor or deterioration
● Because the defect is usually unilateral, the port-wine stain ends (explain especially to pediatric patients that they have
abruptly at the midline. cognitive challenge that a mother should deal with)
● In many children, only the ophthalmic branch of the nerve is
● “Rail-road pattern or double groove pattern” involved and the lesion is confined to the upper aspect of the face.
● Calcification of the involved cerebral cortex” ● Because of the involvement of the meningeal blood vessels, blood
● Picture A: Normal brain, nay mga gyri, fissures, grooves flow is sluggish, and anoxia may develop in some portions of the
● With this disorder, the CT scan or MRI of the brain will show a cerebral cortex.
“railroad track.” When we say a “railroad track,” mura siyag ● The child may have symptoms of:
straight road, instead with grooves kay straight road na siya or ○ Hemiparesis (numbness) on the side opposite the lesion from
double groove pattern. Why man? Because there is a calcification the destruction of motor neurons,
of the involved cerebral cortex of your patient. ○ Intractable seizures,
○ Be cognitively challenged, or
○ Develop blindness from glaucoma.
● A CT scan or an MRI of the skull usually shows calcification in the
involved cerebral cortex. Such calcification follows a diagnostic
“railroad track“ or double groove pattern.
● When the syndrome is first diagnosed, parents may hope that the
defect does not extend beyond the skin lesion. They may ask to
have the skin lesion surgically removed, in the belief that this will
correct their child’s condition completely. Ensure that parents
understand the need for long term follow – up, particularly if the
child has accompanying seizures that require long-term
anticonvulsant therapy.

B. Neurofibromatosis (Von Recklinghausen’s Disease)

● You can see externally of the patient’s lesions but there is an
underlying neurological disease.
● Unexplained development of subcutaneous tumors (Chika
minute with miss: I saw this in one guy walking in colon when I
was a student and ingon ko “unsa mani nga disease oy
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UNIT 13 (Week 14)
First (Top) Picture: Neurofibromas; Second (Bottom) Picture: c. Diplegia or Paraplegia - Lower extremities ● In children younger than 2 months of age, E. coli is the most
Cafe-au-Lait (German language) - Coffee-like feature; some have it as a d. Astereognosis - Difficulty identifying objects placed in their common cause.
birthmark but it is also one feature of your neurofibromatosis. involved hand. If you give the patient with a ball, they are ● In children with myelomeningoceles, they also develop meningitis
unable to recognize it. and the common cause of infection is Pseudomonas.
Cerebral Palsy (CP) e. Pseudobulbar Palsy - Impaired speech; note that they have ● For children with splenectomy, they are susceptible to
● A group of progressive disorders of upper motor neuron difficulty in communicating. pneumococcal meningitis unless they have received the
impairment that result in motor dysfunction. pneumococcal vaccine.
● Affected children also may have speech or ocular difficulties, 2. Dyskinetic or Athetoid Type ● Haemophilus influenzae, once a major cause of meningitis, is now
seizures, cognitive challenges, or hyperactivity (because it involves ● Dyskinetic = Disorder of a muscle tone rarely seen because of routine immunization against this organism
the motor functions of your patients). Muscle spasticity can lead ● Athetoid means “worm-like”; abnormal involuntary in newborns.
to orthopedic or gait difficulties (If the affected part is on the right movement ● Pathologic organisms usually spread to the meninges from upper
side, so tip-toed gyud na ang patient; some form a scissor gait ● Slow, writhing motions = four extremities: face, neck, and respiratory tract infections by lymphatic drainage possibly through
which is one type of cerebral palsy. They cannot really stand.) tongue (e.g. lip smacking, drooling) the mastoid or frontal sinuses or by direct introduction through a
● Cause: ● Poor tongue and swallowing movements. Some patients need lumbar puncture or skull fracture.
○ Nutritional deficiencies to have attachments like NGT to aid nutrition ● Once organisms enter the meningeal space, they multiply rapidly
○ Drug use ● Choroid-irregular jerking and then spread throughout the CSF to invade brain tissue
○ Maternal infections such as cytomegalovirus (maternal ● Dyskinetic - d/o muscle tone through the meningeal folds, which extend down into the brain
patients or pregnant mothers do not really know if they have 3. Ataxic Type itself.
this because this virus is asymptomatic man gud so murag ● Awkward, wide-based gait ● Brain abscess or invasion of the infection into cranial nerves can
wala ra but inig anak nila, mao na small for gestational age ● Unable to perform the coordinated motions: finger-to-nose result in blindness, hearing impairment, or facial paralysis.
and there is cognitive difficulties ilahang baby so there are test (cerebellar function) and tandem walking test ● If a thick exudate accumulates in the narrow aqueduct of Sylvius, it
abnormalities, different birth defects, if infected sila) or 4. Mixed Type can cause obstruction leading to hydrocephalus.
toxoplasmosis ● Both spasticity and athetoid or ataxic and athetoid, either of ● Brain tissue edema can put pressure on the pituitary gland,
○ Direct birth injury the pair. causing increased production of antidiuretic hormone, resulting in
● Movements = Severe degree of physical impairment the syndrome of inappropriate antidiuretic hormone secretion
Types of Cerebral Palsy ● Nursing Considerations: (SIADH), causing hyponatremia.
1. Spastic Type ○ Assess their nutrition (e.g. less than body requirement). ● Assessment:
● Excessive tone in the voluntary muscles that results from loss ○ Feeding via NGT, OGT, or gastrostomy. ○ Children usually have had 2 or 3 days of upper respiratory
of upper neurons. tract infection prior to the development of meningitis.
● Signs and Symptoms: Additional Information: ○ They then grow increasingly irritable because of an intense
○ Hypertonic muscles Since their ADLs (Activities of daily living) are affected, some patients headache.
○ Abnormal clonus are using crutches depending on the case and type of CP. They need to ○ They experience sharp pain when they bend their head
○ Exaggeration of DTR (Deep Tendon Reflexes) have rehabilitation especially in their motor functions, walking and forward.
○ (+) Babinski and tonic-clonic reflexes pass the age speech coordination (speech therapist). Minimal type of CP, some ○ In the newborn, symptoms such as poor sucking, weak cry, or
patients can really live a normal life. lethargy develop.
“Parachute Reflex” ○ As the disease progresses, signs of meningeal irritability then
● Lower then scissor gait-tight adductor thigh muscles; tightening of Bacterial Meningitis occur, as evidenced by positive Brudzinski and Kernig signs.
heel cord ● Infection of cerebral meninges ○ Children may hold their back arched and their neck
● Affected Extremities: ● Mostly occur in children younger than 24 months of age and most hyperextended (opisthotonos).
a. Hemiplegia - One side, CP more involvement in an arm than common season would be winter ○ If third and sixth cranial nerve paralysis occurs, a child will not
leg ○ Organisms involved: Streptococcus pneumoniae, Group B be able to follow a light through full visual fields.
b. Quadriplegia - All four extremities Streptococcus
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UNIT 13 (Week 14)
○ If the fontanelles are open, they bulge upward and feel tense; start of antibiotic therapy to prevent transmission of the ○ It is also caused by direct invasion of CSF during lumbar
if they are closed, papilledema may develop. infection to other family members or healthcare providers. puncture.
○ If the meningitis is caused by H. influenzae, the child may ○ An antibiotic may be prescribed prophylactically for the child’s ○ Complication of childhood diseases such as measles, mumps,
develop septic arthritis. immediate family members or for playmates who have been and chickenpox.
○ If it is caused by Neisseria meningitidis, a papular or purple in close contact with the child. ● Most frequent cause is the enteroviruses, followed by
petechial skin rash may occur. ○ Neurologic sequelae, such as learning problems, seizures, arboviruses.
○ After this beginning of a myriad of general symptoms, sudden hearing and cognitive challenges, and inability to concentrate ● Several encephalitis viruses such as those that cause:
cardiovascular shock, seizures, nuchal rigidity, or apnea can urine from lessened antidiuretic hormone secretion, must be ○ St. Louis Encephalitis
occur. assessed in the weeks to come because these can be ○ Eastern Equine Encephalitis
○ Because the infant has open fontanelles, nuchal rigidity long-term consequences. ○ West Nile Encephalitis
appears late and is not as useful a sign for diagnosis as in the are born by mosquitos are seen often during summer months.
older child. Group B Streptococcal Infection ● Treatment (to prevent encephalitis):
○ As a rule, a child with a high temperature who then has a ● A major cause of meningitis in newborns is Group B Streptococci. ○ Children should receive immunizations to cope up with the
seizure is assumed to have meningitis until CSF findings prove ● The organism is contracted either in utero or from secretions in virus.
otherwise. the birth canal. ○ use of mosquito repellents if the area is mosquito infested.
○ CSF analysis obtained by lumbar puncture confirms the ● It can spread to other newborns if good handwashing technique is ○ assessing the child with encephalitis.
diagnosis. not used. ○ Administer medications right away
○ CSF results indicative of meningitis include increased white ● Group B Streptococci colonization can result in either early-onset ● Characteristics of the disease are sudden or gradual that would
blood cell and protein levels, increased ICP, and a glucose or late-onset illness. include symptoms of:
level less than 60% of blood glucose (because bacteria have ● With the early-onset form, symptoms of pneumonia become ○ Headache
fed on the glucose). apparent in the first few hours of life. ○ increase temperature
○ In addition to supplying blood for glucose level, blood is ● The late-onset type leads to meningitis instead of pneumonia. At ○ Ataxia (loss of visual muscle movements)
cultured and examined for increased WBC count. approximately 2 weeks of age, the infant gradually becomes ○ Muscle weakness or paralysis
○ If the child has had close association with someone with lethargic and develops a fever and upper respiratory tract ○ Diplopia
tuberculosis, a tuberculin skin test to rule out tuberculosis symptoms. ○ Confusion
meningitis will be done. ● The fontanelles bulge from increased ICP. Mortality from group B ○ Irritability
○ A CT scan, MRI, or ultrasound study will be prescribed to streptococcal infection is approximately 25%; surviving infants may ● If meninges are involved the signs and symptoms of meningeal
examine for brain abscess. develop neurologic consequences such as hydrocephalus or irritation are:
● Therapeutic Management seizures. ○ Nuchal rigidity
○ Antibiotic therapy (primary therapy) as indicated by ● Treatment is with antibiotics, such as ampicillin and ○ Positive Brudzinski
sensitivity studies, is the primary therapy. cephalosporins, that are effective against group B streptococcal ○ Kernig sign
○ Intrathecal injections (directly into the CSF) may also be infections. ● Child will eventually become lethargic or comatose.
necessary, especially because the blood– brain barrier may ● It can be difficult for parents to understand how their infant ● Diagnosis:
prevent the chosen antibiotic from passing freely into the CSF. suddenly became so ill. They may need considerable support in ○ History
○ In some children, it takes a month before the CSF cell count caring for the infant if the infant is left neurologically challenged. ○ Physical Assessment
returns to normal. ● CSF (Cerebrospinal Fluid) Evaluation will reveal:
○ A corticosteroid such as dexamethasone or the osmotic Encephalitis ○ Increase leukocyte count
diuretic mannitol may be administered to reduce ICP and ● It is an inflammation of the brain tissue and possibly the meninges ○ increase protein level
help prevent hearing loss. as well. ● EEG (Electroencephalogram Test) will demonstrate:
○ In addition to standard precautions, children with meningitis ● Causes: ○ Wide-spread cerebral movement
are placed on respiratory precautions for 24 hours after the ○ It is caused by protozoan, bacterial, fungal or viral invasions. ○ Brain biopsy (usual taken on temporal lobe or infected CSF
which can identify the said virus)
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UNIT 13 (Week 14)
● Management: ● Diagnostic Test: Electromyography, to support the diagnosis ● Difficult to recognize specially consists only twitching of the head,
○ Give antipyretic if having febrile episodes to control the fever. ● Treatment: Human derived botulinum immune globulin may stop arms, eyes, smacking of the lips slight, cyanosis and apnea or
○ Examples: Aeknil, IVTT (Intravenous Therapy) the progress of disease respiratory difficulties
● Mechanical ventilator to maintain the child’s respiration during the ● The infant may appear limp and flaccid where area seizure older
acute phase Epilepsy (Recurrent Seizures) children are often of unknown causes
● Different Medications: ● It is ordered that occurs suddenly and recurrently we call that one ● 75% of seizures in neonates have unknown causes such as trauma
○ Zovirax (Acyclovir): An antiviral medication as your paroxysmal disorder and anoxia phramda intrauterine life or new birth
○ Carbamazepine (Tegretol): An anticonvulsant ● Under your paroxysmal disorder is your seizure/epilepsy ● Metabolic disorders such as hypoglycemia, hypocalcemia, lack of
○ Dexamethasone: A steroid Pyridoxine or vitamin B6
○ Mannitol: An osmotic diuretic medication for brain edema. Seizure ● Neonatal infections are acute bilirubin encephalopathy caused by
● The child may recover from initial attack without further ● It is an involuntary contraction of muscle caused by abnormal blood incompatibility, because of nervous system immaturity EEGs
symptoms but there is a residual neurological damage. electrical brain discharges in the newborn may be normal despite extensive disease. You
● 5% of children will have at least 1 seizure by the time they reach need to notice the abnormal EEG of the newborn, therefore
Reye’s Syndrome adulthood. generally means a poor prognosis indicating that involvement
● An acute encephalopathy with accompanying fatty infiltration of ● These episodes of seizures are very frightening to the parents. early in life must be very severe especially intrauterine anoxia
the liver, heart, skeletal muscles, lungs and pancreas. ● 50% of seizures are idiopathic or unknown cause they also can be because almost 20% of all newborn have abnormal CSF values
● Mostly occurs in children ages 1-18 years old (regardless of attributed to trauma, tumor growth especially inside the brain, compared to adult standards, protein is increased and there may
gender) infection. be few red blood cells. From rupture of your subarachnoid
● Cause is unknown ● Familiarity with polygenic kit inheritance may be responsible, they capillaries from the pressure of birth. Your lumbar puncture is also
● Symptoms: Lethargy, Confusion, Vomiting and combativeness are not so much a disease as a symptom of underlying this or not conclusive.
usually occur after a viral infection. You will be infected with there. ● Treatment: High doses of your anti-seizure medication may be
Chickenpox or varicella if the mother gave the child aspirin ● All seizures need to investigated of the root cause of this disease needed to control seizures especially newborns because
(acetylsalicylic acid). metabolize drugs more rapidly than older children
● Because of chicken pox + aspirin = develops Reye’s Syndrome Epilepsy ● For Adults: Phenobarbital may be administered in a range of
● Chicken pox was treated with acetylsalicylic acid, treatment is ● Comes from the Greek word __(1:32:00) take hold of, because the 1.5mg/kg per day
supportive but untreated the condition leads to coma/death. You word has a stigma of cognitive challenge, the institutionalization ● For Newborns: As high as 3-10mg/kg per day
need anticipatory guidance to parents and children to avoid use of or behavioral disorders or unexplainable strangeness attached to it
aspirin during any viral infection. As almost prevented this kind of especially the stigma labeled to the patients who are diagnosed Seizures in the Infant and Toddler Periods
syndrome. with epilepsy. ● Crucial age group
● This term explains the disease process without the effect of ● Infantile spasms which is a form of generalized seizure often called
Botulism discrimination, epilepsy or recurrent seizures for this types and salaam or jackknife seizures or infantile myoclonic seizures
● Is caused by the spores of Clostridium botulinum which is causes vary with age and classified into ● Characteristics: Very rapid movements of the trunk, with sudden
colonized and produce toxins in the intestine ● Two Major Categories: Partial, which the seizure only 1 area of the strong contractions of most of the pathy including: flexion,
● Infant with botulism is not transmitted from person to person brain. Generalized seizure the disturbance appears to involve the abduction of the limbs or the infant suddenly slams forward from
occurs predominantly in infants younger than 6 months of age entire brain there would be loss of consciousness. sitting position or falls from standing position.
● Cause: Honey is the identified root of this disorder, which should ● Be differentiated by their degree of severity type, so that the ● This episode occurs singly or clusters as frequently, a hundred
not be given prior to 12 months of age parents can know how to manage their children and the special times a day.
● If nag eat na in the 7month, avoid giving honey, most common precautions they need for appropriate drug therapy and approach ● 50% of the affected children have an identifiable cause such as
cause of this disease of the child. your trauma, metabolic disease: phenylketonuria, viral invasion:
● Symptoms: Hypotonia, restlessness, weakness, weak cry, diminish herpes or cytomegalovirus.
gag reflex, followed by a flaccid paralysis, bulbar muscles that Seizures in the Newborn Period ● For children the spasm apparently results from failure of normal
leads to diminish respiratory function organized electrical activity in the brain. Approximately 90% of
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UNIT 13 (Week 14)
infants with this type of involvement will be developmentally ○ EEG tracing usually is normal. There usually is a history of ■ In addition, alcohol can be absorbed by the skin or the
delayed as intellectual development appears to halt and even other family members having had similar seizures. fumes can be inhaled in toxic amounts, compounding the
regress after the patterns of seizures begin. ○ Febrile seizures usually occur to you at a sudden spike of child's problems.
● Most children with infantile spasm show high amplitude slow temperature. The seizure only lasts 1 to 2 minutes or less. ■ Parents should not attempt to give oral medications such
waves and spikes a chaotic discharge called hypsarrhythmia on an ○ Such seizures must be taken seriously, however, and as acetaminophen because the child will be in a drowsy
EEG tracing. investigated for possible cause because meningitis often or postictal state after the seizure and might aspirate the
● For seizures caused by poisoning or drugs, possibly poisoning has manifests initially with high fever and a seizure. medicine.
to be considered in any children was a first seizure attack although ○ Prevention of Febrile Seizures: ■ If attempts to reduce the child’s temperature by sponging
most likely to occur between 6 months to 3 years of age must be ■ Because the seizures arise with high fever, they are are unsuccessful, advise parents to put cool wash clothes
consider again in adolescents when drugs will be intentionally self- largely preventable. on child’s forehead , axillary, and groin areas and
administered ■ If acetaminophen or ibuprofen is given to keep a transport the child, lightly clothed to a health care facility
● Seizures also can be late symptom encephalopathy caused by lead developing fever below 101 Fahrenheit or 38.4 C, seizures for immediate evaluation
of your lead poisoning rarely occur. ● Complex Partial (Psychomotor or Temporal Lobe) Seizures
● Because of the response to treatment with anti-seizure therapy ■ They happen most often when a child develops a fever at ○ More than half of the children who develop recurrent seizures
tends to be poor Parenteral Adrenocorticotropic Hormone (ACTH) night when a parent is not aware of it, when a parent is during school age have had an idiopathic type- the cause of
therapy also your prednisone or high dose of vigabatrin, an amino reluctant to give acetaminophen in large enough doses to the seizures cannot be discovered.
acid, are used in its place. be therapeutic. ○ Nevertheless, medication can control idiopathic seizures in
● High dose of valproate or newer anti-seizure agents such as: ■ Although this type of seizure can be prevented by almost all affected children.
topiramate or Topamax may be used in children who do not phenobarbital, prophylactic use during an appearance of ○ Other seizures in this age group occur because of organic
respond to usual therapy as well as your pyridoxine vitamin B6 or respiratory tract infection is not recommended because causes, usually from focal or diffuse brain injury that has left
ketogenic diet. phenobarbital takes 2 to 3 days to reach therapeutic residual damage. The injury may have been caused by
● But research shows non to be as effective as your ACTH treatment blood levels. By this time the seizures would already have laceration of brain tissue in an automobile accident or fall
specially for preserving neuro developmental outcomes in occurred. hemorrhage due to a blood dyscrasia, infection such as
children. ■ In addition, phenobarbital is associated with sleepiness meningitis or encephalitis, anoxia, or toxic conditions such as
● Any associated cognitive or developmental delay remains however which possibly reduces cognitive function in children. lead poisoning.
children need good follow up planning and care, really need of ■ If a second febrile seizure occurs diazepam (valium) may ○ The possibility that a growing brain tumour is causing brain
assistance with the significant other especially if this age group the be prescribed for patients to administer the next time the irritation also must be considered.
mother child has a high fever. ○ It varies greatly in extent and symptoms and tends to be the
■ A good rule is to assume that the child in this situation most difficult type to control.
Seizures in Children Older Than 3 Years Old has meningitis until it is ruled out by a complete ○ The child may have a slight aura, but it is rarely as definite as
Types are dependent on the cause of the episode: neurologic workup. that scene with tonic-clonic seizures.
● Febrile Seizures ■ Lumbar puncture will be done to rule out meningitis. ○ Results of a CT or MRI scan and EEG are invariably normal.
○ Caused by a febrile episode or high fever around 102 to 104 F ○ Therapeutic Management: ○ This type of seizure may begin with a sudden change in
(38.9 to 40 degrees Celsius). ■ Teach parents that after a seizure subsides, to sponge the posture, such as an arm drooping suddenly to the side.
○ Most common type seen in preschool children (5 months to 5 child with tepid water to reduce the fever quickly. ○ Other motor, sensory, and behavioral signs may include
years). ■ Advise them not to put the child in the bathtub or automatisms (complex purposeless movements, such as lip
○ Although these can occur as early as 3 months or as late as 7 because it would be easy for the child to slip underwater smacking her fumbling hand movements). The child then
years of age. should a second seizure occur. slumps to the ground , and is conscious.
○ Febrile seizure may occur after immunization because of an ■ Applying alcohol or cold water is not advisable. Extreme ○ Circumoral pallor may develop due to a halt in respirations.
accompanying fever. cooling causes shock to an immature nervous system. ○ The child usually regains consciousness in less than 5 minutes.
○ Seizures show active tonic-clonic patterns which last for 15 to He or she may feel slightly drowsy afterward but does not
20 seconds. have an actual postictal stage as in tonic clonic seizures.
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UNIT 13 (Week 14)
○ Management: ○ They generally have normal intelligence , however, if they ● Parents may observe simply that their child is acting
■ Common drugs used to treat this type of seizure include have frequent episodes, they may be doing poorly in school differently than usual.
carbamazepine (tegretol), valproic acid (depakine), because they are missing instructional content. ● As a child reaches school age, the child may be able
phenytoin (Dilantin), phenobarbital. ○ Absence seizures can usually be demonstrated in children by to predict from these vague previous preliminary
■ Carbamazepine can lead to neutropenia, so white blood asking them to hyperventilate and count out loud. If they are feelings when a seizure is about to occur.
cell counts need to be monitored during therapy. If these susceptible to such seizures, they will breathe in and out 2. Aura, or second phase. May reflect the portion of the
drugs are not effective, surgery to remove epileptogenic deeply, possibly 10 times, stop and stare for three seconds, brain in which the seizure originates.
focus or implantation of vagus nerve stimulator can then continue to hyperventilate and count, unaware that they ● Smelling unpleasant odor (often reported as feces)
significantly reduce seizure frequency. paused. denotes activity in the medial portion of the
● Partial (Focal) Seizures ○ Management: temporal lobe.
○ Partial seizure originates from a specific brain area. ■ Seizures can be controlled by ethosuximide (Zarontin), ● Seeing flashing lights suggests the occipital area;
○ A typical partial seizure with motor signs begins in the fingers sodium valproate, or lamotrigine. No first aid measures Repeated hallucinations arise from the temporal
and spreads to the wrist, arm, and face in a clonic contraction. are necessary for absence seizures. lobe; numbness of an extremity relates to the
○ If the movement remains localized, there will be no loss of ■ If seizures are fully controlled by medication, children can opposite parietal lobe; and a “Cheshire-cat grin”
consciousness. participate in normal school activities and ride a bicycle relates to the frontal lobe.
○ If the spread is extensive, the seizure becomes generalized or motorcycle. ● Young children, unable to describe or understand an
and then is impossible to differentiate from tonic-clonic ■ If seizures cannot be controlled fully, parents need to aura, may exactly screen in fright or run to their
seizure. anticipate potentially hazardous situations during the parents with its onset.
○ Therefore, it is important to observe children carefully as child's day, such as crossing a busy street on the way to 3. The third phase is the tonic stage. All muscles of the body
seizure begins to distinguish this type. school or learning. contract, and the child falls to the ground.
○ A partial seizure with sensory signs may include numbness, ■ Approximately 1/3 to 1/2 of the children with absent ● Extremities stiffen; the face distorts. Although this
tingling, paresthesia, or pain originating in one area and seizures outgrow them by adulthood. This does not mean phase lasts only about 20 seconds, the respiratory
spreading to the other parts of the body. that treatment is not necessary during childhood, muscles are contracted, so the child may experience
○ These types of seizures may be caused by a rapidly growing however in order to keep the child safe and maintain self hypoxia and turn cyanotic.
brain tumour. esteem. ● Contraction of the throat prevents swallowing, some
○ Documenting the spread can help localize a spot in the brain ■ Absence seizures usually occur independently of tonic saliva collects in the mouth.
that first initiated the abnormal electrical discharge. clonic seizures, although it is possible for a child to ● The child may bite the tongue when the jaws
● Absence Seizures manifest both types. contract.
○ Generalized seizure formerly known as “petit mal” seizures. ■ Some children's seizure pattern changes from absence ● As the chest muscles contract initially, air is pushed
○ More often in girls than boys. involvement to tonic clonic involvement as they approach through the glottis, producing guttural cry.
○ A child might be reciting in class when he pauses and stares adulthood. ● The seizure then enters a clonic stage, in which
for 1 to 5 seconds before continuing the recitation and he is ● Tonic-Clonic Seizures muscles of the body rapidly contract and relax,
unaware that the time has passed. ○ Typical tonic-clonic seizures formerly known as “grand mal producing quick jerky motions.
○ Rhythmic blinking and twitching of the mouth or an extremity seizures.” ● The child may blow bubbles or foamy saliva and, if
may accompany the staring. ○ Generalized seizures consisting of four stages. There may be a the tongue was bitten when the jaw shut with a
○ The usual age of occurrence is 6 to 7 years. prodromal period of hours or days; aura or warning spasm, saliva will be bloody.
○ Absence seizures can occur up to 100 times per day. immediately before the seizure; the tonic clonic stage; and, ● A child will be incontinent of stool and urine. This
○ Children with absence episodes may be accused of finally a postictal stage. Not all four stages occur with every phase usually lasts 20 to 30 seconds.
daydreaming in school and maybe referred to the school seizure. 4. Postictal Period. After the tonic-clonic period, the child
nurse for behavioral problems. ○ Stages: falls into a sound sleep called the “postictal period.”
1. Prodromal period. May consist of drowsiness, dizziness, ○ He will sleep soundly for 1 to 4 hours and will arouse
malaise, lack of coordination, or tension. only painful stimuli during this time.
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UNIT 13 (Week 14)
○ When he awakens, he often experiences a severe ■ Parents may administer diazepam by enema at home. ■ Children may be unable to move their eyes or follow
headache. He has no memory of the seizure. ■ Lorazepam (Ativan), long acting benzodiazepines used for movement through visual fields
○ Seizures may only occur at night. The child wakes in children all day than 2 years of age, provides longer ■ Changes of the eyes would be conjunctival telangiectasia
the morning with a bitten tongue, blood on the duration of action and less respiratory depression. developed by five years of age
pillow, or a bed wet with urine. In a child with ■ Newer drugs that may be also included are topiramate ● Friedreich Ataxia
persistent bedwetting, the possibility of nocturnal (Topamax), lamotrigine (Lamictal), and tiagabine ○ Carried on the short arm of chromosome 9, which is an
seizures must be considered. (Gabitril). autosomal recessive trait.
○ Children with this type of seizure have an abnormal ○ These are a variety of degenerative symptoms.
EEG pattern. Ataxic Disorders ○ It progresses from cerebellar and spinal cord dysfunction
○ Management: ● Failure of muscle or muscular coordination or irregularity of a which occur in late adolescence. Teenagers develop
■ Daily administration of an anticonvulsant such as muscle action progressive gait disturbance and lack of coordinated arm
valproic acid (depakene) and carbamazepine ● Manifested by an awkward gait or lack of coordination movements.
(Tegretol). ● Causes of ataxia really differ but degeneration of cerebellar or ○ A high arch foot which is referred to as the pes cavus would
■ Children with tonic clonic seizures also may be vestibular function is always involved with this disorder most likely to occur, as well as hammer toes, and scoliosis.
given phenytoin sodium (dilantin) as first ● Ataxia-Telangiectasia ○ The combined symptoms of positive Babinski reflex, absence
control. ○ Transmitted as an autosomal recessive trait attributed to a of deep tendon reflexes in the ankle, and ataxia are strongly
■ Phenobarbital doses should be tapered, never defect of chromosome 11 diagnostic.
stopped suddenly, because the body becomes ○ It is a primary immunodeficiency disorder associated in ○ The examination shows difficulty in recognizing foot positions,
dependent on it. Rapid withdrawal may progressive cerebellar degeneration. whether the foot is moved up or down.
precipitate a seizure. ○ Multi-system disease with neurological and immunological ○ Ataxia remains untreated up until now that occurs in young
■ Medications are usually continued until the child aspects adulthood from myocardial failure.
has been seizure free for 2 to 3 years. ○ With the endocrine abnormalities, it really occurs in this kind ○ Antioxidant therapy may help delay this outcome by reducing
■ Some children are prescribed a ketogenic diet of disease, with an increased risk in cancer as well ventricular hypertrophy.
(high in fat and low in protein and (particularly brain tumor).
carbohydrate). ○ Telangiectasias are red vascular markings that appear on the
● Status Epilepticus conjunctiva, and skin at the flexor creases.
○ Refers to a seizure that lasts continuously for longer than 30 ○ With both the neurological and immunological symptoms vary
minutes or a series of seizures from which the child does not in severity and onset. We have the serum immunoglobulin A
return to the previous level of consciousness . (IgA) and immunoglobulin E (IgE). Levels may be low and
○ This is an emergency situation requiring immediate there is often evidence of reduced level of T cell function.
treatment. Otherwise, exhaustion, respiratory failure, ○ With the children having this disorder, frequent infections,
permanent brain injury, or death may occur. primarily sinopulmonary will most likely to occur due to the
○ Management: immunologic defects with the tonsillar tissue in the pharynx
■ Oxygen may be necessary to relieve cyanosis. which appears cant(?)
■ An IV benzodiazepine such as diazepam (valium) or ○ Symptoms of Degeneration:
lorazepam (Ativan) halts seizures dramatically. ■ Processes can usually be detected early in infancy when
■ This may be followed by IV phenobarbital or phenytoin developed mental milestones are not yet met.
(dilantin). ■ Children develop an awkward gait (choreoathetosis)
■ Diazepam must be administered with extreme caution, when they begin to walk. Choreoathetosis is a rapid
because the drug is incompatible with many other purposeless movement.
medications, and accidental infiltration into ■ Nystagmus and tension tremor
subcutaneous tissue causes extensive tissue sloughing. ■ Scoliosis
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UNIT 14 (Week 15)
● Break the continuity or structure of bone. Especially, during the with osteomyelitis, has the potential to also threaten bone
PEDIATRIC VARIATIONS AND NURSING CARE OF THE CHILD WITH A
child's period. We have here, allowing the child to grow (bone growth. Although it is easy to think of bones as rigid, they are
MUSCULOSKELETAL DISORDER
growth). But in children, the most frequent disorders of the really rigid (what mssss?? HAHAHA). Also a solid structure. In fact,
Mygel 1-3 (Done) musculoskeletal is usually in children than in adults. active living tissue to which nutrients must be supplied for growth.
Pain is the common complaint of patients who suffer with ● Heal much more quickly than fractures in adults The number 1 component to bone which is very important is
musculoskeletal disorders. Unlike any other diseases in children, ● If the fracture is situated in the Epiphysis or growth plate, calcium.
disorders of the musculoskeletal system usually manifest specific fracture-cause serious complication or deformity. ● Calcium - Main components of bone
localized symptoms. Therefore, parents usually bring children to ● Ik wa mo kasabot kay same, nalibog sad ko ni ms haha ● Remodeling (replacement old-new bone tissue)
healthcare facilities early in the course of such illnesses. Disorders of ● Resorption - Bone breakdown. The process strongly influenced
the muscles or joints however, such as juvenile idiopathic arthritis may vitamin D… so the parathyroid hormone. The age of the bone of
Anatomy and Physiology Overview of Musculoskeletal Function
manifest insidiously. When the disorder is diagnosed, parents may feel the children can be determined by an x-ray of the wrist that shows
guilty for not having sought healthcare. One condition whose Bones and Bone Growth the ossification level of the bone.
seriousness where parents underestimate is a childhood limp. A limp is ● Long-Extremities ● Red Bone Marrow - Produces RBC
never normal, it may be the first manifestation of a serious hip or knee ● Short-wrist or ankle ● Yellow Bone Marrow - Adipose tissue (fat cells). The blood supply
problem. When weighing or measuring children at healthcare visits, ● Flat-skull, ribs, scapula, and clavicle to the bone is abundant so that the marrow can actively supply
take the opportunity to assess for gait of the child. With proper ● Irregular-vertebrae, pelvis, and facial bones of the skull enough blood components for the entire body as with other
assessment, proper diagnosis may be given to the child. tissues. If the blood supply is cut off, bone cells die and blood cell
Bone Anatomy production is hindered. We also have muscles which are
Musculoskeletal System composed of striated muscle. Differentiated from smooth muscle
● It is an organ system that gives us humans the ability to move found in body organs which is responsible for some activities such
using the muscular and skeletal systems which give us support and as intestinal peristalsis. The activation of your skeletal muscles is
stability, movement of the whole body. under voluntary control. We have the term myopathy, which is the
● It is made of the body bones, the skeletal muscles, cartilage, disease of the muscular system that can be inherited as in
tendons, ligaments, joints, and other connective tissue that muscular dystrophy or acquired in myostiniographs?? (inaudible).
supports and binds tissue organs together. ● Ik wa nagkadimao ang grammar pero ako ra gisunod si ms, sabta
nalang ahaha :*
Skeletal System specifically,
● It is composed of 200 bones connected by joints and tendons
Assessment of Musculoskeletal Function
which provides the central casing or protective armor for the
organs of the body. Shannen 4-6 (Done)
● It supplies the body with red and white blood cells grown in the In addition to a history and physical examination, diagnostic tests
central marrow. frequently are necessary to detect musculoskeletal dysfunction in
● Skeletal muscles which are attached to the bones by connective ● Diaphysis - Lengthy central shaft children. These may include x-ray and bone scans, bone and muscle
tissue, tendons, and ligaments, allow for voluntary movement ● Epiphysis - Rounded end portion of the bone biopsies, electromyography, and arthroscopy. Ultrasound and magnetic
● It also includes gross motor activities such as running; fine motor ● Metaphysis - Thin area between them resonance imagining (MRI) studies are also used to reveal soft tissue
activities such as writing. ● Cartilage - Connective tissues segment studies. Parents and children are adjusting because of the poor
● Together, the skeletal muscular system both supports the body ● Epiphyseal plate - Between epiphysis and metaphysis. Injury to acceptance of the condition.
and makes coordinated movements possible. this area in a growing child is always potentially serious because it
may stimulate abnormal growth or cause irregular growth. Radiography
● Periosteum - Outer sensitive layer. Bone with increase by growth ● Because bones are opaque, they outline well on radiography.
Childhood Fractures
in the inner surface by this… Injury to the periosteum may occur Information can be provided about a specific bone, groups of

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UNIT 14 (Week 15)
bones, or a joint Radiograph can also provide information about ● Muscle biopsy is usually done using conscious sedation and a local large body cast is being applied like body or hip spica cast, mas
soft tissue structure, swelling or calcification around bones. anesthetic. If local anesthetic is used, caution children that they daghan nga tao ang needed, children may be positioned in a
However, other tests are indicated to confirm problems with will feel the initial prick of an anesthetizing needle. As the actual special cast table with traction apparatus at the chin and pelvis to
cartilage, tendons, and ligaments. biopsy needle enters the muscle mass, they will feel an additional initiate tension.
momentary pressure. They can be assured that the amount of ● Most children are unaware that casts are formed from strips or
Bone Scan (Scintigraphy) tissue taken from them is no larger than the inner bore of the rolls impregnated with the casting material. The normal curiosity
● Study of the uptake by bone of intravenously injected radioactive biopsy needle, comparable to the size of the lead in a pencil. of children as they watch a cast grow and mold to their body part
substances. makes casting a pleasant procedure.
● This distribution and concentration of the substance are evaluated Arthroscopy ● Before a cast is applied, a stockinette is stretched over the area,
to determine the exact problem. ● Involves direct visualization of a joint with a fiber optic and soft cotton padding is placed over the bony prominences.
● Areas of increased metabolic activity caused the substance to instrument. This stockinette is pulled up and over the raw edges of the cast as
concentrate in that area. ● Allows a Joint, commonly the knee also hip, shoulder, wrist, to be it is applied to create a smooth, padded surface.
● A bone scan provides information on very early stages of bone examined without large incision. ● If a plaster cast is to be applied, caution children that at first the
disease and healing, often before they are visible on radiographs. ● It is usually done under local anesthesia in an ambulatory care wet stripes of plaster of paris feels cool.
setting. ● Proper handling should be observed, not water spill should be put
Electromyography ● It is most often used to diagnose athletic injuries and to on the casted site. Also if it is a body or hip spica cast, they should
● Studies electrical activity of the skeletal muscle and nerve differentiate between acute and chronic joint disorders. really put a room or a window.
conduction to determine location and cause disorders such as ● Almost immediately, the strips begin to generate heat as
Myasthenia gravis, muscular dystrophy, lower motor neuron and evaporation begins, and the body feels warm. If the cast is a full
Therapeutic Management of Musculoskeletal Disorders in Children
peripheral nerve d/o. body cast, children may become uncomfortably warm, with
● Oscilloscope screen - Fasciculations and noises Various methods may be used for therapy for children with perspiration possibly running from their forehead. Assure them
● Needle electrodes are inserted into muscle masses; electrical musculoskeletal disorders, including casting, traction, distraction and that this feeling of warmth is transient.
activity of the muscle at rest and in motion is detected by audio open reduction. Amputation is a rare necessity for children. ● 5-30 minutes to dry
amplification and recorded on an oscilloscope screen. Normally,
resting muscle is quiet. If defects and fasciculations are present, Casting - Used to treat a wide range of musculoskeletal disorders from Plaster Cast - 10 – 72 hours to dry
abnormal noises or oscilloscope spikes will be observed. simple fractures to correction of congenital deformity or correction of
● Although the needle electrodes are small, the test may be congenital structural bone disorders. Window - Placed when infection is suspected, so that the area can be
frightening for children because they are pricked by needles. They observed.
need support from someone they know during the procedure. Cast Application - Created from either Plaster of Paris or Fiberglass
Before and after the procedure, provide opportunities for Body or Hip Spica Cast - Window prevent uncomfortable abdominal
therapeutic play so a child can express anxiety and feelings. Fiberglass distention and allow bowel sounds to be assessed
● Attractive material for children, light in weight and waterproof.
Muscle or Bone Biopsy ● Attractive material to use in children’s casts because it is light in Slides 7-9 Mary (Done)
● Involve removal of a tissue sample for examination of its weight, comes in attractive colors, and when a special waterproof Compartment Syndrome
microscopic structure. liner is used, it can be immersed in water. ● Phenomena that can occur when a cast or tight, constrictive
● Identifies information, malignant bone growth, inflammation and ● Unfortunately, it is more expensive and may not be practical for dressing puts pressure on an enclosed space.
atrophy. casts that need frequent changing, such as those to correct talipes ● After casting, you need to reassess and keep the casted area
● It can provide evidence about infection, malignant bone growth, disorders, a common congenital disorder that requires casting. elevated with a pillow to prevent edema. Check the circulation
inflammation, or atrophy in the area. Either type may be done ● Children need an explanation of what to expect with casting. To every 15 minutes during the first hour, hourly for the next 4 hours,
during surgery or as an ambulatory procedure. maintain alignment of body parts, a physician gently exerts a pull and then every 4 hours throughout the first day.
on the body part being casted during the cast application. If a ● What are we going to assess in the casted sight?

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UNIT 14 (Week 15)
○ Assess the color, especially that is why we have a window or ● Many children report a sensation of itching inside a cast about the
we never really cast the whole affected extremity. We give end of the first week. If the area is immediately under the edge of
room to reassess the color, warmth, presence of pedal or the cast, the itching is probably the result of dry skin caused by
radial pulses and sensations of numbness or tingling. the drying effect of the cast. Reaching a hand under the edge of
○ Signs of impaired neurovascular function include the 5 Ps the cast and massaging the area usually relieves the itching.
(Pallor including blueness or coldness of the distal part, Applying hand lotion may relieve the dryness. If the area is
Pulselessness, Pain in the casted part, Paresthesia or unreachable, blowing cool air through the cast with a fan or a hair
numbness or tingling in the part as if it were “asleep,” dryer set on cool air may relieve the uncomfortable feeling.
Paralysis). Caution both the child and parents not to use implements such as
○ Children younger than 6 or 7 years of age have difficulty a coat hanger or knitting needle to scratch the area. These can
describing paresthesia (so you need to explain to them); injure the skin, causing an infection under the cast.
however, they may whine or cry with the discomfort of the
sensation. Edema that does not improve with elevation is also Cast Removal
an important sign. Any of these symptoms requires ● Most cases remain in place for 4 to 8 weeks and are then removed
immediate attention because neurovascular impairment can using an electric cast cutter with a rapidly vibrating, circular disk.
lead to nerve ischemia and destruction. ● Surgical opening of the compartment. Cast cutters are frightening because the disk makes a very loud
■ So with the casted area, we need to put very light ● Really important in opening the casted area that is very noise as it cuts through the cast material and also generates heat.
pressure. That is why when we first casted the area, we compressed, so that there would be no necrosis in the affected To the child, the disk appears capable of cutting through not only
put a tube of ? to aid the pressure that we put in the area with Compartment Syndrome. the plaster but also an arm or leg as well. The person removing
fiber glass or your plaster of paris. Too much pressure can ● In addition to casting, we need to have proper handling, especially the cast usually demonstrates that the disk does not cut skin by
result in severely decreased blood flow that potentially with these children. Handling a child in a large cast can seem so touching a thumb to the edge of it. Not all children are totally
threatens and damages the nerve and necrosis of the overwhelming for parents that they do not see how they will be convinced by the demonstration, however, may require additional
surrounding soft tissues. able to care for their child at home. Assure them the child is quite support while the disk movies from one end of a cast to the other,
○ Pathophysiology remains uncertain, although mechanisms comfortable in the cast despite its awkward, constricting such as saying, “It’s all right to cry; I know this looks scary” or by
involving artery compression involve injury, damage, or appearance. Role model moving the child to show them that it is holding your hands over the child’s ears to lessen the noise.
arteries with inadequate collateral circulation which can lead not an impossible task. Be sure to caution them that if an ● The skin of the child’s extremity looks macerated and dirty after a
to decreased perfusion and ischemia of both capillaries and abduction bar is used with a cast, it must never be used as a cast is removed; a good bath usually washes away most of this. If
muscles, resulting in increased permeability of capillary walls handle for lifting. Such use can break the bar from the cast or an arm has been casted in flexion, the elbow may feel stiff and
that ultimately causes edema. weaken its support. even sore when the child is asked to extend it for the first time.
○ Assess the site after casting. ● Parents may need to use good body mechanics (lift with the Children often continue to use extremities with caution after a
thighs, not the back) when turning or positioning the child in a cast has been removed. Advise parents to allow children to begin
Fasciotomy full-body cast. They may appreciate suggestions on ways to move using extremities again at their own pace. As children naturally
the child from room to room, such as using a toy wagon with a flat play and reach for objects, they gradually forget to favor the arm
board on top or using a skateboard for children to propel or leg, and full function then returns. Once healing has taken
themselves forward. place, the extremity is as strong as it was before the fracture. The
● Point out that all children thrive on being touched. Children in child does not need to continue to favor the extremity to protect it
large body casts need their head and arms stroked (or any areas of from a second fracture.
the body that are not covered by the cast) so they receive this.
Demonstrate how even a child in a large hip spica cast can be held, Medical Boots (Fracture Boots) or Splints
cuddled, and supported for feeding. In some instances, a fracture does not require a cast for immobility but
can be immobilized by a supportive boot or splint. The child wears the

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boot or arm splint continuously as if it were a cast; an advantage is parents to clear articles such as throw rugs, small footstools, or (good) foot forward and down to that step. To go upstairs, they
that, if a complication should occur, it can be readily removed by its toys out of paths at home. place their unaffected (good) foot on the elevated step and then
Velcro attachments. Ask at return appointments if children who are raise the crutches onto the step and lift themselves up. To help
prescribed boots or splints are wearing the immobilizer continually. Be Crutch Walking children remember this pattern, the following saying can be
certain children who say they take them off “a little” are not actually taught: “Angels” (the good foot) go up; “devils” (the bad foot
describing taking them off often and, therefore, are not receiving the with the crutches) go down.
support necessary for effective bone healing.
Slides 10-12 Chloe (Done)
Crutches Traction
Are prescribed for children for one of three reasons: ● Next therapeutic management is the traction. This is a very unique
● To keep weight off one or both legs, way of doing therapeutics with your patient because with traction,
● To support weakened legs, or we have pulleys, we have to balance everything to the patient.
● To maintain balance. ● Reduce dislocation and immobilize fractures, involves pulling of
Usually, a physical therapist measures crutch length and gives body part in one direction against a counter pull exerted in the
beginning instruction in crutch walking. Being familiar with how opposite direction
crutches are measured and having crutch walking supervised not only
allows you to offer emotional support to children as they learn to use Types of Traction
crutches but also helps you assess progress at follow-up visits. 1. Skin Traction
● Child’s extremity is wrapped in a material such as an elastic
Fit and Adjustment bandage and then suspended from a nearby pole or frame.
● If crutches are properly fitted, there should be a space of 1 to 1.5 ● Used if minimal traction is necessary. The child’s skin must be
inches between the axilla crutch pad and the child’s axilla. When in good condition for this procedure. On the other hand, use
the child stands upright and places his hands on the hand rests of ● Two main crutch-walking patterns are used. A two-point gait is skeletal traction for a longer period ang healing process
the crutches, the elbows should flex about 20 degrees. This used when a child needs support for weakened muscles or especially if the fractured area murag greater strength of
degree of flexion ensures that when the child bears weight on the balance but may bear weight on both lower extremities. The child traction is needed.
crutch, the body weight will be borne by the arm, not the axilla. places the right crutch and left foot forward, then the left crutch ● With this type, the use of intramedullary rods is making its
Pressure of a crutch against the axilla could lead to compression and right foot forward, and so on. Using the crutch opposite a foot use unnecessary in many instances. In straight running
and damage of the brachial nerve plexus crossing the axilla, provides a wider base of support than using the crutch next to the traction, the child’s body weight serves as the counterpull. In
resulting in permanent nerve palsy. Teach children not to rest with foot. Caution children to take small steps until they feel confident. suspended or balance tractions, the body part is suspended
the crutch pad pressing on the axilla but to always support their ● A three-point swing-through gait is used when no weight bearing by a sling and a counter pull and primary pull is accomplished
weight at the hand grip. is allowed on one foot. For this, the crutches are both brought by pulleys and weights. Either Skin traction in which skin
● Always assess the tips of the crutches to be certain the rubber tip forward. The weight of the body is then shifted forward as both provides counter pull or skeletal traction, in which bones
is intact and not worn through because the tip prevents the crutch legs are swung through the crutches. The child bears weight on provide the counter pill may be used with this one.
from slipping. Be certain the child is walking with the crutches the unaffected (good) leg and moves the crutches forward again.
placed about 6 inches to the side of the foot. This distance It takes strong arm support to bear full weight on crutches this
furnishes a wide, balanced base for support. way. Be certain the child is bearing weight on the hands and not
● Before discharge from a healthcare facility, explore with children on the axillae. Some children use a swing-through gait rather
any problems crutches may cause with their daily activities. If they recklessly and need to be advised to slow their pace to a safer
carry books to school, for example, they will need to wear a one.
backpack so their hands are free for the hand rests. Caution ● To walk downstairs, using a swing-through gait, children place
their crutches on the lower step and then swing the unaffected

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● The sites are clean using a hydrogen peroxide. Using sterile
technique to keep them free of drainage. Be certain to
observe pin sites daily for drainage because odorous or
excessive drainage or local erythema may be a sign of
infection.
● In caring for patients with both skin or skeletal tractions, you
need to assess for infection in the extremity every 15
minutes. Every 15 minutes for the first hour and in the second
hour would be 24 hours and every 4 hours thereafter for signs
of pallor, lack of warmth, tingling, absence of peripheral
pulses, edema or pain, same as your five P’s in your
compartment syndrome.
Dunlop Traction - More complicated but is also used to immobilize ● Traction can lead to hypertension because the head typically
upper extremity is positioned lower than the lower extremities especially with
the cervical type traction
Example of Skin Traction: ● Be extremely careful in changing bed linens or carrying out
Bryant Traction - Used for fractured femurs in children younger than 2 nursing functions that you do not move the weights or
years of age. Also can be used for preparation of surgical repairs of interfere with the traction.
congenital developmental disorder such as your developmental hip ● Provide good skin care for the child’s back, elbows and heels
dysplasia. This type of traction is used less frequently because it can because they may become irritable from the friction against
cause pulling of the blood downward. the sheets.
● For suspended over the bed, provides great deal of
immobility and assists children using a bedpan in positioning.
● Explain why this type of treatment is best for them.
● Keep parents informed with x ray assessment.
Cervical Skin Traction - 30 degrees angle. This type of traction uses a ● Help children contact their school friends for emotional
halter type device attached to weights and the head of the bed is support.
elevated to provide counter action and instruct the patient regarding
moving. Distraction

Buck Extension - Used in tibial area or femoral. This is used for older 2. Skeletal Traction
children. ● With the use of your pin such as your steinmann pin or your
wire such as your kirschner wire. With this one pass from your
skin into your bone, this is surgically put by the orthopedic
doctors. The pin or wire can be inserted with the emergency
department under local anesthesia. Child can hold absolutely
still but is usually done under local anesthesia in the OR. With
this traction, rope strung over pulleys and attached to
weights, exert the pull in the extremity at the pin site, cotton, Use an external device to separate opposing bones, which encourage
gauze squares are usually placed around the pin on the new bone growth.
outside. The sites are clean so you need to really provide
sterility in handling the surface of the skin of the patient. Ilizarov External Fixator

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UNIT 14 (Week 15)
● Wires that are inserted through the bone attach to the telescoping of the newborn with this kind of disorder and may cause the parents ● As a result of deformity, lung volume is up to be decreased and
rods. Used to lengthen the bone if one limb is shorter than the to view their infant as defective rather than a simple anomaly. Point the heart is displaced to the left
other and used to immobilize fracture or to correct other defects out that it is just only a simple disorder so that the child’s ● Can it be repaired for either cosmetic reasons or physiologic
if bone is rotated or angled. Attached wires with a full or half ring. development, especially the self esteem. Children may need the same reasons such as to expand lung volume?
● For bone lengthening, the rods are adjusted approx. 1 mm each type of assurance as they grow older so they can think of themselves ● It is milder, more on genetics. No dysfunction, especially capacity
day. The device will remain in place until the consolidation is as well people. You really need to instruct the parents so they can of the lungs. If the parents are uncomfortable, they can have it
complete. For parents, they need thorough preparation for the incorporate the it’s okay to have this kind of anomaly because it’s just cosmetically but If the child’s lungs are affected, the child should
surgery. Also explain to the child and how it would look like kay a simple one have a direct surgery.
basin mahadlok unya sila.
● Instruct patients to provide care in adjusting the rods in how to Pectus Carinatum
manipulate the wire insertion sites and restricting activity. ● It is displaced anteriorly
● Ascertain them to have follow up appointments because continue ● Increasing the antero-posterior diameter of the chest
care s very essential to this one ● It can be surgically corrected

Open Reduction
● Surgical technique used to align and repair bone. If there's spinal
Polydactyly
fracture, both bones of the forehead or lower leg fracture.
● Extra digit, no fusion
● With this open reduction completed the area is usually casted
● A presence of one or more additional fingers or toes
provides support. Invariably, at least a small amount of
● When an entire extra finger or toe forms a supernumerary digit is
serosanguineous fluid oozes from the open reduction site into the
usually amputated in infancy or early childhood
cast.
● Extra fingers or toes are just cartilage or skin tags?
● Outline with the ball point pen, any string that suggests oozing
● Removal is simple and cosmetically sound
from surgical incision so that an increase in the size of the marken
be detected. Do not use magic markers for this because the child
Syndactyly
tends to penetrate the cats. Use pen or crayons.
● Fusion of fingers or toes
● Add a time in which you make the mark so you can tell how
● Caused by simple webbing Torticollis (Wry Neck)
rapidly the spot is increasing because children with open
● Separation of digits into two sound in cosmetically peeling once is
reduction are prone to infection so we need to reassess
usually successful
constantly.
● There are instances where bones of the fingers or toes are also
● Be aware os systemic symptoms, increased in temperature,
fused and cosmetic appearance and function cannot be fully
lethargy, pain, tingling, edema, coolness of distal extremity
reconstructed. Case to case basis, we have simple, complex,
● ORIF - Open Reduction Internal Fixator
complicated syndactyly.

Disorders of Bone Development Pectus Excavatum

● Described as funnel chest
Slide 13-15 Hannah (Done) ● Tortus (twisted)
● Indentation of the lower portion of the sternum
Polydactyly and Syndactyly ● Column neck (twisted neck)
● Most common congenital deformity of the anterior chest occurs in
These disorders often, parents get upset when they see an anomaly, ● Is a congenital anomaly when the sternocleidomastoid muscle is
1 out of 500 live births
especially with the fingers which is very important when writing, self injured and bleeds during birth
● Mostly, boys are 4x more often than girls. Concern may be present
care and computing. You should let them view that this is just a simple ● Newborns with wide shoulders, when pressure is exerted in the
at birth but becomes more obvious as the child goes to school or
anomaly. First thing new parents do is really count the fingers and toes head to deliver the shoulder either with vaginal or CS delivery,
adolescent age
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there are really problems with vaginal delivery with these irregularities of calcium or phosphate, metabolism especially forms cram intrauterine. These patients were brought into straight
newborns. We have extension or hyperextension, the process of during pregnancy or while developing the baby inside the utero. position by manual manipulation, without properly aligned or
delivery of the infant Occurs in dominantly inherited traits and occurs more often in further intervention. If pseudo disorder is present, the foot can
● The infant holds the head tilted to the same side as the muscle boys than in girls. For measuring infants head circumference easily be brought into line or is not deformed. Otherwise, the first
that is involved. The chain rotates to the opposite side. during the first 18 months of life is advocated by your American time parents fit booties or shoes to the infant they may notice an
● The injury may not be noticeable with newborns and may become academy of pediatrics. This condition detected early because odd position and worry the foot is miss-hyphen when it is not.
evident only as the original hemorrhage resides and fibrous premature closure of suture line will close the fontanels, seal the Stretching the foot into line everyday will solve the problem in a
contraction occurs. skull close and compromise brain growth short time. Instruct them to have exercise with the affected foot.
● Might it be caused by the way the infant is delivered via NSVD or ● Sagittal closure line is the one that closes prematurely. The child’s ● True talipes d/o can be one of the 4 separate types:
CS delivery. The way of handling. That is why we have a specialist. head tends to grow anteriorly and posteriorly if the coronal suture ○ Plantar flexion
Midwives could also do deliveries but they are highly trained and line infuses early. The orbits of the eyes become miss hyphen(?) ○ Equinus/ horse foot – forefoot lower than the heel
licensed to do deliveries because might it be a cause of the way and the increased intracranial pressure may lead to eye disorders ○ Dorsiflexion – heel is held lower than the forefoot or the
they handle the neck of the child such as your exophthalmos, nystagmus, pupil edema, strabismus, anterior foot is flexed toward the anterior leg
● To relieve the torticollis, parents need to begin a program of optic nerve with consequence of loss of vision ○ Varus deviation – foot turns inward
passive stretching exercises and also therapy. Laying the infant on ● Fourth premature closure of the coronal suture line is associated ○ Valgus deviation – foot turns outward
a flat surface and rotating the head though a full range of motion. with syndactyly therefore make up the point of well child. ● In children with talipes deformities have a combination of these
Proper therapy, especially the neck, is affected. We really need a ● Assessment to observe the head circumference for all infants symptoms. Conditions have an equino-varus, calcaneovalgus
physical therapist involving the treatment or the therapy of the having this disorder especially those with syndactyly. disorder (child walks on heel with foot everted). We really need to
infant ● There could also be a cardiac anomaly, choanal atresia, can also be have an initial assessment earlier to recognize the disorder. The
● Always encourage the parents to have the infant to look in the associated better it is recognized earlier, the better the prognosis and the
direction of the affected muscle to exercise the muscle. Also ● It can be diagnosed through x-ray or utz that could reveal the correction may be intervened. Make a habit of strengthening all
holding the child to fill in such a position that a child must look in fused suture line newborn fit to midline as part of initial assessment to detect this
the desired direction. Placing a mobile on a child's crib can ● If the suture line involved is sagittal, treatment may involve only kind of disorder.
encourage the child to look toward the affected side. Speaking to careful observation of the coronal suture line. It will need to be ● Correction is achieved best if it begins in the newborn period. For
handling the child objects is another helpful exercise of the neck surgically open to prevent brain compression and abnormal shape. correction is casted to mold the foot into good alignment as a
Some doctors really have a helmet to aid the closure of ponseti method. Although the disorder involves the ankle, the
Craniosynostosis craniosynostosis but others do an operation especially with those cast or brace extends above the knee to ensure a firm correction
extra bones if frontal more on anomaly, they cut the edges in form of the affected foot
the structure of the skull. ● Casting is important.
● Denis browne splint – The shoes are attached to a metal bar to
Talipes Disorders maintain position or high tap shoes at night for a few more
● Also known as clubfoot (avoid using this word because some months to ensure an effective correction of the talipes foot.
parents may misinterpret this one as permanent crimping too Parents may need to perform passive foot exercises such as pitting
many people) the infant's foot and ankle to a full range of motion several times a
● .With the aid of technology and effective surgery, this can be day for several months. This seems to be a simple maneuver to be
corrected certain to stress the importance of the parents otherwise there
● Latin word “talus” (ankle) and “pes” (foot) are easy exercises to omit when people live or parents are busy.
● Concerns that may remain after surgery include that the child’s Pediatric PT also are part of the interprofessional therapy to assist
● For the premature closure of the suture, especially of the skull, right and left shoe size may vary if the child may have a symmetry rehabilitation at the hospital and also could have been at home.
the brain is not really affected but more on the bones. This may of leg length. Some newborn with this disorder actually have only
occur in the utero or early in infancy because of the rickets or an unusual foot position called pseudo talipes. Most commonly, it

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outward curve and lumbar lordosis or inward curve. Cross motor ● With your developmental hip dysplasia of the hip is fairly common
development may be slowed but intelligence is not affected musculoskeletal in newborns with a percent estimation range of
● Diagnosed by utz or at birth x-ray 1.6 to 28.5 per 1000 infants.
● Comparing the length of extremities, usual length in the average ● With this kind of disorder, mostly the problem is the acetabulum,
child, the arms can be extended to the distance of the mid thigh. a leading cause of orthopedic disability of childhood and adult life
● X-ray reveals abnormal flaring epiphyseal lines. Children in this d/o because it can lead to premature arthritis requiring hip
rarely reach a height of more than 4 ft 6 inches. The Philippines is replacement.
the top shortest dwarfism. ● The disorder is responsible for 28% of hip replacement in people
● Woman with this condition have difficulty in childbearing and can under 60 years of age.
be passed to children if can bear a child ● With this disorder acetabulum ang problem of the pelvis is
● Children become aware of their appearance as early as preschool unusually flattened or shallow this prevents the head of the femur
and school age. Main problem of this d/o is the self esteem of the from remaining in the acetabulum in rotating adequately.
child. The parents play a vital role in developing the self esteem of ● In subluxated hip, the femur rides up because of the flattened
the child in this d/o. Children need to be informed as they reach acetabulum
Achondoplasia adolescence with all the dominantly inherited d/o there is ● In a dislocated hip, the femur rides so far, it actually leaves the
probability that their children will inherit it. acetabulum for the dislocated.
● As nurses we should continue the guidance and counseling can ● Why does the disorder occur? It is unknown but it may be a prom
help them to emerge from this period of feeling of high self polygenic inheritance pattern. With this one, the uterine
esteem up until adulthood positioning causes less than usual pressure of the femur head of
the acetabulum. With this kind of disorder, if breech delivery of
Slide 16-18 Brian (Done) especially female infant and mother’s first pregnancy usually
Developmental Dysplasia of the Hip unilateral found 6 times more frequently in girls than boys
because of the hormone relaxing that causes pelvic ligaments to
be more relaxed during pregnancy which causes the femur to not
press as effectively into the acetabulum during intrauterine life
deepening the space. So we have here for all infants what we call
as ortolani and barlow maneuver. This one is performed to detect
developmental dysplasia of the hip in newborns, important
because the longer the condition goes undetected the more
● Also known as chondrodystrophy or chondrodystrophia which is difficult it is corrected so inspection is very important.
a failure of bone growth inherited as the dominant trait which ● For the affected leg it appears slightly shorter than the other
causes a disorder in cartilage production in uteru. There is no because the femur head rides so high in the socket. Most
problem with the brain but with the growth. noticeable when the child is lying in supine position and the thigh
● Epiphyseal plates of long bones cannot produce adequate is flexed to a 90 degree angle toward the abdomen causing one
cartilage for longitudinal bone growth. This results in both arms knee to be lower than the other. Some patients have unequal
and legs becoming stunted. Due to the bones of a membranous number of skin folds it also presents in the posterior thighs, so the
origin tends to grow normally causing the heads to appear findings would be unrelatable, however because some infants
unusually large in contrast to their extremities. ● Often referred to as congenital hip dysplasia
infants with normal hips have uneven of posteriors thigh skin folds
● The forehead is particularly prominent and the bridge of the nose ● Is the improper formation of the hip socket and is considered as a
subluxed or dislocated hips are best assessed when noting the
becomes flat area of near normal size but a thoracic kyphosis or spectrum of abnormalities affecting the hip joint.
hips are abduct, so with this one there is a sound if the hip is
especially dislocated one so saba siya when doing your ortolani

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and barlow's signs. With the ortolani aahhh what we call barlow ● With this normal development, record the extent of the bowing at ● Children who continue to have this problem and those in whom
sign if positive the feeling of the femur head slipping out of the health maintenance visits by approximating the medial malleoli of the abnormality is unilateral or becomes more pronounced need a
socket posterior laterally, the ankles and measuring the distance between the patellas referral to an orthopedist for further evaluation because obesity
(knees) for changes. as well as both the vitamin D and calcium deficiencies can cause
Flat Feet (Pes Planus) ● Genu Varum gradually corrects itself in young children by about 3 the deformity.
● Relaxation of the longitudinal arch of the years of age or, at the latest by school age.
foot. ● If the problem is unilateral, becomes rigidly worsem or persists Toeing-In
● Although it is rare; many parents beyond this time, the child needs referral to an orthopedist for ● May occur as a result of foot, tibial,
become concerned because their further evaluation. femoral, or hip displacement.
newborn’s foot is flatter and ● Assess for these conditions if the parents
proportionately wider than an adult’s Blount Disease (Tibia Vara) describe their child as “always falling over
foot. ● A developmental disorder of an unknown the feet” or “awkward”.
● In actuality, a transverse arch may not etiology that primarily affects the ● Metatarsus adductus is turning in the
be present until the child has been posteromedial portion of the proximal tibial forefoot. The heel is in good alignment;
walking for months. growth plate and results in bowed legs. only the forefoot is turned in.
● How do we evaluate the child’s feet? ● Unlike the normal developmental aspect of ● This condition may develop or become
Evaluate children’s feet at healthcare genu varum, Blount disease is usually more pronounced in infants who sleep
visits by having them stand tiptoe. In unilateral and is a serious disturbance in bone with rone with the feet adducted and in
this position, a longitudinal arch should growth that requires treatment. older children who watch television by
be visible. Observing whether the children are able to stand on ● It is not possible to rule out Blount disease by kneeling and turning their feet in. If you stand the child on a
their heels with the soles of the feet off the ground is another appearance alone, almost all children with copying machine and make a print, the turning in of the foot can
good assessment. Lastly, examine the ankle joint to be certain a bowed legs have an initial X-ray to identify if be well demonstrated.
full range of motion is present and the Achilles tendon is not Blount disease is present. ● Metatarsus Adductus resolve without therapy.
shortened. Tarsal and metatarsal should also show a full range of ● In those with Blount disease, the medial aspect of the proximal ● Those that persist beyond 1 year can be corrected by passive
motion. tibia will show a sharp, beaklike appearance on X-ray. stretching exercises; a few infants with extremely rigid, incorrect
● Some children may experience foot pain at the end of the day ● Either Bracing or Osteotomy may be necessary to correct this foot posture may require casts or splints for correction.
because of poor arch development. Their arch can be deformity or prevent it from becoming more severe. ● Early detection of these extreme instances is important because
strengthened and the pain diminished if the child walks on tiptoes ● Parents may need an explanation of why their child requires treatment for metatarsus adductus is most effective if it is begun
for 5 to 10 minutes daily or practices picking up marbles with the treatment or surgery when another child on their block with before an infant walks. With early treatment, the prognosis is
toes. similar appearance (developed genu varum) is predicted to excellent.
outgrow the problem. ● For an inward tibial torsion may also be evidenced as toeing-in.
Bowlegs (Genu Varum) ○ This condition is diagnosed when a line drawn from the
● Lateral bowing of the tibia Knock Knees (Genu Valgum) anterior superior iliac crest through the center of the patella
● If this is present, the malleoli (rounded ● Opposite of genu varum intersects the fourth or fifth toe (or a position even more
prominence on either side of the ankles) will be ● The medial surfaces of the knees lateral) because, ordinarily such a line should intersect the
touching and the medial surfaces of the knees touch, and the medial surfaces of the second toe.
will be more than 2inches(5 cm) apart. ankle malleoli are separated by more ○ Tibial torsion usually improves as the tibia grows, so this
● Children develop this condition as part of normal than 3 inches (7.5 cm) requires no treatment.
development; it is seen most commonly in 2 ● Seen most commonly in children 3 to 4 ● Inward femoral torsion can be detected if you ask a child to lie
years olds. It can also occur in athletes who play years old and corrects itself by school supine and attempt to rotate the leg internally and then externally
load-bearing sports such as football. age as the child grows. at the hip.

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UNIT 14 (Week 15)
autosomal recessive form where symptoms, including hearing and ○ Reconstruction Stage: marks the final healing with deposition
Limps (Limping) cardiovascular anomalies, develop later in life (osteogenesis of new bone
● Refers to the type of difficulty that occurs while walking imperfecta III). ● Treatment (children <6 years of age):
● Describe to be a form of walking that ccours the use of one leg ● Children with Type I disease may be born with countless fractures ○ Focuses on pain reduction with non-steroidal
over another, and is most commonly due to a disease or a damage already present from the force of birth. They develop many anti-inflammatory drug plus keeping the head of the femur
to the legs and feet including all of the structures such as your fractures from the everyday activities of childhood. X-rays reveal a within the acetabulum by a containment device
bones, muscles, joints, blood vessels and nerves that make up the particular ribbonlike or mosaic pattern in their bones, which aids ■ The acetabulum acts as a mold to preserve the shape of
lower extremities in diagnosis. The sclera of the eye is unusually blue because of the femoral head and maintain range of motion
● Limping is a result from either of an acute, having a recent onset poor connective tissue formation. ● Treatment (>6 years old):
or chronic long term condition; injuries such as bone fractures, ● Children with the Type III form may have associated deafness and ○ Reconstructive surgery: An osteotomy to center the femur
strains, sprains are common causes of limping arthritis, and dental deformities. In both instances, the major clinical head in the acetabulum followed by cast application; most
congenital malformations or birth defects are the other potential manifestation is a tendency for bones to fracture easily because often prescribed. This technique returns the child to normal
causes. of the poor collagen formation. In some children, the bones are so activity within 3 to 4 months of restricted activity required by
● Limping can also result from conditions that damage the central fragile that fractures can result not only from trauma, such as fall, non-weight-bearing devices
nervous system such as cerebral palsy depending on the precise but also from simple walking. Because the child has such frequent ● Parents and children need thorough education about treatment
cause. injuries, parents may be accused of child maltreatment before the and care because most of this occurs on an ambulatory basis.
● Limping may be treatable, in some cases or severity may be child’s condition is firmly diagnosed and documented ● It can be difficult for young children to accept the extended
reduced to use of medication or surgical intervention. ● As the child grows older, the multiple breaks tend to cause limb treatment period involved with this disorder.
and spinal column deformities, interfering with alignment growth ● Be certain that both parents and children understand the
Growing Pains so you really need to have a good uhmm i care gyud maayo ang long-term consequences if rest is not followed
● You really need to listen to parents carefully when they state their child not to really introduce more harm. Always lift children gently ● Without treatment, the femur head tends to remold into a
child has “growing pains” because what they are reporting may be and avoid lifting them bya single arm or leg to avoid placing strain mushroom shape, making the hip unstable and leads to
symptoms indicative of rheumatic fever or JIA rather than a on a bone. degenerative changes later in life which leads to chronic pain,
simple, transient phenomenon. reduced mobility of the hip joint, and possibly permanent
● Occur most frequently in the muscle of the calf, never in a joint. Leg-Calve-Perthes Disease (Coxa Plana) disability
● Reported most often in preschool and school-age children, who ● Avascular necrosis due to lack of blood flow resulting in ● Parents may need assistance with devising appropriate activities
wake at night because of the pain such cramping usually follows a destruction of the proximal femoral epiphyses for the child during the time that activity is limited and weight
day of vigorous activity or wearing new shoes with a heel of ● Child looks well enough and does not have a fever. Child is bearing is not allowed.
different height than before. ambulatory and can have a limp which may be subtle.
● Some children, especially adolescents, who report they have ● There is little pain in the motion of the hip, but there is guarding Osgood-Schlatter Disease
growing pains may actually be reporting restless leg syndrome. of the hip while moving it. ● Thickening and enlargement of the tibial tuberosity resulting from
This syndrome (involuntary leg movements that cause insomnia) is ● X-ray studies distinguish the condition from simple synovitis microtrauma probable caused from overuse
thought to be associated with genetics and brain iron deficiency (inflammation of the hip joint), which begins with the same ● Occurs more often in boys that girls and at preadolescence or
that causes decreased dopamine production. symptoms. X-ray changes may not be apparent when a child is first early adolescence because of rapid growth at these times
seen, but they appear after about 3 weeks for a repeat film. ● Children notice pain and swelling just below the knee that is
Osteogenesis Imperfecta ● Stages: aggravated by running or squatting
● A connective tissue (collagen) disorder in which fragile bone ○ Synovitis stage: Period of painful inflammation ● Therapy depends on the extent of the bone changes
formation leads to recurring (pathologic) fractures. ○ Necrotic stage: bone in the femur head shrinks in size and ● Administration of NSAIDs, ice, and limiting strenuous physical
● Although as may as eight types have been identified, the disease shows increased density on X-ray; lasts 6-12 months exercise may be all that is necessary for effective healing
occurs most frequently as a severe autosomal dominant form that ○ Fragmentation stage: resorption of dead bone occurs over a ● Immobilization of the leg in a walking cast or immobilizer for
is recognized at birth (osteogenesis imperfecta Type I) or an 1-2 year period about 6 weeks may be required

Aquino, Bacon, Gonzaga, Jalang, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Teves, Troyo, Yap
UNIT 14 (Week 15)
● If the child is obese, they need nutritional counseling to bring ● Scoliometer - Document extend of spinal curve
Slipped Capital Femoral Epiphysis weight back to a healthy level and to relieve strain on the lower ● Inclinometer - Reading greater than 7 degrees equals a 20 degree
● Slipping or displacement of the capital femoral epiphysis (femoral extremities scoliotic curve detected by x-ray
head) from the femoral neck (metaphysis) through the epiphyseal ● Children’s bone age x-ray of left wrist or
plate iliac crest bones
Disorders of Bone Structure
● The proximal femoral head displaced posteriorly and inferiorly, ● Therapeutic Management:
allowing avascular necrosis (similar to that in Legg-Calve-Perthes Slides 19-21 Trisha (Done) ○ Spinal Curve less than 20 degrees - No
disease) to begin Functional (Postural) Scoliosis​ therapy
● If the cartilage covering the femur head is destroyed, permanent ● Three-dimensional spine deformity ○ Curve greater than 20 degrees -
loss of motion of the femoral head in the acetabulum can result characterized by lateral and Conservative, nonsurgical approach
● Surgical reconstruction of the hip joint will then be necessary to rotational curvature of the spine​ using body brace
correct the problem ● Lateral (sideways) curve of the spine ○ 40 degrees - Require surgery with
● Signs & Symptoms: of 10 degrees or more​ spinal fusion
○ Occurs gradually ● Three planes: axial, coronal and ○ Bracing
○ Begin to limp as well as hold the leg on the affected side sagittal​ ■ One of the oldest form of
externally rotated to relieve stress and pain on the hip joint ● Functional-non rotated spinal curve, correction
○ Although the involvement is actually in the hip, they may secondary problem​ ■ Wear 23 hours, removed 1 hour for showering
report pain first in the knee because favoring the hip joint ● Structural-underlying neuromuscular ■ Milwaukee Brace - First type, brace extend to the neck
puts abnormal stress on the knee disorder​ ■ Boston Brace - Thoracolumbar support, fit under clothing
○ Physical Examination: Internal rotation of the hip is difficult ● Occurs as a compensatory ○ Mild analgesics like acetaminophen will decrease the
and painful mechanism in children who have discomfort in most children.
○ X-ray: One diagnostic test that reveals the slipped epiphyses unequal leg lengths, in children with ocular refractive errors ○ Rest
at the femoral head ● C- shaped curve
● Early detection of the condition is important because correction is ● Leg length is measured from the anterior iliac spine to the bottom Slides 22-23 Joash (Done)
easiest if it is attempted before necrosis has progressed to of the medial malleolus ● Charleston Bending Brace (night brace) - At night, the child may
epiphyseal destruction. ● Therapeutic Management: wear a Charleston Bending Brace that confines the spine to an
● Treatment: ○ Children must be reminded to have good posture everyday. overcorrected position.
○ Percutaneous in situ fixation: Standard of care for stable ○ Sit-ups and push-ups , swimming, and walking with a book on ● A mild analgesic such as acetaminophen (Tylenol) to decrease the
slipped capital femoral epiphysis the head for 10 minutes, 3x a day are good exercises. discomfort in most children.
○ Goal of Treatment: Prevent further slippings and achieve ○ Caution parents about nagging. ● Brace adjustments every 3 months
stable closure of the proximal femoral physis while avoiding ● Halo Traction
potentially devastating complications such as osteonecrosis Structural Scoliosis ○ The use of opposing forces to straighten and reduce spinal
and chondrolysis ● Idiopathic, permanent curvature of the spine curves that are severe when first diagnosed (over 80 degrees)
○ Activity restrictions for an extended time afterwards accompanied by damage to the vertebrae. or that progress despite bracing.
● Because the disease is most common in preadolescence, help ● S-shaped curve ○ Halo traction is achieved using a ring of metal (a halo) held in
children to understand the potential seriousness of the condition. ● Primary curve - Right thoracic convexity place with about four stainless steel pins inserted into the
● Although this condition is unilateral, some children later develop ● Original curve - Severe rotation and angulation of skull bones.
the same condition in the opposite hip vertebrae ○ For the first 24 hours after the apparatus is applied, most
● All children with slipped capital epiphysis needs follow-up care ● Thoracic rib cage - Protuberant on the convex children experience a nagging level of pain at the pin insertion
with careful attention to the opposite hip curve sites.
● Adam Test - Child bend forward

Aquino, Bacon, Gonzaga, Jalang, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Teves, Troyo, Yap
UNIT 14 (Week 15)
● Spinal Instrumentation - Instruments, such as rods, screws, and ○ Bone marrow aspiration - this is the last step of ● Polyarticular - Five or more painful joints
wires, are placed next to the spinal column to provide firm treatment of osteomyelitis, especially if there is ● Pauciarticular - Four or less joints
reduction of the curvature; the spine is then fused in the sequestrum or the dead bone tissue. Through biopsy of ● Systemic Onset - Only one but other systems are affected
corrected position. the sequestrum, they can identify what kind of bacterial ● Uveitis - Inflammation of Iris, ciliary body and choroid
microorganism is inside the bone. membrane of the eye (especially the systemic)
● Therapeutic Management:
Infectious and Inflammatory Musculoskeletal Disorders
Slides 24-25 Cybelle (Done) ○ Daily Activities and Exercise in a timely manner and limit
1. Osteomyelitis 2. Transient Synovitis contact sports and explain to the child
● Infection of the bone. ● Acute, nonpurulent inflammation of the synovial membrane ○ Heat Application helps in aiding the comfort especially
● Commonly affects less than 1 year olds, which is an infection of a joint that occurs most commonly in the hip joint in early in the morning
inside the epiphysis. children ○ Medication:
● In older children the infection is situated in the metaphysis ● Signs and Symptoms: Pain in the groin, lower portion of thigh ■ Ibuprofen and Naproxen (Naprosyn) - NSAID’s first
● Signs and Symptoms: or knee/buttocks intense and most noticeable in the morning drug of choice
○ Systemic Malaise, Fever and irritability (first day). when they first wake up ■ Slow-acting antirheumatic drugs (SAARDs) or
○ Sharp pain at bone metaphysis on the second day; warm ● Pelvic X Ray and MRI: Capsular swelling Disease Modifying Antirheumatic Drugs (DMARDs)
to touch affected area and there would be edema. Edema ● Treatment: NSaIDS - Ibuprofen ■ Methotrexate - Second drug of choice (careful in
reduces the blood supply to vast expanses of bone, (Motrin) giving because cytotoxic siya)
causing death of bone tissue, which results in 3. Apophysitis ■ Kinase inhibitors - Tofacitinib
sequestrum. ● Calcaneal Apophysitis (severe ○ Give appropriate nutrition
○ Sequestrum - This is the dead bone tissue, which appears injury or disease)
dense on radiographs or X-rays. ● Inflammation of the Epiphysis of a Muscular Dystrophies
heel bone, may be caused by a ● Group of more than 30 genetic diseases
micro heel fracture. ● Progressive weakness and degeneration of skeletal muscles that
● The heel feels tender, and pain in control movement
walking may be acute. ● Duchenne Muscle Dystrophy - Caused by absence of
● Overuse injury that is dystrophin(protein in the muscle)
self-limiting.
● Common: Active, Overweight, 1. Congenital Myotonic Dystrophy
Male children ● Autosomal dominant trait
● Relieved by adding a lift or cup to the heel of shoe on the ● Myotonia-muscle weakness at birth
affected side-reduce tension to heel cord and bone ● Diagnosis: Serum enzyme analysis and muscle biopsy
● Treatment: NSAIDS, ice application and activity modification
Slide 28-29 Sophia (Done)
● Therapeutic Management: Slides 26-27 Mira (Done) 2. Facioscapulohumeral Muscle Dystrophy
○ Give appropriate bedrest 4. Juvenile Arthritis ● More on the facio, scapula and humerus gyud, gi root word
○ Immobilization of the affected extremity ● Juvenile Rheumatoid Arthritis(JRA) or Juvenile Idiopathic gyud na siya. Most diseases come from the roots of that
○ IV antibiotic such as oxacillin (Bactocill) for prophylaxis. It Arthritis(JIA) combined with different parts of the anatomy.
is very common for this medication to be administered ● American College of Rheumatology defines JIA swelling or ● Dominant trait carried in chromosome 4
via IV route, that’s why IV therapy is most common, effusion with subtypes Polyarticular, Pauciarticular and ● Most commonly affects the 10 years old: you expect the
especially with infection or inflammation. This is because Systemic patient to have a facial weakness- they are unable to wrinkle
with the use of IV fluid therapy, the infection is more ● Pauciarticular Arthritis - Screening with slit-lamp exam the forehead and cannot whistle
likely to subside.
Aquino, Bacon, Gonzaga, Jalang, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Teves, Troyo, Yap
UNIT 14 (Week 15)
● Mostly with these patients, approximately ang pinaka the crutch but a combination of medical boot pud to aid with
nakuanan na with research, 25 year old ra ang life capacity the healing of the strained or sprained muscle. You have a
with this patient limit weight bearing especially at these days (3 to 4 days) after
3. Pseudohypertrophic Muscular Dystrophy (Duchenne’s Disease) the incident of this skeletal injury, mao nay giingon your
● Most common form of muscular dystrophy muscle really talks so if mo ingon imo muscle it is too much
● It is an inherited as sex-linked recessive trait for me to handle you need to really pause or you’re not
● Commonly in 3 years old - Only in boys prepared to do that certain activities that is why we need to
● Milestones later than average infant (wala sya ni sunod sa have a warm up in every exercise.
milestone of an average infant): sitting (dili maka sit ug ○ Application of elastic bandage - Common sa ER na mga
tarong, ma affect niya ang motor coordination), walking, and bandages especially with a sprained/strained muscle even in
standing fractures.
● Gower sign (specifically for Duchenne’s disease) - If padung ○ We need to involve the parents especially in cases of strain or
na mag practice ug walk ang baby kay - walk up their foot, sprain of the child na to really put on protective equipment
so mura syag mag luhod kay dili man siya maka stand gyud during sports so that dili siya mo balik na pud again ang
flat sa iyahng toe. incident or injury.
● Hypertrophied Calf Muscle - Measure larger than normal (fat
and connective tissue). Hypertrophied ang iyang muscle kay
● Sprain - Ligament injury. The bottom picture is an example of Fractures
naa may makitan didto na fat and connective tissue, so mao
ligament injury. More of the ligaments are torn.
na mag lisod ug walk with this patient kay condensed man Slide 30-31 Joseph (Done)
gud kaayo ang fat ug connective tissue especially in the calf ● Is a break in the continuity or structure of the bone.
muscle of the patient. ● Most common automobile accidents, even accidents at home
● Muscle biopsy (the one used in ruling in the Duchenne’s
disease) - Naay makita sa muscle biopsy na there is a fibrous Type of Fractures
degeneration and fatty deposits inside the muscles of the ● Plastic Deformation (Bend) - Bending of the bone/ bone bends,
patient causing a microscopic fracture line that does not cross the bone;
● Increase serum creatinine Phosphokinase and genetic analysis most common in the ulna and fibula.
- Most of this one are genetic anomalies gyud ● Buckle (Torus) - Fracture on the tension side of the bone near
softened metaphyseal bone, causing a buckling and raised area on
the harder diaphyseal bone in the (opposite side).
Musculoskeletal Injuries
● Greenstick - Bone bent with fracture beginning not crossing
Sprains and Strains through the bone.
● Strain - Muscle tendon injury. In the upper picture, you can see ● Complete - Bone divided:
the lining of the muscles, so injured gyud sya na part and mas ○ Either transversely, crosswise at right angle to long axis of the
reddish siya and swelled ang area. ● Slow to heal especially in childhood injuries but with the aid of bone (1st)
your therapeutics/management like: ○ Obliquely, slanted but straight (2nd)
○ Ice packs - You need to apply it for 20 mins to reduce edema ○ or spirally, slanted and circular; bone remnants possibly
of the site (for 4 to 7 days) attached by a periosteal hinge (3rd)
○ Rest, ice, compress and elevate (RICE) especially in treating ○ Different Categories:
sprains and strains ■ Compounded - Bone pierces the skin
○ Crutch with medical boot - Teach your patient how to do
crutch walking. Dili ipa bear ug weight ang lower extremities,
you need to do the 2 point swing through gait. Not only with
Aquino, Bacon, Gonzaga, Jalang, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Teves, Troyo, Yap
UNIT 14 (Week 15)
■ Comminuted - Parts of the bone are fragmented (like a ● Tetanus Prophylaxis and IV antibiotics - Used especially for open humerus and causing a supracondylar fracture of the
broken glass, very complicated case). X-ray is needed fractures because it is more prone to bacterial infection. This is humerus.
before and after given first in the hospital and should not wait for any signs and ○ Fractures of the humerus are reduced and stabilized with an
■ Hematoma-Granulation - Osteoblast invade new tissue symptoms of infection like fever. Prophylaxis and antibiotics are arm cast, a splint, or traction, depending on the position of
■ Callus (calcium deposited) - Extensive callus formation given ahead to prevent the risk for infection. the fracture.
○ Elevating the cast on pillows or suspending the hand by a strip
Complications: Fat Embolism or embolus - release of fat from marrow Types of Fracture (Location): of gauze or traction apparatus reduces edema.
of the broken bone into the bloodstream travel to cerebral vessels ● Forearm Fractures ○ Although the fracture may be minor, the child needs to be
(confusion/hallucinations) - shut off O2 supply; pulmonary ○ Common type assessed carefully for signs of blood vessel or nerve
Embolism/embolus (dyspnea, tachycardia and cyanosis) and ○ Most forearm fractures in children involve the distal third, compression.
Compartment Syndrome while a smaller number of such accidents occur in the middle ● Volkmann’s Ischemic Contracture
or proximal third. ○ When an arm is flexed and put into a cast, the radial artery
Slides 32-33 Tiffany (Done) ○ Only both the radius and ulna, or the displacement of the and nerve may be compressed at the elbow, causing nerve
● Hallmark Sign of Fracture: Deformity, edema, and pain epiphyseal plate of the radius may be involved. injury or severe impairment of circulation.
● Splinting - Reduces pain and prevent movement of the bone ○ With young children, this injury is usually referred to as the ○ If the fracture is in the proximal third of the radius, parents
● Therapeutic Management: greenstick or incomplete fracture. With the green stick, there need to assess for signs of circulatory or nerve impairment for
is really a bend with the bone, but not crossing through the 24 hours.
bone. ○ If symptoms of compression are present but not detected
○ If a greenstick fracture is slight so that the degree of within 6 hours, Volkmann’s contracture and possible
angulation is not great, it may not be reduced or brought into permanent damage to the arm will result. The arm is left
a straight line; as callus is formed and the bone remodels permanently flexed at the elbow. The wrist is hyperextended,
itself, it will naturally straighten into good alignment. and the fingers assume a flexed, clawlike, useless position.
○ Sometimes, greenstick fractures are broken completely before ○ If a child is going to be discharged after application of a cast,
casting to prevent the bone resuming its “bent” position inform parents about the symptoms of compression so that
within the cast. its development can be detected.
○ Refer to this as “straightening” the bone, rather than ○ If a child is admitted to the hospital for 24 hours, the radial
“breaking” the bone. pulse (if palpable at the edge of the cast) should be taken
○ If the fracture is complete and overriding is excessive, traction hourly, along with checks for coldness, blanching, and color of
to the fingers may be used as part of the cast. the fingers, for the first 8 hours.
○ In some instances, a cast is applied incompletely for 24 hours,
Therapeutic Management: the elbow portion being simply splinted and wrapped with
● Banjo Traction elastic bandages. After 24 hours, when edema has subsided
○ Is cumbersome and limits the child’s use of that hand. and the chance of compression is less, the rest of the arm is
○ The hand is covered up to the first phalangeal knuckle to casted.
prevent the child from moving the hand excessively and ● Epiphyseal Separation of the Radius
damaging the edge of the cast, which would loosen it and pull ○ If a child breaks a fall with an outstretched arm, a separation
the arm into poor alignment. of the epiphysis of the distal radius may result.
● X-ray - Confirm diagnosis (type of fracture or if it is really a ● Elbow Fractures ○ When this occurs, the wrist must be casted to restabilize the
fracture or if there is an underlying congenital disease) and ○ If a child falls and stops the fall with a hand, the elbow may epiphysis.
determine alignment of the bone. hyperextend, transmitting the force of the blow to the distal ○ Although epiphyseal injuries are always serious, distal radial
● Apposition - The amount of end-to-end contact of bone fragments injury rarely causes serious sequelae in children.

Aquino, Bacon, Gonzaga, Jalang, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Teves, Troyo, Yap
UNIT 14 (Week 15)
○ Therapeutic Management: “Most people think that when there is a broken bone, a ■ In the past, fractured femurs were not casted
■ Advise parents that it is important to keep appointments cast is needed, but this is an exception.” Doing so allows immediately because strong tendon spasm causes poor
for follow-up visits, so that growth disturbances can be parents to voice their concern and receive necessary alignment and overriding of the femur segments. Only
detected early and correction started. assurance. after muscle spasm had been reduced enough by skeletal
■ Stapling the epiphysis may be done to arrest abnormal ● Dislocation of Radial Head or Bryant’s traction to allow close approximation of the
growth if it occurs. Stimulation of the epiphyseal line may ○ If a small child is lifted by one hand, as happens when a bone edges (7 to 14 days), was the child removed from
increase growth if growth restriction occurs. parent pulls on one arm to lift the child over a curb or up a traction and placed in a hip spica cast.
● Clavicle Fractures step, the head of the radius may escape the ligament ■ Today, a child may be taken to surgery immediately to
○ When young children fall and catch themselves with an surrounding it and become dislocated (nursemaid’s elbow). have an intramedullary rod placed to align and stabilize
outstretched arm, the force of the blow may be transmitted ○ The child holds the arm flexed at the elbow with the forearm the fracture. No cast may be required.
to the clavicle, causing fracture of the clavicle or dislocation at pronated. The child winces with pain when the radial head is ■ Help the child and family identify ways for the child to
the sternal joint. palpated. continue contact with friends during any time of
○ Clavicles also may be fractured during birth or be a mark of ○ Therapeutic Management: restricted activity.
child abuse. ■ A simple dislocation of the radial head can be reduced by
○ Signs of Clavicular Fracture: a physician, using gentle pressure on the radial head
■ Swelling is often present at the site of the break. In the while the arm is flexed and supinated. Relief of pain is
newborn, a Moro reflex can only be demonstrated on the immediate, and the child begins to use the arm again.
unaffected side. An older child refuses to use the arm, ■ Parents feel guilty because they caused this dislocation.
leaving it hanging at the side. Reassure parents that this is a common injury in small
■ Crepitus (Crackling) can be felt over the clavicle. children. They rarely need to be cautioned that lifting a
○ After Radiographic Diagnosis (X-Ray): child in this manner is not wise.
■ The child is placed in a commercially manufactured or ■ Be aware, however, that a dislocation of the radial head
figure-of-eight splint of stockinette placed over the can occur from extremely rough handling, as is seen in
shoulders and under the axilla, keeping the arm adducted child abuse. Investigate the circumstances of the injury
and flexed across the chest. closely.
■ This is left in place for about 3 weeks, during which time ● Fracture of Femur
the wrap tends to look soiled. The child should keep the ○ Children who are involved in automobile accidents or who fall
splint dry—no swimming or showering during this time. from considerable heights and land on their feet may suffer a
■ The parent often needs to tighten the splint every fractured femur.
morning to keep it firmly in place. ○ Child abuse should be considered in an infant who sustains a
■ Parents are usually apologetic about the appearance of fractured femur, because there are few normal instances
the stockinette when they return for a repeat radiograph when a fracture of this magnitude should occur in an infant.
after 3 weeks. They may be worried that the soiled ○ Even with closed femoral fractures, blood loss can be
appearance of the splint reflects the quality of their extensive because of the size of the bone broken.
housekeeping or child care. Assure them that the soiled ○ As the child lies on the examining table in the emergency
splint proves that they followed instructions well and left department, the child tends to hold the leg externally rotated;
the splint in place for 3 weeks. the thigh may appear abnormally short or deformed. Often,
■ Parents may need reassurance that this splint is adequate the child is in a great deal of pain, possibly with signs of shock
therapy. They may ask, “The bone is broken, after from pain and blood loss. Children are frightened as well by
all—why is my child not being placed in a cast?” the force of the accident that caused such a severe injury.
Acknowledge their concern with a statement such as, ○ Therapeutic Management:

Aquino, Bacon, Gonzaga, Jalang, Literato, Miranda, Mollaneda, Monleon, Olila, Racaza, Teves, Troyo, Yap
 HEAD TRAUMA - Assess children’s level of consciousness and motor
- Children receive head injuries when they are involved function.
in multiple-trauma accidents, such as automobile - Stabilize the neck with a brace until cervical trauma
crashes. Falls from swing sets, porches, and bunk beds has been ruled out.
also cause many head injuries. Other children are
injured by being struck on the head by an object, such Immediate Management
as a baseball, rock, or hockey puck, or by falling from a After a head injury, brain edema is likely because fluid rushes
bicycle into the inflamed and bruised area.
- Head injuries are always potentially serious not only - Both central venous and central arterial lines may be
because they can cause an immediate threat to the life inserted.
of the child, but also because several complications - ICP monitoring may be initiated
may follow. - A computed tomography (CT) scan or magnetic
- With a depressed skull fracture, for example, recurrent resonance imaging (MRI) will be ordered to determine
Assessment:
seizures can occur. areas of edema or bleeding.
If the base of the skull is fractured, a child usually exhibits
- Some children experience memory deficits or minor - An attempt may be made to decrease brain edema by
orbital or postauricular ecchymosis.
personality changes after head injury (Fazio et al., intravenous (IV) administration of a hypertonic
- Rhinorrhea or otorrhea (clear fluid draining from
2007). solution, such as mannitol. This will increase
the nose or ear, respectively) may be present. This
- Symptoms such as headache, irritability, and postural intravascular pressure and shift the edema fluid back
is escaping cerebrospinal fluid (CSF)—a serious
vertigo (sensation of feeling faint or the inability to into the blood vessels.
finding, because it means that the child’s central
maintain normal balance—also known as posttrauma - Steroids such as dexamethasone may be added to
nervous system is open to infection.
syndrome) also may occur. decrease inflammation and edema.
- Test the fluid discharge with a glucose reagent strip
- Behavioral manifestations may include aggressiveness - Keeping the head elevated is also effective in reducing
if there is doubt about the source of the drainage.
or poor school performance. It often is difficult to ICP.
CSF will test positive for glucose, whereas the
determine whether these symptoms are organic or the
clear, watery drainage from an upper respiratory
result of being treated differently than usual by SKULL FRUCTURE
tract infection will not.
anxious parents. A skull fracture is a crack in the bone of the skull
- Take a careful history of the accident.
Immediate Assessment - Recognizing skull fractures in children is important,
because associated cerebral injury often occurs under Shock with hypotension rarely occurs with an isolated head
- All children with head trauma require a neurologic
the fracture. injury.
assessment as soon as they are seen and again at
- Many skull fractures are simple linear types, most - If a child is in shock, investigate for bleeding points
frequent intervals to detect signs and symptoms of
often involving the parietal bones. other than the head injury.
increased intracranial pressure (ICP).
- In some children, the skull does not fracture, but the - Skull fractures are confirmed by skull radiography. If
- Increasing pressure puts stress on the respiratory,
suture lines separate. This occurs more commonly in a skull fracture is linear with no underlying
cardiac, and temperature centers, causing dysfunction
the lambdoid suture line; a coronal suture separation pathology, no treatment except observation and
in these areas.
is rare and, if present, indicates severe trauma (Fig. prescription of an analgesic is necessary.
- With increased pressure, the pupils become slow or
52.1) - In about 3 weeks, a repeat radiograph will be
unable to react immediately.
needed to confirm that healing has taken place.
- Level of consciousness and motor ability decrease,
- If a fracture is depressed (a bone fragment is
pulse and respiratory rates decrease, and temperature
pressing inward) or compounded (bone is broken
and pulse pressure increase.
into pieces), surgery will be necessary to remove
- Assess vital signs to detect these changes and observe
or repair broken fragments. Cranial surgery of this
children’s pupils to be certain that they are equal and
type is discussed in Chapter 49.
react to light.
 SUBDURAL HEMATOMA - This happens when head trauma is severe.
Therapeutic Management: - Subdural hemorrhage is usually venous bleeding, but
- It is venous bleeding into the space between the dura epidural hemorrhage is usually a result of rupture of
- If CSF is draining from the nose, a child will be and the arachnoid membrane. It occurs when head the middle meningeal artery and is, therefore, arterial
admitted to the hospital for observation. trauma lacerates minute veins in this area bleeding.
- Keep the child in a semi Fowler’s position so that fluid - The collection of blood is usually bilateral. - It usually is intense and causes rapid brain
drains out, not inward, to reduce the possibility of - tend to occur in infants more often than in older compression.
introducing infection. children. - At the time of the injury, children become
- Make certain that children do not attempt to hold - Symptoms may occur within 3 days or as late as 20 momentarily unconscious.
their nose or pack their nostrils with something to days after trauma. Infants usually have symptoms of - They then regain consciousness and, to the untrained
halt the drainage. increased ICP. eye, appear to be well for minutes or hours.
- Because coughing and sneezing may allow air to enter - Seizures, vomiting, hyperirritability, and enlargement - Then signs of cortical compression—vomiting, loss of
the meningeal space, coughing may be suppressed by of the head may occur. consciousness, headache, seizures, or hemiparesis
medication. - Anemia caused by the substantial blood loss is a (paralysis on one side)—are observed.
- If the drainage is excoriating to the upper lip, coat the prominent sign. - On physical examination, unequal dilation or
space with petrolatum. - Angiography or ultrasound reveals the extent of the constriction of the pupils may be present.
- Children may be prescribed a prophylactic antibiotic hematoma. - Decorticate posturing may be seen, indicating extreme
to reduce the risk for meningitis. In infants, accumulated subdural blood may be removed by a pressure on upper cortical centers. If the pressure is
- If the drainage does not stop within a few days, subdural puncture through the lateral aspect of a patent allowed to continue unchecked, cortical compression
surgery will be necessary to repair the fracture and anterior fontanelle. may be so great that brainstem, respiratory, or
reduce the danger of meningitis. - The procedure is similar to a lumbar puncture. cardiovascular function becomes impaired.
Air that enters intracranial spaces usually is absorbed - Infants receive conscious sedation or must be held - As a rule, the closer to the time of the injury that
rapidly. extremely still during the procedure so that they do symptoms of compression occur, the more extreme is
- If radiographs at 72 hours still show air in the cerebral not move and cause the aspiration needle to be the amount of blood loss.
spaces, it implies that a skull defect remains, and inserted incorrectly. - The treatment is surgical removal of the accumulated
surgery may be indicated to close the defect. - Without conscious sedation, half of the success of blood and cauterization or ligation of the torn artery.
subdural puncture depends on the ability to hold the - The earlier the process is recognized and treated, the
Potential Complications: child still. less the chance of residual damage from extreme
- Subdural punctures may need to be repeated daily to pressure or anoxia to the involved portion of the brain.
A long-term complication of even a linear fracture may be a empty the subdural space.
leptomeningeal cyst. - Once the space is empty, expanding brain tissue will
- This results from projection of the arachnoid naturally occlude it. If the space has not been
membrane into the fracture site. occluded after 2 weeks of daily punctures, active
- With the interfering tissue, bone cannot heal and bleeding is still present, and surgery usually is
actually erodes, so that the fracture site becomes necessary to reduce the space and halt bleeding.
progressively larger, not smaller. This becomes - In older children, surgery usually is necessary, because
evident on a follow-up radiograph. the anterior fontanelle is closed and the space cannot
- It may be suspected if a child develops focal seizures be reached by puncture.
or symptoms of increased ICP. The defect may be
palpated on the skull as an underlying indentation. EPIDURAL HEMATOMA
- Surgical resection is necessary to remove the cyst. - Epidural hematoma is bleeding into the space
between the dura and the skull
 - Parents usually are instructed not to keep waking
children during the night, because multiple wakings
are disorienting and can be confused with
unconsciousness.
- Parents should wake the child at least once during the
night, however, and assess that the pulse rate is
greater than 60 beats per minute.
- To be certain that children are alert, parents can ask
them to name a familiar object, such as a favorite toy,
or to name the color of some object shown to them.
- Telling parents their name or where they live is equally
revealing.
- Advise them to call if their child’s behavior changes in
any way that seems worrisome.
- Be certain they understand that it is all right for
CONCUSSION children to sleep, but they must wake them at least COMA
- Concussion is the temporary and immediate once to assess their status
impairment of neurologic function caused by a hard, - Coma (unconsciousness from which a child cannot
jarring shock
- It may occur on the side of the skull that was struck (a
coup injury) or on the opposite side of the brain (a
contrecoup)
- As the brain recoils from the force of the blow and
strikes the posterior surface of the skull, this second
injury occurs.
- Children have at least a transient loss of
consciousness at the time of the injury. They may
vomit and may show irritability after regaining
consciousness.
- They typically have no memory (amnesia) of the CONTUSION be roused) or stupor (grogginess from which a
events leading up to the injury or of the injury itself. - A brain contusion occurs when there is tearing or child can be roused) may be present in children
- For some children, this makes being asked questions laceration of brain tissue after severe head trauma.
about the accident extremely upsetting because they - The symptoms are the same type as for concussion but - Coma and stupor are both symptoms of underlying
do not remember anything that happened and feel a more severe. disorders; a history of the injury must be obtained
frightening loss of control. - In addition, there are specific symptoms related to the so that treatment can be directed specifically
- The child requires a skull radiograph to rule out skull lacerated brain area such as a focal seizure, eye toward the cause.
fracture and observation for 24 hours to rule out deviation, or loss of speech.
severe brain trauma, edema, or laceration. - Surgery may be necessary to halt bleeding. T Assessment:
- A child usually can be observed at home by the - The child’s prognosis depends on the extent of the - Obtain a history to determine the circumstances
parents, who are instructed to check the child’s level injury and effectiveness of therapy immediately before the time the child became
of consciousness every 1 to 2 hours while the child is comatose.
awake. - Assess children in coma carefully and completely,
so that the cause of the decreased consciousness
can quickly be determined.
- Undress the child completely so that all body parts
can be inspected.
- Although head injury is most likely to be the
underlying cause of coma or seizure, metabolic
disturbances such as diabetes mellitus,
dehydration, severe hemorrhage, or drug
ingestion, also must be considered as possible
causes.
- Count respirations and pulse and measure blood
pressure to establish baseline values, because
 changes in these values often provide good clues lumbar puncture, and toxicology tests may be ordered - An IV route is established so that, when specific
regarding the cause of coma. to rule out possible causes such as bacterial meningitis measures such as blood replacement, electrolyte
- A child with increased ICP, for example, will show or hemorrhage. replacement, or fluid replacement are needed, a
decreased pulse and respiratory rates and increased - Computed tomography (CT) or MRI will be done if a route for immediate administration will be
blood pressure. head injury is the most likely cause (Claret-Teruel et al., available.
- Diabetes, in contrast, leads to increased respirations. 2007). - Blood will be drawn for a complete blood count,
- Hemorrhage leads to an increased pulse rate and electrolyte determination, toxicology tests, and
decreased blood pressure. Coma is usually graded according to a standard scale so that cross-matching.
- Drug ingestion may lead to either increased or changes in the level of consciousness can be evaluated - If the cause of the coma is unknown, a lumbar
decreased measurements, depending on the drug accurately. Figure 52.5 shows the Glasgow Coma Scale, a puncture and EEG may be done.
ingested. commonly used evaluation system (Morris, 2008). Because this - Skull radiography, CT scan, or MRI may be done.
If bulbar (brainstem) compression is present, a child system was devised as an adult assessment scale, it must be - Lumbar puncture has little value at first in
cannot swallow effectively or safely. modified for use with children or infants. (Check book for predicting the severity of a head injury, because
- If this is suspected, turn the child on the side to Modified) any degree of cerebral contusion usually leads to
prevent aspiration. - A score of 3 to 8 on the scale suggests severe trauma (a increased CSF pressure. Lumbar puncture is
- Observe the eyes for signs of increased ICP. If both number less than 5 suggests a very severe prognosis); a contraindicated if increased ICP is present as
pupils are dilated, irreversible brainstem damage is score of 9 to 12, moderate trauma; and 13 to 15, slight release of fluid with the puncture can cause
suggested, although such a finding may also be trauma brainstem compression into the cord.
present with poisoning from an atropine-like drug. - Obtain the child’s vital signs and assess neurologic
- Pinpoint pupils suggest barbiturate or opiate status, such as state of consciousness and the
intoxication. ability of pupils to react to light, every 15 to 20
- One pupil dilated more than the other suggests third minutes or as ordered.
cranial nerve compression. An eye may be deviated A child’s prognosis after coma depends on the initial cause
downward and laterally as well. of the coma.
- This also may be caused by a tentorial tear (laceration - If the increased ICP can be relieved before any
of the membrane between the cerebellum and permanent brain damage results, the effects of the
cerebrum) and herniation of the temporal lobe into coma will be transient.
the torn membrane. This situation requires - Prognosis is always guarded, however, because
immediate surgery to correct temporal compression. coma reflects a potential health problem for a
The retina of the eye should be examined for papilledema, child.
which will be present if increased pressure is long-standing Therapeutic Management
(more than 24 to 48 hours). CHOKING GAMES
- Lack of a doll’s eye reflex suggests that compression If children are unconscious for longer than a transient period,
of the oculomotor nerves (third, fourth, or sixth) or of they usually are admitted to an observation unit for further - Adolescents, seeking an inexpensive way to
the brainstem is involved. assessment. experience a “rush” or euphoria, induce a partial or
Observe for posturing, such as decerebrate posturing, - As a general rule, place a child who is comatose on the complete loss of consciousness in themselves by
which suggests cerebral compression and dysfunction. side to reduce the risk of aspiration. intentionally depriving their brain of oxygen for a
Many laboratory studies are helpful in determining the cause - Oral suctioning to remove mucus from the mouth and short period of time by strangulation or hanging or
of coma. pharynx may be necessary. reducing the oxygen able to reach their nose by
- Blood glucose, blood electrolytes, blood urea nitrogen - If a child has acute signs of respiratory difficulty, some technique such as pulling a plastic bag over
(BUN), liver function tests, blood gas studies, endotracheal intubation may be necessary to ensure their head. Extreme hyperventilation to induce
respiratory function. hypocapnia is yet another technique.
- The practice may be seen as a rite of passage or
initiation into a gang or club.
 - The practice is also known as erotic asphyxiation as it checked visually for blood and to test for occult blood. - Occasionally, a child notices radiated left shoulder
also induces a sexual response. pain while lying in a supine position (Kehr’s sign).
Attach the tube to low intermittent suction if the presence of
Unfortunately, the game results in injury and death. - A radiograph will show little about the spleen itself
blood is established. An indwelling urinary (Foley) catheter is
- At least 82 adolescents between the age of 6 and 19 but may reveal a broken rib over the spleen,
also inserted to evaluate urine for blood and urine output.
have died in the United States as a result of the game. suggesting the extent of the trauma to that area.
Evidence of blood in the urine or decreased output may
Of these 86.6% were male; the mean age was 13.3. The - An IV line is begun immediately for fluid
indicate accompanying kidney or bladder trauma. If the urine
majority of the deaths occurred while the adolescent replacement, and an IV pyelogram or MRI will be
contains blood, an emergency IV pyelogram or ultrasound may
was alone; over 90% of the parents of the child were done to rule out damage to the left kidney, which,
be ordered. Be aware that having NG tubes or catheters passed
unaware of the game (CDC, 2008a).
is always frightening for a child (unsure of their anatomy, because of its location just behind the spleen, may
Injuries such as concussion, bone fractures, and tongue biting
children have no clear idea where the tubes are going). also have suffered trauma.
may occur from falling.
An abdominal radiograph or ultrasound may be ordered to rule - A complete blood count is done to estimate the
- Teach parents that the game exists and to be aware of
out a fractured pelvis, a condition that could contribute to extent of the blood loss. Blood is typed and cross-
signs that their child might be interested or
blood loss. Air under the diaphragm on the radiograph suggests matched, so that blood for replacement can be
participating in the game.
gastric or intestinal rupture with escape of air from these readied if necessary.
- Common signs are discussion of the game, bloodshot
organs into the peritoneal cavity.
eyes, ligature marks on the neck, severe headaches, - The child will be admitted to an observation unit if
Some parents may not bring their child to an emergency
disorientation, and the presence of choke collars, the blood loss from rupture appears to be mild. If
department immediately after abdominal trauma, because they
ropes, scarves, or belts tied to bedroom furniture bleeding is severe, immediate surgery, such as a
are unaware that serious injury can result to this part of the
body. Without frightening them, explain that an injury need not partial or total splenectomy.
ABDOMINAL TRAUMA - After a splenectomy, children are very susceptible
be obvious at first glance to be serious and need care. They
When children are brought to a health care facility after to infection, particularly pneumococcal infections.
may ask why a radiograph is necessary. When their child is
suffering a multiple-injury trauma, several medical specialists
asked to turn on the radiograph table so that an abdominal Therefore, a large percentage of children are
may be required: a neurosurgeon for consultation about a
fluid level can be revealed, they may perceive this as managed expectantly to see if the bleeding will halt
head injury; an orthopedic physician for consultation about a
unnecessary manipulation of an injured child. without spleen removal.
fractured extremity; and a thoracic surgeon to intubate or
Splenic Rupture - Children who have their spleen removed are
investigate lung trauma.
- The spleen is the most frequently injured organ in offered the pneumococcal vaccine to protect them
Assessment
Abdominal trauma results from an object striking the abdomen abdominal trauma, because it is usually palpable against pneumococcal infections.
● Assess vital signs frequently until they are stable under the lower left ribs. It is frequently injured by
inappropriately applied seat belts in automobiles and Liver Rupture
● Hypotension (less than 80 mm Hg systolic pressure in - Livers are also more prone to rupture in children
an older child; less than 60 mm Hg in an infant) usually by handlebar injuries in bicycle accidents. It is
increasingly caused by snowboard injuries. than in adults, because the liver, like the spleen, is
suggests hemorrhage, which may be hidden not completely sheltered by the rib cage in children.
abdominal bleeding. - Children with splenic injury have tenderness in the left
upper quadrant, especially on deep inspiration, when - Children with liver rupture or laceration usually
● Children may have increasing pallor and rapid have severe abdominal pain that is most marked on
respirations. If internal bleeding is present, blood the diaphragm moves down and touches the spleen.
- They may hold their left shoulder elevated, so that the inspiration, when the diaphragm descends and
pressure will show little improvement when IV fluid is touches the liver.
administered. diaphragm is raised on the left side, to keep this from
● If abdominal trauma is suspected, an NG tube is happening. Signs and Symptoms
passed and stomach contents are aspirated to be ● Blood loss
● Tachycardia
 ● Hypotension replacing it. If a tooth is replaced, it usually is wired into - Particularly at risk are male adolescents, because
● Anxiety place to hold it in good alignment. they may take dares to swim farther than their
● Pallor ability allows or may swim under the influence of
Treatment
● Hematocrit will be low or falling. alcohol, which impairs their decision-making ability
- The child receives a course of oral antibiotics, such as
and their physical coordination.
Such children need to be prepared for immediate surgery, penicillin, to prevent infection.
because the liver is a highly vascular organ, and blood loss from - Only soft food must be eaten until the tooth has firmly Pathophysiology of Drowning
it is acute and possibly life-threatening. adhered (approximately 2 weeks). - When children’s heads are submerged and they
Occasionally, a communication between an artery and the bile first inhale water, they cough violently from the
If a blow to a child’s teeth was extensive, a radiograph may be
duct occurs at the time of trauma. In this situation, symptoms irritation of the water in their nose and throat.
taken to rule out a mandibular or maxillary fracture. If a
are not immediate, but gastrointestinal (GI) bleeding, such as - If they cannot get their head out of water at this
portion of a tooth cannot be located, the possibility of
hematemesis or melena, may occur in a few days. point, water will enter the larynx. This causes the
aspiration must be considered and confirmed or ruled out by a
The child may have colicky upper abdominal pain that is larynx to spasm, preventing any further water but
chest radiography.
relieved by emesis. Liver studies, such as a liver arteriogram, also air from entering the trachea, so asphyxia
In young children, often a tooth is not knocked out but is
are necessary to reveal the extent of the problem. After either results.
pushed back up into the gum. These teeth gradually regrow,
liver or spleen surgery, children need careful observation for
and, although they may darken in color, they usually are - If a child is ventilated at this point, treatment
return of bowel function, assessment for the possibility that
healthy. If the affected tooth is a deciduous tooth, the usually is very effective because there is little water
peritonitis may develop, and careful reintroduction of oral
permanent tooth is rarely injured even though it is already in the lungs.
nutrition.careful observation for return of bowel function,
formed in the gum. m. At the appropriate time, the permanent - The condition more closely simulates asphyxia that
assessment for the possibility that peritonitis may develop, and
tooth will erupt normally. occurs with croup or when a foreign body, such as
careful reintroduction of oral nutrition.
NEAR DROWNING a nut, lodges in the trachea and stops air flow.
DENTAL TRAUMA
- Drowning is death caused by suffocation from submersion
- Injuries to teeth occur most often from falls in which a - If treatment is not given at this point, the larynx
in liquid. Inhaled water fills the lungs and therefore blocks
child strikes the upper front incisors or from blows to relaxes from the asphyxia and water enters the
the exchange of oxygen in the alveoli. More than 3500
the face by objects such as baseball bats or hockey lungs.
children die from drowning annually, making it the second
sticks. Such accidents are always potentially serious, - Oxygen can no longer be exchanged, because the
most common cause of death by unintentional injury
because they can lead to aspiration of the injured alveoli fill with water. Hypoxia deepens, and
among children.
teeth or malalignment of future teeth. cardiac arrest occurs.
- The term near drowning is used to describe the child with
- If permanent teeth that have been knocked out - Additional changes that occur when water enters
a submersion injury who requires emergency treatment
recently can be washed with saline in the emergency the lungs depend on whether the water is fresh or
and who survives the first 24 hours after injury.
department and replaced, there is a good chance that salt.
- Most infant drownings occur in bathtubs;
they will reimplant successfully. - Salt water is hypertonic, causing fluid to osmose
- 1- to 4-year-old children most frequently drown in from the bloodstream and enter the alveoli,
- If a tooth is knocked out, parents should rinse the
artificial pools; increasing the amount of fluid in the lung tissue
tooth in water, drop it in a salt solution or milk, and
- older children most frequently drown in bodies of and increasing hypoxia. Tachycardia and decreased
bring it to the emergency department with them.
fresh water. blood pressure from hypovolemia result. Blood
- Some dentists advocate immersing the tooth in an
- The majority of drowning accidents that take place outside viscosity increases as shown by an increased
antiseptic and then in an antibiotic solution before
the home occur in the summer months, when more hematocrit level.
children are swimming and boating. - Fresh water is hypotonic, so fluid in the lungs shifts
into the bloodstream because of osmotic pressure.
This can lead to hemolysis of red blood cells, a
dilution of plasma, and possibly hypervolemia with
tachycardia and increased blood pressure.
- If the release of potassium from destroyed red blood - Assuming that cardiopulmonary resuscitation is effective, prognosis is greatly improved over that of the child
cells is great enough with fresh-water drowning, the child needs follow-up care at a health care facility, who is comatose.
cardiac arrhythmias may occur. In both instances, loss because the child is certain to be acidotic from
POISONING
of surfactant from lung alveoli, caused by introduction accumulated carbon dioxide and hypoxia (resulting from
➔ Poisoning occurs most commonly in children between
of water (adult respiratory distress syndrome), can lack of oxygen because of the water in the alveoli) and is at
the ages of 2 and 3 years. It occurs in all socioeconomic
lead to alveolar collapse on expiration risk for respiratory infection from contaminants in the
groups.
- Parents should advocate for neighborhood pools to be water.
➔ Common agents include soaps, cosmetics, detergents
fenced and advise against hyperventilating before - Follow-up care aims to increase the child’s oxygen and
or cleaners, and plants. Poisoning can occur from
swimming. carbon dioxide exchange capacity, using the lung areas that
over-the- counter drugs, such as vitamins, iron
- When children blow off carbon dioxide with are not filled with water.
compounds, aspirin, or acetaminophen, or from
hyperventilation this way, and then swim underwater - Typically, a child is intubated with a cuffed intratracheal
prescription drugs, such as antidepressants.
for an extended period of time, carbon dioxide levels tube; mechanical ventilation with positive end-expiratory
➔ Unlike other unintentional injuries, poisoning is entirely
will rise, but not adequately enough to cause them to pressure may be necessary to force air into the alveoli.
preventable. Parents need education about the high
experience distress. - Because water has been swallowed, vomiting usually
risk for poisoning and strategies for maintaining a
- Oxygen levels decrease causing drowsiness and occurs as the child is revived. The cuff of the intratracheal
home environment that is safe for children of all ages.
listlessness (children drown without struggling or tube prevents vomitus from being aspirated.
Be aware that when poisoning occurs in an older child,
realizing their danger). - The child is given 100% oxygen so that as much space as
it may not be poisoning but a suicide attempt.
- Very young children display a mammalian diving reflex possible in the available lung alveoli can be used.
when they plunge under cold water that helps them - An NG tube is inserted to decompress the stomach, Emergency Management of Poisoning at Home
survive drowning. prevent vomiting, and free up breathing space. ➔ If poisoning occurs, parents should telephone their
- Immediately after plunging into cold water, a - albuterol is administered by aerosol to prevent local poison control center to ask for advice.
lifesaving bradycardia and shunting of blood away bronchospasm and, again, to allow the child to make Information parents need to provide includes:
from the periphery of the body to the brain and heart maximum use of the oxygen administered. ◆ Child’s name, telephone number, address, weight,
occur. - If the child aspirated salt water, plasma may be and age and what the child swallowed
- This reflex is triggered when water is 70° F (21° C) or administered to replace protein being lost into the lungs ◆ How long ago the poisoning occurred
less and the face is submerged first. and prevent hypovolemia. ◆ The route of poisoning (oral, inhaled, sprayed on skin)
- This explains why very young children can survive - If the child’s body temperature is very low, gradual ◆ How much of the poison the child took (the bottle
better than older children after being submerged in warming (not using a warming blanket) is advised so that should say how many pills or liquid it originally
water that is very cold the metabolic requirement does not rise sharply before held).
alveolar space is ready to accommodate this need. ◆ If the poison was in pill form, whether there are pills
Emergency Management Extracorporeal membrane oxygenation may be used. scattered under a chair or if they are all missing and
- When a child is pulled from the water after near presumed swallowed
- Unfortunately, neurologic damage occurs in as many as
drowning, mouth-to-mouth resuscitation should be ◆ What was swallowed; if the name of a medicine is
21% of near-drowning incidents. If the child is awake or
started at once. not known, what it was prescribed for and a
only lethargic at the scene of the accident and immediately
- If cardiac arrest has occurred from hypoxia, afterward in the hospital, the description of it (color, size, shape of pills)
simultaneous measures to initiate cardiac action must ◆ The child’s present condition (sleepy? hyperactive?
be taken. comatose?)
➔ If one child has swallowed a poison, parents should
investigate whether other children have also poisoned
 themselves as a preschooler often shares “candy” with a ➔ Soon, serum aspartate transaminase (AST [SGOT]) and ◆ The child may immediately vomit blood, mucus,
younger sibling serum alanine transaminase (ALT [SGPT]), liver enzymes, and necrotic tissue.
become elevated. ◆ The loss of blood from the denuded, burned surface
➔ The liver may feel tender as liver toxicity occurs. Parents may lead to systemic signs of tachycardia,
should call their local poison control center. tachypnea, pallor, and hypotension.
➔ In the emergency department, the best method to ➔ In the emergency department, activated charcoal or ◆ A chest radiograph may be ordered to determine
deactivate a swallowed poison is the administration of acetylcysteine, the specific antidote for acetaminophen whether pulmonary involvement has occurred from
activated charcoal, either orally or by way of an NG tube. poisoning, will be administered. any aspirated poison or whether an esophageal
➔ Activated charcoal is supplied as a fine black powder that is ➔ Acetylcysteine prevents hepatotoxicity by binding with the perforation has allowed poison to seep into the
mixed with water for administration. breakdown product of acetaminophen so that it will not mediastinum.
➔ A sweet syrup may be added to the mixture to make it bind to liver cells. ◆ An esophagoscopy under conscious sedation may
more palatable. ➔ Unfortunately, acetylcysteine has an offensive odor and be done to assess the esophagus, although this test
➔ Caution parents that, as the charcoal is excreted through taste. Administer it in a carbonated beverage to help the may be omitted because of the possibility that an
the bowel over the next 3 days, stools will appear black child swallow it. esophagoscope might perforate the burned
(Box 52.6). ➔ For small children, it is administered directly into an NG esophagus.
➔ Always follow emergency measures to neutralize a poison tube to avoid this difficulty. ◆ After 2 weeks, a barium swallow or esophagoscopy
with an education program for the family to prevent ➔ If the child is admitted to an observation unit, continue to may be performed to reveal the final extent of the
poisoning from happening again. observe for jaundice and tenderness over the liver; assess esophageal burns.
➔ Specific measures for each age group are discussed in ALT and AST levels as ordered
previous chapters, along with problems and concerns of THERAPEUTIC MANAGEMENT
that age group. ◆ When parents whose child has ingested a caustic
CAUSTIC POISONING substance call a poison control center to ask for
➔ Ingestion of a strong alkali, such as lye, which is often
advice on how to proceed, they will be advised to
ACETAMINOPHEN POISONING contained in toilet bowl cleaners or hair care products,
immediately take the child to a health care facility
➔ Acetaminophen (Tylenol) is the drug most frequently may cause burns and tissue necrosis in the mouth, for treatment.
involved in childhood poisoning today, because parents use esophagus, and stomach.
◆ There is a high possibility that pharyngeal edema
acetaminophen to treat childhood fevers. ➔ It is important that the parents do not try to make a child will be severe enough to obstruct the child’s airway
➔ Told that acetaminophen is safer than aspirin, parents may vomit after ingestion of these substances, because they by even 20 minutes after the burn.
not be as careful about putting this drug away as they were can cause additional burning as they are vomited ◆ To detect respiratory interference, assess vital signs
with aspirin. closely, especially the respiratory rate.
➔ If their child swallows acetaminophen, they may delay ASSESSMENT ◆ In infants, increasing restlessness is an important
bringing the child for help, thinking it is a harmless drug. ◆ After a caustic ingestion, the child has immediate pain accompanying sign of oxygen want. In the
➔ Acetaminophen in large doses, however, is not an innocent in the mouth and throat and drools saliva because of emergency department, intubation may be
drug; it can cause extreme liver destruction (Morgan & oral edema and an inability to swallow. necessary to provide a patent airway.
Borys, 2008). ◆ The mouth turns white immediately from the burn. ◆ Assess the child also for the degree of pain involved.
➔ Immediately after ingestion, the child will experience ◆ Later, the mouth turns brown as edema and ulceration ◆ A strong analgesic, such as morphine, may need to
anorexia, nausea, and vomiting. occur. There may be such marked edema of the lips and be ordered and administered to achieve pain relief
mouth that it is difficult to examine them.
HYDROCARBON INGESTION
➔ Hydrocarbons are substances contained in products such swallowed, because parents can only guess at the ◆ Parents should contact their poison control center
as kerosene and furniture polish. number of pills in the bottle. immediately after the ingestion.
➔ Because these substances are volatile, fumes rise from ◆ In addition, the amount of elemental iron in ◆ In the emergency department, stomach lavage will be
them, and their major effect is respiratory, not gastric, compounds varies. The child’s serum iron level should done to remove any pills not yet absorbed.
irritation be measured to establish a baseline. ◆ A cathartic may be given to help the child pass
enteric-coated iron pills.
➔ Pulmonary effects: cough, choke, cyanosis, hypoxia,
THERAPEUTIC MANAGEMENT ◆ Activated charcoal is NOT given, because it is not
respiratory distress
effective at neutralizing iron.
➔ CNS effects: euphoria, mental status changes, lethargy,
◆ A soothing compound such as Maalox or Mylanta
coma, seizure
(aluminum hydroxide and magnesium hydroxide) may
➔ TTT:
be given to help decrease gastric irritation and pain.
- Intubation - severe pulmonary toxicity
◆ A child who has ingested a potentially toxic dose will be
- Supportive care
given a chelating agent, such as IV or intramuscular
● Contraindications: Gastric emptying and activated
(IM) deferoxamine.
charcoal
◆ Chelating agents combine with metals and allow them
IRON POISONING to be excreted from the body.
➔ Iron is frequently swallowed by small children because it ◆ Caution parents that deferoxamine causes urine to turn
is an ingredient in vitamin preparations, particularly orange as iron is excreted.
pregnancy vitamins. ◆ An exchange transfusion is another way that excess
➔ When it is ingested, it is corrosive to the gastric mucosa iron can be removed from the body.
and leads to signs and symptoms of gastric irritation ◆ An upper GI x-ray series and liver studies may be
➔ The immediate effects include nausea and vomiting, ordered 1 week after the ingestion to screen for long-
diarrhea, and abdominal pain. term effects.
➔ After 6 hours, these symptoms fade, and the child’s ◆ The hope is that the iron load was removed from the
condition appears to improve. By this time, however, stomach in time so that not all of it was absorbed.
hemorrhagic necrosis of the lining of the GI tract has ◆ Assist with emergency measures, such as gastric
occurred. lavage, and administer chelating agents as ordered.
➔ By 12 hours, melena (blood in stool) and hematemesis ◆ Parents may be asked to test any stool passed for the
(blood in emesis) are present. next 3 days for occult blood, to assess for stomach
irritation and subsequent GI bleeding.
➔ Lethargy and coma, cyanosis, and vasomotor collapse
may occur. LEAD POISONING
➔ Coagulation defects may occur, and hepatic injury also can ➔ When lead enters the body, it interferes with red blood
result. cell function by blocking the incorporation of iron into the
➔ Shock resulting from an increase in peripheral vascular protoporphyrin compound that makes up the heme
resistance and decreased cardiac output can occur. portion of hemoglobin in red blood cells (Morgan & Borys,
➔ Long-term effects can include gastric scarring from fibrotic 2008).
tissue formation. ➔ This leads to a hypochromic, microcytic anemia.

ASSESSMENT
◆ It is difficult to estimate the amount of iron a child has
➔ Kidney destruction may occur in addition, causing
excess excretion of amino acids, glucose, and
phosphates in the urine.
➔ The most serious effect, however, is lead encephalitis:
inflammation of brain cells because of the toxic lead
content.
➔ Lead poisoning (plumbism), like all forms of poisoning
in children, tends to occur most often in the toddler or
preschool child.

ASSESSMENT
◆ Lead poisoning is said to be present when the child
has two successive blood lead levels greater than 10
ug/dL.
◆ The usual sources of ingested lead are paint chips or
paint dust, home-glazed pottery, or fumes from
burning or swallowed batteries (Olson, 2009).
◆ Paint tastes sweet, and a child will repeatedly pick
chips up off the floor or off the walls.
◆ If a crib rail is painted with lead paint, a child will
ingest it as the child teethes on the rail.
◆ Chewing on windowsills is also common. In fishing
communities, swallowing lead sinkers can be a
common source.
◆ Restoring an older home saturates the air with lead
dust. In such homes, lead plumbing also may
contaminate the drinking water
◆ Many children with fairly high blood lead levels are
asymptomatic. Others show insidious symptoms of
anorexia and abdominal pain caused by the
presence of lead in the stomach.
◆ Children with encephalopathy usually have
beginning symptoms of lethargy, impulsiveness, and
learning difficulties.
◆ As the child’s blood level of lead increases, severe
encephalopathy with seizures and permanent
neurologic damage will result.
 ◆ The most widely used method of screening for lead o After some months, the new paint will begin to peel CLASSIFICATION OF LEAD POISONING RISK
levels is the blood lead determination (serum ferritin). because of the defective paint underneath. The walls must Class Lead Recommended
◆ Unfortunately, this test requires the use of atomic therefore be covered by paneling or Masonite. Blood Action
absorption spectrophotometry, which is a costly o All children with lead levels greater than 20 ug/100 mL Level
procedure. may be prescribed an oral CHELATING AGENT such as Conc.
SUCCIMER (ug/dL)
◆ The free erythrocyte protoporphyrin test is a simple
o Children with blood lead levels of greater than 45 ug/100 Class I (low risk) <9 Retest at 24
screening procedure that involves only a fingerstick.
mL may be admitted to the hospital for CHELATION months for
◆ Because protoporphyrin is blocked from entering heme
THERAPY with agents such as DIMERCAPROL (BAL) or children age 6–35
by the lead, it will be elevated in a child with lead months who
poisoning. EDETATE CALCIUM DISODIUM (CaEDTA) (Karch, 2009).
are considered low
◆ Basophilic stippling (an odd striation of basophils) may o Chelating agents remove the lead from soft tissue and
risk; retest every 6
be apparent on a blood smear. bone (although not from red blood cells), allowing it to be months for ages
◆ A radiograph of the abdomen may reveal paint chips in eliminated in the urine. 6–35 months who
the intestinal tract (Fig. 52.6A). o Injections of EDTA, which must be given IM into a large are considered
◆ “Lead lines” (areas of increased density) may be muscle mass, are painful and may be combined with 0.5 high risk
present near the epiphyseal line of long bones (see Fig. mL of procaine. Class IIa 10–14 Retest
52.6B). o EDTA also removes calcium from the body; therefore, (rescreen) yearly; continue
◆ The thickness of the line shows the length of time lead serum calcium must be measured periodically to determine retesting yearly
ingestion has been occurring (Kosnett, 2007). whether it is at a safe level. for
o Damage to the kidney nephrons from the presence of o Measure intake and output to ensure that kidney function children
lead leads to proteinuria, ketonuria, and glycosuria. is adequate to handle the lead being excreted. >36 months until
o BUN, serum creatinine, and protein in urine may also be age 6
◆ Urine analysis reveals this.
assessed to ensure that kidney function is adequate. years
◆ The CSF may have an increased protein level.
o If kidney function is not adequate, EDTA may lead to Class IIb 15–19 Retest every 3–4
nephrotoxicity or kidney damage. (moderate risk) months for
THERAPEUTIC MANAGEMENT children age 6–35
◆ A child with a blood lead level between 10 and 14 o BAL has the advantage of removing lead from red blood
months
ug/dL needs to be rescreened to confirm the level. cells, but, because of severe toxicity, it is used only for
Class III 20–44 Retest every 3–4
◆ If the lead level is 15 ug/dL or higher, a child needs children who have severe forms of lead intoxication.
(high risk) months; begin
active interventions to prevent further lead exposure. o Penicillamine (Cuprimine) is yet another drug used for lead home abatement
◆ These interventions may include removal of the child poisoning. It is given orally after BAL or EDTA. Weekly program
from the environment containing the lead source or complete blood cell counts and renal and liver function Class IV (urgent 45–69 Initiate chelating
removal of the source of lead from the child’s tests accompany the administration of penicillamine. It risk) therapy and
environment. may be given for as long as 3 to 6 months. environmental
◆ Removal of the lead source can be difficult. If the remediation
family lives in a rented apartment, the landlord may be Class V (urgent >70 Immediately treat
legally obligated to remove the lead. risk) with a chelating
◆ Simple repainting or wallpapering does not remove a agent
source of peeling paint adequately.
PESTICIDE POISONING
➔ Pesticide poisoning can occur by accidental ingestion or PLANT POISONING having a paranoid reaction will be unable to cope
through skin or respiratory tract contact when children ➔ Plant poisoning (ingestion of a growing plant) occurs rationally with this approach.
play in an area that has recently been sprayed. because parents commonly do not think of plants as ◆ If friends accompany an ill child, point out that your
➔ Long-term exposure may result from exposure to a being poisonous role is not that of a law enforcer.
parent’s clothing if the parent comes home covered with ➔ Common plants to which children may be exposed and the ◆ Your role is to help the child, and you cannot do that
pesticide spray. effects of ingestion are: effectively unless the drug is identified.
➔ Although pesticide poisoning was once thought to be only ➔ Chewed Castor beans: highly toxic substance; ◆ Approaching a child’s friends in this way is more likely to
causes delayed vomiting, diarrhea, and result in their naming the drug.
a rural problem, the increase in the use of lawn sprays by
commercial lawn care companies now makes this a
neurological symptoms o If a child is brought in by parents who have no idea what
➔ Lily of the Valley or digitalis glycosides: drug could possibly have been taken, ask them to have
suburban problem as well (Olson, 2009).
gastroenteritis, confusion, hyperkalemia, and someone at home check the child’s bedroom
➔ Insecticides: Organophosphates, Organochlorine,
arrhythmias
aluminum phosphide, carbamates, pyrethrins, and
- Digoxin: specific fractionated antibody
pyrethroids
(Fab); used to treat ventricular
➔ Many pesticides have an organophosphate base that
arrhythmias
causes acetylcholine to accumulate at neuromuscular
junctions; this accumulation leads to muscle paralysis. ➔ Parents should phone their poison control center for
➔ S/S: Eye tearing, coughing, heart problems and breathing specific emergency steps.
difficulties, decreased BP and PR, seizures, respiratory POISONING BY DRUGS OF ABUSE
paralysis ➔ Adolescents and even grade-school children are brought to
➔ Within a few minutes to 2 hours after exposure, children health care facilities by parents or friends because of a drug
develop nausea and vomiting, diarrhea, excessive overdose or a “bad trip” caused by an unusual reaction or
salivation, weakness of respiratory muscles, confusion, the effect of an unfortunate combination of drugs.
depressed reflexes, and possibly seizures. ➔ Typical drugs involved include codeine and antidepressant
➔ In the emergency department, activated charcoal may be drugs.
administered if the pesticide was swallowed. ➔ Frequently, the drugs taken were prescription drugs
➔ Treatment: Proper oxygenation, escalating doses of removed from the family medicine cabinet (Schiesser,
atropine, and high doses of pralidoxime
2007).
➔ If clothing is contaminated, remove it and wash the child’s
➔ Children are often extremely disoriented after this form of
skin and hair. To prevent coming in contact with the
ingestion.
pesticide yourself, wear gloves while bathing the child.
➔ They may be having hallucinations.
➔ Intravenous atropine and a cholinesterase reactivator,
➔ Obtaining a history may be difficult because children may
pralidoxime (Protopam Chloride) are effective antidotes to
have no idea what they took except that it was a red or a
reverse symptoms.
yellow capsule.
➔ If parents apply a pesticide to children to help avoid
➔ They may know but may be reluctant to name a drug if it
mosquito bites to reduce exposure to West Nile virus was obtained illegally.
infection or tick bites to reduce exposure to Lyme disease,
diethyltoluamide (DEET)-based pesticides appear to be safe
ASSESSMENT
if used sparingly, not applied to a child’s face, and washed
◆ Although a child may not appear to hear well or may
off when the child returns indoors (AAP, 2008). not seem coherent, try to elicit a history.
o Avoid shouting or aggravating, because children who are
 for drugs or what could be missing from the
medicine cabinet (provided the child became ill
while at home).
◆ Expect to obtain blood specimens for electrolyte
levels and a toxicology screen. If the child is
vomiting, save any vomitus for analysis. Try to
determine whether the ingestion was an accident
(perhaps the child was unaware that two drugs
would react this way or took a wrong dose) or
whether the child was actually attempting suicide.
◆ All poisonings or drug ingestions in children older than
7 years of age should be considered potential
suicides until established otherwise.
◆ If the ingestion was an accident, the child will need
counseling to avoid drug use or about which drugs
do not mix.
◆ If the incident was an attempted suicide, the child
will need observation and counseling toward more
effective coping mechanisms in self-care.

THERAPEUTIC MANAGEMENT
◆ Children need supportive measures for their specific
symptoms, including oxygen administration,
electrolyte replacement (particularly if there is
accompanying nausea and vomiting), and perhaps
IV fluid administration in an attempt to dilute the
drug.
◆ Children who have swallowed a drug of abuse need
immediate treatment followed by investigation into
the events leading to the poisoning.
◆ This potentially lethal ingestion may act as a turning
point in the child’s life, possibly alerting the child
and family to a drug problem and the need for help.
Factors such as reduction of fear and anxiety,
increased coping mechanisms, knowledge of the
effects of drug use, and availability of referral
sources for a drug problem are important areas to
address.

FOREIGN BODY OBSTRUCTION

➔ Foreign bodies can become lodged in children’s FOREIGN BODIES IN THE NOSE that the coin does pass through the GI tract (about 48
esophagus, ear canals, or noses, causing stasis of ➔ Foreign objects stuffed into the nose eventually cause hours after ingestion).
secretions and infection. inflammation and purulent discharge from the nares. ➔ Without frightening them, caution parents to observe
➔ Direct obstruction or laceration of the mucous membrane ➔ The odor accompanying such impaction is often the first for signs of bowel perforation or obstruction, such as
may also result, leading to serious consequences. sign noticed by a parent. vomiting or abdominal pain, until the object has
➔ Whether a foreign substance is inhaled or embedded ➔ Objects pushed into the nose usually can be removed with passed.
forceps. ➔ If there is any doubt, a radiograph taken 3 to 7 days
elsewhere, nursing interventions should focus first on
comforting the child and aiding in removal of the ➔ A local antibiotic might be necessary after removal if after ingestion will establish whether the object has
ulceration resulted from the local irritation. been evacuated from the body.
substance, and then on teaching the child and parents
ways to avoid such occurrences in the future. Foreign Bodies in the Esophagus or Stomach SUBCUTANEOUS OBJECTS
➔ Children tend not to chew food well or to swallow ➔ Children receive many wood splinters in the hands
FOREIGN BODIES IN THE EAR
➔ Any child with a history of draining exudate from the ear portions that are too big to pass safely through the and feet.
canal needs an otoscopic examination to establish the esophagus. ➔ These usually are removed easily by a probing needle
reason for the drainage. ➔ Pieces of candy, such as Lifesavers, are common objects and tweezers after cleaning with an antiseptic solution.
➔ In toddlers and preschoolers, the drainage often is the caught in the esophagus in young children; coins may be ➔ If the penetrating object is metal, such as a sewing
result of a foreign body in the ear canal. swallowed by adolescents playing drinking games. needle or nail, its presence can be detected by
➔ The object might be a small piece of a toy, a piece of paper, ➔ Orthodontic appliances may become dislodged and radiography.
a small battery, or food, such as a peanut (Singh et al., swallowed. ➔ If the object is one that would have been in contact
2007). ➔ Intense pain at the site where the object is lodged will with soil, such as a rusty nail, the child will need
result. tetanus prophylaxis after extraction of the object if
➔ Removal of a foreign body from the ear is difficult
➔ If it is an object that will dissolve, such as a Lifesaver or a tetanus immunization is not current.
because children are afraid that the instrument used will
piece of digestible meat, offer the child fluid to drink to
hurt them, so they have difficulty lying still for the BITES
help flush the object into the stomach.
procedure. ➔ Children receive bites from snakes and animals such as
➔ Even after the object dissolves or passes into the stomach,
➔ If there is reason to think that the tympanic membrane is dogs or raccoons; they occasionally receive bites from
the child will feel transient pain at the original site of the
intact, irrigating the object from the ear canal with a other children.
obstruction.
syringe and normal saline may be possible. ➔ The source of a bite needs to be documented as human
➔ Magnets, particularly those in watches or hearing aids, are
➔ This should NOT be done if the object is a substance that bites can also result from sexual abuse.
will swell when wet, such as a peanut. also frequently swallowed by young children. These need
➔ If it is possible that the tympanic membrane is ruptured, to be removed by endoscopy as soon as possible as they MAMMALIAN BITES
the ear canal must not be irrigated or fluid will be forced can lead to bowel perforation or volvulus ➔ Dog bites account for approximately 90% of all bites
into the middle ear, possibly introducing infection (otitis ➔ Objects, such as a part of a toy or a chicken bone, that will inflicted on humans, and children and adolescents are
media). not dissolve and should not be passed, are also removed by involved in one third to one half of reported incidents.
➔ Often, it is better to wait for an otolaryngologist to care for endoscopy ➔ The dog is usually one owned by the child’s family.
the child, because trauma to the ear canal during an ➔ Small coins, such as pennies and dimes, usually pass by ➔ Cat bites, wild animal bites, and human bites also
attempt to remove a foreign body will increase the edema themselves without difficulty. constitute a threat, although they are less common in
➔ Parents (or children themselves if adolescents) should children.
and make removal even more difficult
observe stools over the next several days to determine ➔ All of these bites can cause abrasions, puncture
wounds, lacerations, and crushing injuries related to
the size of the animal and the location of the bite
 ➔ The biggest concerns associated with animal bites are the SNAKEBITE ◆ The pupils may be dilated, showing the potent effect
possibility of longterm scarring and disfigurement and the ➔ In the United States, snakebites tend to occur during the on cerebral centers.
possibility of infection, especially rabies, from the presence warm months of the year, from April to October. ◆ If the envenomation is not treated, seizures, coma,
of microorganisms in the animal’s mouth. ➔ Most fatal snakebites (envenomations) in the United and death may result
States are copperhead or rattlesnake bites.
➔ Copperheads are found in eastern and southern states, and Emergency Management at the Scene
Dog Bites or Rabies rattlesnakes in almost every state. o At the scene of a snakebite, apply a cold compress to
- Causative agent: RABV ➔ A few bites occur from cottonmouth moccasins or coral the bite, in the hope of slowing the spread of the
- Incubation period: 1-3 months but can range for days to snakes (both found in southeastern states). venom and to reduce edema formation.
years ➔ The effect of the bite of a rattlesnake, copperhead, or ◆ Urge the child to lie quietly, to slow circulation.
- Period of communicability: 3-5 days before the onset of cottonmouth moccasin (all pit vipers) is a failure of the ◆ Keep the bitten extremity dependent, again to slow
symptoms blood coagulation system (Clark, 2007). venous circulation.
- Mode of transmission: bite of rabid animal ➔ Coral snakes are known for the small coral, yellow, and ◆ Commercial snakebite kits have rubber suction cups
- Active artificial immunity: human diploid cell rabies black rings encircling their body. in them for suctioning out venom. If these are
vaccine ➔ Fortunately, they are shy and seldom bite. However, the available, they should be used at the site where the
- Passive artificial immunity: rabies immune globulin (RIG) venom injected through the bite of these snakes leads to bite occurred.
- Prodromal signs: malaise, fever, anorexia, nausea, sore neuromuscular paralysis o Excising the bite with a knife and sucking out the
throat, drowsiness, irritability, restlessness venom orally (often shown in old western movies) is
- Clinical manifestations: anxiety, radicular pain pruritus, ASSESSMENT of questionable value and contradicts rules of
hydrophobia, dysautonomia, paralysis ◆ Reaction to a pit viper bite is almost immediate. standard infection precautions.
- Hydrophobia: water fear; when children try to drink, they o A white wheal forms at the site, showing the puncture ◆ If the person administering the treatment has open
experience violent contractions of the muscles in the marks, accompanied by excruciating pain at the site. mouth lesions, such as carious teeth, the procedure
mouth which leads to drooling of saliva o Purplish erythema and edema begin to extend rapidly could be dangerous to that person (venom is not
- Peripheral vascular collapse and death follows as quickly from the site. dangerous when swallowed, only when absorbed
as 5-6 days ◆ By the time a child is seen at a health care facility, through open lesions).
- ASk the child what the animal looked like or show sanguineous fluid may be oozing from the bite. o Excising the bite also may lead to secondary infection
pictures of different animals asking them to point to the ◆ Systemic symptoms, such as dizziness, vomiting, and, if done too vigorously, may injure tendon or
one that bit them perspiration, and weakness, may be present. muscle.
- Immunity status of the animal is key in deciding whether ◆ Because snake venom interferes with blood o No time should be wasted before the child is
treatment will be necessary coagulation, the child may have hematemesis or transported to a health care facility for treatment.
- prophylaxis should be initiated as soon as possible bleeding from the nose, intestines, or bladder
- Prophylaxis because of subcutaneous or internal hemorrhage. Emergency Management at the Health Facility
● Human rabies vaccine: allows the child to being ◆ In the emergency facility, ask the child or a person
additional antibody formation so that by the who was with the child to describe the snake.
time the RABV from the bite begins to have an ◆ In areas where snakebites are frequent, keep available
effect, the child has developed sufficient photographs of the venomous snakes commonly
antibodies to combat it and prevent the illness found. Even a preschooler may be able to identify the
● RIG: into the area of the bite (day 0) and snake by pointing to a photograph.
remainder of the dose given through IM (day
3,7,14)
 ◆ Specific antivenin is then administered. Because
rattlesnakes, copperheads, and cottonmouth
moccasins are all one type of snake (pit vipers),
one form of antivenin acts against all of these
bites.
◆ Specific antivenin is prepared for coral snake or
cobra bites and is kept at most zoos.
o If the child receives antivenin promptly after a bite,
the prognosis for full recovery is good.
◆ Tetanus prophylaxis is instituted if the child’s
immunization status is unknown or if it has been
more than 10 years since a tetanus immunization
was given.
◆ Antivenin may contain a horse-serum base.
Therefore, before the serum is injected IM or IV, a
skin test may need to be performed to prevent a
possible anaphylactic reaction to the horse serum.
o If the serum is given IM, do not inject it into an
edematous body part, because medication
absorption will be poor.
◆ Giving antivenin in the limb opposite the bitten
limb is just as effective as administering it into the
bitten limb.

THERMAL INJURIES
➔ Thermal injuries include those caused by either cold
(frostbite) or by excessive heat (burns)
➔ Frostbite
◆ Frostbite is tissue injury caused by freezing cold
(Stallard, 2008).
◆ Cold exposure leads to peripheral vasoconstriction,
cutting off the oxygen supply to surrounding cells.
◆ In children, the body parts involved usually are the
nose, fingers, or toes. Cells at the site can be so
injured that they die.

ASSESSMENT
◆ The affected body part appears white or
erythematous; edema is present and it feels
numb.
 ◆ Explore the cause of frostbite by careful history Classification Description
taking.
Minor First-degree burn or
◆ It occurs most frequently in children who have been
seconddegree burn "10% of body
skiing, snowmobiling, or snowboarding for long BURNS surface or third-degree burn "2%
periods. ➔ Burns are injuries to body tissue caused by excessive heat of body surface; no area of the
◆ If parents failed to provide adequate clothing because (heat greater than 104° F [40° C]). face, feet, hands, or genitalia
they underestimated the degree of cold outside, the ➔ Such injuries commonly occur in children of all ages after burned
possibility of neglect or child abuse must be ruled out infancy.
as a cause. ➔ They are the second greatest cause of unintentional injury Moderate Second-degree burn between 10%
◆ Frostbite also can occur from sucking on popsicles and in children 1 to 4 years of age and the third greatest cause to 20% or on the face, hands, feet,
from inhalant abuse. in children age 5 to 14 years. or genitalia or third-degree burn
➔ Toddlers are often burned by pulling pans of scalding water "10% of body surface or if smoke
THERAPEUTIC MANAGEMENT or grease off the stove and onto themselves or from bath inhalation has occurred
◆ Always warm frostbitten areas gradually. Sudden water that is too hot. They can bite into electrical cords.
warming increases the metabolic rate of cells; without ➔ Older children are more apt to suffer burns from flames Severe Second-degree burn #20% of body
adequate blood flow to the area because of when they move too close to a campfire, heater, or surface or third-degree burn #10%
still-present vasoconstriction, additional damage can fireplace; touch a hot curling iron; or play with matches or of body surface
occur. lighted candles. o Along with the size and depth, be certain to assess and
◆ Administration of a vasodilator and use of hyperbaric ➔ Eye burns can occur from splashed chemicals in science document the location of the burn.
oxygen may help reduce the effect on body cells. classes). o Face and throat burns are particularly hazardous
➔ Some burns (particularly scalding) can be caused by child because there may be accompanying but unseen burns
Degrees of Frostbite abuse). in the respiratory tract. Resulting edema could lead to
➔ Burn injuries tend to be more serious in children than in respiratory tract obstruction.
adults, because the same size burn covers a larger surface o Hand burns are also hazardous because, if the fingers
of a child’s body. and thumb are not positioned properly during healing,
➔ As many as 50% of burns could be prevented with adhesions will inhibit full range of motion in the future.
improved parent and child education. o Burns of the feet and genitalia carry a high risk for
secondary infection.
ASSESSMENT o Genital burns are also hazardous because edema of the
◆ When children are brought to a health care facility urinary meatus may prevent a child from voiding.
with a burn injury, the first questions must be, “Where o With adults, the “rule of nines” is a quick method of
is the burn and what is its extent and depth?” estimating the extent of a burn. For example, each
◆ Burns are classified according to the criteria of the upper extremity represents 9% of the total body
American Burn Association as major, moderate, or surface; each lower extremity represents two 9s, or
minor. 18%, and the head and neck represent 9%. Because the
body proportions of children are different from
 those of adults, this heal
rule does not always
apply and is misleading
in the very young child.
o Computer analysis is
now available to rapidly
assess the extent of
burns.

Data for determining the extent of burns in children

Degree Description

First Mild freezing of

epidermis;
appears
erythematous
with edema
Second Partial- or
full-thickness
injury; appears
erythematous
with blisters and
pain occurring
after rewarming
Third Full-thickness
injury
(epidermis,
dermis, and
subcutaneous
tissue); appears
white
Fourth Complete
necrosis
with
gangrene and
possible ultimate
Second Epidermis Erythematous, Scalds
Degree dry, painful An infant with a first-degree burn on the arm and chest caused by scalding with
Portion of hot water.
(Partial
Dermis o Second-Degree Burn
Thickness)
− Involves the entire epidermis. Sweat glands and hair follicles are left intact.
Third Degree Entire skin, Leathery; black Flame The area appears very erythematous, blistered, and moist from exudate. It
(Full including nerves or white; not is extremely painful.
Thickness) and blood sensitive to − Scalds can cause second-degree burns.
vessels in skin pain (nerve
− Such burns heal by regeneration of tissue but take 2 to 6 weeks to heal.
endings
destroyed)

o Depth Size
o When estimating the depth of a burn, use the Severity Depth of Appearance Example
appearance of the burn and the sensitivity of Tissue Involved
the area to pain as criteria. First degree Epidermis Erythematous, Sunburn
Characteristics of Burns (Partial dry, painful
Thickness)

o First-Degree Burn A toddler with a second-degree burn caused by scalding.

− Involves only the superficial epidermis. The The area appears severely reddened and moist with some
area appears erythematous. It is painful to blistering
touch and blanches on pressure.
− Scalds and sunburn are examples of first- o Third-Degree Burn
degree burns. − A third-degree burn is a full-thickness burn
− Such burns heal by simple regeneration and involving skin layers, epidermis and dermis.
take only 1 to 10 days to
 − It may also involve adipose tissue, fascia, o A first-degree burn is painful, whereas a third- type of burn, they involve pain and death of
muscle, and bone. degree burn is not. Therefore, a child may be skin cells, so they must be treated seriously.
− The burn area appears either white or black. crying from a superficial burn that is obvious on o Immediately apply ice to cool the skin and
− Flames are a common cause of third-degree the arm, although the condition needing the prevent further burning.
burns. Because the nerves, sweat glands, and most immediate attention is a third-degree burn o Application of an analgesic–antibiotic
hair follicles have been burned, third- degree on the chest, which is covered by a jacket. ointment and a gauze bandage to prevent
burns are not painful. o Be certain to ask what caused the burn, because infection is usually the only additional
− Such burns cannot heal by regeneration different materials cause different degrees of burn. treatment required.
because the underlying layers of skin have Hot water, for example, causes scalding, a generally o The child should have a follow-up visit in 2
been destroyed. lesser degree of burn than one caused by flaming days to have the area inspected for a
− Skin grafting is usually necessary, and healing clothing. Ask where the fire happened. Fires in closed secondary infection and to have the dressing
spaces are apt to cause more respiratory changed.
takes months. Scar tissue will cover the final
involvement than fires in open areas. o Caution parents to keep the dressing dry
healed site.
o Ask whether the child has any secondary health (no swimming or getting the area wet while
− Many burns are compound, involving first-,
problem. bathing for 1 week). A first-degree burn
second-, and thirddegree burns.
o In their anxiety over the present burn, parents heals in about that time.
− There may be a central white area that is
may forget to report important facts, such as ● Moderate Burns
insensitive to pain (third degree), surrounded
the child has diabetes or is allergic to a common o Moderate or second-degree burns may have
by an area of erythematous blisters (second
drug. After a fire, parents may pick up a burned blisters. Do not rupture them, because doing
degree), surrounded by another area that is
child and bring the child to a health care facility, so invites infection.
erythematous only (first degree).
leaving other children unprotected at home. o The burn will be covered with a topical
o Ask about other children and where they are. antibiotic such as silver sulfadiazine and a
o Parents may have burned hands from putting bulky dressing to prevent damage to the
out the fire on the child’s clothes and need denuded skin.
equal care, but in their anxiety about the o The child usually is asked to return in 24
child’s condition, they do not mention this. hours to assess that pain control is adequate
o Ask who put out the fire. Were any other family and there are no signs and symptoms of
members or animals hurt? Does anyone else need infection.
care? o Broken blisters may be débrided (cut away)
to remove possible necrotic tissue as the
burn heals.
Emergency Management of Burns ● Severe Burns
Full-thickness (third-degree) burn of the foot. Both layers of skin ● All burns need immediate care because of the pain
o The child with a severe burn is critically
are involved with this type of burn. involved
injured and needs swift, sure care, including
● Minor Burns
o Undress children with burns completely so the entire fluid therapy, systemic antibiotic therapy,
o Although minor burns (typically first-degree pain management, and physical therapy, to
body can be inspected.
partial-thickness burns) are the simplest survive the injury without a disability caused
by scarring, infection, or contracture.
● Electrical Burns of the Mouth o Some children have difficulty with speech ● A synthetic skin covering (Biobrane), artificial skin
o If a child puts the prongs of a plugged-in sounds because of resulting lip scarring. (Integra), or amniotic membrane from placentas
extension cord into the mouth or chews on an They need follow-up care by a plastic can be used to help decrease infection and protect
electric cord, the mouth will be burned surgeon to restore their lip contour. granulation tissue.
severely. Obviously, you need to review with parents ● As a rule, burn dressings are applied loosely for the
o Electrical current from the plug is conducted for the importance of not leaving “live” first 24 hours to prevent interference with circulation
a distance through the skin and underlying electrical cords where young children can as edema forms.
tissue, so a tissue area much larger than where reach them. ● Be certain not to allow two burned body surfaces,
the prongs or cord actually touched is involved, such as the sides of fingers or the back of the ears
THERAPY FOR BURNS
leaving an angry-looking ulcer. and the scalp, to touch, because, as healing takes
● Second- and third-degree burns may receive open
o If blood vessels were burned, active bleeding will place, a webbing will form between these surfaces.
treatment, leaving the burned area exposed to the
be present. The immediate treatment for ● Do not use adhesive tape to anchor dressings to the
air, or a closed treatment, in which the burned area
electrical burns of the mouth is to unplug the skin; it is painful to remove and can leave excoriated
is covered with an antibacterial cream and many
electric cord and control bleeding. areas, which provide additional entry for infection.
layers of gauze.
Pressure applied to the site with gauze is ● Netting is useful to hold dressings in place, because it
Method Description Advantages Disadvantages
usually effective. expands easily and needs no additional tape.
o Most children are admitted to a hospital for at Open Burn is Allows Requires strict
least 24 hours in an observation unit because exposed to air; frequent isolation to ● Topical Therapy
edema in the mouth can lead to airway used for inspection of prevent o Silver sulfadiazine (Silvadene) is the drug of
obstruction. Supply adequate pain relief as long superficial site’ allows infection; area choice for burn therapy to limit infection at the
as necessary. burns or body child to follow may scrape burn site for children.
o Clean the wound about four times a day with an parts that are healing process and bleed o It is applied as a paste to the burn, and the area
antiseptic solution, such as half- strength prone to easily and is then covered with a few layers of mesh gauze.
hydrogen peroxide, or as otherwise ordered to infection, such impede o Silver sulfadiazine is an effective agent against
reduce the possibility of infection (a real danger as perineum healing both gram-negative and gram-positive
in this area, because bacteria are always present organisms and even against secondary infectious
in the mouth). Closed Burn is Provides better Requires agents, such as Candida.
o Eating will be a problem for the child because covered with protection dressing o It is soothing when applied and tends to keep the
the mouth is so sore. The child may be able to non-adherent from injury; is changes that burn eschar soft, making débridement easier. It
gauze; used easier to turn are painful; does not penetrate the eschar well, which is its
drink fluids from a cup best. Bland fluids, such as
for moderate and position possibility of one drawback.
artificial fruit drinks or flat ginger ale, are best.
and severe child; allows infection may o Antiseptic solutions, such as povidone-iodine
o Electrical burns of the mouth turn black as local
burns child to more increase (Betadine), may also be used to inhibit bacterial
tissue necrosis begins. They heal with white,
freedom to because of and fungal growth. Unfortunately, iodine stings
fibrous scar tissue, possibly causing a deformity
play dark, moist as it is applied and stains skin and clothing brown.
of the lip and cheeks with healing. This can be
environment
minimized by the use of a mouth appliance, Dressings must be kept continually wet to keep
which helps maintain lip contour. them from clinging to and disrupting the healing
tissue.
 o If Pseudomonas is detected in cultures, o Children usually have 20 minutes of hydrotherapy o Another trend in débridement is the use of
nitrofurazone (Furacin) cream may be applied. If before débridement to soften and loosen eschar, collagenase (Santyl), an enzyme that
a topical cream is not effective against invading which then can be gently removed with forceps and dissolves devitalized tissue.
organisms in the deeper tissue under the eschar, scissors. ● Grafting
daily injections of specific antibiotics into the o Débridement is painful, and some bleeding o Homografting (also called allografting) is
deeper layers of the burned area may be occurs with it. the placement of skin (sterilized and
necessary. o Premedicate the child with a prescribed analgesic, frozen) from cadavers or a donor on the
o If a burned area, such as the female genitalia, and help the child use a distraction technique cleaned burn site.
cannot be readily dressed, the area can be left during the procedure to reduce the level of pain. o These grafts do not grow but provide a
exposed. The danger of this method is the o Transcutaneous electrical nerve stimulation (TENS) protective covering for the area. In small
potential invasion of pathogens. therapy or patient-controlled analgesia may also be children, heterografts (also called xenografts)
helpful. from other sources, such as porcine (pig) skin,
o Praise any degree of cooperation. Plan an enjoyable may be used.
activity afterward to aid in pain relief and also to o Autografting is a process in which a layer of
● Escharotomy help re-establish some sense of control over the skin of both epidermis and a part of the dermis
o An eschar is the tough, leathery scab that forms situation. (called a split-thickness graft) is removed from
over moderately or severely burned areas. o Children need to have a “helping” person with them, a distal, unburned portion of the child’s body
o Fluid accumulates rapidly under eschars, putting to hold their hand, to stroke their head, and to offer and placed at the prepared burn site, where it
pressure on underlying blood vessels and nerves. some verbal comfort during débridement: “It’s all will grow and replace the burned skin.
o If an extremity or the trunk has been burned so right to cry; we know that hurts. We don’t like to do o Cultured epithelium is derived from a
that both anterior and posterior surfaces have this, but it’s one of the things that makes burns heal” fullthickness skin biopsy. This can be grown
eschar formation, a tight band may form around o Nursing personnel need a great deal of talk time to into a coherent sheet and supply an unlimited
the extremity or trunk, cutting off circulation to voice their feelings about assisting with or doing source for autografts. Larger areas may
distal body portions. débridement procedures. Be careful when serving as require mesh grafts (a strip of
o Distal parts feel cool to the touch and appear the “helping” person that you do not project yourself partial-thickness skin that is slit at intervals so
pale. The child notices tingling or numbness. as the healer and comforter and a fellow nurse as the that it can be stretched to cover a larger area.
o Pulses are difficult to palpate, and capillary refill hurter or “bad guy.” It helps if people alternate this o The advantage of grafting is that it reduces
is slow (longer than 5 seconds). chore so that, on alternate days, each serves as the fluid and electrolyte loss, pain, and the
o To alleviate this problem, an escharotomy (cut into protector or the comforter. chance of infection.
the eschar) is performed. Some bleeding will o If eschar tissue is débrided in this manner day after o After the grafting procedure, the area is
occur after escharotomy. Packing the wound and day, granulation tissue forms underneath. When a full covered by a bulky dressing. So that the
applying pressure usually relieves this. bed of granulation tissue is present (about 2 weeks growth of the newly adhering cells will not be
after the injury), the area is ready for skin grafting. In disrupted, this should not be removed or
● Débridement some burn centers, this waiting period is avoided by changed.
o It is the removal of necrotic tissue from a burned immediate surgical excision of eschar and placement o The donor site on the child’s body (often the
area. Débridement reduces the possibility of of skin grafts. anterior thigh or buttocks) is also covered by
infection, because it reduces the amount of dead a gauze dressing. Both donor and graft
tissue present on which microorganisms could dressings should be observed for fluid
thrive. drainage and odor.
o Observe the child to determine whether there
is pain at either site, which might indicate
 infection.
o Monitor the child’s temperature every 4
hours. A rise in systemic temperature may be
the first
 indication that there is infection at the graft or
donor site.
o Autograft sites can be reused every 7 to 10 days,
so any one site can provide a great deal of skin
for grafting.

IMCI At the out-patient health facility, the health worker should routinely do basic demographic data Novartis Foundation has supported the WHO and the Swiss TPH to develop
collection, vital signs taking, and asking the mother about the child’s problems. Determine IMPACtt - the Integrated Management of Pregnancy and Childbirth training
- Major strategy for child survival, healthy growth, and development whether this is an initial or follow-up visit. The health worker then proceeds with the IMCI tool. IMPACtt is based on the ICATT software and will comprise four modules
process by checking for general danger signs, assessing the main symptoms, and other on antenatal care, childbirth care, essential newborn care and postnatal care
processes indicated in the chart.
- Based on the combined delivery of essential interventions at community, health
facility and healthy systems
Take note that for the pink box, referral facility includes district, provincial, and tertiary hospital.
Once admitted, the hospital protocol is used in the management of the sick child. DYSENTERY
- Includes elements of prevention as well as curative and addresses the most
common conditions that affect young children
Assessed for main symptoms:
- infectious disease characterized by inflammation of the intestine, abdominal
- Developed by WHO and UNICEF pain, and diarrhea with stools that often contain blood and mucus. Dysentery
Older children: cough or difficulty breathing, diarrhoea, fever and ear infection
is a significant cause of illness and death in young children, particularly those
Objectives: who live in less-developed countries. There are two major types: bacillary
Young infants: local bacterial infection, diarrhoea, jaundice dysentery and amebic dysentery, caused respectively by bacteria and by
- Reduce death and frequency and severity of illness and disability amoebas.
IMCI Computerized Adaptation and Training Tool

- Contribute to improved growth and development - Bacillary dysentery, or shigellosis, is caused by bacilli of the genus Shigella.
- Computerized, adaptable tool for training in the IMCI Symptomatically, the disease ranges from a mild attack to a severe course
that commences suddenly and ends in death caused by dehydration and
Components poisoning by bacterial toxins. After an incubation period of one to six days,
- Joint project of WHO and the Novartis Foundation for Sustainable Development
the disease has an abrupt onset with fever and the frequent production of
- Improving case management skills of health workers watery stools that may contain blood. Vomiting may also occur, and
- Chart booklet builder: The IMCI guidelines developed by WHO have been dehydration soon becomes obvious owing to the copious loss of bodily fluids.
summarized in a set of charts presented in a chart booklet. The library In advanced stages of the disease, chronic ulceration of the large intestine
- Improving over-all health systems includes reference and educational materials on IMCI and related child causes the production of bloody stools.
health issues, developed by WHO and other international agencies. It also
- Improving family and community health practices includes a wide variety of videos, pictures, and sounds that are used for
audiovisual practice. - The most severe bacillary infections are caused by Shigella dysenteriae type 1
(formerly Shigella shigae), which is found chiefly in tropical and subtropical
Rational for an integrated approach regions. S. flexneri, S. sonnei, and S. boydii are other Shigella bacilli that cause
- have different maternal approach and procedures dysentery. Other types of bacterial infections, including salmonellosis (caused
- Majority of these deaths are caused by 5 preventable and treatable conditions by Salmonella) and campylobacteriosis (caused by Campylobacter), can
namely: pneumonia, diarrhea, malaria, measles, and malnutrition - facilitates the adaptation of IMCI guidelines to meet country-specific requirements produce bloody stools and are sometimes also described as forms of bacillary
and on the other hand helps scale up IMCI training. dysentery. The treatment of bacillary dysentery is based on the use of
- Three out of 4 episodes of childhood illness are caused by 5 conditions antibiotics. The administration of fluids and, in some cases, blood
- facilitate the scaling-up of training in IMCI as it reduces training time and costs transfusions may be necessary.

- Most children have more than one illness at one time. This overlap means that a while maintaining the same training outcomes as traditional IMCI training
single diagnosis may not be possible or appropriate - Amebic dysentery, or intestinal amebiasis, is caused by the protozoan
IMPACC – Integrated Management of Pregnancy and Childbirth
Entamoeba histolytica. This form of dysentery, which traditionally occurs in
Basis for classifying the child’s illness the tropics, is usually much more chronic and insidious than the bacillary
- addressing the improvement of skills of health workers to better respond to the disease and is more difficult to treat because the causative organism occurs
Pink – urgent hospital referral or admission needs of pregnant women and their newborns. in two forms, a motile one and a cyst, each of which produces a different
disease course. The motile form causes an acute dysentery, the symptoms of
IMPACTT – Integrated Management of Pregnancy and Childbirth Training Tool which resemble those of bacillary dysentery. The cyst form produces a
Yellow – initiation of specific outpatient treatment
chronic illness marked by intermittent episodes of diarrhea and abdominal
pain. Bloody stools occur in some patients. The chronic type is the more
Green – supportive home care - To increase the skilled health workforce in maternal and newborn health, the
 common of the two and is marked by frequent remissions and exacerbations
of symptoms. The chronic form may also produce ulcerations of the large
intestine and pockets of infection in the liver. Both forms of amebic
dysentery are treated with drugs that specifically kill the amebic parasites
that thrive in the intestines.

- Dysentery is transmitted through the ingestion of food or water that has been
contaminated by the feces of a human carrier of the infective organism. The
transmission is often by infected individuals who handle food with unwashed
hands. The spread of amebic dysentery is often accomplished by people who are
carriers of the disease but who at the time show no symptoms. Dysentery is
commonly found when people are crowded together and have access only to
primitive sanitary facilities. Spread of the disease can be controlled by boiling
drinking water and by adequately disposing of human waste to avoid the
contamination of food.

Diarrheal stools
- Watery stool with sodium, potassium, bicarbonate
- Leads to decreased blood volume, hypovolemia, collapse, death
- Isotonic dehydration – losses of sodium and water equal to ECF; thirst,
tachycardia, dry mucous membranes, lack of tears, oliguria; fluid deficit
approach 5% of body weight; 10% of body weight(anuria, hypotension, rapid
pulse, cool and pale extremities, other signs of hypotension)
- Hypertonic or hypernatremic dehydration: reflects a net loss of water more than
sodium; ingestion of fluids or osmotically active solutes during diarrhea;
- Isonatremic (isotonic) dehydration occurs when the lost fluid is similar in sodium
concentration to the blood. Sodium and water losses are of the same relative
magnitude in both the intravascular and extravascular fluid compartments.
- Hyponatremic (hypotonic) dehydration occurs when the lost fluid contains more
sodium than the blood (loss of hypertonic fluid). Relatively more sodium than
water is lost. Because the serum sodium is low, intravascular water shifts to
the extravascular space, exaggerating intravascular volume depletion for a
[
given amount of total body water loss.
- Hypernatremic (hypertonic) dehydration occurs when the lost fluid contains less
sodium than the blood (loss of hypotonic fluid). Relatively less sodium than
water is lost. Because the serum sodium is high, extravascular water shifts to
the intravascular space, minimizing intravascular volume depletion for a
given amount of total body water loss
Nursing Management of
Pediatric Emergencies
Basic Principle of Emergency Care
• Rendered without delay, some patients with diverse health problems-some
life threatening, some not
• ABCD Evaluation(Airway, Breathing, Circulation and Disability)
• Unintentional Injuries from child maltreatment
• Hallmark of Maltreatment: Conflicting Stories(parent and child recounting
different stories)
Triage
-to sort, group patient in the severity of health problems and immediacy the
problem must be treated
Emergent: Conditions that are a potential threat to life, limb or function
Urgent: Serious conditions that require emergency intervention
Non-urgent: chronic problem
Head Trauma
• Head injuries potentially serious that can be life-threatening
to the child
• Increase ICP-decrease pulse and respiration rate, increase
temperature and pulse pressure
• Skull Fracture
Crack in one of the bones of the skull, cerebral injury. Bone
fracture the suture line separate most common lambdoid
Skull X-ray,”Rhinorrhea or Otorrhea”(clear fluid draining from
nose and ear which is CSF-open to infxn(glucose strip test)
Depressed fracture-pressing inward
Compound-broken into pieces
Leptomeningeal Cyst-projection of arachnoid membrane into
the fractured site(focal seizure and increase ICP)
Subdural Hematoma
• Venous bleeding into the space between
dura and arachnoid membrane
• S/S: Increase ICP, seizures, vomiting,
hyperirritability and enlargement of the
diameter of the head,Anemia
• DT: Angiography, MRI, Ultrasound
• Subdural puncture to the accumulated
subdural blood-anterior fontanelle
 Epidural Hematoma
• Bleeding into the space between dura and
the skull occurs when head trauma is severe
• Rupture of middle meningeal artery, thus
arterial bleeding(Rapid brain compression)
• S/S: Unconscious with signs of cortical
compression(vomiting, loss of
consciousness, headache,seizures or
hemiparesis(paralysis on one side),unequal
dilation and constricted pupils, decorticate
posturing
• Cauterization and ligation of the torn artery
Concussion
• Temporary and immediate impairment of
neurologic function caused by a hard jarring
shock to the skull
• Coup Injury-Side of the injury
• Contrecoup- brain recoils from the force of the
blow and strikes the opposite surface of the
skull
• S/S: vomiting, irritability and amnesia
Contusion
• Tearing or laceration of brain tissue/bruising in
the brain,more severe symptoms than
concussion
• Focal,seizure, eye deviation or loss of speech
Coma
• Unconscious;child cannot be aroused
• Stupor-grogginess from which the child can
be aroused occur after severe trauma
• Turn the pt to side-avoid brain stem
compression
• Dilated pupils-increased ICP-irreversible brain
stem damage
• Cranial Nerve compression or Tentorial tear-
one pupil dilated and one eye deviated
downward or laterally
• GCS: Severe Trauma(3-8),Very Severe
Prognosis(less than 5),Moderate Trauma(9-
12), Slight Trauma (13-15)
Abdominal Trauma
• Spleen and Liver-more exposed in children than in adults, injury
difficult to detect; increase RR, decrease BP(older child<80mmHg
systolic and Infant <60mmHg), pallor
• Low BP no improvement with IVTT and NGT tube insertion(stomach
contents aspirated);FBC insertion(inspect Urine for blood)
• Paracentesis-introduction of catheter into the abdomen to aspirate
for presence of blood
• DT: X-ray and MRI or Ultrasound
• No analgesics unless pain is severe to avoid masking increasing pain
• Splenic Rupture
❖Most frequently injured organ when there is abdominal trauma because of
its location under the lower left ribs
❖S/S: Tenderness in the left upper quadrant of the abdomen esp deep
inspiration (diaphragm moves down and touches spleen)
❖Kehr Sign-child holds left shoulder elevated so that diaphragm raised left
side or report left radiated left shoulder pain while lying in supine position
❖MRI reveal Kidney damage behind spleen
• Liver Rupture
❖Prone to rupture in children not completely sheltered by the rib cage
❖S/S: Severe abdominal pain marked on inspiration(diaphragm descends
and touched spleen, Hematemesis(vomiting of blood) or melena, colicky
upper abdominal pain relieved by emesis
❖Blood loss(increase PR, decrease BP, anxiety and pallor)
❖Liver arteriogram-reveal extent of injured artery
Near Drowning
• Death caused by suffocation from submersion in liquid when the
inhaled water fills the lungs and therefore blocks the exchange of
oxygen in the alveoli
• Water enters larynx causing it to spasm-prevent air entering the
trachea resulting in asphyxia-larynx relaxes and H2O enters lungs-
alveoli fill with H2O-Hypoxia deepens and cardiac arrest occurs
• Salt Water-Hypertonic-Hypovolemia
• Fresh Water-Hypotonic-Hypervolemia
• Acidotic-accumulated carbon dioxide and Hypoxic
Acetaminophen Poisoning
Treat childhood fever and readily available at home
S/S: Anorexia, nausea, vomiting
Labs: Serum Aspartate Transaminase(AST/SGOT) and Serum Alanine
Transaminase(ALT/SGPT), Increase Liver enzymes
TTT: Activated Charcoal-Antidote, absorb toxic substances that have
been swallowed to prevent stomach absorption
Acetylcysteine-mucolytic agent and specific antidote for
acetaminophen poisoning. Prevents hepatoxicity by binding with the
breakdown product of acetaminophen so that it will not bind to the
liver
Caustic Poisoning
Strong alkali such as lye contained in toilet bowl cleaner or hair care
products causes burns and tissue necrosis in the mouth, esophagus and
stomach
S/S: drools saliva, oral edema, inability to swallow;Mouth turns
white(vomit blood, mucus and necrotic tissue);tachycardia, tachypnea,
pallor and hypotension
TTT: Activated Charcoal-not be administered and IV Morphine-1st
Step relieve pain, Proton pump inhibitor IV for acid reflux
CXR, Laryngoscope and esophagoscopy under conscious sedation
or GA,Intubation or tracheostomy, NG tube contraindicated
Iron Poisoning
• Large amt corrosive to the gastric mucosa and leads to gastric irritation
• S/S: N/V, diarrhea, abdominal pain. After 6H,hemorrhagic necrosis og lining
of GI tract. By 12H, melena,hematemesis,lethargy,coma,cyanosis,
vasomotor collapse, coagulation defects and hepatic injury.Hypovolemic
shock(blood loss and decrease cardiac output.Long term effects,gastric
scarring from fibrotic tissue formation
• TTT:Activated charcoal not given. Stomach Lavage is done instead to
remove any pills not yet absorbed
• Maalox and Mylanta(Aluminum HCI and Mg HCI) help decrease gastric
irritation and pain. Deferoxamine IV or IM,a chelating agent-urine turn
orange
Lead Poisoning
• Plumbism,Interferes RBC function, kidney destruction and
encephalitis
• Present when the child has two successive blood serum lead levels
greater than 5 micrograms/dl
• Lead levels greater than 10-20 micrograms/100ml-prescribed oral
chelating agent such as Dimercaptosuccinic acid(DMSA) or Succimer.
Lead levels greater than 45micrograms/100ml are treated with
stronger chelation therapy such as Dimercaprol(British anti-
Lewisite/BAL) or Edetate Calcium Disodium (CaEDTA)
• CaEDTA-plus 0.5ml procaine, assess BUN, serum creatinine and
protein in urine; remove Ca+ from the body
• BAL-given with severe form of lead toxicity
Hydrocarbon Ingestion
Commonly ingested gasoline, lubricating oil, motor oil, lamp oil and
kerosene
S/S: Pulmonary effects:cough, choke, cyanosis, hypoxia, respiratory
distress
CNS effects: euphoria, mental status changes lethargy ,coma,
seizure
TTT: Intubation-severe pulmonary toxicity,Supportive care, C/I-Gastric
emptying and activated charcoal
Insecticide Poisoning
Insecticides: Organophosphates, Organochlorine, aluminium phosphide,
carbamates, pyrethrins and pyrethroids
S/S: Eye tearing, Coughing, heart problems, and breathing difficulties.
Decrease BP and PR, seizures, respiratory paralysis
TTT: Proper oxygenation, Atropine escalating doses and pralidoxime high
doses
Plant Poisoning
Ingesting or coming in contact with a poisonous plant or a substance from a
plant
S/S: Chewed Castor beans-highly toxic substance ricin: delayed vomiting,
diarrhea and neurological symptoms
Lily of the Valley(digitalis Glycosides)-Gastroenteritis, confusion,
hyperkalemia, and arrhythmias: Digoxin-specific fractionated antibody(Fab)
used to treat Ventricular arrhythmias
Foreign Body Obstruction
• Causing direct obstruction of the airway or long-term stasis of secretions
and infection
Foreign Bodies in the Ear
✓Otoscopic examination to determine cause
✓Outer canal-irrigating object from ear canal with syringe and normal saline
Foreign Bodies in the Nose
Foreign Bodies in the Esophagus
✓Magnet-lead to bowel perforation or volvulus from their acid content
Subcutaneous Objects(e.g wood Splinters)
✓Probing needle and tweezers after cleaning with antiseptic sol’n
Bites
Dog Bites and other Mammalian Bites
Dog bites-90% of all bites on humans; Rabies can cause encephalitis is
fatal and caused by Lyssavirus genus which include rabies virus
Clinical manifestations: anxiety, radicular pain pruritus, hydrophobia,
dysautonomia and paralysis
TTT: Tetanus Toxoid and Human Tetanus Immunoglobulin(TIG); Human
diploid cell rabies vaccine and rabies immune globulin(RIG);Rabies
vaccine given Day 0,3,7 and 14
Snakebite
• Occur during warm months of the year April-October
• Cottonmouth moccasins and copperheads or rattlesnakes(pit vipers)
and coral snakes(yellow and black rings encircling their body)
• S/S: Systemic symptoms: dizziness, vomiting, perspiration and
weakness,Immediate failure of blood coagulation
system:Hematemesis or bleeding from nose,intestines, or bladder
due to SQ or internal hemorrhage.Cerebral center:dilated
pupils,seizure and coma
• Coral snakes-neuromuscular paralysis
• TTT: cold compress to the bite and Antivenin contain horse-serum
base
Thermal Injuries
Caused by either cold(frostbite) or excessive heat(burns)
Frostbite
Tissue injury caused by freezing cold; the extreme cold causes peripheral vasoconstriction,
cutting off the oxygen supply to surrounding cells. Nose, finger and toes.
1st degree: mild freezing of epidermis, erythematous with edema
2nd degree: partial- or full-thickness injury; appears erythematous;blisters and pain occur
after re-warming
3rd degree: full-thickness injury(epidermis,dermis and SQ)appears white
4th degree: complete necrosis with gangrene and possible ultimate loss of body part
Skiing,snowbowling or snowboarding
TTT: Gradual warming, sudden can cause damage,administer vasodilator and use of
hyperbaric oxygen
Burn Trauma
• Injury to body tissue caused by excessive heat( heat greater than 104 degree
Fahrenheit/40 degree celcius
• Depth of Burn
1st degree: epidermis or outer layer of the skin. Reddened, dry, and feels mildly
painful. Heals by simple regeneration takes 1-10 days to heal-SUNBURN
2nd degree: Epidermis and part of dermis. Appears red, blistered, and may be
swollen. Very painful. Heals by regeneration of tissue over 2-6 weeks-SCALDING
3rd degree: Epidermis and full extent of the dermis. Appears white or charred and
lacks sensation as the nerve endings are destroyed. Skin drafting and healing takes
months-FLAMES
4th degree: Full-thickness burn extending into muscle or bone. Skin drafting; muscle
and bone may be permanently damaged; scarring will cover the healed site.-HIGH-
VOLTAGE ELECTRIC OR SEVERE FIRE
Determination of extent of burns in children
 Managements:
Minor: Analgesic-antibiotic ointment and gauze to prevent infxn
Moderate: Do not rupture blisters-denudes site and invades infxn; Silver
Sulfadiazine
Severe: Fluid therapy, systemic antibiotic therapy, pain mgt(Morphine Sulfate
or Epidural injxn) and physical therapy
Electrical Burns of the mouth: control bleeding, pain mgt and wound
care,hydrogen pyroxide, edema of mouth can lead to airway obstruction
Hypothermia-keep body parts not burned well covered
Severe Anemia-injury to RBC cause by heat and loss of blood at wound site-
hyponatremia and hyperkalemia
Lactated Ringer’s Solution-compatible with extracellular fluids
Plasma and 5% Dextrose in Water
Carbon Monoxide Poisoning-smoke inhalation from a fire
Managements:
Topical Therapy: Silver Sulfadiazine(Silvadene)-drug of choice for burn
therapy, mesh gauze after
Eschar-tough,leathery scab that forms over moderately or severely burned
areas
Nitrofurazone(Furacin) cream-pseudomonas,detected in cultures
Escharotomy-cut into the eschar
Debridement-removal of necrotic tissue,reduce possibility of infxn
Collagenase(Santy)-enzyme dissolves devitalize tissue or manually
Grafting
Allografting-placement of skin from cadavers and donors
Xenografts-porcine(pig)skin
Autografting-layer of skin of both epidermis and part of dermis removed
from distal, unborned portion of the child’s body and placed over the
prepared burn site
CARE OF THE CHILD
APPLYING
INTEGRATED
MANAGEMENT OF
CHILDHOOD
ILLNESSES (IMCI)
Overview of Integrated Management of
Childhood Illnesses (IMCI) Process
The Integrated Management of Childhood Illness
strategy has been introduced in an increasing
number of countries in the region since
1995. IMCI is a major strategy for child survival,
healthy growth and development and is based on
the combined delivery of essential interventions
at community, health facility and health systems
levels. IMCI includes elements of prevention as
well as curative and addresses the most common
conditions that affect young children. The
strategy was developed by the World Health
Organization (WHO) and United Nations
Children’s Fund (UNICEF).
OBJECTIVES OF IMCI
Reduce death and frequency and severity of illness and disability, and
Contribute to improved growth and development
COMPONENTS OF IMCI
✓Improving case management skills of health workers
✓Improving over-all health systems
✓Improving family and community health practices
Rationale for an integrated approach in the management of sick children
Majority of these deaths are caused by 5 preventable and treatable conditions
namely: pneumonia, diarrhea, malaria, measles and malnutrition. Three (3) out of
four (4) episodes of childhood illness are caused by these five conditions
Most children have more than one illness at one time. This overlap means that
a single diagnosis may not be possible or appropriate.
BASIS FOR CLASSIFYING THE CHILD’S ILLNESS
(please see enclosed portion of the IMCI Chartbooklet) The child’s illness is
classified based on a color-coded triage system:
PINK- indicates urgent hospital referral or admission
YELLOW- indicates initiation of specific Outpatient Treatment
GREEN – indicates supportive home care
Steps of the IMCI Case management Process
The following is the flow of the IMCI process. At the out-patient health
facility, the health worker should routinely do basic demographic data
collection, vital signs taking, and asking the mother about the child's problems.
Determine whether this is an initial or a follow-up visit. The health worker then
proceeds with the IMCI process by checking for general danger signs, assessing
the main symptoms and other processes indicated in the chart below.
Take note that for the pink box, referral facility includes district,
provincial and tertiary hospitals. Once admitted, the hospital protocol is used in
the management of the sick child.
The children and infants are then assessed for main symptoms:

In older children the main symptoms

include:
• Cough or difficulty breathing
• Diarrhoea
• Fever and Ear Infection
In young infants the main symptoms
include:
• Local bacterial infection
• Diarrhoea
• Jaundice
IMCI Computerized Adaptation and Training Tool
(ICATT)
• Computerized, adaptable tool for training in
the Integrated Management of Childhood
Illness (IMCI). A joint project of WHO and the
Novartis Foundation for Sustainable
Development, ICATT is now available for use
globally.
• Chart booklet builder: The IMCI guidelines
developed by WHO have been summarized in
a set of charts presented in a chart booklet.
The library includes reference and educational
materials on IMCI and related child health
issues, developed by WHO and other
international agencies. It also includes a wide
variety of videos, pictures and sounds that are
used for audiovisual practice
Management of Sick Child Aged 2 Months to 5 Years

COUGH OR DIFFICULTY BREATHING

ASSESS CLASSIFY IDENTIFY TREATMENT
Any general danger Pink:
•Give first dose of an appropriate antibiotic
signs or stridor in calm SEVERE PNEUMONIA OR •Refer URGENTLY to hospital
child. VERY SEVERE DISEASE

•Give oral Amoxicillin for 5 days

•If wheezing (or disappeared after rapidly acting bronchodilator)
give an inhaled bronchodilator for 5 days
•If chest indrawing in HIV exposed/infected child, give first dose of
Yellow: amoxicillin and refer.
Fast breathing •Soothe the throat and relieve the cough with a safe remedy
PNEUMONIA
•If coughing for more than 14 days or recurrent wheeze, refer for
possible TB or asthma assessment
•Advise mother when to return immediately
•Follow-up in 3 days

•Treat wheeze with inhaled salbutamol for 5 days

Yellow: •Soothe the throat and relieve the cough with a safe remedy
Wheezing
WHEEZE •Sooth throat and relieve cough with safe remedy
• Advise mother when to return immediately
•Follow-up in 5 days if not improving
 DIARRHEA
ASSESS CLASSIFY IDENTIFY TREATMENT

Two of the following signs: •If child has no other severe classification: Give fluid
Lethargic or for severe dehydration (Plan C) OR
unconscious Sunken eyes •If child also has another severe
Pink: classification: Refer URGENTLY to hospital with mother giving
Not able to drink or frequent sips of ORS on the way
SEVERE DEHYDRATION
drinking poorly •Advise the mother to continue breastfeeding.
Skin pinch goes back • If child is 2 years or older and there is cholera in your
very slowly. area, give antibiotic for cholera

•Give fluid, zinc supplements, and food for some

Two of the following dehydration (Plan B)
signs: Restless, irritable • If child also has a severe classification: Refer
Yellow: URGENTLY to hospital with mother giving frequent sips of ORS
Sunken eyes on the way
SOME DEHYDRATION
Drinks eagerly, thirsty •Advise the mother to continue breastfeeding
Skin pinch goes back slowly. •Advise mother when to return immediately
• Follow-up in 5 days if not improving

Not enough signs to classify •Give fluid, zinc supplements, and food to
Green: treat diarrhoea at home (Plan A)
as some or severe •Advise mother when to return immediately
NO DEHYDRATION
dehydration. • Follow-up in 5 days if not improving
CLASSIFY: DIARRHOEA 14 days or more
•Treat dehydration before referral unless the child has another severe
Pink:
Dehydration present. classification
SEVERE PERSISTENT DIARRHOEA •Refer to hospital

Yellow: •Advise the mother on feeding a child who has PERSISTENT DIARRHOEA
•No dehydration. PERSISTENT DIARRHOEA • Give multivitamins and minerals (including zinc) for 14 days
•Follow-up in 5 days

•Blood in the Stool Yellow: DYSENTERY •Give Ciprofloxacin for 3 days

GIVE EXTRA FLUID TO DIARRHOEA AND CONTINUE FEEDING

PLAN A: Treat Diarrhoea at PLAN B: Treat Some Dehydration with ORS

Home ORS in 4 hours period
•Counsel the mother on the 4 Rules 200ml-450ml(<6kg;up to 4 months old)
of Home Treatment: 450ml-800ml(6-10kg;4-12months old)
1. Give Extra Fluid​ 800ml-960ml(10-12kg;12months-2 years old)
INTAKE: Up to 2 years 50-100ml 960ml-1600ml(12-19kg;2-5 years old)
after each loose stools
2 yrs or more 100-200ml
after loose stool
2. Give Zinc Supplements: 2months up PLAN C: Treat Severe Dehydration Quickly
to 6 months-1/2 tablet daily for 14 days ❑ Start IV Fluid immediately
AND 6 months or more-1 tablet daily ❑ Reassess the child every 1-2 hours
for 14 days ❑ Start Rehydration by NG tube
3. Continue Feeding​(exclusive
❑ Refer Urgently to the Hospital
breastfeeding less than 6 months)
4. When to Return ​
 FEVER
ASSESS CLASSIFY IDENTIFY TREATMENT
•Give first dose of artesunate or quinine for severe malaria
•Give first dose of an appropriate antibiotic
Pink:
Any general danger sign or stiff neck. •Treat the child to prevent low blood sugar
VERY SEVERE FEBRILE DISEASE
•Give one dose of paracetamol in clinic for high fever (>38.5 degree Celsius)
•Refer URGENTLY to hospital.
•Give recommended first line oral antimalarial
•Give one dose of paracetamol in clinic for high fever (>38.5 degree Celsius)
•Give appropriate antibiotic treatment for an identified bacterial cause of
Yellow:
Malaria test POSITIVE. fever
MALARIA
•Advise mother when to return immediately
•Follow-up in 3 days if fever persists
•If fever is present every day for more than 7 days, refer for assessment
•Give one dose of paracetamol in clinic for high fever (>38.5 degree Celsius)
•Give appropriate antibiotic treatment for an identified bacterial cause of
Green: fever
•Malaria test NEGATIVE.
FEVER •Advise mother when to return immediately
•Other cause of fever PRESENT.
NO MALARIA •Follow-up in 3 days
•if fever persists If fever is present every day for more than 7 days, refer for
assessment
 •Give first dose of an appropriate antibiotic.
•Treat the child to prevent low blood sugar.
Any general danger sign or Pink:
•Give one dose of paracetamol in clinic for high fever
stiff neck. VERY SEVERE FEBRILE DISEASE
(>38.5 degree Celsius)
•Refer URGENTLY to hospital

•Give one dose of paracetamol in clinic for high fever

(>38.5 degree Celsius)
•Give appropriate antibiotic treatment for any
Green:
•No danger signs. identified bacterial cause of fever
FEVER
•No stiff neck. •Advise mother when to return immediately
•Follow-up in 2 days if fever persists
• If fever is present every day for more than 7 days, refer
for assessment
ASSESS CLASSIFY IDENTIFY TREATMENT
•Any general danger sign or •Give Vitamin A treatment
•Clouding of cornea or •Give first dose of an appropriate antibiotic
Pink:
•Deep and extensive mouth ulcers. •If clouding of the cornea or pus draining from the eye,
SEVERE COMPLICATED MEASLES
apply tetracycline eye ointment
•Refer URGENTLY to hospital

•Give Vitamin A treatment

•If pus draining from the eye, treat eye infection with tetracycline
•Pus draining from the eye or
eye ointment
•Mouth Ulcers
Yellow: MEASLES WITH EYE OR •If mouth ulcers, treat with gentian violet
MOUTH COMPLICATIONS •Follow-up in 3 days

•Measles now or within the last 3 Green:MEASLES

•Give Vitamin A treatment
months
EAR PROBLEM
ASSESS CLASSIFY IDENTIFY TREATMENT
Look for pus draining from the
•Give first dose of an appropriate antibiotic
ear Pink:
•Give first dose of paracetamol for pain
Tender swelling behind the ear MASTOIDITIS
•Refer URGENTLY to hospital

•Give an antibiotic for 5 days

•Pus draining less than 14 days Yellow:​ACUTE EAR INFECTION • Give paracetamol for pain
•Dry the ear by wicking
• Follow-up in 5 days

•Dry the ear by wicking

•Pus draining more than 14 days Yellow: CHRONIC EAR
•Treat with topical quinolone eardrops for 14 days
INFECTION • Follow-up in 5 days

•No Ear pain and pus draining Green:NO EAR INFECTION

•No Treatment
from the ear
ACUTE MALNUTRITION
ASSESS CLASSIFY IDENTIFY TREATMENT
Edema of both feet OR WFH/L less than -
•Give first dose appropriate antibiotic
3 z scores OR MUAC less than 115 mm Pink:​ COMPLICATED SEVERE ACUTE
• Treat the child to prevent low blood sugar
AND any one of the following: Medical MALNUTRITION
• Keep the child warm
complication present or Not able to finish
•Refer URGENTLY to hospital
RUTF or Breastfeeding problem.

•Give oral antibiotics for 5 days

• Give ready-to-use therapeutic food for a child aged 6 months or more
Yellow:​ UNCOMPLICATED SEVERE ACUTE
FH/L less than -3 zscores OR MUAC less • Counsel the mother on how to feed the child
MALNUTRITION
than 115 mm AND Able to finish RUTF. •Assess for possible TB infection
•Advise mother when to return immediately
•Follow up in 7 days
•Assess the child's feeding and counsel the mother on the feeding
Yellow: MODERATE ACUTE recommendations
WFH/L between -3 and - 2 z-scores OR •If feeding problem, follow up in 7 days
MUAC 115 up to 125 mm.
MALNUTRITION •Assess for possible TB infection.
•Advise mother when to return immediately
•Follow-up in 30 days

Green: ​NO ACUTE MALNUTRITION If child is less than 2 years old, assess the child's feeding and counsel the
WFH/L - 2 z-scores or more OR MUAC 125
mother on feeding according to the feeding recommendations If feeding
mm or more
problem, follow-up in 7 days
ANAEMIA
ASSESS CLASSIFY IDENTIFY TREATMENT

Pink: SEVERE ANAEMIA

Severe palmar pallor •Refer URGENTLY to hopsital

•Give iron
•* Give mebendazole if child is 1 year or older and has
•Some pallor Yellow: ANAEMIA not had a dose in the previous 6 months
•Advise mother when to return immediately
•Follow-up in 14 days

If child is less than 2 years old, assess the child's

Green: NO ANAEMIA feeding and counsel the mother according to the
•No palmar pallor
feeding recommendations If feeding problem, follow-
up in 5 days
 HIV INFECTION
ASSESS CLASSIFY IDENTIFY TREATMENT
•Initiate ART treatment and HIV care Give cotrimoxazole
prophylaxis*
•Positive virological test in child •Assess the child’s feeding and provide appropriate counselling
OR Positive serological test in a Yellow: CONFIRMED HIV INFECTION to the mother
child 18 months or older •Advise the mother on home care
•Assess or refer for TB assessment and INH preventive therapy
•Follow-up regularly as per national guidelines
Mother HIV-positive AND
•Give cotrimoxazole prophylaxis
negative virological test in a
•Start or continue ARV prophylaxis as recommended
breastfeeding child or only
•Do virological test to confirm HIV status
stopped less than 6 weeks ago
Yellow: HIV EXPOSED •Assess the child’s feeding and provide appropriate counselling
OR Mother HIV-positive, child
to the mother
not yet tested OR Positive
• Advise the mother on home care
serological test in a child less
•Follow-up regularly as per national guidelines
than 18 months old

•Negative HIV test in mother or Green: HIV INFECTION UNLIKELY

Treat, counsel and follow-up existing infections
child
 Management of Sick Young Infant Aged 1 Week up to 2 Months
LOCAL BACTERIAL INFECTION
ASSESS CLASSIFY IDENTIFY TREATMENT
Any one or more of the
following signs:
• Not able to feed at all or
not feeding well or
• Convulsions or • Severe •➜ Give fi rst dose of intramuscular antibiotics.
chest indrawing or •➜ Treat to prevent low blood sugar.
Pink:POSSIBLE SERIOUS
• High body temperature • ➜ Advise the mother how to keep the infant warm on
BACTERIAL INFECTION or VERY
(38°C* or above) or the way to the hospital.
SEVERE DISEASE
• Low body temperature • ➜ Refer URGENTLY to hospital. OR
(less than 35.5°C*) or • ➜ If referral is REFUSED or NOT FEASIBLE, treat in the
• Movement only when clinic until referral is feasible.
stimulated or no movement
at all or • Fast breathing (60
breaths per minute or more)
in infants less than 7 days old
ASSESS CLASSIFY IDENTIFY TREATMENT
•• Fast breathing (60 breaths •➜ Give oral amoxicillin for 7 days.
per minute or more) in Yellow: PNEUMONIA • ➜ Advise the mother to give home care.
infants 7–59 days old •➜ Follow up in 3 days.
•➜ Give amoxicillin for 5 days.
•➜ Teach the mother how to treat local infections at
• Umbilicus red or draining Yellow: LOCAL BACTERIAL
home.
pus • Skin pustules INFECTION • ➜ Advise the mother to give home care.
• ➜ Follow up in 2 days

•• No signs of bacterial
➜ Advise the mother on giving home care to the
infection or very severe Green: INFECTION UNLIKELY
young infant.
disease
 JAUNDICE
ASSESS CLASSIFY IDENTIFY TREATMENT
• Any jaundice in an infant aged •➜ Treat to prevent low blood sugar.
less than 24 hours or • ➜ Refer URGENTLY to hospital.
Pink: SEVERE JAUNDICE
• Yellow palms or soles at any • ➜ Advise the mother how to keep the infant warm on the
age way to the hospital.

•➜ Advise the mother to give home care.

•➜ Advise the mother to return immediately if the infant’s
• Jaundice appearing after 24
palms or soles appear yellow.
hours of age and Yellow: JAUNDICE
• ➜ If the young infant is older than 3 weeks, refer to a
• Palms or soles not yellow
hospital for assessment.
•➜ Follow-up in 1 day.

• No jaundice Green: NO JAUNDICE ➜ Advise the mother on giving home care to the young infant.
Vitamin A
Supplementation
Give every child a dose of
Vitamin A every six
months from the age of 6
months. Record the dose
on the child's chart
ROUTINE WORM
TREATMENT
Give every child
mebendazole every 6
months from the age of
one year. Record the dose
on the child's card.
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Chapter
Nursing Care of a Family When a
52 Child Has an Unintentional Injury

K E Y T E R M S Jason, a 5-year-old

• allografting • homografting boy, is seen in the

• autografting • near drowning emergency depart-
• contrecoup injury • otorrhea
• débridement ment after an automo-
• plumbism
• drowning • rhinorrhea bile accident. He is crying and upset,
• escharotomy • stupor
although the only visible signs of
• heterografts
trauma are a reddened and edema-
O B J E C T I V E S tous area on the middle of his fore-
After mastering the contents of this chapter, you should be able to: head. Vital signs reveal the following:
1. Describe the causes and consequences of common accidents and temperature, 99.4° F (37.5° C); respi-
injuries in childhood and measures to prevent them.
rations, 18 breaths/minute; pulse,
2. Identify National Health Goals related to children who have
experienced trauma that nurses can help the nation achieve. 62 beats per minute; and blood pres-
3. Use critical thinking to analyze ways that care of children with sure, 110/62 mm Hg. His left pupil is
unintentional injuries can be more family centered.
4. Assess a child who is unintentionally injured from an accident. more dilated than his right and it re-
5. Formulate nursing diagnoses related to an unintentionally acts sluggishly to light. His Glasgow
injured child.
6. Establish expected outcomes for an unintentionally injured child. Coma Scale score is 10. His mother
7. Plan nursing care related to an unintentionally injured child. tells you, “I’m sure he’s not injured
8. Implement nursing care for a child with an unintentional injury, such
as providing pain relief. badly. He was wearing his seat belt.”
9. Evaluate expected outcomes for achievement and effectiveness of Previous chapters described the
care.
growth and development of well
10. Identify areas related to care of children with unintentional injuries
that could benefit from additional nursing research or application of children and care of children with
evidence-based practice.
disorders of specific body systems.
11. Integrate knowledge of unintentional injuries in childhood with nursing
process to achieve quality maternal and child health care. This chapter adds information about
the characteristic changes, both
physical and psychosocial, that occur
when children experience an
unintentional injury.

Suppose you are a triage nurse. Would

you rate Jason as a child to be seen
immediately, or could he be given
second priority?

1543
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1544 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

Accidents, such as those involving motor vehicles, falls,

burns, and water immersions, cause more deaths in the 1- to BOX 52.1 ✽ Focus on
4-year age group than the next six most prevalent causes National Health Goals
combined. In the 15- to 24-year age group, they cause half of
the deaths of the age group (NCHS, 2009). If unintentional Because prevention of unintentional injuries could have
injuries such as these could be prevented, therefore, a major immediate and long-term effects on the nation’s health,
cause of childhood morbidity and mortality could be elimi- several National Health Goals are concerned with pre-
nated. However, total accident elimination may not be pos- venting accidents and unintentional injuries in children:
sible. Children commonly believe that accidents will not • Reduce the number of drownings each year from
happen to them and, as a result, fail to take sensible precau- a baseline of 1.5 per 100,000 to 0.7 per 100,000
tions against them. Some parents may predispose their chil- children.
dren to accidents by overestimating their development and • Reduce the rate of firearm-related deaths from a base-
giving them responsibility beyond their capabilities. line of 10.3 per 100,000 to 3.6 per 100,000 children.
The frequency of various types of accidents varies accord- • Reduce the number of nonfatal poisonings from
ing to age group (Table 52.1). Because the anatomy and a baseline of 348 per 100,000 to 292 per 100,000
physiology of children are different from those of adults, they children.
are not only involved in different types of accidents than • Reduce the number of deaths caused by suffocation
adults, but accidents affect them differently. from a baseline of 4.2 per 100,000 to 3.3 per 100,000
Family stress plays a large role in childhood poisoning ac- children.
cidents because these types of accidents tend to occur when • Reduce the rate of deaths caused by unintentional
parents are preoccupied. Many medicine poisoning inges- injury from a baseline of 35.3 per 100,000 to 17.1 per
tions occur on the same day that the medicine was pur- 100,000 children.
chased, implying that the stress of family illness plays a major • Reduce the number of deaths caused by motor ve-
role. Eliminating accidents in children, therefore, is not a hicle crashes from a baseline of 14.7 per 100,000 to
simple procedure, because it involves reducing family stress 8 per 100,000 children.
as well. National Health Goals related to children and • Increase the use of child automobile safety restraints
trauma are shown in Box 52.1. from a baseline of 92% to 100%.
• Increase the proportion of bicyclists, 1 to 15 years of
age, who regularly wear a bicycle helmet from a
Nursing Process Overview baseline of 69% to 76%.
• Reduce the number of residential fire deaths from a
For Care of a Child With an Unintentional Injury baseline of 1.2 per 100,000 to 0.2 per 100,000 chil-
dren (http://www.nih.gov).
Assessment
When children are seen at health care facilities because of Nurses can help the nation achieve these goals by
unintentional injuries, neither they nor their parents may providing counseling on safety precautions to parents
be functioning at their optimal level because of the stress and children. Nursing research in these areas that
of the situation. Both may be apprehensive and frightened would be helpful is: What are effective ways to com-
not only about what has happened, but also about what municate safety information to parents at well-child
could have happened. Children often feel guilty and fear visits when time is at a premium? In what ways should
that they will be scolded or punished. Their parents may safety teaching given after an accident to prevent a
feel equally guilty; they may feel that if they were really further accident be different from that given as primary
prevention? Is there an association between children
setting fires and their exposure to fire experiences
with fireplaces or candles?
TABLE 52.1 ✽ Most Common Accidents in
Children by Age Group

Age (yr) Type of Accident

“good” parents, they would have been watching more
0–1 Falls, inhalation of foreign objects, closely. They may feel defensive because they are worried
poisoning, burns, drowning
2–4 Falls, drowning, motor vehicles,
about being criticized. People under stress do not hear
poisoning, burns well and may not perceive the information given to them
5–9 Motor vehicles, bicycle accidents, correctly. Information they receive in the emergency de-
drowning, burns, firearms partment, therefore, may be grossly misinterpreted or not
10–14 Motor vehicles, drowning, burns, heard at all.
firearms, falls, bicycle accidents Children are likely to be in pain. They are frightened
15–18 Motor vehicles, drowning, firearms not just from the pain of the injury but also from the cir-
cumstance of the injury. Children count on their parents
National Center for Health Statistics. (2009). Health Data to keep them safe, yet they have been hurt. The trust is
for All Ages. Hyattsville, MD: Author. broken momentarily. How can they be safe here if their
parents are no longer protecting them?
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1545

Because the emergency department nurse is often the Evaluating children in an emergency department is dif-
first person who sees a child after an injury, be ready to ficult, because they may be too young to communicate or
make a preliminary assessment of the extent of a child’s unconscious or they are so frightened that they cannot
injuries before a physician arrives. Remember that chil- stop crying to report which body parts are painful or to
dren may be seriously hurt but not crying because they indicate which parts should be assessed first. Spend a few
are in shock. They may be hemorrhaging, but, if they are minutes attempting to calm children and get them past
bleeding internally, the blood may not be visibly evident. this initial fright, unless symptoms of major body system
Accidents become fatal when lung, heart, or brain func- disturbances require that you direct your immediate ef-
tion becomes inadequate. These three body systems, forts elsewhere. Parents need frequent explanations of care
therefore, must be evaluated first (Airway, Breathing, given or planned, because as long as they are worried and
Circulation and Disability, or an ABCD evaluation). tense, children cannot be calmed easily.
Table 52.2 lists signs and symptoms to assess when de- A proportion of unintentional injuries in children re-
termining the respiratory, cardiovascular, and neurologic sult from child abuse. Conflicting histories or a parent
status of an injured child. and child recounting different stories is a hallmark of
While conducting a preliminary assessment of a child’s this. Always ask yourself if this could be a possibility (see
major body systems, take a brief history of the accident. Chapter 55).
What happened? How long ago did it happen? Was the
child using protective equipment such as a helmet or a se- Nursing Diagnosis
cured seatbelt? What have the parents done? If the child The nursing diagnosis used most frequently with injured
fell, how far was the fall? On what body part did the child children is Pain. Depending on the particular injury, several
land? (A head injury is more likely to be serious than an other nursing diagnoses are relevant, as are those that relate
ankle injury, although a child may be in more pain and to the suffering that parents experience when their child is
may have more obvious symptoms with the lesser injury.) injured. Examples of possible nursing diagnoses are:
Ask the parents what they think are their child’s major in- • Pain related to fractured tibia from sports injury
juries. Children may report one body part hurts at first, • Ineffective airway clearance related to burned
but then a small cut elsewhere begins to bleed, and they esophageal tissue
focus on the minor bleeding as their major injury. If par- • Impaired physical mobility related to severe burn
ents say, “At first, he acted as if his stomach hurt,” this injury
may be the first suggestion that he has a serious abdomi- • Disturbed body image related to change in physical
nal injury such as splenic rupture. appearance from thermal injury
• Parental fear related to outcome after head injury
in child
• Interrupted family processes related to child’s uninten-
tional injury
TABLE 52.2 ✽ Important Assessments on Initial • Anxiety related to apprehension and lack of knowl-
Examination of an Injured Child edge regarding medical treatment of child

Body System Assessment

Outcome Identification and Planning
Parents in an emergency department are rarely ready for
Respiratory Quality of respirations long-term planning. They often have great difficulty in
system Rate of respirations coming up with answers to the most straightforward im-
Sound of obstruction (wheezing, mediate questions. Therefore, long-term planning may
stridor, retractions, coughing?) have to be delayed until the immediate concern of the in-
Color (cyanotic?)
Oxygen hunger (restlessness,
jury has passed.
inability to lie flat?) On discharge from the emergency department, parents
Cardiovascular Color (pallor from hemorrhage or need printed instructions about the child’s care at home
system cardiovascular collapse?) and the name and number of the person to call if they have
Gross bleeding questions about care or progress. They also need an ap-
Pulse rate (increases with pointment (or the number to call for a return appointment)
hemorrhage) for follow-up care. If a child is admitted to the hospital
Blood pressure (decreases with from the emergency department, it is helpful if the nurse
hemorrhage) who cared for the child in the emergency department can
Feeling of apprehension from accompany the child to the hospital unit. The first person
altered vascular pressure
Nervous Level of consciousness (child
who cares for a child after an injury becomes very impor-
system answers questions coherently, tant to the child and parents, because that person was the
infant attunes to parent’s voice?) first one to recognize their distress. Parents have difficulty
Pupils (equal and reacting to light?) letting this person go and accepting a new caregiver. A tran-
Bumps or bruises on head or sition period, a “passing on of care,” helps a parent accept
spinal column the child’s new caregivers as being as dependable and trust-
Loss of motion or sensory function worthy as the emergency department staff.
in a body part A key component of nursing intervention in an emer-
gency department is to help parents understand why an
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1546 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

injury happened and plan ways to make their immedi- Examples of expected outcomes suggesting achieve-
ate or community environment safe for children. An ment of goals are:
organization that might be appropriate for referral is
the American Association of Poison Control Centers • Child swallows fluids without distress after esophageal
(http://www.aapcc.org). burns.
• Child states pain is at tolerable level within 30
minutes.
Implementation
• Child demonstrates full range of motion in hand after
The extent of a child’s injury depends on the injuring
thermal injury.
agent, the part of the body that was injured, and often the
• Child states he understands that wearing a seat belt is
immediate care, including both physical and psychologi-
an important safety measure.
cal management, that a child receives.
• Child states she will wear helmet when riding bicycle
The diameter of the airway in children is smaller than
in adults, so an injury to this body area almost always re-
in the future. ❧
sults in a greater danger of airway closure than in adults.
This could happen from the child’s inhaling a substance,
such as water, that directly obstructs the airway or from HEALTH PROMOTION AND
inhaling toxic fumes that cause inflammation along the RISK MANAGEMENT
lining of the airway, resulting in obstruction. A blow to
the neck can result in edema of surrounding tissues, caus- In every care setting, nurses have the unique opportunity
ing the airway to close. among health care professionals to provide child and family
Injuries may involve some blood loss. Fortunately, a teaching concerning the prevention of accidents. Even in the
child’s circulatory system is capable of rapid compensa- acute care setting when an accident has already occurred,
tion for blood loss by vasoconstriction. Because the total nurses can provide valuable instruction to families about
volume of blood in a child is reduced, however, blood loss safeguarding their children against future accidents. In a
in children is always potentially serious. Because of this, community setting, nurses have a great opportunity for as-
many health care agencies have standing orders that allow sessment of the unique threats that are present in particular
emergency care nurses to begin intravenous normal saline environments such as lead-based paint or kerosene heaters in
boluses on children with obvious blood loss. older homes, risk of drowning in a home with an unfenced
Often, in the emergency department, large portions swimming pool, or the danger for children riding in the back
of the child’s body must be exposed to view so that care of pickup trucks. To teach effective accident prevention,
can be given easily. This means that rapid cooling can nurses need to be knowledgeable about common measures
occur. Because of the large body surface area of children that prevent injury.
in relation to weight, always be conscious of body tem- Poisoning is an important cause of serious injuries in chil-
perature and take active measures to decrease cooling by dren younger than 6 years of age; more than 1 million
keeping a child covered as much as possible during ex- episodes occur every year (Dart & Rumack, 2008). Common
amination times. household agents are often the cause. Since passage of the
Standard infection precautions must be maintained in Poison Prevention Packaging Act of 1970, potentially haz-
emergency situations, the same as at any other time. ardous products must be sold in child-resistant containers.
Parental consent must be obtained for treatment proce- Passage of this act initiated a decrease in the incidence of
dures even in an emergency, except for life-saving actions, childhood poisonings from common medicines.
such as cardiopulmonary resuscitation. In these instances, The home environment may still contain products that
action can and should be taken to save a child’s life with can be hazardous and poisonous to children if handled im-
or without parental permission (it is assumed that parents properly. Plants, cosmetics, and cleaning products can be
would consent to life-saving procedures). Delaying emer- dangerous to children if ingested or absorbed through the
gency procedures until parents can be located may result skin. Teach parents to be aware of these dangers and of
in permanent disability or death. strategies for maintaining a safe home environment, includ-
ing learning basic first aid procedures.
Outcome Evaluation Measures for a safe home environment include actions
After an injury, children need follow-up care to be certain such as installing child-resistant locks on low cabinets where
that the immediate interventions were adequate and that household products are stored, moving plants to a higher sur-
healing is taking place. Evaluation visits are also the time face or removing them from the home until the child is older,
to determine whether the child’s environment has been keeping matches in safe places, and teaching street safety. In
changed and is safer now than at the time of the accident addition, parents should anticipate that, even in the safest en-
(if applicable). At the time of the accident, parents may vironment, a child can be injured. Along with knowledge of
have been too anxious to hear health supervision informa- basic first aid, the telephone number of the local poison con-
tion. Now, with the accident behind them, they are ready trol center should be posted by the telephone.
for such information and prepared to make changes.
If an injury could not have been anticipated, parents
appreciate hearing one more time that such an accident HEAD TRAUMA
could not have been avoided and that they are good par- Children receive head injuries when they are involved in mul-
ents. This helps them maintain adequate self-esteem to tiple-trauma accidents, such as automobile crashes. Falls from
continue to function well as parents. swing sets, porches, and bunk beds also cause many head in-
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1547

juries. Other children are injured by being struck on the head urine is between 1.003 and 1.030; pulse remains be-
by an object, such as a baseball, rock, or hockey puck, or by tween 60 to 100 beats per minute; blood pressure
falling from a bicycle (Faries & Battan, 2008). remains consistent for age group; lungs are clear to
Head injuries are always potentially serious not only be- auscultation.
cause they can cause an immediate threat to the life of the When hypertonic solutions are being infused intra-
child, but also because several complications may follow. With venously into children, assess vital signs frequently to
a depressed skull fracture, for example, recurrent seizures can be certain that the fluid load being pulled into the in-
occur. Many of these children show focal abnormalities on an travascular system does not overtax it. This fluid must
electroencephalogram (EEG) because of scar tissue formation. be excreted by the kidneys to keep the vascular sys-
Some children with seizure involvement have normal EEGs, tem from becoming overloaded. Keep accurate intake
however, so, by itself, the EEG is of limited value in predict- and output records to ensure that the kidneys are
ing whether posttraumatic seizures will occur. functioning, and test the specific gravity of urine to
Some children experience memory deficits or minor per- detect the development of pituitary compression and
sonality changes after head injury (Fazio et al., 2007). resultant overproduction or underproduction of antidi-
Symptoms such as headache, irritability, and postural ver- uretic hormone from the posterior pituitary.
tigo (sensation of feeling faint or the inability to maintain
normal balance—also known as posttrauma syndrome) also Nursing Diagnosis: Risk for delayed growth and devel-
may occur. Behavioral manifestations may include aggres- opment related to late sequelae of head injury
siveness or poor school performance. It often is difficult to Outcome Evaluation: Child shows no evidence of any
determine whether these symptoms are organic or the result alteration in thought processes, seizure activity, or
of being treated differently than usual by anxious parents. memory at follow-up visits. Cognitive and physical de-
velopment are appropriate for age.
Immediate Assessment Helping care for a child with a head injury can be dif-
All children with head trauma require a neurologic assess- ficult for parents because they are so worried. Offer
ment as soon as they are seen and again at frequent intervals information on the child’s progress as it becomes
to detect signs and symptoms of increased intracranial pres- available to you. Urge parents to help care for the
sure (ICP). Increasing pressure puts stress on the respiratory, child to increase their sense of control.
cardiac, and temperature centers, causing dysfunction in During the acute phase of illness, ensure that
these areas. With increased pressure, the pupils become slow parents are informed about the dangers of increased
or unable to react immediately. Level of consciousness and ICP. If they ask about the possibility that personality
motor ability decrease, pulse and respiratory rates decrease, changes or seizures will develop later in life, their
and temperature and pulse pressure increase. questions should be answered truthfully. At the same
Assess vital signs to detect these changes and observe chil- time, do not give unnecessary warnings about
dren’s pupils to be certain that they are equal and react to observing the child carefully in the months to come.
light. Assess children’s level of consciousness and motor Head injuries by themselves are worrisome enough
function. Stabilize the neck with a brace until cervical trauma to parents and children without adding to their
has been ruled out. burden.

Immediate Management Skull Fracture

After a head injury, brain edema is likely because fluid rushes
A skull fracture is a crack in the bone of the skull (Aminoff,
into the inflamed and bruised area. Both central venous and
2009). Recognizing skull fractures in children is important,
central arterial lines may be inserted. ICP monitoring may be
because associated cerebral injury often occurs under the
initiated (see Chapter 49). A computed tomography (CT)
fracture. Many skull fractures are simple linear types, most
scan or magnetic resonance imaging (MRI) will be ordered to
often involving the parietal bones. In some children, the
determine areas of edema or bleeding. An attempt may be
skull does not fracture, but the suture lines separate. This
made to decrease brain edema by intravenous (IV) adminis-
occurs more commonly in the lambdoid suture line; a coro-
tration of a hypertonic solution, such as mannitol. This will
nal suture separation is rare and, if present, indicates severe
increase intravascular pressure and shift the edema fluid back
trauma (Fig. 52.1).
into the blood vessels. Steroids such as dexamethasone may
be added to decrease inflammation and edema. Keeping the
head elevated is also effective in reducing ICP.
Assessment
If the base of the skull is fractured, a child usually exhibits or-
bital or postauricular ecchymosis. Rhinorrhea or otorrhea
Nursing Diagnoses and Related (clear fluid draining from the nose or ear, respectively) may
Interventions be present. This is escaping cerebrospinal fluid (CSF)—a se-
rious finding, because it means that the child’s central ner-
✽ vous system is open to infection. Test the fluid discharge
Nursing Diagnosis: Risk for excess fluid volume related with a glucose reagent strip if there is doubt about the source
to administration of hypertonic solution of the drainage. CSF will test positive for glucose, whereas
Outcome Evaluation: The child’s respiratory rate remains the clear, watery drainage from an upper respiratory tract in-
between 16 to 24 breaths/minute; specific gravity of fection will not.
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1548 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

Frontal suture tissue, bone cannot heal and actually erodes, so that the frac-
Anterior fontanel ture site becomes progressively larger, not smaller. This be-
comes evident on a follow-up radiograph. It may be sus-
pected if a child develops focal seizures or symptoms of
Frontal bone increased ICP. The defect may be palpated on the skull as an
Coronal suture underlying indentation. Surgical resection is necessary to re-
move the cyst.
Sagittal suture
Subdural Hematoma
Subdural hematoma is venous bleeding into the space be-
Parietal bone tween the dura and the arachnoid membrane (Fig. 52.2A). It
occurs when head trauma lacerates minute veins in this area
(Amirjamshidi et al., 2007). The collection of blood is usu-
ally bilateral.
Subdural hematomas tend to occur in infants more often
Lambdoid suture than in older children. Symptoms may occur within 3 days
Posterior fontanel
or as late as 20 days after trauma. Infants usually have symp-
Occipital toms of increased ICP. Seizures, vomiting, hyperirritability,
bone
and enlargement of the head may occur. Anemia caused by
FIGURE 52.1 Location of suture lines of the skull. the substantial blood loss is a prominent sign. Angiography
or ultrasound reveals the extent of the hematoma.
In infants, accumulated subdural blood may be removed
Take a careful history of the accident, so that the strength by a subdural puncture through the lateral aspect of a patent
of the blow to the head can be judged. Shock with hypoten- anterior fontanelle. The procedure is similar to a lumbar
sion rarely occurs with an isolated head injury. If a child is in puncture. Infants receive conscious sedation or must be held
shock, investigate for bleeding points other than the head in- extremely still during the procedure so that they do not move
jury. Skull fractures are confirmed by skull radiography. and cause the aspiration needle to be inserted incorrectly.
If a skull fracture is linear with no underlying pathology, Without conscious sedation, half of the success of subdural
no treatment except observation and prescription of an anal- puncture depends on the ability to hold the child still.
gesic is necessary. In about 3 weeks, a repeat radiograph will Subdural punctures may need to be repeated daily to
be needed to confirm that healing has taken place. Parents empty the subdural space. Once the space is empty, expand-
can be reassured that a second radiograph this soon is not ing brain tissue will naturally occlude it. If the space has not
harmful but necessary. been occluded after 2 weeks of daily punctures, active bleed-
If a fracture is depressed (a bone fragment is pressing in- ing is still present, and surgery usually is necessary to reduce
ward) or compounded (bone is broken into pieces), surgery the space and halt bleeding.
will be necessary to remove or repair broken fragments. In older children, surgery usually is necessary, because the
Cranial surgery of this type is discussed in Chapter 49. anterior fontanelle is closed and the space cannot be reached
by puncture.
Therapeutic Management
If CSF is draining from the nose, a child will be admitted to Epidural Hematoma
the hospital for observation. Keep the child in a semi-
Fowler’s position so that fluid drains out, not inward, to re- Epidural hematoma is bleeding into the space between the
duce the possibility of introducing infection. Make certain dura and the skull (Fig. 52.2B). This happens when head
that children do not attempt to hold their nose or pack their trauma is severe. Subdural hemorrhage is usually venous bleed-
nostrils with something to halt the drainage. Because cough- ing, but epidural hemorrhage is usually a result of rupture of
ing and sneezing may allow air to enter the meningeal space, the middle meningeal artery and is, therefore, arterial bleeding.
coughing may be suppressed by medication. If the drainage It usually is intense and causes rapid brain compression.
is excoriating to the upper lip, coat the space with petrola- At the time of the injury, children become momentarily
tum. Children may be prescribed a prophylactic antibiotic to unconscious. They then regain consciousness and, to the un-
reduce the risk for meningitis. If the drainage does not stop trained eye, appear to be well for minutes or hours. Then
within a few days, surgery will be necessary to repair the frac- signs of cortical compression—vomiting, loss of conscious-
ture and reduce the danger of meningitis. Air that enters in- ness, headache, seizures, or hemiparesis (paralysis on one
tracranial spaces usually is absorbed rapidly. If radiographs at side)—are observed. On physical examination, unequal dila-
72 hours still show air in the cerebral spaces, it implies that a tion or constriction of the pupils may be present. Decorticate
skull defect remains, and surgery may be indicated to close posturing (see Chapter 49) may be seen, indicating extreme
the defect. pressure on upper cortical centers. If the pressure is allowed
to continue unchecked, cortical compression may be so great
Potential Complications that brainstem, respiratory, or cardiovascular function be-
comes impaired.
A long-term complication of even a linear fracture may be a As a rule, the closer to the time of the injury that symp-
leptomeningeal cyst. This results from projection of the arach- toms of compression occur, the more extreme is the
noid membrane into the fracture site. With the interfering amount of blood loss. The treatment is surgical removal of
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1549

Subdural hematoma

Dura mater
Pia
arachnoid

Dura mater

Epidural
hematoma

A B
FIGURE 52.2 (A) Subdural hematoma. The red area in the upper left area of the drawing is the hematoma. Note
the shift of structures. (B) Epidural hematoma. The red area in the lower left area of the drawing is the hematoma.
Note the broken blood vessel and the shift of midline structures.

the accumulated blood and cauterization or ligation of & Matthews, 2008). It may occur on the side of the skull
the torn artery. The earlier the process is recognized and that was struck (a coup injury) or on the opposite side of the
treated, the less the chance of residual damage from extreme brain (a contrecoup injury; Fig. 52.3). As the brain recoils
pressure or anoxia to the involved portion of the brain. from the force of the blow and strikes the posterior surface of
the skull, this second injury occurs. Children have at least a
Concussion transient loss of consciousness at the time of the injury. They
may vomit and may show irritability after regaining con-
Concussion is the temporary and immediate impairment of sciousness. They typically have no memory (amnesia) of the
neurologic function caused by a hard, jarring shock (Wilson events leading up to the injury or of the injury itself. For

Head
strikes
object

A B

COUP INJURY CONTRECOUP INJURY

Anterior of brain strikes Brain recoils and strikes
skull and is injured posterior skull, so is FIGURE 52.3 Etiology of (A) coup and (B) con-
injured twice trecoup injuries.
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1550 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

some children, this makes being asked questions about the Undress the child completely so that all body parts can be
accident extremely upsetting because they do not remember inspected. Although head injury is most likely to be the un-
anything that happened and feel a frightening loss of control. derlying cause of coma or seizure, metabolic disturbances
The child requires a skull radiograph to rule out skull frac- such as diabetes mellitus, dehydration, severe hemorrhage, or
ture and observation for 24 hours to rule out severe brain drug ingestion, also must be considered as possible causes.
trauma, edema, or laceration. A child usually can be observed Count respirations and pulse and measure blood pressure to
at home by the parents, who are instructed to check the establish baseline values, because changes in these values
child’s level of consciousness every 1 to 2 hours while the often provide good clues regarding the cause of coma. A child
child is awake. Parents usually are instructed not to keep with increased ICP, for example, will show decreased pulse
waking children during the night, because multiple wakings and respiratory rates and increased blood pressure. Diabetes,
are disorienting and can be confused with unconsciousness. in contrast, leads to increased respirations. Hemorrhage leads
Parents should wake the child at least once during the night, to an increased pulse rate and decreased blood pressure. Drug
however, and assess that the pulse rate is greater than 60 beats ingestion may lead to either increased or decreased measure-
per minute. ments, depending on the drug ingested.
To be certain that children are alert, parents can ask them If bulbar (brainstem) compression is present, a child can-
to name a familiar object, such as a favorite toy, or to name not swallow effectively or safely. If this is suspected, turn the
the color of some object shown to them. Telling parents their child on the side to prevent aspiration. Observe the eyes for
name or where they live is equally revealing. signs of increased ICP. If both pupils are dilated, irreversible
Give parents the telephone number to call if they have brainstem damage is suggested, although such a finding may
any questions about their child’s care. Advise them to call if also be present with poisoning from an atropine-like drug.
their child’s behavior changes in any way that seems worri- Pinpoint pupils suggest barbiturate or opiate intoxication.
some. Many parents need to set an alarm clock to wake One pupil dilated more than the other suggests third cranial
themselves during the night to assess their child’s status. nerve compression. An eye may be deviated downward and
There is an old belief that, if children fall asleep after a head laterally as well. This also may be caused by a tentorial tear
injury, they will die in their sleep; this belief causes some (laceration of the membrane between the cerebellum and
parents to keep shaking children awake or making them cerebrum) and herniation of the temporal lobe into the torn
walk continually. Be certain they understand that it is all membrane. This situation requires immediate surgery to cor-
right for children to sleep, but they must wake them at least rect temporal compression.
once to assess their status (see Focus on Nursing Care The retina of the eye should be examined for papilledema,
Planning Box 52.2). which will be present if increased pressure is long-standing
(more than 24 to 48 hours). Lack of a doll’s eye reflex sug-
Contusion gests that compression of the oculomotor nerves (third,
fourth, or sixth) or of the brainstem is involved. Observe for
A brain contusion occurs when there is tearing or laceration posturing, such as decerebrate posturing, which suggests
of brain tissue (Fig. 52.4). The symptoms are the same type cerebral compression and dysfunction.
as for concussion but more severe. In addition, there are spe- Many laboratory studies are helpful in determining the
cific symptoms related to the lacerated brain area such as a cause of coma. Blood glucose, blood electrolytes, blood urea
focal seizure, eye deviation, or loss of speech. Surgery may be
necessary to halt bleeding. The child’s prognosis depends on
the extent of the injury and effectiveness of therapy. Intracerebral
hemorrhage

What if... In the emergency department, Jason’s par-

ents state that since his head injury he has been vom-
iting? Is it more likely that the vomiting is a result of the
head injury, or that he has contracted a gastrointesti-
nal infection?

Coma
Coma (unconsciousness from which a child cannot be
roused) or stupor (grogginess from which a child can be
roused) may be present in children after severe head trauma.
Coma and stupor are both symptoms of underlying disor-
ders; a history of the injury must be obtained so that treat-
ment can be directed specifically toward the cause.

Assessment
Obtain a history to determine the circumstances immediately
before the time the child became comatose. Assess children
in coma carefully and completely, so that the cause of the de- FIGURE 52.4 Intracerebral hemorrhage. The central large
creased consciousness can quickly be determined. dark area represents the hemorrhage. Note the midline shift.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1551

BOX 52.2 ✽ Focus on Nursing Care Planning

A Multidisciplinary Care Map for a Child With a Concussion

Jason, a 5-year-old boy, is seen in the emergency de- edematous area on the middle of his forehead. His twin
partment after an automobile accident. His family is sister, in a car seat beside him, was not injured. His
here on vacation. Child is crying and upset, although mother tells you, “I’m sure he’s not injured badly. He
the only visible signs of trauma are a reddened and was wearing his seat belt.”

Family Assessment ✽ Child is staying with twin sister him. Pupils equal, round, reactive to light and accommo-
and two parents in motel room while on 10-day vacation. dation bilaterally. 1.5-cm raised area noted on forehead.
Father normally works as a salesman. Mother clerks in Skin intact without evidence of bleeding. Child cries
department store. Father describes finances as “good.” when area is touched. Negative otorrhea or rhinorrhea.
Father concerned because rented car was totally de- Small 2-cm abrasion noted on right knee; 3-cm abrasion
stroyed in accident and his insurance may not cover this. noted on right hand. No other injuries noted. Able to
move all extremities through range of motion.
Client Assessment ✽ A 5-year-old boy visibly upset
A diagnosis of mild contrecoup concussion is made,
and crying. Height and weight at 75th percentile for age.
and child is to be discharged to motel in parents’ care.
Child unable to report or recall anything about the inci-
dent. Mother reports he was restrained by a seat belt Nursing Diagnosis ✽ Risk for injury related to effects of
but not a car seat. Head hit side window when a car concussion
struck their vehicle.
Vital signs: temperature, 99.4° F (37.5° C); respira- Outcome Criteria ✽ Child remains alert and oriented;
tions, 18 breaths/minute; pulse, 62 bpm; and blood pres- easily arousable. Pupils equal, round, react to light and
sure, 110/62 mm Hg. Left pupil is more dilated than his accommodation; vital signs within age-acceptable para-
right; it reacts sluggishly to light. Glasgow Coma score is meters; exhibits no signs or symptoms of neurologic
10. Alert enough to name toy racing car brought in with dysfunction.

Team Member
Responsible Assessment Intervention Rationale Expected Outcome

Activities of Daily Living

Nurse Take history of acci- Assess child’s vital Changes in vital signs, Parent describes acci-
dent, speed car was signs, level of con- level of conscious- dent and reactions of
traveling, and posi- sciousness, and ness, or neurologic child since accident.
tion of child in neurologic function function indicate a
vehicle. initially, and then worsening of the
every 30 min until child’s condition and
discharge. possibly increasing
intracranial pressure.

Consultations

N/A N/A N/A N/A N/A

Procedures/Medications

Physician/nurse Assess whether child’s Institute measures to Crying increases Parents are able to
demeanor (crying) is calm the child. intracranial pressure. calm child to allow
from fright or pain. Encourage the par- Involving the parents for better evaluation
ents to hold and provides them with a of condition.
reassure him. concrete activity,
helping to provide
some sense of
control over the
situation.
Physician/nurse Assess whether child Schedule a skull radi- Skull radiograph rules out Child cooperates with
has had experi- ograph or other a possible skull frac- diagnostic proce-
ence with x-ray diagnostic tests as ture secondary to the dures; results are
examination. ordered, such as CT trauma. CT scan or available for physi-
scan or MRI. MRI helps determine cian review.
any areas of bleeding
or edema if present.
(continued)
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1552 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

BOX 52.2 ✽ Focus on Nursing Care Planning (continued)

Nutrition

Nurse Assess whether If not NPO, feed small Vomiting is a symptom of Child eats some food
child has vom- amount of a favorite increased intracranial without vomiting.
ited since head food to be certain pressure.
injury. child does not have
vomiting.

Patient/Family Education

Nurse Assess what par- Teach parents how A contrecoup injury Parents state they un-
ents understand contrecoup injuries causes injury or edema derstand why their
about concus- occur and symp- to the posterior brain. child has posterior
sion in children. toms they cause. (eye control) cranial
symptoms, such as
unequal pupils.

Psychosocial/Spiritual/Emotional Needs

Nurse Assess whether Orient the child to his Children often have no Parents and child state
child or parents surroundings. Offer memory of events with they understand
have any ques- explanations about concussion. Parents procedures being
tions about care. any treatments or are in strange commu- carried out. Voice
procedures that are nity. Orientation and confidence in new
to come. explanation help to situation.
minimize a child’s fear
of the unknown and of
his situation.
Nurse Attempt to identify Encourage parents to Identification of the mean- Parents state they were
the meaning and express their feel- ing and effect of the not responsible for
effect of the ings about them- child’s accident assists accident, or at least
child’s accident selves as parents in determining the did everything possi-
for the parents and their role in the degree to which the ble to avoid their
(e.g., father child’s accident. situation is affecting child’s injury.
upset over rent- the parents.
a-car liability).

Discharge Planning

Nurse/physician Assess whether Instruct parents to rouse Frequent waking can be Parents state they will
parents will be the child approximately disorienting to a child remain in motel for
staying in city or every 2 hours during and can be confused 24 hours, rather
traveling back daytime hours and at with altered levels of than fly home imme-
home during least once during the consciousness, but diately, so they can
next 24 hours. night, asking the child occasional waking is a observe child.
to name a familiar good way to assess
object or color. whether complications
are occurring.
Nurse Assess whether par- Schedule a return ap- A follow-up visit is neces- Parents state they un-
ents will be able pointment to clinic sary to be certain child derstand importance
to keep a follow- for 24-hour follow- can travel safely. of follow-up visit and
up appointment up visit. Supply will keep appoint-
for additional clinic telephone ment with child.
care. number if needed
before then.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1553

nitrogen (BUN), liver function tests, blood gas studies, lum- Lumbar puncture has little value at first in predicting the
bar puncture, and toxicology tests may be ordered to rule out severity of a head injury, because any degree of cerebral con-
possible causes such as bacterial meningitis or hemorrhage. tusion usually leads to increased CSF pressure. Lumbar
Computed tomography (CT) or MRI will be done if a head puncture is contraindicated if increased ICP is present as re-
injury is the most likely cause (Claret-Teruel et al., 2007). lease of fluid with the puncture can cause brainstem com-
Coma is usually graded according to a standard scale so pression into the cord. Obtain the child’s vital signs and as-
that changes in the level of consciousness can be evaluated ac- sess neurologic status, such as state of consciousness and the
curately. Figure 52.5 shows the Glasgow Coma Scale, a com- ability of pupils to react to light, every 15 to 20 minutes or
monly used evaluation system (Morris, 2008). Because this as ordered. Accurately and carefully record this information
system was devised as an adult assessment scale, it must be so that a picture of gradual change will become apparent.
modified for use with children or infants. Such a modifica- A child’s prognosis after coma depends on the initial cause
tion is shown in Box 52.3. of the coma. If the increased ICP can be relieved before any
A score of 3 to 8 on the scale suggests severe trauma (a permanent brain damage results, the effects of the coma will
number less than 5 suggests a very severe prognosis); a score be transient. Prognosis is always guarded, however, because
of 9 to 12, moderate trauma; and 13 to 15, slight trauma. coma reflects a potential health problem for a child.

Therapeutic Management
If children are unconscious for longer than a transient period,
Nursing Diagnoses and Related
they usually are admitted to an observation unit for further Interventions
assessment. As a general rule, place a child who is comatose ✽
on the side to reduce the risk of aspiration. Oral suctioning Care of the child in coma is directed toward maintain-
to remove mucus from the mouth and pharynx may be nec- ing body function in an optimal state until the child
essary. If a child has acute signs of respiratory difficulty, en- reawakens.
dotracheal intubation may be necessary to ensure respiratory Nursing Diagnosis: Risk for ineffective airway clear-
function. ance related to brainstem pressure
An IV route is established so that, when specific measures
such as blood replacement, electrolyte replacement, or fluid Outcome Evaluation: Child’s respiratory rate remains
replacement are needed, a route for immediate administra- between 16 and 20 breaths/minute; there are no re-
tion will be available. Blood will be drawn for a complete tractions or signs of obstruction.
blood count, electrolyte determination, toxicology tests, and Some children who are comatose require endotra-
cross-matching. If the cause of the coma is unknown, a lum- cheal intubation or tracheostomy to ensure an open
bar puncture and EEG may be done. Skull radiography, CT airway. Some are placed on mechanical ventilation.
scan, or MRI may be done. Oxygen may be prescribed if arterial blood gases

Glasgow Coma Scale A.M. P.M. A.M.

Assessment Reaction Score 8 10 12 2 4 6 8 10 12 2 4 6 8
Eye Opening Spontaneously 4 X X X X X X
Response To speech 3 X X

To pain 2 X X X

No response 1

Motor Response Obeys verbal command 6 X X X X X X

Localizes pain 5 X X

Flexion withdrawal 4 X X

Flexion 3 X

Extension 2
No response 1

Verbal Response Oriented x3 5 X X X X X X

Conversation confused 4 X X
Inappropriate speech 3 X

Incomprehensible sounds 2 X X

No response 1

FIGURE 52.5 Glasgow Coma Scale scoring for a child. A score of 3 to 8 denotes severe
trauma; 9 to 12, moderate trauma; 13 to 15, slight trauma. Notice the gradual improvement
from coma in this example.
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1554 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

Bathe children who are comatose daily to stimulate skin

BOX 52.3 ✽ Scoring for Glasgow Coma Scale circulation. Include the hair as part of the bath about
every 3 days. Change their position at least every 2
Eye Opening hours to prevent pressure ulcer formation and develop-
4. Child opens eyes spontaneously when you ment of hydrostatic pneumonia from pooled secretions.
approach. When turning, assess skin for reddened points. Keep
3. Child opens eyes in response to speech (spo- linen dry and free from wrinkles. Perform thorough pas-
ken or shouted). sive range-of-motion exercises to maintain muscle tone
2. Child opens eyes only in response to painful and prevent contractures. Use of a sheepskin, an egg-
stimuli, such as pressure on a nail bed. carton foam, or an alternating pressure or water mat-
1. Child does not open eyes in response to tress also can be important in decreasing pressure to
painful stimuli. the skin.
Motor Response Nursing Diagnosis: Risk for imbalanced nutrition, less
6. Child can obey a simple command such as than body requirements, related to inability to take in
“hand me a toy” (infant smiles or attunes). oral food or fluid
5. Child moves an extremity to locate a painful Outcome Evaluation: Child’s skin turgor is normal; weight
stimulus applied to the head or trunk and at- remains within acceptable percentile; hourly urine out-
tempts to remove the source. put remains greater than 1 mL/kg.
4. Child attempts to withdraw from the source of Children who are unconscious cannot be fed orally or
pain. they might aspirate. Therefore, nutrition is maintained
3. Child flexes arms at the elbows and wrists in by nasogastric (NG) or gastrostomy tube feedings, IV
response to painful stimuli to the nail beds fluid administration, or total parenteral nutrition. IV
(decorticate rigidity). fluid is only a short-term answer, because adequate
2. Child extends arms (straightens the elbows) in protein and fat cannot be supplied solely by this route.
response to painful stimuli (cerebrate rigidity). NG or gastrostomy feedings can supply total nutrient
1. Child has no motor response to pain on any needs. Always aspirate NG or gastrostomy tubes for
extremity. stomach contents before giving a feeding to check
Verbal Response tube placement and assess gastric residual amounts.
5. Child is oriented to time, place, and person Return any amount of stomach residue aspirated, be-
(child >4 years old knows name, date, and cause if this is discarded each time, a child will lose a
where he or she is; infant appears to recog- large amount of stomach acid, possibly leading to al-
nize parent). kalosis. Check whether the amount of the feeding
4. Child is able to converse, although not ori- should be reduced by the amount of fluid remaining in
ented to time, place, or person (does not know the stomach before feeding the full amount of pre-
who or where he or she is; infant says words scribed formula.
but does not appear to differentiate parents Give mouth care at least twice daily with clear
from others). water and a padded tongue blade. Coat lips with
3. Child speaks only in words or phrases that petrolatum to prevent drying and cracking. If a
make little or no sense (“I want frazzle no”; in- child’s eyes tend to be dry, close them to prevent
fant’s vocabulary is less than it is normally). corneal ulceration. Artificial tears (methylcellulose)
2. Child responds with incomprehensible sounds, may be prescribed to keep eyes from drying until the
such as groans. child regains consciousness.
1. Child does not respond verbally at all.

Modified from Teasdale, G., & Bennett, B. (1974).

Choking Games
Assessment of coma and impaired consciousness: A prac- Adolescents, seeking an inexpensive way to experience a
tical scale. Lancet, 2 (7872), 81–84. “rush” or euphoria, induce a partial or complete loss of con-
sciousness in themselves by intentionally depriving their
brain of oxygen for a short period of time by strangulation or
hanging or reducing the oxygen able to reach their nose by
reveal poor oxygenation of body cells (oxygen ten- some technique such as pulling a plastic bag over their head.
sion [PO2] lower than 80 mm Hg). Endotracheal Extreme hyperventilation to induce hypocapnia is yet an-
tubes are replaced with a tracheostomy after 3 to other technique.
7 days to prevent necrosis of the pharynx from pres- The practice may be seen as a rite of passage or ini-
sure of the endotracheal tube. tiation into a gang or club. The practice is also known as
erotic asphyxiation as it also induces a sexual response.
Nursing Diagnosis: Risk for impaired skin integrity re- Unfortunately, the game results in injury and death. At
lated to lack of mobility least 82 adolescents between the age of 6 and 19 have died
Outcome Evaluation: Child exhibits no areas of broken in the United States as a result of the game. Of these
or irritated skin. 86.6% were male; the mean age was 13.3. The majority of
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1555

the deaths occurred while the adolescent was alone; over

90% of the parents of the child were unaware of the game BOX 52.4 ✽ Focus on Communication
(CDC, 2008a).
Injuries such as concussion, bone fractures, and tongue Jason, a 5-year-old boy, is brought to the emergency
biting may occur from falling. Teach parents that the game room after an automobile accident. He is being as-
exists and to be aware of signs that their child might be in- sessed for multiple trauma.
terested or participating in the game. Common signs are Less Effective Communication
discussion of the game, bloodshot eyes, ligature marks on Mr. Varton: Why are you looking at his belly? He didn’t
the neck, severe headaches, disorientation, and the presence hurt that.
of choke collars, ropes, scarves, or belts tied to bedroom Nurse: We need to assess his entire body just to make
furniture. sure that there aren’t any problems. He’s had major
trauma. You need to sign a consent form so he can
have a central intravenous line and indwelling uri-
ABDOMINAL TRAUMA nary catheter inserted and a CT scan to rule out
any problems.
When children are brought to a health care facility after suf-
Mr. Varton: I don’t want to put him through any more.
fering a multiple-injury trauma, several medical specialists
What if something else goes wrong?
may be required: a neurosurgeon for consultation about a
Nurse: If you don’t consent to these tests and treat-
head injury; an orthopedic physician for consultation about
ments, we cannot take care of your child.
a fractured extremity; and a thoracic surgeon to intubate or
Mr. Varton: OK. Do what you have to. But I’m still
investigate lung trauma. A nurse may serve the important
not sure.
function of being the person who is best able to observe a
Nurse: Good. Sign this consent for me.
total child and recognize the subtle signs of abdominal
trauma. More Effective Communication
Mr. Varton: Why are you looking at his belly? He didn’t
Assessment hurt that.
Nurse: We need to assess his entire body just to make
Abdominal trauma results from an object striking the ab- sure that there aren’t any problems. He’s had major
domen, such as a baseball bat or a seat belt drawn tight in a trauma. You need to sign a consent form so he can
motor vehicle crash (Humphries, 2008). Assess vital signs have a central intravenous line and indwelling uri-
frequently until they are stable. Hypotension (less than nary catheter inserted and a CT scan to rule out
80 mm Hg systolic pressure in an older child; less than 60 any problems.
mm Hg in an infant) usually suggests hemorrhage, which Mr. Varton: I don’t want to put him through any more.
may be hidden abdominal bleeding. In addition, children What if something else goes wrong?
may have increasing pallor and rapid respirations. If internal Nurse: I know it’s difficult for you to see your child in
bleeding is present, blood pressure will show little improve- such pain. Are you worried about anything specific?
ment when IV fluid is administered. Mr. Varton: Is he going to die?
If abdominal trauma is suspected, an NG tube is passed Nurse: The things we’re doing are aimed to prevent
and stomach contents are aspirated to be checked visually for that very thing. Let me explain a little more about
blood and to test for occult blood. Attach the tube to low in- what we’re doing and why these things are neces-
termittent suction if the presence of blood is established. An sary. I want you to feel comfortable signing the
indwelling urinary (Foley) catheter is also inserted to evalu- consent form.
ate urine for blood and urine output. Evidence of blood in
the urine or decreased output may indicate accompanying In the first scenario, the nurse focuses on obtaining
kidney or bladder trauma. If the urine contains blood, an the parent’s consent but fails to recognize the fear and
emergency IV pyelogram or ultrasound may be ordered. Be apprehension in the parent. In the second scenario,
aware that having NG tubes or catheters passed is always the nurse recognizes and attends to the fears of the
frightening for a child (unsure of their anatomy, children parent. By doing so, she helps to establish a sense of
have no clear idea where the tubes are going). After an acci- support and trust in addition to obtaining consent for
dent, when they are already frightened, they and their par- procedures.
ents need a great deal of support to accept these procedures
(Box 52.4).
An abdominal radiograph or ultrasound may be ordered fractured extremities or lacerations. Some parents may not
to rule out a fractured pelvis, a condition that could con- bring their child to an emergency department immediately
tribute to blood loss. Air under the diaphragm on the radi- after abdominal trauma, because they are unaware that se-
ograph suggests gastric or intestinal rupture with escape of rious injury can result to this part of the body. Without
air from these organs into the peritoneal cavity. Free fluid frightening them, explain that an injury need not be obvi-
in the abdomen, shown on the radiograph when the child ous at first glance to be serious and need care. They may ask
is turned on the side, suggests leakage of bowel fluid or why a radiograph is necessary. When their child is asked to
splenic rupture and pooling of blood. Parents often find it turn on the radiograph table so that an abdominal fluid
difficult to appreciate the seriousness of abdominal trauma, level can be revealed, they may perceive this as unnecessary
because the signs are not as dramatic or obvious as those of manipulation of an injured child.
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1556 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

with splenic injury have tenderness in the left upper quad-

Nursing Diagnoses and Related rant, especially on deep inspiration, when the diaphragm
Interventions moves down and touches the spleen. They may hold their left
✽ shoulder elevated, so that the diaphragm is raised on the left
side, to keep this from happening. Occasionally, a child no-
Nursing Diagnosis: Pain related to abdominal injury
tices radiated left shoulder pain while lying in a supine posi-
Outcome Evaluation: Child states that level of pain is tion (Kehr’s sign). A radiograph will show little about the
tolerable; child does not grimace when body parts are spleen itself but may reveal a broken rib over the spleen, sug-
touched. gesting the extent of the trauma to that area.
Routinely, analgesics are not administered to most An IV line is begun immediately for fluid replacement,
children after abdominal trauma unless their pain is and an IV pyelogram or MRI will be done to rule out dam-
severe, to avoid masking the pain, as the location of age to the left kidney, which, because of its location just be-
the pain can help identify which organs may be in- hind the spleen, may also have suffered trauma. A complete
jured. If parents did not recognize that the child was blood count is done to estimate the extent of the blood loss.
injured, guilt and fear on their part may compound the Blood is typed and cross-matched, so that blood for replace-
problem. Goal setting is usually concerned with the ment can be readied if necessary. The child will be admitted
immediate diagnostic procedures or anticipated to an observation unit if the blood loss from rupture appears
surgery. Interventions differ according to the specific to be mild. If bleeding is severe, immediate surgery, such as
injury present. a partial or total splenectomy, may be necessary to halt bleed-
ing and save the child’s life.
After a splenectomy, children are very susceptible to in-
Splenic Rupture fection, particularly pneumococcal infections. Therefore, a
large percentage of children are managed expectantly to see if
In children, the spleen is the most frequently injured organ the bleeding will halt without spleen removal (Dobremez et
in abdominal trauma, because it is usually palpable under the al., 2007). Children who have their spleen removed are of-
lower left ribs (Huether & McCance, 2007). It is frequently fered the pneumococcal vaccine to protect them against
injured by inappropriately applied seat belts in automobiles pneumococcal infections.
and by handlebar injuries in bicycle accidents. It is increas-
ingly caused by snowboard injuries (Box 52.5). Children Liver Rupture
Livers are also more prone to rupture in children than in
adults, because the liver, like the spleen, is not completely
sheltered by the rib cage in children (Tataria et al., 2007).
Children with liver rupture or laceration usually have severe
BOX 52.5 ✽ Focus on Evidence- abdominal pain that is most marked on inspiration, when the
Based Practice diaphragm descends and touches the liver. They show symp-
toms of blood loss, including tachycardia, hypotension, anx-
Do snowboards cause as many injuries as skis in iety, and pallor. The hematocrit will be low or falling. Such
children? children need to be prepared for immediate surgery, because
Snowboarding is a relatively new sport. To compare the the liver is a highly vascular organ, and blood loss from it is
risk of unintentional injury as a result of skiing to the risk acute and possibly life-threatening.
of injury by snowboarding, researchers analyzed the Occasionally, a communication between an artery and the
history of children seen in a pediatric trauma center over bile duct occurs at the time of trauma. In this situation, symp-
a seven-year period. During the study period, there toms are not immediate, but gastrointestinal (GI) bleeding,
were 57 snowboarders and 22 skiers seen for care. The such as hematemesis or melena, may occur in a few days. The
site of the injuries differed as all skiing injuries occurred child may have colicky upper abdominal pain that is relieved
at recreational facilities whereas 12% of snowboard in- by emesis. Liver studies, such as a liver arteriogram, are neces-
juries occurred at home, another residence, or a public sary to reveal the extent of the problem.
park. Forty-one (72%) of snowboarders and 16 (73%) of After either liver or spleen surgery, children need careful
skiers required surgery for their injuries; 32 (56% of observation for return of bowel function, assessment for the
snowboarders and 9 (41%) of skiers sustained frac- possibility that peritonitis may develop, and careful reintro-
tures; and 14 (25%) of snowboarders and 6 (27%) of duction of oral nutrition.
skiers sustained abdominal injuries. Serious splenic in-
juries were more common in snowboarders (14% vs 4%)
but the difference was not statistically significant.
DENTAL TRAUMA
Based on the above study, would it be important to ask
Injuries to teeth occur most often from falls in which a child
if a child was skiing or snowboarding when brought into
strikes the upper front incisors or from blows to the face by ob-
the hospital by the ski patrol?
jects such as baseball bats or hockey sticks. Such accidents are
Source: Hayes, J. R., & Groner, J. I. (2008). The increasing in-
always potentially serious, because they can lead to aspiration
cidence of snowboard-related trauma. Journal of Pediatric of the injured teeth or malalignment of future teeth. If perma-
Surgery, 43(5), 928–930. nent teeth that have been knocked out recently can be washed
with saline in the emergency department and replaced, there is
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1557

a good chance that they will reimplant successfully. If a tooth hypertonic, causing fluid to osmose from the bloodstream
is knocked out, parents should rinse the tooth in water, drop and enter the alveoli, increasing the amount of fluid in the
it in a salt solution or milk, and bring it to the emergency de- lung tissue and increasing hypoxia. Tachycardia and de-
partment with them (Andersson, 2007). creased blood pressure from hypovolemia result. Blood vis-
Some dentists advocate immersing the tooth in an antisep- cosity increases as shown by an increased hematocrit level.
tic and then in an antibiotic solution before replacing it. If a Fresh water is hypotonic, so fluid in the lungs shifts into
tooth is replaced, it usually is wired into place to hold it in good the bloodstream because of osmotic pressure. This can lead
alignment. The child receives a course of oral antibiotics, such to hemolysis of red blood cells, a dilution of plasma, and pos-
as penicillin, to prevent infection. Only soft food must be eaten sibly hypervolemia with tachycardia and increased blood
until the tooth has firmly adhered (approximately 2 weeks). pressure. If the release of potassium from destroyed red blood
If a blow to a child’s teeth was extensive, a radiograph may cells is great enough with fresh-water drowning, cardiac ar-
be taken to rule out a mandibular or maxillary fracture. If a rhythmias may occur. In both instances, loss of surfactant
portion of a tooth cannot be located, the possibility of aspi- from lung alveoli, caused by introduction of water (adult res-
ration must be considered and confirmed or ruled out by a piratory distress syndrome), can lead to alveolar collapse on
chest radiography. In young children, often a tooth is not expiration (Bowers & Anderson, 2008).
knocked out but is pushed back up into the gum. These teeth Parents should advocate for neighborhood pools to be
gradually regrow, and, although they may darken in color, fenced and advise against hyperventilating before swimming.
they usually are healthy. If the affected tooth is a deciduous When children blow off carbon dioxide with hyperventilation
tooth, the permanent tooth is rarely injured even though it is this way, and then swim underwater for an extended period of
already formed in the gum. At the appropriate time, the per- time, carbon dioxide levels will rise, but not adequately
manent tooth will erupt normally. enough to cause them to experience distress. Oxygen levels
decrease causing drowsiness and listlessness (children drown
without struggling or realizing their danger).
NEAR DROWNING Very young children display a mammalian diving reflex
when they plunge under cold water that helps them survive
Drowning is death caused by suffocation from submersion drowning. Immediately after plunging into cold water, a life-
in liquid. Inhaled water fills the lungs and therefore blocks saving bradycardia and shunting of blood away from the pe-
the exchange of oxygen in the alveoli. More than 3500 chil- riphery of the body to the brain and heart occur. This reflex
dren die from drowning annually, making it the second most is triggered when water is 70° F (21° C) or less and the face
common cause of death by unintentional injury among chil- is submerged first. This explains why very young children can
dren. The term near drowning is used to describe the child survive better than older children after being submerged in
with a submersion injury who requires emergency treatment water that is very cold.
and who survives the first 24 hours after injury (Lee, Mao, &
Thompson, 2007). Emergency Management
Most infant drownings occur in bathtubs; 1- to 4-year-old
children most frequently drown in artificial pools; older chil- When a child is pulled from the water after near drowning,
dren most frequently drown in bodies of fresh water. The mouth-to-mouth resuscitation should be started at once. If
majority of drowning accidents that take place outside the cardiac arrest has occurred from hypoxia, simultaneous mea-
home occur in the summer months, when more children are sures to initiate cardiac action must be taken. The technique
swimming and boating. Particularly at risk are male adoles- of cardiopulmonary resuscitation for infants and children is
cents, because they may take dares to swim farther than their discussed in Chapter 41.
ability allows or may swim under the influence of alcohol, Assuming that cardiopulmonary resuscitation is effective,
which impairs their decision-making ability and their physi- the child needs follow-up care at a health care facility, be-
cal coordination. cause the child is certain to be acidotic from accumulated
carbon dioxide and hypoxia (resulting from lack of oxygen
Pathophysiology of Drowning because of the water in the alveoli) and is at risk for respira-
tory infection from contaminants in the water.
When children’s heads are submerged and they first inhale Follow-up care aims to increase the child’s oxygen and car-
water, they cough violently from the irritation of the water in bon dioxide exchange capacity, using the lung areas that are
their nose and throat. If they cannot get their head out of not filled with water. Typically, a child is intubated with a
water at this point, water will enter the larynx. This causes the cuffed intratracheal tube; mechanical ventilation with positive
larynx to spasm, preventing any further water but also air end-expiratory pressure may be necessary to force air into the
from entering the trachea, so asphyxia results. If a child is ven- alveoli. Because water has been swallowed, vomiting usually
tilated at this point, treatment usually is very effective because occurs as the child is revived. The cuff of the intratracheal
there is little water in the lungs. The condition more closely tube prevents vomitus from being aspirated. The child is
simulates asphyxia that occurs with croup or when a foreign given 100% oxygen so that as much space as possible in the
body, such as a nut, lodges in the trachea and stops air flow. available lung alveoli can be used. An NG tube is inserted to
If treatment is not given at this point, the larynx relaxes decompress the stomach, prevent vomiting, and free up
from the asphyxia and water enters the lungs. Oxygen can no breathing space. Usually, albuterol is administered by aerosol
longer be exchanged, because the alveoli fill with water. to prevent bronchospasm and, again, to allow the child to
Hypoxia deepens, and cardiac arrest occurs. make maximum use of the oxygen administered. If the child
Additional changes that occur when water enters the lungs aspirated salt water, plasma may be administered to replace
depend on whether the water is fresh or salt. Salt water is protein being lost into the lungs and prevent hypovolemia.
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1558 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

If the child’s body temperature is very low, gradual warm- when poisoning occurs in an older child, it may not be poi-
ing (not using a warming blanket) is advised so that the soning but a suicide attempt.
metabolic requirement does not rise sharply before alveolar
space is ready to accommodate this need. Extracorporeal
membrane oxygenation may be used. Nursing Diagnoses and Related
Unfortunately, neurologic damage occurs in as many as
21% of near-drowning incidents. If the child is awake or Interventions
only lethargic at the scene of the accident and immediately ✽
afterward in the hospital, the prognosis is greatly improved Nursing Diagnosis: Risk for injury related to matura-
over that of the child who is comatose. tional age of child and presence of poisons
Outcome Evaluation: Parents identify poisonous and
toxic items in the home and describe how they are
Nursing Diagnoses and Related stored safely; parents state local poison control cen-
Interventions ter number; parents describe measures to seek help
immediately if poisoning occurs.
✽
Nursing Diagnosis: Risk for infection related to foreign
substance in respiratory tract
Emergency Management of Poisoning at Home
Outcome Evaluation: Child’s temperature remains within
normal parameters orally; rales are absent on lung If poisoning occurs, parents should telephone their local poi-
auscultation; respiratory rate is within age-acceptable son control center to ask for advice. Information parents need
parameters. to provide includes:
Following near drowning, a child may be prescribed • Child’s name, telephone number, address, weight, and
prophylactic antibiotic therapy to prevent pneumonia age and what the child swallowed
and additional airway interference. Assess vital signs • How long ago the poisoning occurred
and auscultate lung sounds for adventitious sounds, • The route of poisoning (oral, inhaled, sprayed on skin)
such as rales or fine rhonchi. Turning the child every • How much of the poison the child took (the bottle should
2 hours if on bedrest and encouraging deep breath- say how many pills or liquid it originally held).
ing and incentive spirometry every hour help to aerate • If the poison was in pill form, whether there are pills scat-
the lungs fully and prevent the accumulation of fluid, tered under a chair or if they are all missing and presumed
which promotes infection. swallowed
Nursing Diagnosis: Fear related to near-drowning • What was swallowed; if the name of a medicine is not
experience known, what it was prescribed for and a description of it
(color, size, shape of pills)
Outcome Evaluation: Child discusses fears; child • The child’s present condition (sleepy? hyperactive? comatose?)
states that she understands that, although frightening,
the experience is over, and she is now safe. If one child has swallowed a poison, parents should inves-
tigate whether other children have also poisoned themselves
Children may be admitted to an observation unit for as a preschooler often shares “candy” with a younger sibling.
monitoring of blood gases until water from the alveoli
is absorbed and they once again can ventilate effec-
tively on their own. Such children may wake at night
Emergency Management of Poisoning at the
from a nightmare that they are drowning. They need Health Care Facility
their parents to reassure them that they are now safe In the emergency department, the best method to deactivate
and definitely out of the water. Near drowning is a a swallowed poison is the administration of activated char-
thoroughly frightening experience. Encourage chil- coal, either orally or by way of an NG tube.
dren to verbalize this fright. They may need support Activated charcoal is supplied as a fine black powder that
from parents before they try swimming again after is mixed with water for administration. A sweet syrup may be
such a frightening experience. added to the mixture to make it more palatable. Caution par-
ents that, as the charcoal is excreted through the bowel over
the next 3 days, stools will appear black (Box 52.6).
POISONING Always follow emergency measures to neutralize a poison
with an education program for the family to prevent poison-
Poisoning occurs most commonly in children between the ing from happening again. Specific measures for each age
ages of 2 and 3 years. It occurs in all socioeconomic groups. group are discussed in previous chapters, along with prob-
Common agents include soaps, cosmetics, detergents or lems and concerns of that age group.
cleaners, and plants. Poisoning can occur from over-the-
counter drugs, such as vitamins, iron compounds, aspirin, or Acetaminophen Poisoning
acetaminophen, or from prescription drugs, such as antide-
pressants. Unlike other unintentional injuries, poisoning is Acetaminophen (Tylenol) is the drug most frequently involved
entirely preventable. Parents need education about the high in childhood poisoning today, because parents use
risk for poisoning and strategies for maintaining a home en- acetaminophen to treat childhood fevers. Told that aceta-
vironment that is safe for children of all ages. Be aware that minophen is safer than aspirin, parents may not be as careful
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1559

After the child is stabilized, take some time to talk with

BOX 52.6 ✽ Focus on the parents about how they feel about this event.
Pharmacology Remember that poisoning tends to happen in homes
where there is stress. If stress was already present,
Activated Charcoal how has this poisoning added to it?
Classification: Activated charcoal is an antidote for Before the child is discharged from a health care
poisoning. facility, be certain the parents are comfortable with
Action: Absorbs toxic substances that have been swal- any further assessment measures they will need to
lowed to prevent them from being absorbed by the continue at home, such as temperature taking and
stomach (Karch, 2009). urging a high fluid intake. Talk with the parents about
Pregnancy Risk Category: C the necessity for childproofing their home.
Dosage: Provided as a powder that must be mixed with
water and administered orally or by way of nasogas-
tric (NG) tube. ✔Checkpoint Question 52.1
Possible Adverse Effects: Vomiting, diarrhea, black You see Jason’s sister in the emergency department after ac-
stools
etaminophen poisoning. Which of the following would be an
Nursing Implications appropriate action to take?

• Administer orally to conscious victims only. a. Advise the parents that their child must never receive ac-
• Give the drug as soon as possible after poisoning. etaminophen again.
• Store the drug in a closed container, because it ab- b. Counsel the parents about not taking medications in front of
sorbs gases from the air and is inactivated. children.
• Know that the solution feels gritty and tastes disagree- c. Question an order to give activated charcoal to neutralize
able, so young children have difficulty swallowing the the drug.
drug. May have to be administered by NG tube. d. Sympathize with parents, but reassure them this poisoning
• Caution child or parent that stools will be black for is not serious.
several days after administration.
Caustic Poisoning
about putting this drug away as they were with aspirin. If their Ingestion of a strong alkali, such as lye, which is often con-
child swallows acetaminophen, they may delay bringing the tained in toilet bowl cleaners or hair care products, may cause
child for help, thinking it is a harmless drug. Acetaminophen burns and tissue necrosis in the mouth, esophagus, and stom-
in large doses, however, is not an innocent drug; it can cause ach. It is important that the parents do not try to make a child
extreme liver destruction (Morgan & Borys, 2008). vomit after ingestion of these substances, because they can
Immediately after ingestion, the child will experience cause additional burning as they are vomited (ATSDR, 2008).
anorexia, nausea, and vomiting. Soon, serum aspartate
transaminase (AST [SGOT]) and serum alanine transami- Assessment
nase (ALT [SGPT]), liver enzymes, become elevated. The After a caustic ingestion, the child has immediate pain in the
liver may feel tender as liver toxicity occurs. mouth and throat and drools saliva because of oral edema and
Parents should call their local poison control center. In an inability to swallow. The mouth turns white immediately
the emergency department, activated charcoal or acetylcys- from the burn. Later, the mouth turns brown as edema and ul-
teine, the specific antidote for acetaminophen poisoning, will ceration occur. There may be such marked edema of the lips
be administered. Acetylcysteine prevents hepatotoxicity by and mouth that it is difficult to examine them. The child may
binding with the breakdown product of acetaminophen so immediately vomit blood, mucus, and necrotic tissue. The loss
that it will not bind to liver cells. Unfortunately, acetylcys- of blood from the denuded, burned surface may lead to sys-
teine has an offensive odor and taste. Administer it in a temic signs of tachycardia, tachypnea, pallor, and hypotension.
carbonated beverage to help the child swallow it. For small A chest radiograph may be ordered to determine whether
children, it is administered directly into an NG tube to avoid pulmonary involvement has occurred from any aspirated poi-
this difficulty. If the child is admitted to an observation unit, son or whether an esophageal perforation has allowed poison
continue to observe for jaundice and tenderness over the to seep into the mediastinum. An esophagoscopy under con-
liver; assess ALT and AST levels as ordered. scious sedation may be done to assess the esophagus, although
this test may be omitted because of the possibility that an
esophagoscope might perforate the burned esophagus. After
Nursing Diagnoses and Related 2 weeks, a barium swallow or esophagoscopy may be per-
Interventions formed to reveal the final extent of the esophageal burns.
✽
Nursing Diagnosis: Situational low self-esteem related Therapeutic Management
to child’s poisoning When parents whose child has ingested a caustic substance
Outcome Evaluation: Parents state guidelines for con- call a poison control center to ask for advice on how to pro-
tinued assessment of child at home; parents state ceed, they will be advised to immediately take the child to a
ways they can improve “childproofing.” health care facility for treatment. There is a high possibility
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1560 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

that pharyngeal edema will be severe enough to obstruct the Iron Poisoning
child’s airway by even 20 minutes after the burn.
To detect respiratory interference, assess vital signs closely, Iron is frequently swallowed by small children because it is an
especially the respiratory rate. In infants, increasing restlessness ingredient in vitamin preparations, particularly pregnancy vi-
is an important accompanying sign of oxygen want. In the tamins. When it is ingested, it is corrosive to the gastric mu-
emergency department, intubation may be necessary to pro- cosa and leads to signs and symptoms of gastric irritation
vide a patent airway. Assess the child also for the degree of pain (Aldridge, 2007). The immediate effects include nausea and
involved. A strong analgesic, such as morphine, may need to vomiting, diarrhea, and abdominal pain. After 6 hours, these
be ordered and administered to achieve pain relief. symptoms fade, and the child’s condition appears to im-
prove. By this time, however, hemorrhagic necrosis of the
lining of the GI tract has occurred. By 12 hours, melena
(blood in stool) and hematemesis (blood in emesis) are pres-
Nursing Diagnoses and Related ent. Lethargy and coma, cyanosis, and vasomotor collapse
Interventions may occur. Coagulation defects may occur, and hepatic in-
✽ jury also can result. Shock resulting from an increase in pe-
Nursing Diagnosis: Risk for ineffective airway clear- ripheral vascular resistance and decreased cardiac output can
ance related to burns of esophagus and mouth occur. Long-term effects can include gastric scarring from fi-
brotic tissue formation.
Outcome Evaluation: Child’s respiration rate remains
within 16 to 20 breaths/minute.
Assessment
Starting therapy immediately after a caustic burn with a
steroid such as dexamethasone (Decadron) and con- It is difficult to estimate the amount of iron a child has swal-
tinuing it for about 4 weeks helps to reduce the chance lowed, because parents can only guess at the number of pills
of permanent esophageal scarring. In addition, chil- in the bottle. In addition, the amount of elemental iron in
dren may be prescribed a prophylactic antibiotic to compounds varies. The child’s serum iron level should be
reduce the possibility of infection and additional inflam- measured to establish a baseline.
mation in the denuded mouth and esophageal area.
Children who respond well to steroid therapy usu- Therapeutic Management
ally recover with no important sequelae. Children who Parents should contact their poison control center immediately
do not receive steroid therapy for some reason may after the ingestion. In the emergency department, stomach
be left with scarring of the esophagus, resulting in lavage will be done to remove any pills not yet absorbed. A
complete obstruction. To correct complete obstruc- cathartic may be given to help the child pass enteric-coated iron
tion, a gastrostomy for feeding and repeated surgical pills. Activated charcoal is not given, because it is not effective
procedures are necessary. Sometimes transplanta- at neutralizing iron. A soothing compound such as Maalox or
tion of intestinal tissue or a synthetic graft is required Mylanta (aluminum hydroxide and magnesium hydroxide)
to replace stenosed esophageal tissue. may be given to help decrease gastric irritation and pain.
Nursing Diagnosis: Risk for imbalanced nutrition, less A child who has ingested a potentially toxic dose will be
than body requirements, related to esophageal stric- given a chelating agent, such as IV or intramuscular (IM) de-
ture from burn scarring feroxamine. Chelating agents combine with metals and allow
them to be excreted from the body. Caution parents that de-
Outcome Evaluation: Child’s diet meets recommended
feroxamine causes urine to turn orange as iron is excreted.
daily allowance requirements for age.
An exchange transfusion is another way that excess iron
Oral intake commonly will be a problem for the first can be removed from the body. An upper GI x-ray series and
week following a caustic injury because of soreness in liver studies may be ordered 1 week after the ingestion to
the child’s mouth. Liquid food is introduced first. screen for long-term effects. The hope is that the iron load
Liquid passing through the burned and scarring was removed from the stomach in time so that not all of it
esophagus tends to maintain esophageal patency, so was absorbed.
it is therapeutic for the burn as well as nutritious for the Assist with emergency measures, such as gastric lavage, and
child. Observe children carefully the first time they at- administer chelating agents as ordered. Parents may be asked to
tempt to drink something for coughing, choking, or test any stool passed for the next 3 days for occult blood, to as-
cyanosis, signs that are indicative of esophageal sess for stomach irritation and subsequent GI bleeding. Be cer-
stenosis or perforation. IV fluid may be needed as a tain that parents understand how to do this accurately.
supplement for such children. If a child is totally un-
able to swallow, gastrostomy feedings or total par-
enteral nutrition will be necessary.
Nursing Diagnoses and Related
Interventions
Hydrocarbon Ingestion ✽
Hydrocarbons are substances contained in products such Nursing Diagnosis: Deficient parental knowledge re-
as kerosene and furniture polish. Because these substances lated to the danger of iron as a poison
are volatile, fumes rise from them, and their major effect is Outcome Evaluation: Parents state ways they have
respiratory, not gastric, irritation (see Chapter 40). safeguarded their child from future iron exposure.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1561

Iron poisoning occurs frequently because parents do Many children with fairly high blood lead levels are
not think of iron pills or vitamins containing iron as asymptomatic. Others show insidious symptoms of anorexia
real medicine. Additionally, because many children’s and abdominal pain caused by the presence of lead in the
vitamins are manufactured in the shapes of familiar stomach. Children with encephalopathy usually have begin-
television or cartoon characters, children often think ning symptoms of lethargy, impulsiveness, and learning
of vitamins as candy. difficulties. As the child’s blood level of lead increases, severe
When you instruct parents to use an iron supple- encephalopathy with seizures and permanent neurologic
ment for themselves or their children, stress that over- damage will result.
doses can be fatal to small children. Teach them to The most widely used method of screening for lead
think of iron as they would any other medicine and levels is the blood lead determination (serum ferritin).
keep it out of the reach of small children. Unfortunately, this test requires the use of atomic absorp-
tion spectrophotometry, which is a costly procedure. The
free erythrocyte protoporphyrin test is a simple screening
Lead Poisoning procedure that involves only a fingerstick. Because proto-
porphyrin is blocked from entering heme by the lead, it will
When lead enters the body, it interferes with red blood cell be elevated in a child with lead poisoning.
function by blocking the incorporation of iron into the pro- Basophilic stippling (an odd striation of basophils) may
toporphyrin compound that makes up the heme portion of be apparent on a blood smear. A radiograph of the abdomen
hemoglobin in red blood cells (Morgan & Borys, 2008). This may reveal paint chips in the intestinal tract (Fig. 52.6A).
leads to a hypochromic, microcytic anemia. Kidney destruc- “Lead lines” (areas of increased density) may be present near
tion may occur in addition, causing excess excretion of the epiphyseal line of long bones (see Fig. 52.6B). The thick-
amino acids, glucose, and phosphates in the urine. The most ness of the line shows the length of time lead ingestion has
serious effect, however, is lead encephalitis: inflammation of been occurring (Kosnett, 2007).
brain cells because of the toxic lead content. Lead poisoning Damage to the kidney nephrons from the presence of lead
(plumbism), like all forms of poisoning in children, tends to leads to proteinuria, ketonuria, and glycosuria. Urine analy-
occur most often in the toddler or preschool child. (See sis reveals this. The CSF may have an increased protein level.
Chapter 30 for measures to prevent lead poisoning.)

Assessment Therapeutic Management

Lead poisoning is said to be present when the child has two A child with a blood lead level between 10 and 14 ␮g/dL
successive blood lead levels greater than 10 ␮g/dL. A classifi- needs to be rescreened to confirm the level. If the lead level
cation of levels of lead poisoning is shown in Table 52.3. The is 15 ␮g/dL or higher, a child needs active interventions to
usual sources of ingested lead are paint chips or paint dust, prevent further lead exposure. These interventions may in-
home-glazed pottery, or fumes from burning or swallowed clude removal of the child from the environment containing
batteries (Olson, 2009). Paint tastes sweet, and a child will the lead source or removal of the source of lead from the
repeatedly pick chips up off the floor or off the walls. If a crib child’s environment. Removal of the lead source can be dif-
rail is painted with lead paint, a child will ingest it as the ficult. If the family lives in a rented apartment, the landlord
child teethes on the rail. Chewing on windowsills is also may be legally obligated to remove the lead. Simple repaint-
common. In fishing communities, swallowing lead sinkers ing or wallpapering does not remove a source of peeling paint
can be a common source. Restoring an older home saturates adequately. After some months, the new paint will begin to
the air with lead dust. In such homes, lead plumbing also peel because of the defective paint underneath. The walls
may contaminate the drinking water. must therefore be covered by paneling or Masonite.

TABLE 52.3 ✽ Classification of Lead Poisoning Risk

Class Lead Blood Level Recommended Action

Concentration (␮g/dL)
Class I (low risk) ⬍9 Retest at 24 months for children age 6–35 months who
are considered low risk; retest every 6 months for ages
6–35 months who are considered high risk
Class IIa (rescreen) 10–14 Retest yearly; continue retesting yearly for children ⬎36
months until age 6 years
Class IIb (moderate risk) 15–19 Retest every 3–4 months for children age 6–35 months
Class III (high risk) 20–44 Retest every 3–4 months; begin home abatement program
Class IV (urgent risk) 45–69 Initiate chelating therapy and environmental remediation
Class V (urgent risk) ⬎ 70 Immediately treat with a chelating agent

Centers for Disease Control and Prevention. (2008). Preventing lead poisoning in young children. Washington, DC: U.S.
Department of Health and Human Services, Public Health Service.
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1562 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

BOX 52.7 ✽ Focus on

Pharmacology
Succimer (Chemet)
Classification: Succimer is a chelating agent.
Action: Forms water-soluble chelates with lead, leading
to increased urinary excretion of lead (Karch, 2009)
Pregnancy Risk Category: C
Dosage: Orally, starting with 10 mg/kg or 350 mg/m2
every 8 hours orally for 5 days, then reducing dosage
to 10 mg/kg or 350 mg/m2 every 12 hours for 2 weeks.
The drug is taken for a total of 19 days.
Possible Adverse Effects: Nausea; vomiting; loss of
appetite; back, stomach, flank, head, or rib pain;
chills; flulike symptoms
Nursing Implications
• Obtain serum lead levels before beginning therapy
and again at the close of therapy.
• Instruct parents and child about the need to take the
A full 19-day course for optimal effectiveness.
• If the child has difficulty swallowing capsules, encour-
age parents to open capsules and mix capsule con-
tents with a small amount of soft food or administer
capsule contents on a spoon followed by a fruit drink.
• Urge the child to drink increased amount of fluid to
provide enough urine for removing the chelated lead
from the body.
• Ensure that a lead abatement program is instituted
concurrently to reduce the amount of lead to which
the child is exposed.

B BAL has the advantage of removing lead from red blood

cells, but, because of severe toxicity, it is used only for children
FIGURE 52.6 (A) Ingested paint chips (white crescents) in the
intestinal tract. (B) A radiograph of the long bones of a child
who have severe forms of lead intoxication. Penicillamine
with chronic lead ingestion showing the characteristic “lead line” (Cuprimine) is yet another drug used for lead poisoning. It is
or white marking at the epiphyseal line. (Radiographs courtesy given orally after BAL or EDTA. Weekly complete blood cell
of Dr. Jerald P. Kuhn, Children’s Hospital, Buffalo, NY.) counts and renal and liver function tests accompany the
administration of penicillamine. It may be given for as long as
3 to 6 months.
All children with lead levels greater than 20 ␮g/100 mL
may be prescribed an oral chelating agent such as succimer
(Box 52.7). Children with blood lead levels of greater than Nursing Diagnoses and Related
45 ␮g/100 mL may be admitted to the hospital for chelation Interventions
therapy with agents such as dimercaprol (BAL) or edetate cal- ✽
cium disodium (CaEDTA) (Karch, 2009). Care planning can be difficult when a child is diag-
Chelating agents remove the lead from soft tissue and bone nosed with lead poisoning because parents are upset
(although not from red blood cells), allowing it to be elimi- at learning their child has been exposed to lead. They
nated in the urine. Injections of EDTA, which must be given may experience a loss of self-esteem and a sense of
IM into a large muscle mass, are painful and may be combined powerlessness when realizing that their financial cir-
with 0.5 mL of procaine. EDTA also removes calcium from cumstances or lifestyle has hurt their child.
the body; therefore, serum calcium must be measured period-
ically to determine whether it is at a safe level. Measure intake Nursing Diagnosis: Deficient knowledge related to the
and output to ensure that kidney function is adequate to han- dangers of lead ingestion
dle the lead being excreted. BUN, serum creatinine, and Outcome Evaluation: Parents state ways they have
protein in urine may also be assessed to ensure that kidney safeguarded their child against further lead inges-
function is adequate. If kidney function is not adequate, tion; parents identify measures to reduce lead in the
EDTA may lead to nephrotoxicity or kidney damage. environment.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1563

Parental education about the risk of lead poisoning is

crucial. Teach parents to keep toddlers away from win- BOX 52.8 ✽ Focus on
dowsills and other common sources of lead paint. Family Teaching
Placing the television or an overstuffed chair against
the windowsill may be effective as a temporary mea- Identifying Poisonous Plants
sure. As a rule, children’s cribs should be placed about Q. Jason’s father says to you, “We never realized plants
3 feet away from walls in older homes to reduce the risk could be poisonous to our children. Which ones
of children’s picking at loose wallpaper when they first should we be aware of?”
wake in the morning or before they fall asleep at night A. Several common plants can lead to poisoning in chil-
(plaster, which contains lead, clings to the wallpaper). dren. Here are some and the symptoms they produce:
All children with elevated lead levels need careful fol- English ivy: Nausea, vomiting, excess salivation, diar-
low-up care to determine the seriousness of their con- rhea, abdominal pain
dition and to ensure that they are kept from a lead Holly (berries): Vomiting, diarrhea, abdominal pain
source. Because children who recover from sympto- Hydrangea: Nausea, vomiting, muscular weakness,
matic lead poisoning have a high incidence of perma- seizures, dyspnea
nent neurologic damage, all children with elevated Lily of the valley: Vomiting, abdominal pain, diarrhea,
blood lead levels need appropriate follow-up care to cardiac disturbances
evaluate development and intelligence (CDC, 2008b). Mistletoe: Vomiting, diarrhea, bradycardia
Morning glory (seeds): Nausea, diarrhea, hallucinations
Philodendron: Swelling of the tongue, lips, irritation
Pesticide Poisoning of mouth
Poinsettia: Nausea, vomiting
Pesticide poisoning can occur by accidental ingestion or Rhododendron: Nausea, vomiting, abdominal pain,
through skin or respiratory tract contact when children play in seizures, limb paralysis
an area that has recently been sprayed. Long-term exposure may Rhubarb (leaves): Irritant action on gastrointestinal tract
result from exposure to a parent’s clothing if the parent comes
home covered with pesticide spray. Although pesticide poison-
ing was once thought to be only a rural problem, the increase
in the use of lawn sprays by commercial lawn care companies overdose or a “bad trip” caused by an unusual reaction or the
now makes this a suburban problem as well (Olson, 2009). effect of an unfortunate combination of drugs. Typical drugs
Many pesticides have an organophosphate base that causes involved include codeine and antidepressant drugs.
acetylcholine to accumulate at neuromuscular junctions; this Frequently, the drugs taken were prescription drugs removed
accumulation leads to muscle paralysis. Within a few minutes from the family medicine cabinet (Schiesser, 2007).
to 2 hours after exposure, children develop nausea and vomit- Children are often extremely disoriented after this form of
ing, diarrhea, excessive salivation, weakness of respiratory mus- ingestion. They may be having hallucinations. Obtaining a
cles, confusion, depressed reflexes, and possibly seizures. history may be difficult because children may have no idea
In the emergency department, activated charcoal may be what they took except that it was a red or a yellow capsule.
administered if the pesticide was swallowed. If clothing is They may know but may be reluctant to name a drug if it
contaminated, remove it and wash the child’s skin and hair. was obtained illegally.
To prevent coming in contact with the pesticide yourself,
wear gloves while bathing the child. Assessment
Intravenous atropine and a cholinesterase reactivator,
pralidoxime (Protopam Chloride) are effective antidotes to Although a child may not appear to hear well or may not
reverse symptoms. If parents apply a pesticide to children to seem coherent, try to elicit a history. Avoid shouting or ag-
help avoid mosquito bites to reduce exposure to West Nile gravating, because children who are having a paranoid reac-
virus infection or tick bites to reduce exposure to Lyme dis- tion will be unable to cope rationally with this approach. If
ease, diethyltoluamide (DEET)-based pesticides appear to be friends accompany an ill child, point out that your role is not
safe if used sparingly, not applied to a child’s face, and that of a law enforcer. Your role is to help the child, and you
washed off when the child returns indoors (AAP, 2008). cannot do that effectively unless the drug is identified.
Approaching a child’s friends in this way is more likely to re-
sult in their naming the drug. If a child is brought in by par-
Plant Poisoning ents who have no idea what drug could possibly have been
Plant poisoning (ingestion of a growing plant) occurs because taken, ask them to have someone at home check the child’s
parents commonly do not think of plants as being poisonous bedroom for drugs or what could be missing from the medi-
(Froberg, Ibrahim, & Furbee, 2007). Common plants to cine cabinet (provided the child became ill while at home).
which children may be exposed and the effects of ingestion Expect to obtain blood specimens for electrolyte levels and
are shown in Box 52.8. Parents should phone their poison a toxicology screen. If the child is vomiting, save any vomitus
control center for specific emergency steps. for analysis. Try to determine whether the ingestion was an ac-
cident (perhaps the child was unaware that two drugs would
Poisoning by Drugs of Abuse react this way or took a wrong dose) or whether the child was
actually attempting suicide. All poisonings or drug ingestions
Adolescents and even grade-school children are brought to in children older than 7 years of age should be considered po-
health care facilities by parents or friends because of a drug tential suicides until established otherwise. If the ingestion was
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1564 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

an accident, the child will need counseling to avoid drug use forced into the middle ear, possibly introducing infection
or about which drugs do not mix. If the incident was an at- (otitis media).
tempted suicide, the child will need observation and counsel- Often, it is better to wait for an otolaryngologist to care
ing toward more effective coping mechanisms in self-care. for the child, because trauma to the ear canal during an at-
tempt to remove a foreign body will increase the edema and
Therapeutic Management make removal even more difficult.
Children need supportive measures for their specific symp- Foreign Bodies in the Nose
toms, including oxygen administration, electrolyte replace-
ment (particularly if there is accompanying nausea and vom- Foreign objects stuffed into the nose eventually cause in-
iting), and perhaps IV fluid administration in an attempt to flammation and purulent discharge from the nares. The odor
dilute the drug. accompanying such impaction is often the first sign noticed
Children who have swallowed a drug of abuse need im- by a parent. Objects pushed into the nose usually can be re-
mediate treatment followed by investigation into the events moved with forceps. A local antibiotic might be necessary
leading to the poisoning. This potentially lethal ingestion after removal if ulceration resulted from the local irritation.
may act as a turning point in the child’s life, possibly alerting
the child and family to a drug problem and the need for help. Foreign Bodies in the Esophagus or Stomach
Factors such as reduction of fear and anxiety, increased cop-
ing mechanisms, knowledge of the effects of drug use, and Children tend not to chew food well or to swallow portions
availability of referral sources for a drug problem are impor- that are too big to pass safely through the esophagus. Pieces
tant areas to address. (See Chapter 33 for more information of candy, such as Lifesavers, are common objects caught in
related to adolescents and drug use.) the esophagus in young children; coins may be swallowed by
adolescents playing drinking games. Orthodontic appliances
may become dislodged and swallowed. Intense pain at the
✔Checkpoint Question 52.2 site where the object is lodged will result. If it is an object
Suppose Jason’s older brother had lead poisoning. What is that will dissolve, such as a Lifesaver or a piece of digestible
the most common source of lead poisoning in young children? meat, offer the child fluid to drink to help flush the object
a. Smelling lead fumes from cooking utensils. into the stomach. Even after the object dissolves or passes
b. Chewing on batteries that fall out of toys. into the stomach, the child will feel transient pain at the orig-
c. Drinking lead-contaminated drinking water. inal site of the obstruction.
d. Chewing on chips of lead-based outdoor paint. Magnets, particularly those in watches or hearing aids, are
also frequently swallowed by young children. These need to
be removed by endoscopy as soon as possible as they can lead
to bowel perforation or volvulus (Schierling et al., (2008).
Objects, such as a part of a toy or a chicken bone, that will
FOREIGN BODY OBSTRUCTION not dissolve and should not be passed, are also removed by
endoscopy (Weissberg & Refaely, 2007).
Foreign bodies can become lodged in children’s esophagus,
Small coins, such as pennies and dimes, usually pass by
ear canals, or noses, causing stasis of secretions and infection.
themselves without difficulty. Parents (or children them-
Direct obstruction or laceration of the mucous membrane
selves if adolescents) should observe stools over the next sev-
may also result, leading to serious consequences.
eral days to determine that the coin does pass through the GI
Whether a foreign substance is inhaled or embedded else-
tract (about 48 hours after ingestion). Without frightening
where, nursing interventions should focus first on comfort-
them, caution parents to observe for signs of bowel perfora-
ing the child and aiding in removal of the substance, and
tion or obstruction, such as vomiting or abdominal pain,
then on teaching the child and parents ways to avoid such oc-
until the object has passed. If there is any doubt, a radiograph
currences in the future.
taken 3 to 7 days after ingestion will establish whether the
object has been evacuated from the body.
Foreign Bodies in the Ear
Any child with a history of draining exudate from the ear Subcutaneous Objects
canal needs an otoscopic examination to establish the reason Children receive many wood splinters in the hands and feet.
for the drainage. In toddlers and preschoolers, the drainage These usually are removed easily by a probing needle and
often is the result of a foreign body in the ear canal. The ob- tweezers after cleaning with an antiseptic solution. If the pen-
ject might be a small piece of a toy, a piece of paper, a small etrating object is metal, such as a sewing needle or nail, its
battery, or food, such as a peanut (Singh et al., 2007). presence can be detected by radiography. If the object is one
Removal of a foreign body from the ear is difficult because that would have been in contact with soil, such as a rusty
children are afraid that the instrument used will hurt them, nail, the child will need tetanus prophylaxis after extraction
so they have difficulty lying still for the procedure. If there is of the object if tetanus immunization is not current.
reason to think that the tympanic membrane is intact, irri-
gating the object from the ear canal with a syringe and nor- What if... You received a call from your neighbor stating
mal saline may be possible. This should not be done if the that her 2-year-old son has swallowed a penny? What in-
object is a substance that will swell when wet, such as a
terventions would you expect to be necessary? What
peanut. If it is possible that the tympanic membrane is rup-
signs and symptoms would suggest GI obstruction?
tured, the ear canal must not be irrigated or fluid will be
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1565

BITES available, they should be used at the site where the bite oc-
curred. Excising the bite with a knife and sucking out the
Children receive bites from snakes and animals such as dogs venom orally (often shown in old western movies) is of ques-
or raccoons; they occasionally receive bites from other chil- tionable value and contradicts rules of standard infection pre-
dren. The source of a bite needs to be documented as human cautions. If the person administering the treatment has open
bites can also result from sexual abuse. mouth lesions, such as carious teeth, the procedure could be
dangerous to that person (venom is not dangerous when
Mammalian Bites swallowed, only when absorbed through open lesions).
Excising the bite also may lead to secondary infection and, if
Dog bites account for approximately 90% of all bites in- done too vigorously, may injure tendon or muscle. No time
flicted on humans, and children and adolescents are involved should be wasted before the child is transported to a health
in one third to one half of reported incidents. The dog is usu- care facility for treatment.
ally one owned by the child’s family. Cat bites, wild animal
bites, and human bites also constitute a threat, although they Emergency Management at the Health Facility
are less common in children. All of these bites can cause abra-
sions, puncture wounds, lacerations, and crushing injuries re- In the emergency facility, ask the child or a person who was
lated to the size of the animal and the location of the bite with the child to describe the snake. In areas where snakebites
(Jacobs, Guglielmo, & Chin-Hong, 2009). The biggest con- are frequent, keep available photographs of the venomous
cerns associated with animal bites are the possibility of long- snakes commonly found. Even a preschooler may be able to
term scarring and disfigurement and the possibility of infec- identify the snake by pointing to a photograph. Specific an-
tion, especially rabies, from the presence of microorganisms tivenin is then administered. Because rattlesnakes, copper-
in the animal’s mouth. This latter subject is discussed in heads, and cottonmouth moccasins are all one type of snake
Chapter 43. (pit vipers), one form of antivenin acts against all of these
bites. Specific antivenin is prepared for coral snake or cobra
Snakebite bites and is kept at most zoos. If the child receives antivenin
promptly after a bite, the prognosis for full recovery is good.
In the United States, snakebites tend to occur during the Tetanus prophylaxis is instituted if the child’s immunization
warm months of the year, from April to October. Most fatal status is unknown or if it has been more than 10 years since a
snakebites (envenomations) in the United States are copper- tetanus immunization was given.
head or rattlesnake bites. Copperheads are found in eastern Antivenin may contain a horse-serum base. Therefore,
and southern states, and rattlesnakes in almost every state. A before the serum is injected IM or IV, a skin test may need
few bites occur from cottonmouth moccasins or coral snakes to be performed to prevent a possible anaphylactic reaction
(both found in southeastern states). The effect of the bite of to the horse serum. If the serum is given IM, do not inject
a rattlesnake, copperhead, or cottonmouth moccasin (all pit it into an edematous body part, because medication ab-
vipers) is a failure of the blood coagulation system (Clark, sorption will be poor. Giving antivenin in the limb oppo-
2007). Coral snakes are known for the small coral, yellow, site the bitten limb is just as effective as administering it
and black rings encircling their body. Fortunately, they are into the bitten limb.
shy and seldom bite. However, the venom injected through
the bite of these snakes leads to neuromuscular paralysis.

Assessment Nursing Diagnoses and Related

Interventions
Reaction to a pit viper bite is almost immediate. A white
wheal forms at the site, showing the puncture marks, accom- ✽
panied by excruciating pain at the site. Purplish erythema Nursing Diagnosis: Fear related to seriousness of
and edema begin to extend rapidly from the site. child’s condition
By the time a child is seen at a health care facility, san- Outcome Evaluation: Parents and child state that they
guineous fluid may be oozing from the bite. Systemic symp- are able to cope with the degree of fear present.
toms, such as dizziness, vomiting, perspiration, and weak- Children with snakebites are extremely frightened.
ness, may be present. Because snake venom interferes with Their parents who have seen old western movies
blood coagulation, the child may have hematemesis or bleed- showing the agony of snakebite also are thoroughly
ing from the nose, intestines, or bladder because of subcuta- frightened. Children need a great deal of support from
neous or internal hemorrhage. The pupils may be dilated, health care personnel, because their parents may be
showing the potent effect on cerebral centers. If the enveno- too frightened to offer adequate support.
mation is not treated, seizures, coma, and death may result. As a final care measure, teach children safety rules
for avoiding snakebites:
Emergency Management at the Scene
• Look for snakes before stepping into underbrush.
At the scene of a snakebite, apply a cold compress to the bite, • Do not lift up rocks without looking at what could be
in the hope of slowing the spread of the venom and to reduce under them.
edema formation. Urge the child to lie quietly, to slow cir- • Listen for the telltale sound of a rattlesnake.
culation. Keep the bitten extremity dependent, again to slow • Be aware that snakes sun on warm rocks.
venous circulation. Commercial snakebite kits have rubber • Know the markings of poisonous snakes.
suction cups in them for suctioning out venom. If these are
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1566 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

THERMAL INJURIES injured register their anoxic state. Children need an

analgesic for pain, such as IV morphine. Morphine
Thermal injuries include those caused by either cold (frost- administered epidurally can be used for pain relief in
bite) or by excessive heat (burns). lower body areas.
During the next few days after severe frostbite,
Frostbite necrosis of destroyed tissue occurs, and the affected
tissue sloughs away. Apply dressings as necessary to
Frostbite is tissue injury caused by freezing cold (Stallard, avoid secondary bacterial contamination of a necrotic
2008). Cold exposure leads to peripheral vasoconstriction, injury site. Assess body temperature conscientiously
cutting off the oxygen supply to surrounding cells. In chil- to detect early symptoms of infection at the site.
dren, the body parts involved usually are the nose, fingers, or
toes. Cells at the site can be so injured that they die.

Assessment Burns
The affected body part appears white or erythematous; Burns are injuries to body tissue caused by excessive heat (heat
edema is present and it feels numb. Degrees of frostbite are greater than 104° F [40° C]). Such injuries commonly occur
summarized in Table 52.4. Explore the cause of frostbite by in children of all ages after infancy. They are the second great-
careful history taking. It occurs most frequently in children est cause of unintentional injury in children 1 to 4 years of age
who have been skiing, snowmobiling, or snowboarding for and the third greatest cause in children age 5 to 14 years.
long periods. If parents failed to provide adequate clothing Toddlers are often burned by pulling pans of scalding water or
because they underestimated the degree of cold outside, the grease off the stove and onto themselves or from bath water
possibility of neglect or child abuse must be ruled out as a that is too hot (Leahy et al., 2007). They can bite into electri-
cause. Frostbite also can occur from sucking on popsicles and cal cords. Older children are more apt to suffer burns from
from inhalant abuse. flames when they move too close to a campfire, heater, or fire-
place; touch a hot curling iron; or play with matches or lighted
Therapeutic Management candles. Eye burns can occur from splashed chemicals in sci-
ence classes (Pavan-Langston & Hamrah, 2008). Some burns
Always warm frostbitten areas gradually. Sudden warming in- (particularly scalding) can be caused by child abuse (Hicks &
creases the metabolic rate of cells; without adequate blood flow Stolfi, 2007). Burn injuries tend to be more serious in children
to the area because of still-present vasoconstriction, additional than in adults, because the same size burn covers a larger sur-
damage can occur. Administration of a vasodilator and use of face of a child’s body. As many as 50% of burns could be pre-
hyperbaric oxygen may help reduce the effect on body cells. vented with improved parent and child education.

Assessment
Nursing Diagnoses and Related When children are brought to a health care facility with a
Interventions burn injury, the first questions must be, “Where is the burn
✽ and what is its extent and depth?” Burns are classified ac-
Nursing Diagnosis: Pain related to frostbite damage cording to the criteria of the American Burn Association as
to cells major, moderate, or minor (Huether & McCance, 2007).
These classifications are shown in Table 52.5. Along with the
Outcome Evaluation: Child states that pain is con-
trolled at a tolerable level.
As soon as warming begins, the frostbitten area be-
comes extremely painful because the cells that are TABLE 52.5 ✽ Classification of Burns

Classification Description
Minor First-degree burn or second-
TABLE 52.4 ✽ Degrees of Frostbite degree burn ⬍10% of body
surface or third-degree burn
Degree Description ⬍2% of body surface; no area
of the face, feet, hands, or
First Mild freezing of epidermis; appears genitalia burned
erythematous with edema Moderate Second-degree burn between
Second Partial- or full-thickness injury; appears 10% to 20% or on the face,
erythematous with blisters and pain hands, feet, or genitalia or
occurring after rewarming third-degree burn ⬍10% of
Third Full-thickness injury (epidermis, dermis, body surface or if smoke
and subcutaneous tissue); appears inhalation has occurred
white Severe Second-degree burn ⬎20% of
Fourth Complete necrosis with gangrene and body surface or third-degree
possible ultimate loss of body part burn ⬎10% of body surface
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1567

size and depth, be certain to assess and document the loca- and is misleading in the very young child. Data for deter-
tion of the burn. Face and throat burns are particularly haz- mining the extent of burns in children are shown in Figure
ardous because there may be accompanying but unseen 52.7. Computer analysis is now available to rapidly assess the
burns in the respiratory tract. Resulting edema could lead to extent of burns.
respiratory tract obstruction. Hand burns are also hazardous
because, if the fingers and thumb are not positioned properly Depth of Burn. When estimating the depth of a burn, use
during healing, adhesions will inhibit full range of motion in the appearance of the burn and the sensitivity of the area to
the future. Burns of the feet and genitalia carry a high risk for pain as criteria. Descriptions of tissue at various burn depths
secondary infection. Genital burns are also hazardous be- are shown in Table 52.6 and are illustrated in Figure 52.8.
cause edema of the urinary meatus may prevent a child from Partial-thickness burns include first- and second-degree
voiding. burns. A first-degree burn involves only the superficial epi-
With adults, the “rule of nines” is a quick method of esti- dermis. The area appears erythematous. It is painful to touch
mating the extent of a burn. For example, each upper ex- and blanches on pressure (Fig. 52.9A). Scalds and sunburn
tremity represents 9% of the total body surface; each lower are examples of first-degree burns. Such burns heal by simple
extremity represents two 9s, or 18%, and the head and neck regeneration and take only 1 to 10 days to heal.
represent 9%. Because the body proportions of children are A second-degree burn involves the entire epidermis. Sweat
different from those of adults, this rule does not always apply glands and hair follicles are left intact. The area appears very

Infant
Anterior A A Posterior

1 1.25
1.25 1

1.5 1.5
2 2 2
2 1.5
13 1.25 13
1.5

1.25
B B
1 2.5 2.5
B
C B
C
C C
1.75 1.75
1.75 1.75

AREA BIRTH AGE 1 YR AGE 5 YR

A = 1/2 of head 9 1/2 8 1/2 6 1/2
B = 1/2 of one thigh 2 3/4 3 1/4 4
C = 1/2 of one leg 2 1/2 2 1/2 2 3/4

A 5-9 year-old A

1 1

2 13 2
2 13 2

1.5 1.5
1.5 1.5
1 2.5 2.5 1.25
1.25 1.25 1.25

B B
B B

C C C C

1.75 1.75 1.75 1.75

AREA AGE 10 YR AGE 15 YR ADULT

A = 1/2 of head 5 1/2 4 1/2 3 1/2
B = 1/2 of one thigh 4 1/2 4 1/2 4 3/4
C = 1/2 of one leg 3 3 1/4 3 1/2
FIGURE 52.7 Determination of extent of
burns in children.
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TABLE 52.6 ✽ Characteristics of Burns

Severity Depth of Tissue Involved Appearance Example

First degree Epidermis Erythematous, dry, painful Sunburn
(partial thickness)
Second degree Epidermis Blistered, erythematous to white Scalds
(partial thickness) Portion of dermis
Third degree Entire skin, including nerves Leathery; black or white; not sensitive Flame
(full thickness) and blood vessels in skin to pain (nerve endings destroyed)

Depths of burns Skin grafts

Epidermis
Superficial
(1st degree)
Split
Partial thickness
thickness
(2nd degree)
Full
thickness

Full
thickness
(3rd degree)
Dermis

Subcutaneous
tissue

FIGURE 52.8 Depths of burns.

A B
FIGURE 52.9 Partial-thickness burns. (A) An infant with a first-degree burn on the arm and chest caused by scalding with hot
water. (B) A toddler with a second-degree burn caused by scalding. The area appears severely reddened and moist with some
blistering. (A, © Dr. P. Marazzi/SPL/Science Source/Photo Researchers. B, © NMSB/Custom Medical Stock Photograph.)
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1569

Emergency Management of Burns

All burns need immediate care because of the pain involved
(Rieman, Gordon, & Marvin, 2007).
Minor Burns. Although minor burns (typically first-degree
partial-thickness burns) are the simplest type of burn, they
involve pain and death of skin cells, so they must be treated
seriously. Immediately apply ice to cool the skin and prevent
further burning. Application of an analgesic–antibiotic oint-
ment and a gauze bandage to prevent infection is usually the
only additional treatment required. The child should have a
follow-up visit in 2 days to have the area inspected for a
secondary infection and to have the dressing changed.
Caution parents to keep the dressing dry (no swimming or
getting the area wet while bathing for 1 week). A first-degree
FIGURE 52.10 Full-thickness (third-degree) burn of the foot. burn heals in about that time.
Both layers of skin are involved with this type of burn. (© Dr.
Michael English/Custom Medical Stock Photograph.) Moderate Burns. Moderate or second-degree burns may
have blisters. Do not rupture them, because doing so invites
erythematous, blistered, and moist from exudate. It is ex- infection. The burn will be covered with a topical antibiotic
tremely painful. Scalds can cause second-degree burns (see such as silver sulfadiazine and a bulky dressing to prevent
Fig. 52.9B). Such burns heal by regeneration of tissue but damage to the denuded skin. The child usually is asked to re-
take 2 to 6 weeks to heal. turn in 24 hours to assess that pain control is adequate and
A third-degree burn is a full-thickness burn involving there are no signs and symptoms of infection. Broken blisters
both skin layers, epidermis and dermis. It may also involve may be débrided (cut away) to remove possible necrotic tis-
adipose tissue, fascia, muscle, and bone. The burn area ap- sue as the burn heals.
pears either white or black (Fig. 52.10). Flames are a com- Severe Burns. The child with a severe burn is critically in-
mon cause of third-degree burns. Because the nerves, sweat jured and needs swift, sure care, including fluid therapy, sys-
glands, and hair follicles have been burned, third-degree temic antibiotic therapy, pain management, and physical
burns are not painful. Such burns cannot heal by regenera- therapy, to survive the injury without a disability caused by
tion because the underlying layers of skin have been de- scarring, infection, or contracture.
stroyed. Skin grafting is usually necessary, and healing takes
months. Scar tissue will cover the final healed site. Many Electrical Burns of the Mouth. If a child puts the prongs of
burns are compound, involving first-, second-, and third- a plugged-in extension cord into the mouth or chews on an
degree burns. There may be a central white area that is in- electric cord, the mouth will be burned severely (Kidd et
sensitive to pain (third degree), surrounded by an area of al., 2007). Electrical current from the plug is conducted for
erythematous blisters (second degree), surrounded by an- a distance through the skin and underlying tissue, so a tis-
other area that is erythematous only (first degree). sue area much larger than where the prongs or cord actually
Undress children with burns completely so the entire touched is involved, leaving an angry-looking ulcer. If
body can be inspected. A first-degree burn is painful, whereas blood vessels were burned, active bleeding will be present.
a third-degree burn is not. Therefore, a child may be crying The immediate treatment for electrical burns of the mouth
from a superficial burn that is obvious on the arm, although is to unplug the electric cord and control bleeding. Pressure
the condition needing the most immediate attention is a applied to the site with gauze is usually effective. Most chil-
third-degree burn on the chest, which is covered by a jacket. dren are admitted to a hospital for at least 24 hours in an
Be certain to ask what caused the burn, because different observation unit because edema in the mouth can lead to
materials cause different degrees of burn. Hot water, for ex- airway obstruction.
ample, causes scalding, a generally lesser degree of burn than Supply adequate pain relief as long as necessary. Clean the
one caused by flaming clothing. Ask where the fire happened. wound about four times a day with an antiseptic solution, such
Fires in closed spaces are apt to cause more respiratory in- as half-strength hydrogen peroxide, or as otherwise ordered to
volvement than fires in open areas. reduce the possibility of infection (a real danger in this area,
Ask whether the child has any secondary health problem. because bacteria are always present in the mouth).
In their anxiety over the present burn, parents may forget to Eating will be a problem for the child because the mouth
report important facts, such as the child has diabetes or is al- is so sore. The child may be able to drink fluids from a cup
lergic to a common drug. After a fire, parents may pick up a best. Bland fluids, such as artificial fruit drinks or flat ginger
burned child and bring the child to a health care facility, ale, are best.
leaving other children unprotected at home. Ask about other Electrical burns of the mouth turn black as local tissue
children and where they are. Parents may have burned hands necrosis begins. They heal with white, fibrous scar tissue,
from putting out the fire on the child’s clothes and need possibly causing a deformity of the lip and cheeks with heal-
equal care, but in their anxiety about the child’s condition, ing. This can be minimized by the use of a mouth appliance,
they do not mention this. Ask who put out the fire. Were any which helps maintain lip contour. Some children have diffi-
other family members or animals hurt? Does anyone else culty with speech sounds because of resulting lip scarring.
need care? They need follow-up care by a plastic surgeon to restore their
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1570 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

lip contour. Obviously, you need to review with parents the tissue (Fig. 52.11). If the anterior throat is burned, for
importance of not leaving “live” electrical cords where young example, the head will be hyperextended to keep scar
children can reach them. tissue that forms on the anterior neck from pulling the
chin down against the chest in a contracture. It is diffi-
cult for children to watch television in this position or
Nursing Diagnoses and Related even to view activities on the unit so they need to be
encouraged to maintain this position. If they have
Interventions burns at extremity joints, they may have splints applied
✽ over burn dressings to maintain the joints in extension.
Nursing Diagnosis: Pain related to trauma to body cells Again, this makes activities very difficult and adds to
Outcome Evaluation: Child states that pain is at a tol- their stress if they do not have adequate pain relief.
erable level. Children who experience smoke inhalation may be
unconscious from brain anoxia immediately after a
Morphine sulfate is commonly the agent of choice. It
burn. Most children, however, are awake and very
can be administered IM, but, because circulation is
aware of the pain and treatments involved. Therefore,
impaired in children with shock, IV or epidural admin-
a priority need is immediate pain relief. After the first
istration is most effective. Use of patient-controlled
week following a major burn, some children develop
analgesia before performing any burn care such as
symptoms of delirium, seizures, and coma that result
débridement (the removal of necrotic tissue from a
from toxic breakdown of damaged cells, sensory de-
burned area) is also effective. Be sure to assess after
privation, isolation, and lack of sleep. Nursing care
administration that pain relief was adequate.
aimed at reducing unnecessary stimuli and providing
In addition to the pain from the burn, children may
adequate pain relief helps to prevent these late symp-
be required to remain in awkward positions to keep
toms from occurring.
joints overextended for most of every day. Doing so
helps to prevent formation of contractures from scar Nursing Diagnosis: Deficient fluid volume related to
fluid shifts from severe burn
Outcome Evaluation: Skin turgor remains good; hourly
urine output is greater than 1 mL/kg, with specific
gravity between 1.003 and 1.030; vital signs are within
acceptable parameters.
Immediately after a severe burn, the child’s circulatory
system becomes hypovolemic, because of a loss of
plasma, which oozes from blood vessels into the burn
site and then sequesters in edematous tissue sur-
rounding the site. This outpouring of plasma is caused
by an increased permeability of capillaries (or dam-
age to capillaries). It is most marked during the first
6 hours after a burn. It continues to some extent for the
first 24 hours.
A primary response of the myocardium to the shock
A of burn injury and hypovolemia can lead to a marked
reduction in cardiac output and decreased blood pres-
sure. Therefore, even with relatively minor burns, moni-
tor vital signs closely to allow early detection of this
event. A child may be severely anemic because of in-
jury to red blood cells caused by heat and loss of blood
at the wound site. The large amount of sodium lost with
the edematous burn fluid and the release of potassium
from damaged cells can lead to an immediate hypona-
tremia and hyperkalemia (Table 52.7).
Lactated Ringer’s solution is the commercially
available solution most compatible with extracellular
fluid. Usually, it is one of the first fluids begun for fluid
replacement, although normal saline may be used. A
FIGURE 52.11 (A) An adoles- child may also need plasma replacement and addi-
cent’s hand scarred from third- tional fluid, such as 5% dextrose in water. Do not
degree burns. Note the proper
administer potassium immediately after a burn until
extension and alignment of the
hand and fingers, which were kidney function is evaluated, to be certain that extra
maintained by the use of splints potassium can be eliminated. IV fluid is usually ad-
(B) during healing. (A, © Dr. P. ministered by the most convenient venous access, so
Marazzi/SPL/Science that morphine sulfate can be administered to relieve
B Source/Photo Researchers.) pain. A more stable fluid line may then be inserted.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1571

pulse, blood pressure, and central venous pressure

TABLE 52.7 ✽ Fluid Shifts After Burn Injury hourly until the child passes the immediate danger of
shock (at least 24 hours). Another important period
Fluid Shifts in Remobilization of Fluid occurs at 48 hours after the injury, when fluid is re-
First 24 Hours After 48 Hours turning to the bloodstream. Remember that gradual
but persistent changes in blood pressure may be as
Burn Edematous tissue surround-
informative as sudden changes.
ing burn area
↓ ↓
A complete blood cell count, blood typing and
Increased capillary Intravascular compartment cross-matching, electrolyte and BUN determinations,
permeability and blood gas studies to ascertain blood levels of
↓ ↓ oxygen and carbon dioxide are important to obtain.
Hypoproteinemia Nursing Diagnosis: Risk for ineffective breathing pat-
Hyponatremia Hypervolemia
terns related to respiratory edema from burn injury
Hyperkalemia Hypernatremia
Hypovolemia Hypokalemia Outcome Evaluation: Child’s respiratory rate remains
within 16 to 20 breaths/minute; lung auscultation re-
veals no rales.
If a child inhaled smoke from a fire, the injury from the
smoke inhalation can be more serious than the skin
The amount of fluid necessary is calculated carefully, surface burns. Smoke coming from a fire is at the tem-
based on predicted insensible fluid loss and loss be- perature of the fire. Inhaling smoke, therefore, is the
cause of the burn. The Parkland formula is commonly same as exposing the upper respiratory tract to open
used to calculate the amount of fluid needed for the flame. In addition, toxic substances and soot given off
first 24 hours: 4 mL/kg body weight for each 1% of by the fire cause even more irritation to the respiratory
body surface area burned. tract. If carbon monoxide is inhaled with the smoke, it
This fluid is administered rapidly for the first 8 hours enters red blood cells in place of oxygen, shutting off
(half of the 24-hour load), then more slowly for the next the oxygen supply to body cells. If this is extensive, it
16 hours (the second half). It is important that admin- can lead to loss of consciousness because of cere-
istration be continued beyond the time of increased bral anoxia. If the trachea is burned, edema fluid will
capillary permeability (at least the first 24 hours). The pass into the injured bronchioles and trachea, caus-
administration site, therefore, must be protected to ing pulmonary edema or obstruction limiting air inflow.
prevent infiltration. A central venous pressure or pul- This can lead to dyspnea and stridor. About 1 week
monary artery catheter may be inserted to determine after the smoke inhalation, the child is at risk for the
hemodynamic and fluid volume status and evaluate development of pneumonia because of denuded tra-
that the child is receiving adequate fluid. cheal and bronchial tract areas. The fact that inhala-
About 48 hours after the burn, as inflammation de- tion of smoke or flame from a fire can be more serious
creases, the extracellular fluid at the burn site begins than the skin burns the child suffers may be difficult
to be reabsorbed into the bloodstream. Edema begins for parents to understand. They are relieved if they
to subside; the child has diuresis and loses weight. learn that the child has suffered only smoke inhalation.
The heart rate increases because of temporary hyper- They may need an explanation of the physiologic con-
volemia. The hematocrit level is low because red sequences that can result from pulmonary injury.
blood cells are diluted. The child needs frequent eval- To help rule out smoke inhalation, obtain a history
uation of electrolyte levels to determine fluid balance to assess whether the fire occurred in a closed
during this period. Potassium supplements may be space, such as a garage. Assess for burns of the
necessary to maintain normal heart function, because, face, neck, or chest, which would indicate that the fire
although potassium was released into the serum from was near the nose and respiratory tract. Assess the
destroyed cells, it is rapidly excreted by the kidneys. quality of the child’s voice (it will be hoarse if the
If the child needs continued electrolyte replacement throat is irritated from smoke). Carefully monitor the
at this time, carefully monitor the rate of flow so the respiratory rate of all burned children, because respi-
blood volume does not exceed the child’s tolerance. If ratory rate increases with respiratory obstruction.
many red blood cells were destroyed at the burn site, A child also may become restless and thrash about
the child may need packed red blood cells to maintain because of lack of oxygen. Measurement of blood
an adequate hemoglobin level. gases will demonstrate the degree of hypoxia present
Nursing Diagnosis: Risk for ineffective tissue perfusion from carbon monoxide intoxication. Administration of
related to cardiovascular adjustments after burn injury 100% oxygen is the best therapy for displacing car-
bon monoxide and providing adequate oxygenation
Outcome Evaluation: Child’s vital signs stay within nor- to body cells. The child may need endotracheal intu-
mal limits; hourly urine output remains greater than bation or a tracheostomy with assisted ventilation to
1 mL/kg. ensure adequate oxygenation. Intubation is best, be-
Take height, weight, and vital signs on admission, and cause tracheostomies can lead to infection, and this
continue to take vital signs every 15 minutes until they child is at a much higher risk for pneumonia than the
are stable. Once vital signs are stabilized, record average child.
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Symptoms of smoke inhalation may not occur im- tic therapy to prevent aspiration of vomitus. The tube
mediately but only 8 to 24 hours after the burn. A chest must remain in place until bowel sounds are detected.
radiograph taken at this time will reveal collecting ede- This usually occurs within 24 hours but may take as
matous fluid and decreased aeration. Continue to as- long as 72 hours in severely burned children. Fluid suc-
sess the child’s temperature every 4 hours for the first tioned from an NG tube may be blood-tinged (coffee-
week after the injury, to assess that lung infection is not ground fluid) because of bleeding caused by stomach
developing. Bronchodilators and antibiotics may be vessel congestion. Closely observe this drainage for a
prescribed. High-frequency ventilation may be helpful change to fresh bleeding, which can be caused by a
to keep alveoli functioning. Some children need extra- stress ulcer (Curling’s ulcer). This type of ulcer can be
corporeal membrane oxygenation (ECMO) support prevented by administering a histamine-2 receptor an-
because smoke inhalation has compromised their lung tagonist, such as cimetidine (Tagamet) or a proton
function to such a great extent. pump inhibitor such as omeprazole (Prilosec) in an at-
Nursing Diagnosis: Risk for impaired urinary elimina- tempt to reduce gastric acidity and ulcer formation.
tion related to burn injury If a bleeding ulcer occurs, gastric lavage with iced
saline may be necessary. Blood for transfusion should
Outcome Evaluation: Child’s urine output is greater be readily available, because the blood loss from a GI
than 1 mL/kg of body weight per hour. ulcer can be rapid and severe.
Because the child’s blood volume decreases immedi- If a child has burns over more than 30% of the body
ately after a burn, renal function is threatened by kidney surface, paralytic ileus may occur. Symptoms of in-
ischemia just when it is needed to rid the body of break- testinal obstruction, such as vomiting, abdominal dis-
down products from burned cells. If the child is burned tention, and colicky pain, will appear within hours of
over more than 10% of body surface, urinary output the burn.
may decrease immediately. Blood volume must be Children with severe burns usually are allowed
maintained by IV fluid administration to establish good nothing by mouth for 24 hours because of the danger
urinary output once more. Urine output should be of vomiting or paralytic ileus. After this, most children
1 mL/kg of body weight per hour. The specific gravity are able to eat, so oral feedings are begun as soon as
of urine also should be monitored to determine whether possible. To supply adequate calories for increased
the kidneys can concentrate urine to conserve body metabolic needs and spare protein for repair of cells,
fluid (failing kidneys lose this ability rapidly). In the days the diet is high in calories and protein (25 kcal/kg
after the burn, because products of necrotic tissue and body weight plus 40 kcal for each percent of burn sur-
toxic substances must be evacuated by the kidneys face per 24 hours). Children may also need supple-
and antidiuretic hormone and aldosterone levels are in- mental vitamins (particularly B and C) and iron sup-
creased in response to low blood pressure, kidney plements (Moelleken, 2009). High-protein drinks may
function may fail again. If free hemoglobin from de- be necessary between meals to ensure an adequate
stroyed red blood cells plugs kidney tubules (acute protein intake (Faries & Battan, 2008).
tubular necrosis), urine color will be red to black be- Because adequate nutrition is important, it may be
cause of the hemoglobin present. necessary to supplement the child’s diet with IV or
An indwelling urinary (Foley) catheter should be in- parenteral nutrition solutions or NG tube feeding. As
serted in the emergency department, and an immedi- additional methods of stimulating interest in eating,
ate urine specimen should be obtained for analysis. A encourage school-age children to help add intake
diuretic, such as mannitol, may be administered to and output columns, help the dietitian add a calorie-
flush hemoglobin from the kidneys. If this is effective, count list, or keep track of their own daily weight
the urine returns to its usual straw color. Throughout (taken at the same time each day in the same cloth-
the child’s hospital stay, observing urinary output is a ing). It may be helpful to make contracts with older
major nursing responsibility. children for a good nutritional intake.
Nursing Diagnosis: Risk for imbalanced nutrition, less Nursing Diagnosis: Risk for injury related to effects of
than body requirements, related to burn injury burn, denuded skin surfaces, and lowered resistance
Outcome Evaluation: Child’s weight remains within to infection with burn injury
normal age-appropriate growth percentiles; skin tur- Outcome Evaluation: Child’s temperature remains at
gor remains normal; urine specific gravity remains be- 98.6° F (37° C); skin areas surrounding burned areas
tween 1.003 and 1.030. show no signs of erythema or warmth.
After burns, the metabolic rate increases in children There appears to be some defect in the ability of neu-
as the body begins to pool its resources to adjust to trophils to phagocytize bacteria after burn injury. The
the insult. If children do not receive enough calories in formation of immunoglobulin G antibodies also ap-
IV fluid, their body will begin to break down protein. parently fails. For these reasons, a child has reduced
This is particularly dangerous because a child needs protection against infection. Staphylococcus aureus
protein for burn healing. Additionally, breakdown of and group A ␤-hemolytic streptococci are the gram-
protein can lead to acidosis. positive organisms, and Pseudomonas aeruginosa is
After a severe burn, some children are nauseated the gram-negative organism, that commonly invade
from the systemic shock. An NG tube may be inserted burn tissue. Children are usually prescribed par-
and attached to low, intermittent suction as prophylac- enteral penicillin to prevent group A ␤-hemolytic
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1573

streptococcal infection and tetanus toxoid to prevent Netting is useful to hold dressings in place, because it expands
tetanus. In addition to bacteria, fungi also may invade easily and needs no additional tape.
burns. Candida species are the most frequently seen
(Madoff, 2008). Topical Therapy. Silver sulfadiazine (Silvadene) is the drug
Nose, throat, and wound cultures may be done im- of choice for burn therapy to limit infection at the burn site
mediately and then daily to detect offending organ- for children. It is applied as a paste to the burn, and the area
isms. Bacteria and fungi can penetrate the burn es- is then covered with a few layers of mesh gauze. Silver sulfa-
char readily, so this tissue offers little protection from diazine is an effective agent against both gram-negative and
infection. Fortunately, granulation tissue, which forms gram-positive organisms and even against secondary infec-
under the eschar 3 to 4 weeks after the burn, is resis- tious agents, such as Candida. It is soothing when applied
tant to microbial invasion. and tends to keep the burn eschar soft, making débridement
Systemic antibiotics are not very effective in con- easier. It does not penetrate the eschar well, which is its one
trolling burn-wound infection, probably because the drawback.
burned and constricted capillaries around the burn Antiseptic solutions, such as povidone-iodine (Betadine),
site cannot carry the antibiotic to the area. For this rea- may also be used to inhibit bacterial and fungal growth.
son, any equipment used with the child must be ster- Unfortunately, iodine stings as it is applied and stains skin and
ile, to avoid introducing infection. Children are placed clothing brown. Dressings must be kept continually wet to
on a sterile sheet on the examining table. Personnel keep them from clinging to and disrupting the healing tissue.
caring for the severely burned child should wear caps, If Pseudomonas is detected in cultures, nitrofurazone
masks, gowns, and gloves, even for emergency care. (Furacin) cream may be applied. If a topical cream is not ef-
Although their burns may be covered by gauze fective against invading organisms in the deeper tissue under
dressings, children usually are cared for in private the eschar, daily injections of specific antibiotics into the
rooms to help reduce the possibility of infection. deeper layers of the burned area may be necessary.
Helping children maintain their self-esteem and keep- If a burned area, such as the female genitalia, cannot be
ing them from withdrawing from social contacts can be readily dressed, the area can be left exposed. The danger of
difficult when infection control precautions are required. this method is the potential invasion of pathogens.
Escharotomy. An eschar is the tough, leathery scab that
Therapy for Burns forms over moderately or severely burned areas. Fluid accu-
mulates rapidly under eschars, putting pressure on underly-
Second- and third-degree burns may receive open treatment, ing blood vessels and nerves. If an extremity or the trunk has
leaving the burned area exposed to the air, or a closed treat- been burned so that both anterior and posterior surfaces have
ment, in which the burned area is covered with an antibacter- eschar formation, a tight band may form around the extrem-
ial cream and many layers of gauze. These two methods are ity or trunk, cutting off circulation to distal body portions.
compared in Table 52.8. A synthetic skin covering (Biobrane), Distal parts feel cool to the touch and appear pale. The child
artificial skin (Integra), or amniotic membrane from placentas notices tingling or numbness. Pulses are difficult to palpate,
can be used to help decrease infection and protect granulation and capillary refill is slow (longer than 5 seconds). To allevi-
tissue. As a rule, burn dressings are applied loosely for the first ate this problem, an escharotomy (cut into the eschar) is per-
24 hours to prevent interference with circulation as edema formed (Moelleken, 2009). Some bleeding will occur after
forms. Be certain not to allow two burned body surfaces, such escharotomy. Packing the wound and applying pressure usu-
as the sides of fingers or the back of the ears and the scalp, to ally relieves this.
touch, because, as healing takes place, a webbing will form
between these surfaces. Do not use adhesive tape to anchor Débridement. Débridement is the removal of necrotic tissue
dressings to the skin; it is painful to remove and can leave ex- from a burned area. Débridement reduces the possibility
coriated areas, which provide additional entry for infection. of infection, because it reduces the amount of dead tissue

TABLE 52.8 ✽ Comparing Open and Closed Burn Therapy

Method Description Advantages Disadvantages

Open Burn is exposed to air; used Allows frequent inspection of Requires strict isolation to
for superficial burns or site; allows child to follow prevent infection; area may
body parts that are prone healing process scrape and bleed easily and
to infection, such as impede healing
perineum
Closed Burn is covered with non- Provides better protection from Requires dressing changes that
adherent gauze; used for injury; is easier to turn and are painful; possibility of
moderate and severe burns position child; allows child infection may increase
more freedom to play because of dark, moist
environment
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1574 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

present on which microorganisms could thrive. Children

usually have 20 minutes of hydrotherapy before débridement
to soften and loosen eschar, which then can be gently re-
moved with forceps and scissors. Débridement is painful,
and some bleeding occurs with it. Premedicate the child with
a prescribed analgesic, and help the child use a distraction
technique during the procedure to reduce the level of pain.
Transcutaneous electrical nerve stimulation (TENS) therapy
or patient-controlled analgesia may also be helpful. Praise
any degree of cooperation. Plan an enjoyable activity after-
ward to aid in pain relief and also to help re-establish some
sense of control over the situation.
Children need to have a “helping” person with them, to
hold their hand, to stroke their head, and to offer some ver-
bal comfort during débridement: “It’s all right to cry; we
know that hurts. We don’t like to do this, but it’s one of the
things that makes burns heal” (Fig. 52.12). Nursing person-
nel need a great deal of talk time to voice their feelings about
assisting with or doing débridement procedures. Be careful
when serving as the “helping” person that you do not project
yourself as the healer and comforter and a fellow nurse as the
hurter or “bad guy.” It helps if people alternate this chore so
that, on alternate days, each serves as the protector or the
comforter.
If eschar tissue is débrided in this manner day after day, FIGURE 52.13 Mesh grafting is necessary to cover large
granulation tissue forms underneath. When a full bed of areas of the body such as in this young child with third-degree
granulation tissue is present (about 2 weeks after the injury), burns. (© CC Studio/SPL/Photo Researchers Inc.)
the area is ready for skin grafting. In some burn centers, this
waiting period is avoided by immediate surgical excision of
eschar and placement of skin grafts. Another trend in
débridement is the use of collagenase (Santyl), an enzyme porcine (pig) skin, may be used. Autografting is a process in
that dissolves devitalized tissue. which a layer of skin of both epidermis and a part of the der-
mis (called a split-thickness graft) is removed from a distal, un-
Grafting. Homografting (also called allografting) is the burned portion of the child’s body and placed at the prepared
placement of skin (sterilized and frozen) from cadavers or a burn site, where it will grow and replace the burned skin
donor on the cleaned burn site. These grafts do not grow but (Robinson, 2008). Cultured epithelium is derived from a full-
provide a protective covering for the area. In small children, thickness skin biopsy. This can be grown into a coherent sheet
heterografts (also called xenografts) from other sources, such as and supply an unlimited source for autografts. Larger areas
may require mesh grafts (a strip of partial-thickness skin that is
slit at intervals so that it can be stretched to cover a larger area;
Fig. 52.13). The advantage of grafting is that it reduces fluid
and electrolyte loss, pain, and the chance of infection.
After the grafting procedure, the area is covered by a bulky
dressing. So that the growth of the newly adhering cells will
not be disrupted, this should not be removed or changed. The
donor site on the child’s body (often the anterior thigh or but-
tocks) is also covered by a gauze dressing. Both donor and
graft dressings should be observed for fluid drainage and odor.
Observe the child to determine whether there is pain at either
site, which might indicate infection. Monitor the child’s tem-
perature every 4 hours. A rise in systemic temperature may be
the first indication that there is infection at the graft or donor
site. Autograft sites can be reused every 7 to 10 days, so any
one site can provide a great deal of skin for grafting.

Nursing Diagnoses and Related

Interventions
✽
FIGURE 52.12 A nurse provides comfort and support to a Nursing Diagnosis: Social isolation related to infection
child before débridement. (© Kathy Sloane/Science control precautions necessary to control spread of
Source/Photo Researchers.) microorganisms
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1575

Outcome Evaluation: Child states that he understands home and possessions to fire. They may need help in
the reason for infection control precautions; child ac- establishing priorities. It may be important that they
cepts it as a necessary part of therapy. wait at home one morning for an insurance inspector to
Infection control measures involved in the care of chil- make an estimate on damage to their house or furni-
dren with major burns consist of more than just plac- ture caused by the fire. Other tasks, such as shopping
ing the child in a private room. Aseptic technique and or house cleaning, could possibly be done by relatives
appropriate barriers are necessary to reduce the risk or neighbors, leaving them time to visit their child.
of exposing the child to infection. In some agencies, Nursing Diagnosis: Deficient diversional activity re-
all the people who come into the room must wear lated to restricted mobility after severe burn
gowns, masks, caps, and sterile gloves. The child is
Outcome Evaluation: Child expresses interest in obtain-
doubly isolated—by distance and by never being
ing school homework; child communicates with friends
touched directly.
and relatives by way of telephone, letters, or e-mail.
It is easy for children with burns (who were told
measures such as not to play with matches or go too Remember that, even if a child’s chest, abdomen, and
close to the fireplace) to interpret confinement in a hands are burned, he does not stop thinking so chil-
room as punishment. Make every effort to make the dren who are burned need stimulation in their envi-
child’s environment as warm and comforting as possi- ronment. A television set is good for passing time but
ble, despite infection control procedures. Place chil- should not be the child’s main communication with the
dren’s beds so they can see as much unit activity as outside world. Listening to favorite tapes, having sto-
possible. Decorate walls in front of them with cards ries read to them, talking about what is going on at
they receive or with a changing gallery of pictures home or what they normally do at school, and doing
drawn by staff members of things in which the child schoolwork are also important.
appears interested. It is important to make toys and play materials
Provide time for children to discuss their feelings available. Make certain to visit the child just to talk to
about being kept in a room by themselves. A question him or come to play a game at times other than pro-
such as, “It’s hard to understand a lot of things about cedure or treatment times. The child may be hospital-
a hospital; do you understand why your bed is in this ized for a long time. He needs to view the nursing staff
special room?” gives children a chance to express as friends and caregivers. Frequent visits convey that
their feelings. he is not alone and that others are aware of important
Show parents how to put on gowns, gloves, and needs.
masks (depending on agency policy), so they can Nursing Diagnosis: Disturbed body image related to
participate in the child’s care as much as possible. changes in physical appearance with burn injury
Parents often do not ask to do these things sponta-
neously when their children are severely burned. They Outcome Evaluation: Child expresses fears about
are in a state of grief, so they do not react in a normal physical appearance; demonstrates desire to resume
manner. They may believe the bulky dressings will age-appropriate activities.
make it impossible for them to hold the child. Actually, Children with burns are often forced to become ex-
the closed bulky dressings on the burned area make tremely dependent on the nursing staff because of the
it possible for the child to be held. If it is not possible position in which they must lie and because the bulky
for the child to be held, help the parents to see that dressings that cover their arms or hands prevent them
stroking their child’s face or touching a hand (even from feeding themselves. They respond to this forced
with gloves in place) gives the child a feeling of still dependence at first with gratitude. They are hurt, and
being loved. someone is taking care of them. After a period, how-
Nursing Diagnosis: Interrupted family processes re- ever, their response may become less healthy. The
lated to the effects of severe burns in family member young school-age child or preschooler may revert to
bedwetting or baby talk. Older children respond by
Outcome Evaluation: Family members state that they becoming openly aggressive to counteract their feel-
are able to cope effectively with the degree of stress ings of helplessness. They attempt to re-establish in-
to which they are subjected; family demonstrates pos- dependence in the ways that they can, often by refus-
itive coping mechanisms. ing to eat or to lie in a position that is best for them.
Children with severe burns always have a difficult hos- Make certain to allow independent decision-making
pitalization because of the pain, restrictions, and (at whenever possible. Children must take their 10 o’clock
some point) awareness of the disfigurement that ac- medicine, for example, but they can choose the fluid
companies major burns. they want to swallow after it. They must be fed meals
Some parents grieve so deeply over the child’s con- because of the bulky dressings over their hands, but
dition or are so concerned with other upsetting factors they can decide which food they will eat first. They
in their lives (many burns happen because of situa- must have their dressings changed, but they can
tional crises in the family) that their interaction with the choose the story you will read them afterward.
child seems to falter or proves very difficult for them. Be careful not to give choices when there really are
They may avoid visiting because the sound of the none to give. Inappropriate questions include, “Can I
child’s crying when they leave is more than they can change your dressing now?” “Do you want dinner
endure. At the same time, they may have lost their now?” “Will you swallow this pill?”
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1576 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

Immediately after a severe burn, children (if they parents’ biggest concern. A father who dreamed that
are old enough to understand), parents, and proba- his son would be a great track star may be most con-
bly the hospital staff are most concerned with cerned about a leg scar; the child may be most con-
whether the child will live. After body systems have cerned about a facial burn.
stabilized and it seems appropriate to reassure the Children watch you as you care for them to see if
parents that their child will live, thoughts turn to the you find them unattractive. As dressings are removed,
child’s cosmetic appearance. At first, it is easy for children may expose parts of their body seemingly in-
children and parents to ignore this problem, be- appropriately, to see if you are shocked or revolted by
cause the burned areas are covered by dressings. them. It is easy to think that you will not react this way,
Even when the dressings are removed for débride- but, for everyone, the first sight of a severe burn is
ment or whirlpool therapy, it is easy for children to a shock and it is difficult not to react accordingly.
assume that the appearance of the burned area is Imagining how children feel, realizing that this muti-
only temporary and that the area will eventually heal lated skin is their skin, helps health care providers
and have a good appearance. They have probably maintain a professional attitude.
never seen anyone with a scar from a second- or Returning to school can be difficult for children
third-degree burn and have no reason to worry who have been hospitalized or have been receiving
about it (Fig. 52.14). home care for a long time. Their old friends have
When children see others on the unit with burn new friends, so they may feel cut out of school ac-
scars, they begin to realize what healing will look like. tivities. They look different if they have burn scars.
Depending on the extent and the site of the burn, par- The appearance of scar formation can be improved
ents and children have varying degrees of difficulty by the application of pressure dressings that the
accepting this reality. It can cause them to lose confi- child wears 24 hours a day. If the child has facial
dence in health care personnel. burns, facing friends with a compression bandage
Parents and children need time to talk about their in place or returning for laser therapy to reduce burn
feelings. A girl may be extremely concerned if her scarring may be difficult. They need a great deal of
chest is burned because she is worried that breast tis- support from health care personnel to be able to en-
sue will not develop, a very real concern, depending dure this. Some children need referral for formal
on the extent of the burn (Foley et al., 2008). Her par- counseling. Some parents need formal counseling
ents may be most concerned because they can see also, to help them accept their child’s changed
that, although a blouse can cover her chest, her right appearance.
hand will not have full function. Do not assume that
your biggest concern is the same as the child’s or the
✔Checkpoint Question 52.3
If Jason spilled scalding hot water on his hand, which of the
following would be the best emergency action?
a. Apply an ice compress to his hand.
b. Pour vegetable oil over his hand.
c. Cover his hand with a gauze dressing.
d. Apply hand lotion to keep the area moist.

Key Points for Review

● Children need total body assessment after an uninten-
tional injury, because they may be unable to describe
other injuries besides the primary one they have suffered.
● Be aware that some trauma in children occurs as a result
of child abuse. Screen for this by history and physical
examination.
● Use aseptic technique when caring for trauma victims, so
that the child does not develop an additional unnecessary
infection.
● Head injuries are always potentially serious in children.
Skull fractures, subdural hematomas, epidural hematomas,
FIGURE 52.14 Extensive scarring on the chest of a 9-year-old
boy with third-degree burns. The child and his family will need concussions, and contusions can occur. Coma (uncon-
much support to help them deal with his appearance. (© Dr. sciousness from which a child cannot be roused) may be
P. Marazzi/SPL/Science Source/Photo Researchers.) present after severe head trauma.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1577

● Abdominal trauma resulting in rupture of the spleen or

liver may occur in connection with multiple trauma.
● Near drowning can occur in salt or fresh water. The phys- CRITICAL THINKING SCENARIO
iologic basis for complications after drowning differs de-
pending on the type of water. Open the accompanying CD-ROM or visit http://
● Common substances children swallow that result in poi- thePoint.lww.com and read the Patient Scenario in-
soning include acetaminophen (Tylenol), caustic sub- cluded for this chapter, then answer the questions to
stances, and hydrocarbons. Teach parents to keep the further sharpen your skills and grow more familiar
number of the local poison control center next to their with NCLEX style questions related to unintentional
telephone and always to call first before administering an injuries in children. Confirm your answers are cor-
antidote for poisoning. rect by reading the rationales.
● Lead poisoning most frequently occurs from the ingestion
of paint chips in older housing units. Preventing this is a
major nursing responsibility. REFERENCES
● Burns are classified as mild, moderate, and severe and can be
divided into three types—first, second, and third degree— Agency for Toxic Substances and Disease Registry. (2008). Managing haz-
ardous material incidence. Washington, DC: Centers for Disease Control
depending on the depth of the burn. Burns produce sys- and Prevention.
temic body reactions and require long-term nursing care. Aldridge, M. D. (2007). Acute iron poisoning: What every pediatric inten-
sive care unit nurse should know. DCCN: Dimensions of Critical Care
Nursing, 26(2), 43–48.
American Academy of Pediatrics (AAP). (2008). Prevention of Lyme disease.
CRITICAL THINKING EXERCISES Evanston, IL: Author.
Aminoff, M. J. (2009). Neurology. In S. J. McPhee & M. A. Papadakis (Eds.).
Current medical diagnosis and treatment. Columbus, OH: McGraw-Hill.
1. Jason, a 5-year-old boy, is seen in the emergency depart- Amirjamshidi, A., et al. (2007). Outcomes and recurrence rates in chronic
ment after an automobile accident. He is crying and subdural haematoma. British Journal of Neurosurgery, 21(3), 272–275.
upset, although the only visible signs of trauma are a red- Andersson, L. (2007). Tooth avulsion and replantation. Dental Traumatology,
dened and edematous area on the middle of his forehead. 23(3), 129–130.
Vital signs reveal the following: temperature, 99.4° F Bowers, R. C., & Anderson, T. K. (2008). Disorders due to physical and
environmental agents. In C. K. Stone & R. L. Humphries (Eds.).
(37.5° C); respirations, 18 breaths per minute; pulse, 62 Current diagnosis and treatment: Emergency medicine (6th ed). Columbus,
beats per minute; and blood pressure, 110/62 mm Hg. OH: McGraw-Hill.
His left pupil is more dilated than his right; it reacts slug- Centers for Disease Control and Prevention. (2008a). Unintentional stran-
gishly to light. His Glasgow Coma Scale score is 10. His gulation deaths from the “choking game” among youths aged 6–19
mother tells you, “I’m sure he’s not injured badly. He was years—United States, 1995–2007. Morbidity and Mortality Weekly
Report, 57(06), 141–144.
wearing his seat belt.” You are the triage nurse. Would Centers for Disease Control and Prevention. (2008b). Preventing lead poi-
you rate Jason as a child to be seen immediately, or could soning in young children. Washington, DC: Author.
he be given second priority? Claret-Teruel, G., et al. (2007). Severe head injury among children: Computed
2. Jason’s twin sister was seen in the emergency depart- tomography evaluation as a prognostic factor. Journal of Pediatric Surgery,
ment for acetaminophen poisoning last month. Her 42(11), 1903–1906.
Clark, R. F. (2007). Snakebite. In Olson, K.R. (2007). Poisoning and drug
father tells you they normally lock all medicine away overdose (5th ed.). Columbus, OH: McGraw-Hill.
carefully. His wife left acetaminophen on the counter Dart, R. C., & Rumack, B. H. (2008). Poisoning. In W. W. Hay, et al.
because she had a bad headache. Would you want to (Eds.). Current pediatric diagnosis and treatment (18th ed.). Columbus,
discuss the necessity of poisoning prevention with these OH: McGraw-Hill.
parents, or should they have learned from this experi- Dobremez, E., et al. (2007). Complications occurring during conservative
management of splenic trauma in children. European Journal of Pediatric
ence that their actions were not safe? Surgery, 16(3), 166–170.
3. A 10-year-old girl has third-degree burns on her legs Faries, G., & Battan, F. K. (2008). Emergencies and injuries. In W. W.
from lighting a fire to burn leaves. She will probably Hay, et al. (Eds.). Current pediatric diagnosis and treatment (18th ed.).
have a lengthy hospitalization and may need skin grafts Columbus, OH: McGraw-Hill.
to improve healing. What precautions does this child Fazio, V. C., et al. (2007). The relation between post concussion symptoms
and neurocognitive performance in concussed athletes. Neurorehabilitation,
need to prevent infection until healing is complete? 22(3), 207–216.
What areas of care would you plan to address during the Foley, P., et al. (2008). Breast burns are not benign: Long-term outcomes
hospitalization? of burns to the breast in pre-pubertal girls. Burns, 34(3), 412–417.
4. Examine the National Health Goals related to trauma Froberg, B., Ibrahim, D., & Furbee, R. B. (2007). Plant poisoning.
and children. Most government-sponsored funds for Emergency Medicine Clinics of North America, 25(2), 375–433.
Hayes, J. R., & Groner, J. I. (2008). The increasing incidence of snow-
nursing research are allotted based on these goals. What board-related trauma. Journal of Pediatric Surgery, 43(5), 928–930.
would be a possible research topic to explore pertinent Hicks, R. A., & Stolfi A. (2007). Skeletal surveys in children with burns
to these goals that would be applicable to Jason’s family caused by child abuse. Pediatric Emergency Care, 23(5), 308–313.
and also advance evidence-based practice? Huether, S. E., & McCance, K. L., (2007). Understanding pathophysiology
(4th ed.). St. Louis: Mosby.
Integrated Management of Childhood Illness

Chart Booklet

March 2014
WHO Library Cataloguing-in-Publication Data:

Integrated Management of Childhood Illness: distance learning course.

15 booklets
Contents: - Introduction, self-study modules – Module 1: general danger signs for
the sick child – Module 2: The sick young infant – Module 3: Cough or difficult
breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and
anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of
the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide –
Implementation: introduction and roll out – Logbook – Chart book

1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control.
4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education,
Distance. 7.Teaching Material. I.World Health Organization.

ISBN 978 92 4 150682 3 (NLM classification: WS 200)

© World Health Organization 2014

All rights reserved. Publications of the World Health Organization are available on the WHO
website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20
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All reasonable precautions have been taken by the World Health Organization to verify the
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Integrated Management of Childhood Illness
SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

ASSESS AND CLASSIFY THE SICK CHILD

ASSESS CLASSIFY IDENTIFY TREATMENT
ASK THE MOTHER WHAT THE CHILD'S
PROBLEMS ARE

Determine if this is an initial or follow-up visit for this USE ALL BOXES THAT MATCH THE
problem. CHILD'S SYMPTOMS AND PROBLEMS
if follow-up visit, use the follow-up instructions TO CLASSIFY THE ILLNESS
on TREAT THE CHILD chart.
if initial visit, assess the child as follows:

CHECK FOR GENERAL DANGER SIGNS

Ask: Look: Any general danger sign Pink: Give diazepam if convulsing now
Is the child able to drink or See if the child is lethargic VERY SEVERE Quickly complete the assessment
breastfeed? or unconscious. DISEASE Give any pre-referal treatment immediately
Does the child vomit Is the child convulsing URGENT attention
Treat to prevent low blood sugar
everything? now? Keep the child warm
Has the child had Refer URGENTLY.
convulsions?

A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.
THEN ASK ABOUT MAIN SYMPTOMS:
Does the child have cough or difficult breathing?

If yes, ask: Look, listen, feel*: Any general danger sign Pink: Give first dose of an appropriate antibiotic
For how long? Count the or SEVERE Refer URGENTLY to hospital**
Classify
breaths in COUGH or Stridor in calm child. PNEUMONIA OR
one minute. DIFFICULT VERY SEVERE
Look for BREATHING DISEASE
chest
CHILD Chest indrawing or Yellow: Give oral Amoxicillin for 5 days***
indrawing.
MUST BE Fast breathing. PNEUMONIA If wheezing (or disappeared after rapidly
Look and
CALM acting bronchodilator) give an inhaled
listen for
bronchodilator for 5 days****
stridor.
If chest indrawing in HIV exposed/infected child,
Look and
give first dose of amoxicillin and refer.
listen for
Soothe the throat and relieve the cough with a
wheezing.
safe remedy
If wheezing with either If coughing for more than 14 days or recurrent
fast breathing or chest wheeze, refer for possible TB or asthma
indrawing: assessment
Give a trial of rapid acting Advise mother when to return immediately
inhaled bronchodilator for up Follow-up in 3 days
to three times 15-20 minutes
No signs of pneumonia or Green: If wheezing (or disappeared after rapidly acting
apart. Count the breaths and
very severe disease. COUGH OR COLD bronchodilator) give an inhaled bronchodilator for
look for chest indrawing
5 days****
again, and then classify.
Soothe the throat and relieve the cough with a
If the child is: Fast breathing is: safe remedy
2 months up to 12 months 50 breaths per minute or more If coughing for more than 14 days or recurrent
wheezing, refer for possible TB or asthma
12 Months up to 5 years 40 breaths per minute or more assessment
Advise mother when to return immediately
Follow-up in 5 days if not improving

*If pulse oximeter is available, determine oxygen saturation and refer if < 90%.
** If referral is not possible, manage the child as described in the pneumonia section of the national referral guidelines or as in WHO Pocket Book for hospital care for children.
***Oral Amoxicillin for 3 days could be used in patients with fast breathing but no chest indrawing in low HIV settings.
**** In settings where inhaled bronchodilator is not available, oral salbutamol may be tried but not recommended for treatement of severe acute wheeze.
Does the child have diarrhoea?

Two of the following signs: Pink: If child has no other severe classification:
If yes, ask: Look and feel:
Lethargic or unconscious SEVERE Give fluid for severe dehydration (Plan C)
For how long? Look at the child's general
for DEHYDRATION Sunken eyes DEHYDRATION OR
Is there blood in the stool? condition. Is the child:
Not able to drink or drinking If child also has another severe
Lethargic or
poorly classification:
unconscious? Classify DIARRHOEA
Skin pinch goes back very Refer URGENTLY to hospital with mother
Restless and irritable? giving frequent sips of ORS on the way
slowly.
Look for sunken eyes. Advise the mother to continue
Offer the child fluid. Is the breastfeeding
child: If child is 2 years or older and there is
Not able to drink or cholera in your area, give antibiotic for
drinking poorly? cholera
Drinking eagerly,
Two of the following signs: Yellow: Give fluid, zinc supplements, and food for some
thirsty?
Restless, irritable SOME dehydration (Plan B)
Pinch the skin of the
Sunken eyes DEHYDRATION If child also has a severe classification:
abdomen. Does it go back:
Drinks eagerly, thirsty Refer URGENTLY to hospital with mother
Very slowly (longer
Skin pinch goes back giving frequent sips of ORS on the way
than 2 seconds)?
slowly. Advise the mother to continue
Slowly? breastfeeding
Advise mother when to return immediately
Follow-up in 5 days if not improving
Not enough signs to classify Green: Give fluid, zinc supplements, and food to treat
as some or severe NO DEHYDRATION diarrhoea at home (Plan A)
dehydration. Advise mother when to return immediately
Follow-up in 5 days if not improving

Dehydration present. Pink: Treat dehydration before referral unless the child
and if diarrhoea 14 SEVERE has another severe classification
days or more PERSISTENT Refer to hospital
DIARRHOEA
No dehydration. Yellow: Advise the mother on feeding a child who has
PERSISTENT PERSISTENT DIARRHOEA
DIARRHOEA Give multivitamins and
minerals (including zinc) for 14 days
Follow-up in 5 days

Blood in the stool. Yellow: Give ciprofloxacin for 3 days

and if blood in stool
DYSENTERY Follow-up in 3 days
Does the child have fever?

If yes: Any general danger sign or Pink: Give first dose of artesunate or quinine for severe malaria
Decide Malaria Risk: high or low Stiff neck. VERY SEVERE FEBRILE Give first dose of an appropriate antibiotic
High or Low Malaria DISEASE Treat the child to prevent low blood sugar
Then ask: Look and feel:
Risk
For how long? Look or feel for stiff neck.
or above)
If more than 7 days, has fever been Look for runny nose.
Classify FEVER Refer URGENTLY to hospital
present every day? Look for any bacterial cause of
Has the child had measles within the fever**. Malaria test POSITIVE. Yellow: Give recommended first line oral antimalarial
last 3 months? Look for signs of MEASLES. MALARIA
Generalized rash and or above)
One of these: cough, runny nose, Give appropriate antibiotic treatment for an identified bacterial cause
or red eyes. of fever
Advise mother when to return immediately
Do a malaria test***: If NO severe classification
Follow-up in 3 days if fever persists
In all fever cases if High malaria risk.
If fever is present every day for more than 7 days, refer for
In Low malaria risk if no obvious cause of fever present. assessment
Malaria test NEGATIVE Green:
Other cause of fever PRESENT. FEVER: or above)
NO MALARIA Give appropriate antibiotic treatment for an identified bacterial
cause of fever
Advise mother when to return immediately
Follow-up in 3 days if fever persists
If fever is present every day for more than 7 days, refer for
assessment

Any general danger sign Pink: Give first dose of an appropriate antibiotic.
No Malaria Risk and No
Stiff neck. VERY SEVERE FEBRILE Treat the child to prevent low blood sugar.
Travel to Malaria Risk
DISEASE
Area
or above).
Refer URGENTLY to hospital.
No general danger signs Green:
No stiff neck. FEVER or above)
Give appropriate antibiotic treatment for any identified bacterial
cause of fever
Advise mother when to return immediately
Follow-up in 2 days if fever persists
If fever is present every day for more than 7 days, refer for
assessment

Any general danger sign or Pink: Give Vitamin A treatment

If the child has measles now or Look for mouth ulcers. Clouding of cornea or SEVERE COMPLICATED Give first dose of an appropriate antibiotic
within the last 3 months: Are they deep and extensive? If MEASLES now or within last 3 Deep or extensive mouth ulcers. MEASLES**** If clouding of the cornea or pus draining from the eye, apply
Look for pus draining from the eye. months, Classify tetracycline eye ointment
Look for clouding of the cornea. Refer URGENTLY to hospital
Pus draining from the eye or Yellow: Give Vitamin A treatment
Mouth ulcers. MEASLES WITH EYE OR If pus draining from the eye, treat eye infection with
MOUTH tetracycline eye ointment
COMPLICATIONS**** If mouth ulcers, treat with gentian violet
Follow-up in 3 days
Measles now or within the last 3 Green: Give Vitamin A treatment
months. MEASLES

**Look for local tenderness; oral sores; refusal to use a limb; hot tender swelling; red tender skin or boils; lower abdominal pain or pain on passing urine in older children.
*** If no malaria test available: High malaria risk - classify as MALARIA; Low malaria risk AND NO obvious cause of fever - classify as MALARIA.
**** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and acute malnutrition - are classified in other tables.
Does the child have an ear problem?

If yes, ask: Look and feel: Tender swelling behind the Pink: Give first dose of an appropriate antibiotic
Is there ear pain? Look for pus draining from ear. MASTOIDITIS Give first dose of paracetamol for pain
Is there ear discharge? the ear. Classify EAR PROBLEM Refer URGENTLY to hospital
If yes, for how long? Feel for tender swelling
Pus is seen draining from Yellow: Give an antibiotic for 5 days
behind the ear.
the ear and discharge is ACUTE EAR Give paracetamol for pain
reported for less than 14 INFECTION Dry the ear by wicking
days, or Follow-up in 5 days
Ear pain.
Pus is seen draining from Yellow: Dry the ear by wicking
the ear and discharge is CHRONIC EAR Treat with topical quinolone eardrops for 14 days
reported for 14 days or INFECTION Follow-up in 5 days
more.
No ear pain and Green: No treatment
No pus seen draining from NO EAR INFECTION
the ear.
THEN CHECK FOR ACUTE MALNUTRITION

CHECK FOR ACUTE MALNUTRITION Oedema of both feet Pink: Give first dose appropriate antibiotic
LOOK AND FEEL: Classify OR COMPLICATED Treat the child to prevent low blood
Look for signs of acute malnutrition NUTRITIONAL WFH/L less than -3 z- SEVERE ACUTE sugar
STATUS scores OR MUAC less MALNUTRITION Keep the child warm
Look for oedema of both feet.
Determine WFH/L* ___ z-score. than 115 mm AND any Refer URGENTLY to hospital
Measure MUAC**____ mm in a child 6 months or older. one of the following:
Medical
If WFH/L less than -3 z-scores or MUAC less than 115 complication present
mm, then: or
Check for any medical complication present: Not able to finish RUTF
Any general danger signs or
Any severe classification Breastfeeding
Pneumonia with chest indrawing problem.
If no medical complications present: WFH/L less than -3 z- Yellow: Give oral antibiotics for 5 days
Child is 6 months or older, offer RUTF*** to scores UNCOMPLICATED Give ready-to-use therapeutic food for a child
eat. Is the child: OR SEVERE ACUTE aged 6 months or more
MUAC less than 115 mm MALNUTRITION Counsel the mother on how to feed the child.
Not able to finish RUTF portion? Assess for possible TB infection
AND
Able to finish RUTF portion? Advise mother when to return immediately
Able to finish RUTF.
Follow up in 7 days
Child is less than 6 months, assess
breastfeeding: WFH/L between -3 and - Yellow: Assess the child's feeding and counsel the
2 z-scores MODERATE ACUTE mother on the feeding recommendations
Does the child have a breastfeeding OR MALNUTRITION If feeding problem, follow up in 7 days
problem? Assess for possible TB infection.
MUAC 115 up to 125 mm.
Advise mother when to return immediately
Follow-up in 30 days
WFH/L - 2 z-scores or Green: If child is less than 2 years old, assess the
more NO ACUTE child's feeding and counsel the mother on
OR MALNUTRITION feeding according to the feeding
recommendations
MUAC 125 mm or more.
If feeding problem, follow-up in 7 days

*WFH/L is Weight-for-Height or Weight-for-Length determined by using the WHO growth standards charts.
** MUAC is Mid-Upper Arm Circumference measured using MUAC tape in all children 6 months or older.
***RUTF is Ready-to-Use Therapeutic Food for conducting the appetite test and feeding children with severe acute malanutrition.
THEN CHECK FOR ANAEMIA

Check for anaemia Severe palmar pallor Pink: Refer URGENTLY to hopsital
Look for palmar pallor. Is it: SEVERE ANAEMIA
Severe palmar pallor*? Classify
Some pallor Yellow: Give iron**
Some palmar pallor? ANAEMIA Classification
arrow ANAEMIA Give mebendazole if child is 1 year or older and
has not had a dose in the previous 6 months
Advise mother when to return immediately
Follow-up in 14 days
No palmar pallor Green: If child is less than 2 years old, assess the
NO ANAEMIA child's feeding and counsel the mother according
to the feeding recommendations
If feeding problem, follow-up in 5 days

*Assess for sickle cell anaemia if common in your area.

**If child has severe acute malnutrition and is receiving RUTF, DO NOT give iron because there is already adequate amount of iron in RUTF.
THEN CHECK FOR HIV INFECTION
Use this chart if the child is NOT enrolled in HIV care.

Positive virological test in Yellow: Initiate ART treatment and HIV care
ASK child CONFIRMED HIV Give cotrimoxazole prophylaxis*
Classify OR INFECTION
Has the mother or child had an HIV test? HIV counselling to the mother
status Positive serological test in a
IF YES: child 18 months or older Advise the mother on home care
Decide HIV status: Asess or refer for TB assessment and INH
Mother: POSITIVE or NEGATIVE preventive therapy
Child: Follow-up regularly as per national guidelines
Virological test POSITIVE or NEGATIVE Mother HIV-positive AND Yellow: Give cotrimoxazole prophylaxis
Serological test POSITIVE or NEGATIVE negative virological test in HIV EXPOSED Start or continue ARV prophylaxis as
a breastfeeding child or only recommended
If mother is HIV positive and child is negative or stopped less than 6 weeks Do virological test to confirm HIV status**
unknown, ASK: ago
Was the child breastfeeding at the time or 6 weeks before OR counselling to the mother
the test? Mother HIV-positive, child Advise the mother on home care
Is the child breastfeeding now? not yet tested Follow-up regularly as per national guidelines
If breastfeeding ASK: Is the mother and child on ARV OR
prophylaxis?
Positive serological test in a
IF NO, THEN TEST: child less than 18 months
Mother and child status unknown: TEST mother. old
Mother HIV positive and child status unknown: TEST child.
Negative HIV test in mother Green: Treat, counsel and follow-up existing infections
or child HIV INFECTION
UNLIKELY

* Give cotrimoxazole prophylaxis to all HIV infected and HIV-exposed children utill confirmed negative after cessation of breastfeeding.
** If virological test is negative, repeat test 6 weeks after the breatfeeding has stopped; if serological test is positive, do a virological test as soon as possible.
THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A AND DEWORMING STATUS

IMMUNIZATION SCHEDULE: Follow national guidelines

AGE VACCINE
Birth BCG* OPV-0 Hep B0 VITAMIN A
6 weeks DPT+HIB-1 OPV-1 Hep B1 RTV1 PCV1*** SUPPLEMENTATION
Give every child a
10 weeks DPT+HIB-2 OPV-2 Hep B2 RTV2 PCV2 dose of Vitamin A
every six months
from the age of 6
months. Record the
dose on the child's
chart.
14 weeks DPT+HIB-3 OPV-3 Hep B3 RTV3 PCV3 ROUTINE WORM
TREATMENT
Give every child
mebendazole every 6
9 months Measles **
months from the age
of one year. Record
the dose on the
18 months DPT child's card.
*Children who are HIV positive or unknown HIV status with symptoms consistent with HIV should not be vaccinated.
**Second dose of measles vaccine may be given at any opportunistic moment during periodic supplementary immunization activities as early as one month following the first dose.
***HIV-positive infants and pre-term neonates who have received 3 primary vaccine doses before 12 months of age may benefit from a booster dose in the second year of life.

ASSESS OTHER PROBLEMS:

MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments. Treat all children with a general danger sign to prevent low
blood sugar.
HIV TESTING AND INTERPRENTING RESULTS
HIV testing is RECOMMENDED for:

Types of HIV Tests

What does the test detect? How to interpret the test?
SEROLOGICAL These tests detect antibodies made by HIV antibodies pass from the mother to the child. Most antibodies have gone by 12 months of age, but in some instances they do not
TESTS immune cells in response to HIV. disappear until the child is 18 months of age.
(Including rapid They do not detect the HIV virus itself. This means that a positive serological test in children less than 18 months in NOT a reliable way to check for infection of the child.
tests)
VIROLOGICAL These tests directly detect the presence of Positive virological (PCR) tests reliably detect HIV infection at any age, even before the child is 18 months old.
TESTS the HIV virus or products of the virus in the If the tests are negative and the child has been breastfeeding, this does not rule out infection. The baby may have just become infected.
(Including DNA blood.
or RNA PCR)
For HIV exposed children 18 months or older, a positive HIV antibody test result means the child is infected.
For HIV exposed children less than 18 months of age:
If PCR or other virological test is available, test from 4 - 6 weeks of age.
A positive result means the child is infected.
A negative result means the child is not infected, but could become infected if they are still breast feeding.
If PCR or other virological test is not available, use HIV antibody test. A positive result is consistent with the fact that the child has been exposed to HIV, but does not tell us if the child is definitely infected.

Interpreting the HIV Antibody Test Results in a Child less than 18 Months of Age
Breastfeeding status POSITIVE (+) test NEGATIVE (-) test
NOT BREASTFEEDING, and has not in HIV EXPOSED and/or HIV infected - Manage as if they could be infected. HIV negative Child is not HIV infected
last 6 weeks Repeat test at 18 months.
BREASTFEEDING HIV EXPOSED and/or HIV infected - Manage as if they Child can still be infected by breastfeeding. Repeat test once breastfeeding has been
could be infected. Repeat test at 18 months or once discontinued for more than 6 weeks.
breastfeeding has been discontinued for more than 6 weeks.
WHO PAEDIATRIC STAGING FOR HIV INFECTION

Stage 1 Stage 2 Stage 3 Stage 4

Asymptomatic Mild Disease Moderate Disease Severe Disease (AIDS)

- - Unexplained severe Severe unexplained wasting/stunting/severe acute

acute malnutrition not responding malnutrition not responding to standard therapy
to standard therapy

Symptoms/Signs No symptoms, or only: Enlarged liver and/or spleen Oral thrush (outside neonatal Oesophageal thrush
Persistent generalized Enlarged parotid period). More than one month of herpes simplex ulcerations.
lymphadenopathy (PGL) Skin conditions (prurigo, seborraic dermatitis, extensive Oral hairy leukoplakia. Severe multiple or recurrent bacteria infections > 2
molluscum contagiosum or warts, fungal nail infection Unexplained and unresponsive episodes in a year (not including pneumonia) pneumocystis
herpes zoster) to standard pneumonia (PCP)*
Mouth conditions recurrent mouth ulcerations, linea therapy: Kaposi's sarcoma.
gingival Erythema) Diarhoea for over 14 days Extrapulmonary tuberculosis.
Recurrent or chronic upper respiratory tract infections Fever for over 1 month Toxoplasma brain abscess*
(sinusitis, ear infection, tonsilitis, Thrombocytopenia*(under Cryptococcal meningitis*
ortorrhea) 50,000/mm3 for 1month Acquired HIVassociated rectal
Neutropenia* (under fistula
500/mm3 for 1 month) HIV encephalopathy*
Anaemia for over 1 month
(haemoglobin under 8 gm)*
Recurrent severe bacterial
pneumonia
Pulmonary TB
Lymp node TB
Symptomatic lymphoid
interstitial pneumonitis (LIP)*
Acute necrotising ulcerative
gingivitis/periodontitis
Chronic HIV associated lung
diseses including
bronchiectasis*

*Conditions requiring diagnosis by a doctor or medical officer - should be referred for appropriate diagnosis and treatment.
TREAT THE CHILD
CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART

TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

Follow the instructions below for every oral drug to be given at home. Give an Appropriate Oral Antibiotic
Also follow the instructions listed with each drug's dosage table. FOR PNEUMONIA, ACUTE EAR INFECTION:
FIRST-LINE ANTIBIOTIC: Oral Amoxicillin
Determine the appropriate drugs and dosage for the child's age or weight. AMOXICILLIN*
Tell the mother the reason for giving the drug to the child. Give two times daily for 5 days
AGE or WEIGHT
Demonstrate how to measure a dose. TABLET SYRUP
Watch the mother practise measuring a dose by herself. 250 mg 250mg/5 ml
Ask the mother to give the first dose to her child. 2 months up to 12 months (4 - <10 kg) 1 5 ml
Explain carefully how to give the drug, then label and package the drug. 12 months up to 3 years (10 - <14 kg) 2 10 ml
If more than one drug will be given, collect, count and package each drug 3 years up to 5 years (14-19 kg) 3 15 ml
separately. * Amoxicillin is the recommended first-line drug of choice in the treatment of pneumonia due to its efficacy and
increasing high resistance to cotrimoxazole.
Explain that all the oral drug tablets or syrups must be used to finish the course of
FOR PROPHYLAXIS IN HIV CONFIRMED OR EXPOSED CHILD:
treatment, even if the child gets better. ANTIBIOTIC FOR PROPHYLAXIS: Oral Cotrimoxazole
Check the mother's understanding before she leaves the clinic. COTRIMOXAZOLE
(trimethoprim + sulfamethoxazole)

AGE Give once a day starting at 4-6 weeks of age

Syrup Paediatric tablet Adult tablet
(40/200 mg/5ml) (Single strength 20/100 mg) (Single strength 80/400 mg)
Less than 6 months 2.5 ml 1 -
6 months up to 5 years 5 ml 2 1/2
FOR DYSENTERY give Ciprofloxacine
FIRST-LINE ANTIBIOTIC: Oral Ciprofloxacine
CIPROFLOXACINE
AGE Give 15mg/kg two times daily for 3 days
250 mg tablet 500 mg tablet
Less than 6 months 1/2 1/4
6 months up to 5 years 1 1/2
FOR CHOLERA:
FIRST-LINE ANTIBIOTIC FOR CHOLERA: ____________________________________________________
SECOND-LINE ANTIBIOTIC FOR CHOLERA: ____________________________________________________
ERYTHROMYCIN TETRACYCLINE
Give four times daily for 3 days Give four times daily for 3 days
AGE or WEIGHT
TABLET TABLET
250 mg 250 mg
2 years up to 5 years (10 - 19 kg) 1 1
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home. Give Oral Antimalarial for MALARIA
Also follow the instructions listed with each drug's dosage table. If Artemether-Lumefantrine (AL)
Give the first dose of artemether-lumefantrine in the clinic and observe for one hour. If the child
vomits within an hour repeat the dose.
Give second dose at home after 8 hours.
Give Inhaled Salbutamol for Wheezing Then twice daily for further two days as shown below.
USE OF A SPACER* Artemether-lumefantrine should be taken with food.
A spacer is a way of delivering the bronchodilator drugs effectively into the lungs. No child under 5 years If Artesunate Amodiaquine (AS+AQ)
should be given an inhaler without a spacer. A spacer works as well as a nebuliser if correctly used. Give first dose in the clinic and observe for an hour, if a child vomits within an hour repeat the
dose.
Then daily for two days as per table below using the fixed dose combination.
Repeat up to 3 times every 15 minutes before classifying pneumonia.

Spacers can be made in the following way: Artemether-Lumefantrine Artesunate plus Amodiaquine tablets
Use a 500ml drink bottle or similar. tablets Give Once a day for 3 days
Cut a hole in the bottle base in the same shape as the mouthpiece of the inhaler. (20 mg artemether and 120
This can be done using a sharp knife. mg lumefantrine)
WEIGHT (age) (25 mg AS/67.5 (50 mg AS/135 mg
Cut the bottle between the upper quarter and the lower 3/4 and disregard the upper quarter of the Give two times daily for 3 mg AQ) AQ)
bottle. days
Cut a small V in the border of the large open part of the bottle to fit to the child's nose and be used as Day Day
a mask. Day 1 Day 2 day 3 Day 2 Day 3 Day 2 Day 3
1 1
Flame the edge of the cut bottle with a candle or a lighter to soften it.
In a small baby, a mask can be made by making a similar hole in a plastic (not polystyrene) cup. 5 - <10 kg (2 months up
1 1 1 1 1 1 - - -
to 12 months)
Alternatively commercial spacers can be used if available.
10 - <14 kg (12 months
1 1 1 - - - 1 1 1
To use an inhaler with a spacer: up to 3 years)
Remove the inhaler cap. Shake the inhaler well. 14 - <19 kg (3 years up to
2 2 2 - - - 1 1 1
Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup. 5 years)
The child should put the opening of the bottle into his mouth and breath in and out through the mouth.
A carer then presses down the inhaler and sprays into the bottle while the child continues to breath
normally.
Wait for three to four breaths and repeat.
For younger children place the cup over the child's mouth and use as a spacer in the same way.
Give paracetamol every 6 hours until high fever or ear pain is gone.
* If a spacer is being used for the first time, it should be primed by 4-5 extra puffs from the inhaler.
PARACETAMOL
AGE or WEIGHT
TABLET (100 mg) TABLET (500 mg)
2 months up to 3 years (4 - <14 kg) 1 1/4
3 years up to 5 years (14 - <19 kg) 1 1/2 1/2
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drug's dosage table.

Give Iron*
Give one dose daily for 14 days.
IRON/FOLATE
IRON SYRUP
TABLET

AGE or WEIGHT Ferrous sulfate

Ferrous fumarate 100 mg per 5 ml (20 mg
Folate (60 mg elemental iron per ml)
elemental iron)
2 months up to 4 months (4 -
1.00 ml (< 1/4 tsp.)
<6 kg)
4 months up to 12 months
1.25 ml (1/4 tsp.)
(6 - <10 kg)
12 months up to 3 years
1/2 tablet 2.00 ml (<1/2 tsp.)
(10 - <14 kg)
3 years up to 5 years (14 -
1/2 tablet 2.5 ml (1/2 tsp.)
19 kg)
* Children with severe acute malnutrition who are receiving ready-to-use therapeutic food (RUTF) should
not be given Iron.
TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME
Treat for Mouth Ulcers with Gentian Violet (GV)
Explain to the mother what the treatment is and why it should be given.
Describe the treatment steps listed in the appropriate box. Treat for mouth ulcers twice daily.
Watch the mother as she does the first treatment in the clinic (except for remedy for Wash hands.
cough or sore throat). Wash the child's mouth with clean soft cloth wrapped around the finger and wet with salt water.
Tell her how often to do the treatment at home. Paint the mouth with half-strength gentian violet (0.25% dilution).
If needed for treatment at home, give mother the tube of tetracycline ointment or a Wash hands again.
small bottle of gentian violet. Continue using GV for 48 hours after the ulcers have been cured.
Give paracetamol for pain relief.
Check the mothers understanding before she leaves the clinic.

Soothe the Throat, Relieve the Cough with a Safe Remedy Treat Thrush with Nystatin
Safe remedies to recommend: Treat thrush four times daily for 7 days
Breast milk for a breastfed infant. Wash hands
_____________________________________________________________________________
Instill nystatin 1ml four times a day
_____________________________________________________________________________ Avoid feeding for 20 minutes after medication
Harmful remedies to discourage:
_____________________________________________________________________________ Advise mother to wash breasts after feeds. If bottle fed advise change to cup and spoon
_____________________________________________________________________________ Give paracetamol if needed for pain
_____________________________________________________________________________

Treat Eye Infection with Tetracycline Eye Ointment

Clean both eyes 4 times daily.
Wash hands.
Use clean cloth and water to gently wipe away pus.
Then apply tetracycline eye ointment in both eyes 4 times daily.
Squirt a small amount of ointment on the inside of the lower lid.
Wash hands again.
Treat until there is no pus discharge.
Do not put anything else in the eye.

Clear the Ear by Dry Wicking and Give Eardrops*

Dry the ear at least 3 times daily.
Roll clean absorbent cloth or soft, strong tissue paper into a wick.
Place the wick in the child's ear.
Remove the wick when wet.
Replace the wick with a clean one and repeat these steps until the ear is dry.
Instill quinolone eardrops after dry wicking three times daily for two weeks.
* Quinolone eardrops may include ciprofloxacin, norfloxacin, or ofloxacin.
GIVE VITAMIN A AND MEBENDAZOLE IN CLINIC
Explain to the mother why the drug is given
Determine the dose appropriate for the child's weight (or age)
Measure the dose accurately

Give Vitamin A Supplementation and Treatment

VITAMIN A SUPPLEMENTATION:
Give first dose any time after 6 months of age to ALL CHILDREN
Thereafter vitamin A every six months to ALL CHILDREN
VITAMIN A TREATMENT:
Give an extra dose of Vitamin A (same dose as for supplementation) for treatment if the child has MEASLES or PERSISTENT DIARRHOEA. If the child has had a dose of vitamin A within the past
month or is on RUTF for treatment of severe acute malnutrition, DO NOT GIVE VITAMIN A.
Always record the dose of Vitamin A given on the child's card.
AGE VITAMIN A DOSE
6 up to 12 months 100 000 IU
One year and older 200 000 IU

Give Mebendazole
Give 500 mg mebendazole as a single dose in clinic if:
hookworm/whipworm are a problem in children in your area, and
the child is 1 years of age or older, and
the child has not had a dose in the previous 6 months.
GIVE THESE TREATMENTS IN THE CLINIC ONLY
Give Artesunate Suppositories or Intramuscular Artesunate or
Explain to the mother why the drug is given.
Determine the dose appropriate for the child's weight (or age). Quinine for Severe Malaria
Use a sterile needle and sterile syringe when giving an injection. FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE:
Measure the dose accurately. Check which pre-referral treatment is available in your clinic (rectal artesunate suppositories,
Give the drug as an intramuscular injection. artesunate injection or quinine).
If child cannot be referred, follow the instructions provided. Artesunate suppository: Insert first dose of the suppository and refer child urgently
Intramuscular artesunate or quinine: Give first dose and refer child urgently to hospital.
IF REFERRAL IS NOT POSSIBLE:
Give Intramuscular Antibiotics For artesunate injection:
Give first dose of artesunate intramuscular injection
GIVE TO CHILDREN BEING REFERRED URGENTLY Repeat dose after 12 hrs and daily until the child can take orally
Give Ampicillin (50 mg/kg) and Gentamicin (7.5 mg/kg). Give full dose of oral antimlarial as soon as the child is able to take orally.
For artesunate suppository:
AMPICILLIN Give first dose of suppository
Repeat the same dose of suppository every 24 hours until the child can take oral antimalarial.
Dilute 500mg vial with 2.1ml of sterile water (500mg/2.5ml).
Give full dose of oral antimalarial as soon as the child is able to take orally
IF REFERRAL IS NOT POSSIBLE OR DELAYED, repeat the ampicillin injection every 6 hours.
For quinine:
Where there is a strong suspicion of meningitis, the dose of ampicillin can be increased 4
times. Give first dose of intramuscular quinine.
The child should remain lying down for one hour.
Repeat the quinine injection at 4 and 8 hours later, and then every 12 hours until the child is able
GENTAMICIN
to take an oral antimalarial. Do not continue quinine injections for more than 1 week.
7.5 mg/kg/day once daily
If low risk of malaria, do not give quinine to a child less than 4 months of age.
AMPICILLIN GENTAMICIN
AGE or WEIGHT
500 mg vial 2ml/40 mg/ml vial
RECTAL ARTESUNATE INTRAMUSCULAR INTRAMUSCULAR
2 up to 4 months (4 - <6 kg) 1m 0.5-1.0 ml SUPPOSITORY ARTESUNATE QUININE
4 up to 12 months (6 - <10 kg) 2 ml 1.1-1.8 ml AGE or WEIGHT 50 mg 200 mg
suppositories suppositories 60 mg 150 mg/ml* 300 mg/ml*
12 months up to 3 years (10 - <14 kg) 3 ml 1.9-2.7 ml vial (20mg/ml) 2.4 (in 2 ml (in 2 ml
Dosage 10 Dosage 10 mg/kg ampoules) ampoules)
3 years up to 5 years (14 - 19 kg) 5m 2.8-3.5 ml mg/kg mg/kg
2 months up to 4
1 1/2 ml 0.4 ml 0.2 ml
months (4 - <6 kg)
4 months up to 12
Give Diazepam to Stop Convulsions months (6 - <10 kg)
2 1 ml 0.6 ml 0.3 ml

Turn the child to his/her side and clear the airway. Avoid putting things in the mouth. 12 months up to 2
2 - 1.5 ml 0.8 ml 0.4 ml
Give 0.5mg/kg diazepam injection solution per rectum using a small syringe without a needle (like a years (10 - <12 kg)
tuberculin syringe) or using a catheter.
2 years up to 3
Check for low blood sugar, then treat or prevent. 3 1 1.5 ml 1.0 ml 0.5 ml
years (12 - <14 kg)
Give oxygen and REFER
If convulsions have not stopped after 10 minutes repeat diazepam dose 3 years up to 5
3 1 2 ml 1.2 ml 0.6 ml
years (14 - 19 kg)
DIAZEPAM
AGE or WEIGHT
10mg/2mls * quinine salt
2 months up to 6 months (5 - 7 kg) 0.5 ml
6 months up to 12months (7 - <10 kg) 1.0 ml
12 months up to 3 years (10 - <14 kg) 1.5 ml
3 years up to 5 years (14-19 kg) 2.0 ml
GIVE THESE TREATMENTS IN THE CLINIC ONLY

Treat the Child to Prevent Low Blood Sugar

If the child is able to breastfeed:
Ask the mother to breastfeed the child.
If the child is not able to breastfeed but is able to swallow:
Give expressed breast milk or a breast-milk substitute.
If neither of these is available, give sugar water*.
Give 30 - 50 ml of milk or sugar water* before departure.
If the child is not able to swallow:
Give 50 ml of milk or sugar water* by nasogastric tube.
If no nasogastric tube available, give 1 teaspoon of sugar moistened with 1-2 drops of water
sublingually and repeat doses every 20 minutes to prevent relapse.
* To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean
water.
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING
PLAN B: TREAT SOME DEHYDRATION WITH ORS
(See FOOD advice on COUNSEL THE MOTHER chart)
In the clinic, give recommended amount of ORS over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
PLAN A: TREAT DIARRHOEA AT HOME WEIGHT < 6 kg 6 - <10 kg 10 - <12 kg 12 - 19 kg
AGE* Up to 4 4 months up to 12 12 months up to 2 2 years up to 5
Counsel the mother on the 4 Rules of Home Treatment: months months years years
1. Give Extra Fluid In ml 200 - 450 450 - 800 800 - 960 960 - 1600
2. Give Zinc Supplements (age 2 months up to 5 years) * Use the child's age only when you do not know the weight. The approximate amount of ORS
3. Continue Feeding required (in ml) can also be calculated by multiplying the child's weight (in kg) times 75.
4. When to Return. If the child wants more ORS than shown, give more.
For infants under 6 months who are not breastfed, also give 100 - 200 ml clean water during this
1. GIVE EXTRA FLUID (as much as the child will take) period if you use standard ORS. This is not needed if you use new low osmolarity ORS.
TELL THE MOTHER: SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
Breastfeed frequently and for longer at each feed. Give frequent small sips from a cup.
If the child is exclusively breastfed, give ORS or clean water in addition to breast milk. If the child vomits, wait 10 minutes. Then continue, but more slowly.
If the child is not exclusively breastfed, give one or more of the following: Continue breastfeeding whenever the child wants.
ORS solution, food-based fluids (such as soup, rice water, and yoghurt drinks), or clean AFTER 4 HOURS:
water. Reassess the child and classify the child for dehydration.
It is especially important to give ORS at home when: Select the appropriate plan to continue treatment.
the child has been treated with Plan B or Plan C during this visit. Begin feeding the child in clinic.
the child cannot return to a clinic if the diarrhoea gets worse. IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:
TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER 2 PACKETS OF Show her how to prepare ORS solution at home.
ORS TO USE AT HOME. Show her how much ORS to give to finish 4-hour treatment at home.
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID Give her enough ORS packets to complete rehydration. Also give her 2 packets as recommended
INTAKE: in Plan A.
Up to 2 years 50 to 100 ml after each loose stool Explain the 4 Rules of Home Treatment:
2 years or more 100 to 200 ml after each loose stool 1. GIVE EXTRA FLUID
Tell the mother to: 2. GIVE ZINC (age 2 months up to 5 years)
Give frequent small sips from a cup. 3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
If the child vomits, wait 10 minutes. Then continue, but more slowly. 4. WHEN TO RETURN
Continue giving extra fluid until the diarrhoea stops.
2. GIVE ZINC (age 2 months up to 5 years)
TELL THE MOTHER HOW MUCH ZINC TO GIVE (20 mg tab):
2 months up to 6 months 1/2 tablet daily for 14 days
6 months or more 1 tablet daily for 14 days
SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS
Infants - dissolve tablet in a small amount of expressed breast milk, ORS or clean water in a
cup.
Older children - tablets can be chewed or dissolved in a small amount of water.
3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
4. WHEN TO RETURN
GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING

PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

FOLLOW THE ARROWS. IF ANSWER IS "YES", GO ACROSS. IF "NO", GO
DOWN.
START HERE Start IV fluid immediately. If the child can drink, give ORS by
Can you give mouth while the drip is set up. Give 100 ml/kg Ringer's Lactate
intravenous (IV) fluid Solution (or, if not available, normal saline), divided as follows
immediately? AGE First give Then give
NO 30 ml/kg in: 70 ml/kg in:
Infants (under 12 1 hour* 5 hours
months)
Children (12 months up 30 minutes* 2 1/2 hours
to 5 years)
* Repeat once if radial pulse is still very weak or not
detectable.
Reassess the child every 1-2 hours. If hydration status is
not improving, give the IV drip more rapidly.
Also give ORS (about 5 ml/kg/hour) as soon as the child can
drink: usually after 3-4 hours (infants) or 1-2 hours (children).
Reassess an infant after 6 hours and a child after 3 hours.
Classify dehydration. Then choose the appropriate plan (A, B,
or C) to continue treatment.

Is IV treatment Refer URGENTLY to hospital for IV treatment.

available nearby (within If the child can drink, provide the mother with ORS solution and
30 minutes)? show her how to give frequent sips during the trip or give ORS
NO by naso-gastric tube.

Are you trained to use Start rehydration by tube (or mouth) with ORS solution:
a naso-gastric (NG) give 20 ml/kg/hour for 6 hours (total of 120 ml/kg).
tube for rehydration? Reassess the child every 1-2 hours while waiting for
NO transfer:
If there is repeated vomiting or increasing abdominal
distension, give the fluid more slowly.
Can the child drink?
If hydration status is not improving after 3 hours, send the
NO child for IV therapy.
After 6 hours, reassess the child. Classify dehydration. Then
choose the appropriate plan (A, B or C) to continue treatment.

Refer URGENTLY to NOTE:

hospital for IV or NG If the child is not referred to hospital, observe the child at least
treatment 6 hours after rehydration to be sure the mother can maintain
hydration giving the child ORS solution by mouth.
GIVE READY-TO-USE THERAPEUTIC FOOD

Give Ready-to-Use Therapeutic Food for SEVERE ACUTE MALNUTRITION

Wash hands before giving the ready-to-use therapeutic food (RUTF).
Sit with the child on the lap and gently offer the ready-to-use therapeutic food.
Encourage the child to eat the RUTF without forced feeding.

If still breastfeeding, continue by offering breast milk first before every RUTF feed.
Give only the RUTF for at least two weeks, if breastfeeding continue to breast and gradually introduce foods recommended for the age (See Feeding recommendations in COUNSEL THE MOTHER
chart).
When introducing recommended foods, ensure that the child completes his daily ration of RUTF before giving other foods.
Offer plenty of clean water, to drink from a cup, when the child is eating the ready-to-use therapeutic food.

Recommended Amounts of Ready-to-Use Therapeutic Food

Packets per day
CHILD'S WEIGHT (kg) Packets per Week Supply
(92 g Packets Containing 500 kcal)
4.0-4.9 kg 2.0 14
5.0-6.9 kg 2.5 18
7.0-8.4 kg 3.0 21
8.5-9.4 kg 3.5 25
9.5-10.4 kg 4.0 28
10.5-11.9 kg 4.5 32
>12.0 kg 5.0 35
TREAT THE HIV INFECTED CHILD

Steps when Initiating ART in Children

All children less than 5 years who are HIV infected should be initiated on ART irrespective of CD4 count or clinical stage.
Remember that if a child has any general danger sign or a severe classification, he or she needs URGENT REFERRAL. ART initiation is not urgent, and the child should be stabilized first.
STEP 1: DECIDE IF THE CHILD HAS CONFIRMED HIV INFECTION STEP 3: DECIDE IF ART CAN BE INITIATED IN YOUR FACILITY
Child is under 18 months: If child is less than 3 kg or has TB, Refer for ART initiation.
HIV infection is confirmed if virological test (PCR) is positive If child weighs 3 kg or more and does not have TB, GO TO STEP 4
Child is over 18 months:
Two different serological tests are positive
Send any further confirmatory tests required
If results are discordant, refer
If HIV infection is confirmed, and child is in stable condition,
GO TO STEP 2

STEP 2: DECIDE IF CAREGIVER IS ABLE TO GIVE ART STEP 4: RECORD BASELINE INFORMATION ON THE CHILD'S HIV TREATMENT CARD
Check that the caregiver is willing and able to give ART. The Record the following information:
Weight and height
to another adult who can assist with providing ART, or be part Pallor if present
of a support group. Feeding problem if present
Caregiver able to give ART: GO TO STEP 3 Laboratory results (if available): Hb, viral load, CD4 count and percentage. Send for any laboratory tests
Caregiver not able: classify as CONFIRMED HIV INFECTION that are required. Do not wait for results. GO TO STEP 5
but NOT ON ART. Counsel and support the
caregiver. Follow-up regularly. Move to the step 3 once the
caregiver is willing and able to give ART.

STEP 5: START ON ART, COTRIMOXAZOLE PROPHYLAXIS AND ROUTINE TREATMENTS

Initiate ART treatement:
Child up to 3 years: ABC or AZT +3TC+ LPV/R or recommended first-line regimen
Child 3 years or older: ABC + 3TC + EFV, or recommended first-line regimen.
Give co-trimoxazole prophylaxis
Give other routine treatments, including Vitamin A and immunizations
Follow-up regularly as per national guidelines
TREAT THE HIV INFECTED CHILD

Preferred and Alternative ARV Regimens

AGE Preferred Alternative Children with TB/HIV Infection

Birth up to 3 YEARS ABC or AZT + 3TC + LPV/r ABC or AZT + 3TC + NVP ABC or AZT + 3TC + NVP
AZT + 3TC + ABC

3 years and older ABC + 3TC + EFV ABC or AZT + 3TC + EFV or NVP ABC or AZT + 3TC + EFV
AZT + 3TC + ABC

Give Antiretroviral Drugs (Fixed Dose Combinations)

AZT/3TC AZT/3TC/NVP ABC/AZT/3TC ABC/3TC
WEIGHT (Kg) Twice daily Twice daily Twice daily Twice daily
60/30 mg tablet 300/150 mg tablet 60/30/50 mg tablet 300/150/200 mg tablet 60/60/30 mg tablet 300/300/150 mg tablet 60/30 mg tablet 600/300 mg tablet
3 - 5.9 1 - 1 - 1 - 1 -
6 - 9.9 1.5 - 1.5 - 1.5 - 1.5 -
10 - 13.9 2 - 2 - 2 - 2 -
14 - 19.9 2.5 - 2.5 - 2.5 - 2.5 -
20 - 24.9 3 - 3 - 3 - 3 -
25 - 34.9 - 1 1 1 - 0.5
TREAT THE HIV INFECTED CHILD

Give Antiretroviral Drugs

LOPINAVIR / RITONAVIR (LPV/r), NEVIRAPINE (NVP) & EFAVIRENZ (EFV)

LOPINAVIR / RITONAVIR (LPV/r) NE VIR AP INE (NVP ) EFAVIRENZ (EFV)

WEIGHT (KG) T arget dos e 15 mg/Konc
g e da ily
80/20 mg liquid 100/25 mg tablet 10 mg/ml liquid 50 mg tablet 200 mg tablet 200 mg tablet
Twice daily Twice daily Twice daily Twice daily Twice daily Once daily
3 - 5.9 1 ml - 5 ml 1 - -
6 - 9.9 1.5 ml - 8 ml 1.5 - -
10 - 13.9 2 ml 2 10 ml 2 - 1
14 - 19.9 2.5 ml 2 - 2.5 - 1.5
20 - 24.9 3 ml 2 - 3 - 1.5
25 - 34.9 - 3 - - 1 2
ABACAVIR (ABC), ZIDOVUDINE (AZT or ZDV) & LAMIVUDINE (3TC)

AB AC AVIR (AB C )
Z IDO VUDINE (AZ T or Z DV)
L AMIVUDINE (3T C )
WEIGHT (KG) T arget dos e: 8mg/K g/dos e twice daily
20 mg/ml liquid 60 mg dispersible tablet 300 mg tablet 10 mg/ml liquid 60 mg tablet 300 mg tablet 10 mg/ml liquid 30 mg tablet 150 mg tablet
Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily
3 - 5.9 3 ml 1 - 6 ml 1 - 3 ml 1 -
6 - 9.9 4 ml 1.5 - 9 ml 1.5 - 4 ml 1.5 -
10 - 13.9 6 ml 2 - 12 ml 2 - 6 ml 2 -
14 - 19.9 - 2.5 - - 2.5 - - 2.5 -
20 - 24.9 - 3 - - 3 - - 3 -
25 - 34.9 - - 1 - - 1 - - 1
TREAT THE HIV INFECTED CHILD

Side Effects ARV Drugs

Very common side-effets: Potentially serious side effects: Side effects occurring later during
treatment:
warn patients and suggest ways patients can warn patients and tell them to seek care discuss with patients
manage;
manage when patients seek care
Abacavir (ABC) Seek care urgently:
Fever, vomiting, rash - this may indicate hypersensitivity to
abacavir
Lamivudine (3TC) Nausea
Diarrhoea
Lopinavir/ritonavir Nausea Changes in fat distribution:
Vomiting Arms, legs, buttocks, cheeks become THIN
Breasts, tummy, back of neck become FAT
Diarrhoea
Elevated blood cholesterol and glucose
Nevirapine (NVP) Nausea Seek care urgently:
Diarrhoea Yellow eyes
Severe skin rash
Fatigue AND shortness of breath
Fever
Zidovudine Nausea Seek care urgently:
(ZDV or AZT) Diarrhoea Pallor (anaemia)
Headache
Fatigue
Muscle pain
Efavirenz (EFV) Nausea Seek care urgently:
Diarrhoea Yellow eyes
Strange dreams Psychosis or confusion
Difficulty sleeping Severe skin rash
Memory problems
Headache
Dizziness
TREAT THE HIV INFECTED CHILD

Manage Side Effects of ARV Drugs

SIGNS or SYMPTOMS APPROPRIATE CARE RESPONSE
Yellow eyes (jaundice) or Stop drugs and REFER URGENTLY
abdominal pain
Rash If on abacavir, assess carefully. Is it a dry or wet lesion? Call for advice. If the rash is severe, generalized, or peeling, involves the mucosa or is associated with
fever or vomiting: stop drugs and REFER URGENTLY
Nausea Advise that the drug should be given with food. If persists for more than 2 weeks or worsens, call for advice or refer.
Vomiting Children may commonly vomit medication. Repeat the dose if the medication is seen in the vomitus, or if vomiting occurred 30 minutes of the dose being given.
If vomiting persists, the caregiver should bring the child to clinic for evaluation.
If vomiting everything, or vomiting associated with severe abdominal pain or difficulty breathing, REFER URGENTLY.
Diarrhoea Assess, classify, and treat using diarrhoea charts. Reassure mother that if due to ARV, it will improve in a few weeks. Follow-up as per chart booklet. If not
improved after two weeks, call for advice or refer.
Fever Assess, classify, and treat using feve chart.
Headache Give paracetamol. If on efavirenz, reassure that this is common and usually self-limiting. If persists for more than 2 weeks or worsens, call for advice or refer.
Sleep disturbances, This may be due to efavirenz. Give at night and take on an empty stomach with low-fat foods. If persists for more than 2 weeks or worsens, call for advice or
nightmares, anxiety refer.
Tingling, numb or painful feet If new or worse on treatment, call for advice or refer.
or legs
Changes in fat distribution Consider switching from stavudine to abacavir, consider to viral load. Refer if needed.
TREAT THE HIV INFECTED CHILD

Give Pain Relief to HIV Infected Child

Give paracetamol or ibuprofen every 6 hours if pain persists.
For severe pain, morphine syrup can be given.
PARACETAMOL ORAL MORPHINE
AGE or WEIGHT
TABLET (100 mg) SYRUP (120 mg/5ml) (0.5 mg/5 ml)

2 up to 4 months (4 - <6 kg) - 2 ml 0.5 ml

4 up to 12 months (6 - <10 kg) 1 2.5 ml 2 ml
12 months up to 2 years (10 - <12 kg) 1 1/2 5 ml 3 ml
2 up to 3 years (12 - <14 kg) 2 7.5 ml 4 ml
3 up to 5 years (14 -<19 kg) 2 10 ml 5 ml
Recommended dosages for ibuprofen
ibuprofen in children under the age of 3 months.

IMMUNIZE EVERY SICK CHILD AS NEEDED

FOLLOW-UP

GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS

DYSENTERY
Care for the child who returns for follow-up using all the boxes that match the
child's previous classifications. After 3 days:
If the child has any new problem, assess, classify and treat the new problem as on Assess the child for diarrhoea. > See ASSESS & CLASSIFY chart.
the ASSESS AND CLASSIFY chart.
Ask:
Are there fewer stools?
Is there less blood in the stool?
PNEUMONIA Is there less fever?
Is there less abdominal pain?
After 3 days: Is the child eating better?
Check the child for general danger signs.
Treatment:
Assess the child for cough or difficult breathing.
Ask: If the child is dehydrated, treat dehydration.
If number of stools, amount of blood in stools, fever, abdominal pain, or eating are worse or
Is the child breathing slower? See ASSESS & CLASSIFY chart.
the same:
Is there a chest indrawing? Change to second-line oral antibiotic recommended for dysentery in your area. Give it for 5 days.
Is there less fever? Advise the mother to return in 3 days. If you do not have the second line antibiotic, REFER to
Is the child eating better? hospital.
Exceptions - if the child: is less than 12 months old, or
Treatment: was dehydrated on the first visit, or REFER to hospital.
If any general danger sign or stridor, refer URGENTLY to hospital. if he had measles within the last 3 months
If chest indrawing and/or breathing rate, fever and eating are the same or worse, refer
URGENTLY to hospital. If fewer stools, less blood in the stools, less fever, less abdominal pain, and eating better,
If breathing slower, no chest indrawing, less fever, and eating better, complete the 5 days of continue giving ciprofloxacin until finished.
antibiotic.
Ensure that mother understands the oral rehydration method fully and that she also understands
the need for an extra meal each day for a week.

PERSISTENT DIARRHOEA
After 5 days: MALARIA
Ask:
Has the diarrhoea stopped? If fever persists after 3 days:
How many loose stools is the child having per day? Do a full reassessment of the child. > See ASSESS & CLASSIFY chart.
DO NOT REPEAT the Rapid Diagnostic Test if it was positive on the initial visit.
Treatment:
If the diarrhoea has not stopped (child is still having 3 or more loose stools per day), do a full Treatment:
reassessment of the child. Treat for dehydration if present. Then refer to hospital.
If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.
If the diarrhoea has stopped (child having less than 3 loose stools per day), tell the mother to follow
If the child has any othercause of fever other than malaria, provide appropriate treatment.
the usual feeding recommendations for the child's age.
If there is no other apparent cause of fever:
If fever has been present for 7 days, refer for assessment.
Do microscopy to look for malaria parasites. If parasites are present and the child has finished a
full course of the first line antimalarial, give the second-line antimalarial, if available, or refer the
child to a hospital.
If there is no other apparent cause of fever and you do not have a microscopy to check for
parasites, refer the child to a hospital.
GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS
EAR INFECTION
After 5 days:
FEVER: NO MALARIA Reassess for ear problem. > See ASSESS & CLASSIFY chart.
Measure the child's temperature.
If fever persists after 3 days:
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart. Treatment:
Repeat the malaria test. If there is , refer URGENTLY to
hospital.
Treatment: Acute ear infection:
If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE. If ear pain or discharge persists, treat with 5 more days of the same antibiotic. Continue wicking
to dry the ear. Follow-up in 5 days.
If a child has a positive malaria test, give first-line oral antimalarial. Advise the mother to return in 3
If no ear pain or discharge, praise the mother for her careful treatment. If she has not yet
days if the fever persists.
finished the 5 days of antibiotic, tell her to use all of it before stopping.
If the child has any other cause of fever other than malaria, provide treatment. Chronic ear infection:
If there is no other apparent cause of fever: Check that the mother is wicking the ear correctly and giving quinolone drops tree times a day.
If the fever has been present for 7 days, refer for assessment. Encourage her to continue.

MEASLES WITH EYE OR MOUTH COMPLICATIONS, GUM OR FEEDING PROBLEM

MOUTH ULCERS, OR THRUSH After 7 days:
Reassess feeding. > See questions in the COUNSEL THE MOTHER chart.
After 3 days: Ask about any feeding problems found on the initial visit.
Look for red eyes and pus draining from the eyes.
Look at mouth ulcers or white patches in the mouth (thrush). Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make
Smell the mouth. significant changes in feeding, ask her to bring the child back again.
If the child is classified as MODERATE ACUTE MALNUTRITION, ask the mother to return 30 days
Treatment for eye infection:
after the initial visit to measure the child's WFH/L, MUAC.
If pus is draining from the eye, ask the mother to describe how she has treated the eye infection. If
treatment has been correct, refer to hospital. If treatment has not been correct, teach mother correct
treatment.
If the pus is gone but redness remains, continue the treatment.
If no pus or redness, stop the treatment. ANAEMIA
After 14 days:
Treatment for mouth ulcers:
Give iron. Advise mother to return in 14 days for more iron.
If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to hospital.
Continue giving iron every 14 days for 2 months.
If mouth ulcers are the same or better, continue using half-strength gentian violet for a total of 5
If the child has palmar pallor after 2 months, refer for assessment.
days.

Treatment for thrush:

If thrush is worse check that treatment is being given correctly.
If the child has problems with swallowing, refer to hospital.
If thrush is the same or better, and the child is feeding well, continue nystatine for a total of 7 days.
GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS

UNCOMPLICATED SEVERE ACUTE MALNUTRITION

After 14 days or during regular follow up:
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart.
Assess child with the same measurements (WFH/L, MUAC) as on the initial visit.
Check for oedema of both feet.
Check the child's appetite by offering ready-to use therapeutic food if the child is 6 months or older.

Treatment:
If the child has COMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 z-scores or
MUAC is less than 115 mm or oedema of both feet AND has developed a medical complication
or oedema, or fails the appetite test), refer URGENTLY to hospital.
If the child has UNCOMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 z-scores
or MUAC is less than 115 mm or oedema of both feet but NO medical complication and passes
appetite test), counsel the mother and encourage her to continue with appropriate RUTF feeding. Ask
mother to return again in 14 days.
If the child has MODERATE ACUTE MALNUTRITION (WFH/L between -3 and -2 z-scores or MUAC
between 115 and 125 mm), advise the mother to continue RUTF. Counsel her to start other foods
according to the age appropriate feeding recommendations (see COUNSEL THE MOTHER chart). Tell

scores or more, and/or MUAC is 125 mm or more.

If the child has NO ACUTE MALNUTRITION (WFH/L is -2 z-scores or more, or MUAC is 125 mm or
more), praise the mother, STOP RUTF and counsel her about the age appropriate feeding
recommendations (see COUNSEL THE MOTHER chart).

MODERATE ACUTE MALNUTRITION

After 30 days:
Assess the child using the same measurement (WFH/L or MUAC) used on the initial visit:
If WFH/L, weigh the child, measure height or length and determine if WFH/L.
If MUAC, measure using MUAC tape.
Check the child for oedema of both feet.
Reassess feeding. See questions in the COUNSEL THE MOTHER chart.
Treatment:
If the child is no longer classified as MODERATE ACUTE MALNUTRITION, praise the mother and
encourage her to continue.
If the child is still classified as MODERATE ACUTE MALNUTRITION, counsel the mother about any
feeding problem found. Ask the mother to return again in one month. Continue to see the child monthly
until the child is feeding well and gaining weight regularly or his or her WFH/L is -2 z-scores or more or
MUAC is 125 mm. or more.
Exception:
If you do not think that feeding will improve, or if the child has lost weight or his or her MUAC has
diminished, refer the child.
GIVE FOLLOW-UP CARE FOR HIV EXPOSED AND INFECTED CHILD
CONFIRMED HIV INFECTION NOT ON ART
Follow up regularly as per national guidelines.
HIV EXPOSED At each follow-up visit follow these instructions:
Follow up regularly as per national guidelines. Ask the mother: Does the child have any problems?
At each follow-up visit follow these instructions: Do a full assessment including checking for mouth or gum problems, treat, counsel and follow up any
new problem
Ask the mother: Does the child have any problems?
Counsel and check if mother able or willing now to initiate ART for the child.
Do a full assessment including checking for mouth or gum problems, treat, counsel and follow up any
Provide routine child health care: Vitamin A, deworming, immunization, and feeding assessment and
new problem
counselling
Provide routine child health care: Vitamin A, deworming, immunization, and feeding assessment and
Continue cotrimoxazole prophylaxis if indicated.
counselling
Initiate or continue isoniazid preventive therapy if indicated.
Continue cotrimoxazole prophylaxis
If no acute illness and mother is willing, initiate ART (See Box Steps when Initiating ART in children)
Continue ARV prophylaxis if ARV drugs and breastfeeding are recommended; check adherence: How
Monitor CD4 count and percentage.
often, if ever, does the child/mother miss a dose?

Home care:
Plan for the next follow-up visit
Counsel the mother about any new or continuing problems
HIV testing:
If appropriate, put the family in touch with organizations or people who could provide support
If new HIV test result became available since the last visit, reclassify the child for HIV according to the Advise the mother about hygiene in the home, in particular when preparing food
test result. Plan for the next follow-up visit

to the test result.

If child is confirmed HIV infected
Start on ART and enrol in chronic HIV care.
Continue follow-up as for CONFIRMED HIV INFECTION ON ART
If child is confirmed uninfected
Continue with co-trimoxazole prophylaxis if breastfeeding or stop if the test resuls are after 6 weeks
of cessation of breastfeeding.
Counsel mother on preventing HIV infection through breastfeeding and about her own health
GIVE FOLLOW-UP CARE FOR HIV EXPOSED AND INFECTED CHILD

CONFIRMED HIV INFECTION ON ART: THE FOUR STEPS OF

FOLLOW-UP CARE
Follow up regularly as per national guidelines.
STEP 1: ASSESS AND CLASSIFY STEP 2: MONITOR PROGRESS ON ART
ASK: Does the child have any IF ANY OF FOLLOWING PRESENT, REFER
problems? NON-URGENTLY:
Has the child received care at another If any of these
health facility since the last visit? present, refer
CHECK: for general danger signs - If NON-
present, complete assessment, give URGENTLY:
pre-referral treatment, REFER Record the Child's weight Not gaining
URGENTLY. and height weight for 3
ASSESS, CLASSIFY, TREAT and Assess adherence months
COUNSEL any sick child as Ask about adherence: how Loss of
appropriate. often, if ever, does the milestones
CHECK for ART severe side effects child miss a dose? Record Poor
your assessment. adherence
Severe Assess and record clinical Stage
skin rash stage worse than
Assess clinical stage. before
Difficulty
breathing CD4 count
and stage at previous visits. lower than
If present, give before
severe Monitor laboratory results
any pre- LDL higher
abdominal Record results of tests
referral than 3.5
pain that have been sent.
treatment, mmol/L
Yellow
REFER TG higher
eyes
URGENTLY than 5.6
Fever,
vomiting, mmol/L
rash (only Manage side effects
if on Send tests that are due
Abacavir)
Check for other ART side effects
STEP 3: PROVIDE ART, STEP 4: COUNSEL THE MOTHER OR CAREGIVER
COTRIMOXAZOLE AND ROUTINE
TREATMENTS Use every visit to educate and provide support to
If child is stable: continue with the the mother or caregiver
ART regimen and cotrimoxazole doses.
Key issues to discuss include:
Check for appropriate doses:
remember these will need to increase How the child is progressing, feeding, adherence,
as the child grows side-effects and correct management, disclosure
Give routine care: Vitamin A (to others and the child), support for the caregiver
supplementation, deworming, and
immunization as needed Remember to check that the mother and other
family members are receiving the care that
they need
Set a follow-up visit: if well, follow-up as per
nastional guidelines. If problems, follow-up as
indicated.
COUNSEL THE MOTHER

FEEDING COUNSELLING

Assess Child's Appetite

All children aged 6 months or more with SEVERE ACUTE MALNUTRITION (oedema of both feet or WFH/L less than -3 z-scores or MUAC less than 115 mm) and no medical
complication should be assessed for appetite.
Appetite is assessed on the initial visit and at each follow-up visit to the health facility. Arrange a quiet corner where the child and mother can take their time to get accustomed to eating the
RUTF. Usually the child eats the RUTF portion in 30 minutes.
Explain to the mother:
The purpose of assessing the child's appetite.
What is ready-to-use-therapeutic food (RUTF).
How to give RUTF:
Wash hands before giving the RUTF.
Sit with the child on the lap and gently offer the child RUTF to eat.
Encourage the child to eat the RUTF without feeding by force.
Offer plenty of clean water to drink from a cup when the child is eating the RUTF.
Offer appropriate amount of RUTF to the child to eat:
After 30 minutes check if the child was able to finish or not able to finish the amount of RUTF given and decide:
Child ABLE to finish at least one-third of a packet of RUTF portion (92 g) or 3 teaspoons from a pot within 30 minutes.
Child NOT ABLE to eat one-third of a packet of RUTF portion (92 g) or 3 teaspoons from a pot within 30 minutes.
FEEDING COUNSELLING

Assess Child's Feeding

Assess feeding if child is Less Than 2 Years Old, Has MODERATE ACUTE MALNUTRITION, ANAEMIA, CONFIRMED HIV INFECTION, or is HIV EXPOSED. Ask questions about the child's usual
feeding and feeding during this illness. Compare the mother's answers to the Feeding Recommendations for the child's age.
ASK - How are you feeding your child?
If the child is receiving any breast milk, ASK:
How many times during the day?
Do you also breastfeed during the night?

Does the child take any other food or fluids?

What food or fluids?
How many times per day?
What do you use to feed the child?
If MODERATE ACUTE MALNUTRITION or if a child with CONFIRMED HIV INFECTION fails to gain weight or loses weight between monthly measurements, ASK:
How large are servings?
Does the child receive his own serving?
Who feeds the child and how?
What foods are available in the home?
During this illness, has the child's feeding changed?
If yes, how?

In addition, for HIV EXPOSED child:

If mother and child are on ARV treatment or prophylaxis and child breastfeeding, ASK:
Do you take ARV drugs? Do you take all doses, miss doses, do not take medication?
Does the child take ARV drugs (If the policy is to take ARV prophylaxis until 1 week after breastfeeding has stopped)? Does he or she take all doses, missed doses,
does not take medication?
If child not breastfeeding, ASK:
What milk are you giving?
How many times during the day and night?
How much is given at each feed?
How are you preparing the milk?
Let the mother demonstrate or explain how a feed is prepared, and how it is given to the infant.
Are you giving any breast milk at all?
Are you able to get new supplies of milk before you run out?
How is the milk being given? Cup or bottle?
How are you cleaning the feeding utensils?
FEEDING COUNSELLING

Feeding Recommendations
Feeding recommendations FOR ALL CHILDREN during sickness and health, and including HIV EXPOSED children on ARV prophylaxis
Newborn, birth up to 1 week 1 week up to 6 6 up to 9 months 9 up to 12 months 12 months up to 2 years 2 years and older
months

Immediately after birth, put your baby in Breastfeed as often Breastfeed as Breastfeed as often Breastfeed as often Give a variety of
skin to skin contact with you. as your child wants. often as your child as your child wants. as your child wants. family foods to
Allow your baby to take the breast within Look for signs of wants. Also give a variety of Also give a variety of your child,
the first hour. Give your baby colostrum, hunger, such as Also give thick mashed or finely mashed or finely including animal-
the first yellowish, thick milk. It protects beginning to fuss, porridge or well- chopped family food, chopped family food, source foods and
the baby from many Illnesses. sucking fingers, or mashed foods, including animal- including animal- vitamin A-rich
Breastfeed day and night, as often as your moving lips. including animal- source foods and source foods and fruits and
baby wants, at least 8 times In 24 hours. Breastfeed day and source foods and vitamin A-rich fruits vitamin A-rich fruits vegetables.
Frequent feeding produces more milk. night whenever vitamin A-rich and vegetables. and vegetables. Give at least 1 full
If your baby is small (low birth weight), your baby wants, at fruits and Give 1/2 cup at each Give 3/4 cup at each cup (250 ml) at
feed at least every 2 to 3 hours. Wake the least 8 times in 24 vegetables. meal(1 cup = 250 ml). meal (1 cup = 250 each meal.
baby for feeding after 3 hours, if baby hours. Frequent Start by giving 2 to Give 3 to 4 meals ml). Give 3 to 4 meals
does not wake self. feeding produces 3 tablespoons of each day. Give 3 to 4 meals each day.
DO NOT give other foods or fluids. Breast more milk. food. Gradually Offer 1 or 2 snacks each day. Offer 1 or 2
milk is all your baby needs. This is Do not give other increase to 1/2 between meals. The Offer 1 to 2 snacks snacks between
especially important for infants of HIV- foods or fluids. cups (1 cup = 250 child will eat if between meals. meals.
positive mothers. Mixed feeding Breast milk is all ml). hungry. Continue to feed If your child
increases the risk of HIV mother-to-child your baby needs. Give 2 to 3 meals For snacks, give your child slowly, refuses a new
transmission when compared to each day. small chewable patiently. Encourage food, offer
exclusive breastfeeding. Offer 1 or 2 items that the child "tastes" several
snacks each day can hold. Let your your child to eat. times. Show that
between meals child try to eat the you like the food.
when the child snack, but provide Be patient.
seems hungry. help if needed. Talk with your
child during a
meal, and keep
eye contact.
A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables.
FEEDING COUNSELLING

Feeding Recommendations for HIV EXPOSED Child on Infant Formula

These feeding recommendations are for HIV EXPOSED children in setting where the national authorities recommend to avoid all breastfeeding or when the mother has chosen
formula feeding.
PMTCT: If the baby is on AZT for prophylaxis, continue until 4 to 6 weeks of age.
Up to 6 months 6 up to 12 monts 12 months up to 2 years Safe preparation of replacement feeding

Infant formula
Always use a marked cup or glass and
spoon to measure water and the
scoop to measure the formula
powder.
Wash your hands before preparing a
feed.
Bring the water to boil and then let it
cool. Keep it covered while it cools.
FORMULA FEED exclusively. Do not give Give 1-2 cups (250 - 500 ml) of infant Give 1-2 cups (250 - 500 ml) of boiled,
Measure the formula powder into a
any breast milk. Other foods or fluids formula or boiled, then cooled, full then cooled, full cream milk or infant
marked cup or glass. Make the scoops
are not necessary. cream milk. Give milk with a cup, not a formula.
level. Put in one scoop for every 25 ml
Prepare correct strength and amount bottle. Give milk with a cup, not a bottle.
of water.
just before use. Use milk within two Give: Give: Add a small amount of the cooled
boiled water and stir. Fill the cup or
can store formula for 24 hours.
glass to the mark with the water. Stir
Cup feeding is safer than bottle
well.
feeding. Clean the cup and utensils * * Feed the infant using a cup.
with hot soapy water.
Start by giving 2-3 tablespoons of food 2 or family foods 3 or 4 times per day. Give Wash the utensils.
Give the following amounts of formula 8 - 3 times a day. Gradually increase to 1/2 3/4 cup (1 cup = 250 ml) at each meal.
to 6 times per day: cup (1 cup = 250 ml) at each meal and to
Offer 1-2 snacks between meals.
Age in months Approx. amount and times giving meals 3-4 times a day.
Continue to feed your child slowly, Cow' s or other animal milks are not
per day Offer 1-2 snacks each day when the
patiently. suitable for infants below 6 months of
0 up to 1 60 ml x 8 child seems hungry.
Encourage - but do not force - your child age (even modified).
1 up to 2 90 ml x 7 For snacks give small chewable items
to eat. For a child between 6 and 12 month of
2 up to 4 120 ml x 6 that the child can hold. Let your child try to
4 up to 6 150 ml x 6 age: boil the milk and let it cool (even if
eat the snack, but provide help if needed.
pasteurized).
Feed the baby using a cup.

* A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables.
FEEDING COUNSELLING

Stopping Breastfeeding
STOPPING BREASTFEEDING means changing from all breast milk to no breast milk.
This should happen gradually over one month. Plan in advance for a safe transition.
1. HELP MOTHER PREPARE:
Mother should discuss and plan in advance with her family, if possible
Express milk and give by cup

Learn how to prepare a store milk safely at home

2. HELP MOTHER MAKE TRANSITION:

Teach mother to cup feed (See chart booklet Counsel part in Assess, classify and treat the sick young infant aged up to 2 months)
Clean all utensils with soap and water

3. STOP BREASTFEEDING COMPLETELY:

Express and discard enough breast milk to keep comfortable until lactation stops

Feeding Recommendations For a Child Who Has PERSISTENT DIARRHOEA

If still breastfeeding, give more frequent, longer breastfeeds, day and night.
If taking other milk:
replace with increased breastfeeding OR
replace with fermented milk products, such as yoghurt OR
replace half the milk with nutrient-rich semisolid food.
For other foods, follow feeding recommendations for the child's age.
EXTRA FLUIDS AND MOTHER'S HEALTH

Advise the Mother to Increase Fluid During Illness

FOR ANY SICK CHILD:
Breastfeed more frequently and for longer at each feed. If child is taking breast-milk substitutes, increase the amount of milk given.
Increase other fluids. For example, give soup, rice water, yoghurt drinks or clean water.

FOR CHILD WITH DIARRHOEA:

Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B on TREAT THE CHILD chart.

Counsel the Mother about her Own Health

If the mother is sick, provide care for her, or refer her for help.
If she has a breast problem (such as engorgement, sore nipples, breast infection), provide care for her or refer her for help.
Advise her to eat well to keep up her own strength and health.
Check the mother's immunization status and give her tetanus toxoid if needed.
Make sure she has access to:
Family planning
Counselling on STD and AIDS prevention.

Give additional counselling if the mother is HIV-positive

Emphasize good hygiene, and early treatment of illnesses

WHEN TO RETURN

Advise the Mother When to Return to Health Worker

FOLLOW-UP VISIT: Advise the mother to come for follow-up at the earliest time listed for the child's
problems.
If the child has: Return for
follow-up in:
PNEUMONIA 3 days
DYSENTERY
MALARIA, if fever persists
FEVER: NO MALARIA, if fever persists
WHEN TO RETURN IMMEDIATELY
MEASLES WITH EYE OR MOUTH
COMPLICATIONS Advise mother to return immediately if the child has any of these signs:
MOUTH OR GUM ULCERS OR THRUSH Any sick child Not able to drink or breastfeed
5 days Becomes sicker
PERSISTENT DIARRHOEA
Develops a fever
ACUTE EAR INFECTION
CHRONIC EAR INFECTION If child has COUGH OR COLD, also return if: Fast breathing
COUGH OR COLD, if not improving Difficult breathing
UNCOMPLICATED SEVERE ACUTE If child has diarrhoea, also return if: Blood in stool
14 days
MALNUTRITION Drinking poorly
FEEDING PROBLEM
ANAEMIA 14 days
MODERATE ACUTE MALNUTRITION 30 days
CONFIRMED HIV INFECTION According to national
HIV EXPOSED recommendations

NEXT WELL-CHILD VISIT: Advise the mother to return for next immunization according to
immunization schedule.
SICK YOUNG INFANT AGE UP TO 2 MONTHS

ASSESS AND CLASSIFY THE SICK YOUNG INFANT

ASSESS CLASSIFY IDENTIFY TREATMENT
DO A RAPID APRAISAL OF ALL WAITING INFANTS
ASK THE MOTHER WHAT THE YOUNG INFANT'S
PROBLEMS ARE USE ALL BOXES THAT MATCH THE
INFANT'S SYMPTOMS AND
Determine if this is an initial or follow-up visit for this PROBLEMS TO CLASSIFY THE
problem.
ILLNESS
if follow-up visit, use the follow-up instructions.
if initial visit, assess the child as follows:
CHECK FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION

ASK: LOOK, LISTEN, FEEL: Any one of the following Pink: Give first dose of intramuscular antibiotics
Is the infant having Count the signs VERY SEVERE Treat to prevent low blood sugar
Classify ALL YOUNG
difficulty in feeding? breaths in one DISEASE Refer URGENTLY to hospital **
YOUNG INFANTS Not feeding well or
Has the infant had minute. Repeat Advise mother how to keep the infant warm
INFANT Convulsions or
convulsions (fits)? the count if more on the way to the hospital
MUST Fast breathing (60 breaths
than 60 breaths
BE per minute or more) or
per minute.
CALM Severe chest indrawing or
Look for severe
or
chest indrawing.
Low body temperature (less
Measure axillary or
temperature. Movement only when
Look at the umbilicus. Is it stimulated or no movement
red or draining pus? at all.
Look for skin pustules.
Umbilicus red or draining pus Yellow: Give an appropriate oral antibiotic
Look at the young infant's
Skin pustules LOCAL Teach the mother to treat local infections at home
movements.
If infant is sleeping, ask
BACTERIAL Advise mother to give home care for the young
the mother to wake
INFECTION infant
him/her. Follow up in 2 days
Does the infant move None of the signs of very Green: Advise mother to give home care.
on his/her own? severe disease or local SEVERE DISEASE
If the young infant is not bacterial infection OR LOCAL
moving, gently stimulate INFECTION
him/her. UNLIKELY
Does the infant not
move at all?

** If referral is not possible, management the sick young infant as described in the national referral care guidelines or WHO Pocket Book for hospital care for children.
CHECK FOR JAUNDICE

If jaundice present, ASK: LOOK AND FEEL: Any jaundice if age less Pink: Treat to prevent low blood sugar
When did the jaundice Look for jaundice (yellow than 24 hours or SEVERE JAUNDICE Refer URGENTLY to hospital
appear first? eyes or skin) CLASSIFY Yellow palms and soles at Advise mother how to keep the infant warm
Look at the young infant's JAUNDICE any age on the way to the hospital
palms and soles. Are they
Jaundice appearing after 24 Yellow: Advise the mother to give home care for the
yellow?
hours of age and JAUNDICE young infant
Palms and soles not yellow Advise mother to return immediately if palms and
soles appear yellow.
If the young infant is older than 14 days, refer to a
hospital for assessment
Follow-up in 1 day
No jaundice Green: Advise the mother to give home care for the
NO JAUNDICE young infant

THEN ASK: Does the young infant have diarrhoea*?

IF YES, LOOK AND FEEL: Two of the following signs: Pink: If infant has no other severe classification:
Look at the young infant's general condition: Movement only when SEVERE Give fluid for severe dehydration (Plan C)
Infant's movements Classify stimulated or no movement DEHYDRATION OR
Does the infant move on his/her own? DIARRHOEA for at all If infant also has another severe
Does the infant not move even when stimulated but DEHYDRATION Sunken eyes classification:
then stops? Skin pinch goes back very Refer URGENTLY to hospital with
Does the infant not move at all? slowly. mother giving frequent sips of ORS on
Is the infant restless and irritable? the way
Advise the mother to continue
Look for sunken eyes.
breastfeeding
Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)? Two of the following signs: Yellow: Give fluid and breast milk for some dehydration
or slowly? Restless and irritable SOME (Plan B)
Sunken eyes DEHYDRATION If infant has any severe classification:
Skin pinch goes back Refer URGENTLY to hospital with
slowly. mother giving frequent sips of ORS on
the way
Advise the mother to continue
breastfeeding
Advise mother when to return immediately
Follow-up in 2 days if not improving
Not enough signs to classify Green: Give fluids to treat diarrhoea at home and
as some or severe NO DEHYDRATION continue breastfeeding (Plan A)
dehydration. Advise mother when to return immediately
Follow-up in 2 days if not improving

* What is diarrhoea in a young infant?

A young infant has diarrhoea if the stools have changed from usual pattern and are many and watery (more water than faecal matter).
The normally frequent or semi-solid stools of a breastfed baby are not diarrhoea.
THEN CHECK FOR HIV INFECTION

Positive virological test in Yellow: Give cotrimoxazole prophylaxis from age 4-6
ASK young infant CONFIRMED HIV weeks
Classify INFECTION Give HIV ART and care
Has the mother and/or young infant had an HIV test? HIV Advise the mother on home care
status
Follow-up regularly as per national guidelines
IF YES: Mother HIV positive AND Yellow: Give cotrimoxazole prophylaxis from age 4-6
What is the mother's HIV status?: negative virological test HIV EXPOSED weeks
Serological test POSITIVE or NEGATIVE in young Start or continue PMTCT ARV prophylaxis as per
What is the young infant's HIV status?: infant breastfeeding or if national recommendations**
Virological test POSITIVE or NEGATIVE only stopped less than 6 Do virological test at age 4-6 weeks or repeat 6
Serological test POSITIVE or NEGATIVE weeks ago. weeks after the child stops breastfeeding
OR Advise the mother on home care
If mother is HIV positive and NO positive virological test Mother HIV positive, young Follow-up regularly as per national guidelines
in child ASK: infant not yet tested
Is the young infant breastfeeding now? OR
Was the young infant breastfeeding at the time of test Positive serological test in
or before it? young infant
Is the mother and young infant on PMTCT ARV
Negative HIV test in mother Green: Treat, counsel and follow-up existing infections
prophylaxis?*
or young infant HIV INFECTION
UNLIKELY

IF NO test: Mother and young infant status unknown

Perform HIV test for the mother; if positive, perform
virological test for the young infant

* Prevention of Maternal-To-Child-Transmission (PMTCT) ART prophylaxis.

**Initiate triple ART for all pregnant and lactating women with HIV infection, and put their infants on ART prophylaxis from birth for 6 weeks if breastfeeding or 4-6 weeks if on replacement
feeding.
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE
Use this table to assess feeding of all young infants except HIV-exposed young infants not breastfed. For HIV-exposed non-breastfed young infants see chart "THEN CHECK FOR FEEDING
PROBLEM OR LOW WEIGHT FOR AGE IN NON-BREASTFED INFANTS"
If an infant has no indications to refer urgently to hospital:

Ask: LOOK, LISTEN, FEEL: Not well attached to breast Yellow: If not well attached or not suckling effectively,
Is the infant breastfed? If Determine weight for age. or FEEDING PROBLEM teach correct positioning and attachment
yes, how many times in 24 Look for ulcers or white Classify FEEDING Not suckling effectively or OR If not able to attach well immediately, teach the
hours? patches in the mouth Less than 8 breastfeeds in LOW WEIGHT mother to express breast milk and feed by a cup
Does the infant usually (thrush). 24 hours or If breastfeeding less than 8 times in 24 hours,
receive any other foods or Receives other foods or advise to increase frequency of feeding. Advise
drinks? If yes, how often? drinks or the mother to breastfeed as often and as long as
If yes, what do you use to Low weight for age or the infant wants, day and night
feed the infant? Thrush (ulcers or white If receiving other foods or drinks, counsel the
patches in mouth). mother about breastfeeding more, reducing other
foods or drinks, and using a cup
If not breastfeeding at all*:
Refer for breastfeeding counselling and
possible relactation*
Advise about correctly preparing breast-milk
substitutes and using a cup
Advise the mother how to feed and keep the low
weight infant warm at home
If thrush, teach the mother to treat thrush at home
Advise mother to give home care for the young
infant
Follow-up any feeding problem or thrush in 2 days
Follow-up low weight for age in 14 days
Not low weight for age and Green: Advise mother to give home care for the young
no other signs of inadequate NO FEEDING infant
feeding. PROBLEM Praise the mother for feeding the infant well

ASSESS BREASTFEEDING:
Has the infant breastfed in the previous hour?
If the infant has not fed in the previous hour, ask the
mother to put her infant to the breast. Observe the
breastfeed for 4 minutes.
(If the infant was fed during the last hour, ask the mother if
she can wait and tell you when the infant is willing to feed
again.)
Is the infant well attached?
not well attached good attachment
TO CHECK ATTACHMENT, LOOK FOR:
Chin touching breast
Mouth wide open
Lower lip turned outwards
More areola visible above than below the mouth
(All of these signs should be present if the attachment is
good.)
Is the infant suckling effectively (that is, slow deep sucks,
sometimes pausing)?
not suckling effectively suckling effectively
Clear a blocked nose if it interferes with breastfeeding.

* Unless not breastfeeding because the mother is HIV positive.

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN NON-BREASTFED INFANTS
Use this chart for HIV EXPOSED infants not breastfeeding AND the infant has no indications to refer urgently to hospital:

Ask: LOOK, LISTEN, FEEL: Milk incorrectly or Yellow: Counsel about feeding
What milk are you giving? Determine weight for age. unhygienically prepared or FEEDING PROBLEM Explain the guidelines for safe replacement feeding
How many times during the Look for ulcers or white Classify FEEDING
Giving inappropriate OR Identify concerns of mother and family about
day and night? patches in the mouth replacement feeds or LOW WEIGHT feeding.
How much is given at each (thrush). If mother is using a bottle, teach cup feeding
Giving insufficient
feed? Advise the mother how to feed and keep the low
replacement feeds or
How are you preparing the weight infant warm at home
milk? An HIV positive mother
If thrush, teach the mother to treat thrush at home
mixing breast and other
Let mother demonstrate or Advise mother to give home care for the young
feeds before 6 months or
explain how a feed is infant
prepared, and how it is Using a feeding bottle or
Follow-up any feeding problem or thrush in 2 days
given to the infant. Low weight for age or Follow-up low weight for age in 14 days
Are you giving any breast Thrush (ulcers or white
milk at all? patches in mouth).
What foods and fluids in Not low weight for age and Green: Advise mother to give home care for the young
addition to replacement no other signs of inadequate NO FEEDING infant
feeds is given? feeding. PROBLEM Praise the mother for feeding the infant well
How is the milk being
given?
Cup or bottle?
How are you cleaning the
feeding utensils?
THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN A STATUS:

IMMUNIZATION SCHEDULE: AGE VACCINE VITAMIN

A
Birth BCG OPV-0 Hep B0 200 000
IU to the
mother
within 6
weeks of
delivery
6 weeks DPT+HIB-1 OPV-1 Hep B1 RTV1 PCV1

Give all missed doses on this visit.

Include sick infants unless being referred.
Advise the caretaker when to return for the next dose.

ASSESS OTHER PROBLEMS

Nutritional status and anaemia, contraception. Check hygienic practices.

TREAT AND COUNSEL

TREAT THE YOUNG INFANT

GIVE FIRST DOSE OF INTRAMUSCULAR ANTIBIOTICS

Give first dose of both ampicillin and gentamicin intramuscularly.
AMPICILLIN
Dose: 50 mg per kg GENTAMICIN
To a vial of 250 mg
WEIGHT Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml OR Add 6 ml sterile water to 2 ml vial containing 80
mg* = 8 ml at 10 mg/ml
Add 1.3 ml sterile water = 250 mg/1.5ml
AGE <7 days AGE >= 7 days
Dose: 5 mg per kg Dose: 7.5 mg per kg
1-<1.5 kg 0.4 ml 0.6 ml* 0.9 ml*
1.5-<2 kg 0.5 ml 0.9 ml* 1.3 ml*
2-<2.5 kg 0.7 ml 1.1 ml* 1.7 ml*
2.5-<3 kg 0.8 ml 1.4 ml* 2.0 ml*
3-<3.5 kg 1.0 ml 1.6 ml* 2.4 ml*
3.5-<4 kg 1.1 ml 1.9 ml* 2.8 ml*
4-<4.5 kg 1.3 ml 2.1 ml* 3.2 ml*
* Avoid using undiluted 40 mg/ml gentamicin.
Referral is the best option for a young infant classified with VERY SEVERE DISEASE. If referral is not possible, continue to give ampicillin and gentamicin for at least 5 days. Give ampicillin two times
daily to infants less than one week of age and 3 times daily to infants one week or older. Give gentamicin once daily.

TREAT THE YOUNG INFANT TO PREVENT LOW BLOOD SUGAR

If the young infant is able to breastfeed:
Ask the mother to breastfeed the young infant.
If the young infant is not able to breastfeed but is able to swallow:
Give 20-50 ml (10 ml/kg) expressed breast milk before departure. If not possible to give expressed breast milk, give 20-50 ml (10 ml/kg) sugar water (To make sugar water: Dissolve 4 level
teaspoons of sugar (20 grams) in a 200-ml cup of clean water).
If the young infant is not able to swallow:
Give 20-50 ml (10 ml/kg) of expressed breast milk or sugar water by nasogastric tube.
TREAT THE YOUNG INFANT

TEACH THE MOTHER HOW TO KEEP THE YOUNG INFANT WARM ON THE WAY TO THE HOSPITAL
Provide skin to skin contact
OR
Keep the young infant clothed or covered as much as possible all the time. Dress the young infant with extra clothing including hat, gloves, socks and wrap the infant in a soft dry cloth and cover with
a blanket.

GIVE AN APPROPRIATE ORAL ANTIBIOTIC FOR LOCAL BACTERIAL INFECTION

First-line antibiotic: ___________________________________________________________________________________________
Second-line antibiotic:_________________________________________________________________________________________
AMOXICILLIN
Give 2 times daily for 5 days
AGE or WEIGHT
Tablet Syrup
250 mg 125 mg in 5 ml
Birth up to 1 month (<4 kg) 1/4 2.5 ml
1 month up to 2 months (4-<6 kg) 1/2 5 ml
.

TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

Explain how the treatment is given.
Watch her as she does the first treatment in the clinic.
Tell her to return to the clinic if the infection worsens.

To Treat Skin Pustules or Umbilical Infection To Treat Thrush (ulcers or white patches in mouth)
The mother should do the treatment twice daily for 5 days: The mother should do the treatment four times daily for 7 days:
Wash hands Wash hands
Gently wash off pus and crusts with soap and water Paint the mouth with half-strength gentian violet (0.25%) using a soft cloth wrapped around the finger
Dry the area Wash hands
Paint the skin or umbilicus/cord with full strength gentian violet (0.5%)
Wash hands

To Treat Diarrhoea, See TREAT THE CHILD Chart.

TREAT THE YOUNG INFANT

Immunize Every Sick Young Infant, as Needed

GIVE ARV FOR PMTCT PROPHYLAXIS

Initiate triple ART for all pregnant and lactating women with HIV infection, and put their infants on ART prophylaxis*:
Nevirapine or zidovudine are provided to young infant classified as HIV EXPOSED to minimize the risk of mother-to-child HIV transmission (PMTCT).
If breast feeding: Give NVP for 6 weeks beginning at birth or when HIV exposure is recognized.
If not breast feeding: Give NVP or ZDV for 4-6 weeks beginning at birth or when HIV exposure is recognized.
NEVIRAPINE ZIDOVUDINE (AZT)
AGE
Give once daily. Give once daily
Birth up to 6 weeks:
Birth weight 2000 - 2499 g 10 mg 10 mg
Birth weight > 2500 g 15 mg 15 mg
Over 6 weeks: 20 mg -

* PREVENTION OF MATERNAL-TO-CHILD-TRANSMISSION (PMTCT) ART PROPHYLAXIS:

OPTION B+: MOTHER ON LIFELONG TRIPLE ART REGIMEN, YOUNG INFANT ON NVP PROPHYLAXIS FROM BIRTH FOR 6 WEEKS IF BREASTFEEDING OR NVP OR AZT FOR 4-6 WEEKS IF ON
REPLACEMENT FEEDING.
OPTION B: MOTHER ON TRIPLE ART REGIMEN TO BE DISCONTINUED ONE WEEK AFTER CESSATION OF BREASTFEEDING, YOUNG INFANT ON NVP PROPHYLAXIS FROM BIRTH FOR 6 WEEKS OR NVP OR
AZT FOR 4-6 WEEKS IF ON REPLACEMENT FEEDING.
COUNSEL THE MOTHER
TEACH THE MOTHER HOW TO KEEP THE LOW WEIGHT INFANT
WARM AT HOME
TEACH CORRECT POSITIONING AND ATTACHMENT FOR
Keep the young infant in the same bed with the mother.
BREASTFEEDING
of cold air.
Show the mother how to hold her infant.
Avoid bathing the low weight infant. When washing or bathing, do it in a very warm room with warm
with the infant's head and body in line. water, dry immediately and thoroughly after bathing and clothe the young infant immediately.
with the infant approaching breast with nose opposite to the nipple. Change clothes (e.g. nappies) whenever they are wet.
with the infant held close to the mother's body. Provide skin to skin contact as much as possible, day and night. For skin to skin contact:
with the infant's whole body supported, not just neck and shoulders. Dress the infant in a warm shirt open at the front, a nappy, hat and socks.
Place the infant in skin to skin contact on the mother's chest between her breasts. Keep the infat's
Show her how to help the infant to attach. She should: head turned to one side.
touch her infant's lips with her nipple Cover the infant with mother's clothes (and an additional warm blanket in cold weather).
wait until her infant's mouth is opening wide When not in skin to skin contact, keep the young infant clothed or covered as much as possible at all
move her infant quickly onto her breast, aiming the infant's lower lip well below the nipple. times. Dress the young infant with extra clothing including hat and socks, loosely wrap the young
infant in a soft dry cloth and cover with a blanket.
Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try Check frequently if the hands and feet are warm. If cold, re-warm the baby using skin to skin contact.
again. Breastfeed the infant frequently (or give expressed breast milk by cup).

TEACH THE MOTHER HOW TO EXPRESS BREAST MILK

Ask the mother to:
Wash her hands thoroughly.
Make herself comfortable.
Hold a wide necked container under her nipple and areola.
Place her thumb on top of the breast and the first finger on the under side of the breast so they
are opposite each other (at least 4 cm from the tip of the nipple).
Compress and release the breast tissue between her finger and thumb a few times.
If the milk does not appear she should re-position her thumb and finger closer to the nipple and
compress and release the breast as before.
Compress and release all the way around the breast, keeping her fingers the same distance from
the nipple. Be careful not to squeeze the nipple or to rub the skin or move her thumb or finger on
the skin.
Express one breast until the milk just drips, then express the other breast until the milk just drips.
Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes.
Stop expressing when the milk no longer flows but drips from the start.

TEACH THE MOTHER HOW TO FEED BY A CUP

Put a cloth on the infant's front to protect his clothes as some milk can spill.
Hold the infant semi-upright on the lap.
Put a measured amount of milk in the cup.
Hold the cup so that it rests lightly on the infant's lower lip.
Tip the cup so that the milk just reaches the infant's lips.
Allow the infant to take the milk himself. DO NOT pour the milk into the infant's mouth.
COUNSEL THE MOTHER

ADVISE THE MOTHER TO GIVE HOME CARE FOR THE YOUNG

INFANT
1. EXCLUSIVELY BREASTFEED THE YOUNG INFANT
Give only breastfeeds to the young infant. Breastfeed frequently, as often and for as long as the
infant wants.
2. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES.
In cool weather cover the infant's head and feet and dress the infant with extra clothing.
3. WHEN TO RETURN:
Follow up visit
If the infant has: Return for first follow-up in:
JAUNDICE 1 day
LOCAL BACTERIAL INFECTION 2 days
FEEDING PROBLEM
THRUSH
DIARRHOEA
LOW WEIGHT FOR AGE 14 days
CONFIRMED HIV INFECTION According to national recommendations
HIV EXPOSED

WHEN TO RETURN IMMEDIATELY:

Advise the mother to return immediately if the young infant has any of these
signs:
Breastfeeding poorly
Reduced activity
Becomes sicker
Develops a fever
Feels unusually cold
Fast breathing
Difficult breathing
Palms and soles appear yellow
FOLLOW-UP

GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT

ASSESS EVERY YOUNG INFANT FOR "VERY SEVERE DISEASE" DURING FOLLOW-UP VISIT

LOCAL BACTERIAL INFECTION

After 2 days:
Look at the umbilicus. Is it red or draining pus?
Look at the skin pustules.

Treatment:
If umbilical pus or redness remains same or is worse, refer to hospital. If pus and redness are improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local
infection at home.
If skin pustules are same or worse, refer to hospital. If improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home.

DIARRHOEA
After 2 days:
Ask: Has the diarrhoea stopped?

Treatment
If the diarrhoea has not stopped, assess and treat the young infant for diarrhoea. >SEE "Does the Young Infant Have Diarrhoea?"
If the diarrhoea has stopped, tell the mother to continue exclusive breastfeeding.
GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT

JAUNDICE
After 1 day:
Look for jaundice. Are palms and soles yellow?

Treatment:
If palms and soles are yellow, refer to hospital.
If palms and soles are not yellow, but jaundice has not decreased, advise the mother home care and ask her to return for follow up in 1 day.
If jaundice has started decreasing, reassure the mother and ask her to continue home care. Ask her to return for follow up at 2 weeks of age. If jaundice continues beyond two weeks of age, refer
the young infant to a hospital for further assessment.

FEEDING PROBLEM
After 2 days:
Reassess feeding. > See "Then Check for Feeding Problem or Low Weight".
Ask about any feeding problems found on the initial visit.
Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make significant
changes in feeding, ask her to bring the young infant back again.
If the young infant is low weight for age, ask the mother to return 14 days of this follow up visit. Continue follow-up until the infant is gaining weight well.

Exception:
If you do not think that feeding will improve, or if the young infant has lost weight, refer the child.

LOW WEIGHT FOR AGE

After 14 days:
Weigh the young infant and determine if the infant is still low weight for age.
Reassess feeding. > See "Then Check for Feeding Problem or Low Weight".
If the infant is no longer low weight for age, praise the mother and encourage her to continue.
If the infant is still low weight for age, but is feeding well, praise the mother. Ask her to have her infant weighed again within 14 days or when she returns for immunization, whichever is the
earlier.
If the infant is still low weight for age and still has a feeding problem, counsel the mother about the feeding problem. Ask the mother to return again in 14 days (or when she returns for
immunization, if this is within 14 days). Continue to see the young infant every few weeks until the infant is feeding well and gaining weight regularly and is no longer low weight for age.

Exception:
If you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.
GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT

THRUSH
After 2 days:
Look for ulcers or white patches in the mouth (thrush).
Reassess feeding. > See "Then Check for Feeding Problem or Low Weight".
If thrush is worse check that treatment is being given correctly.
If the infant has problems with attachment or suckling, refer to hospital.
If thrush is the same or better, and if the infant is feeding well, continue half-stregth gentian violet for a total of 7 days.

CONFIRMED HIV INFECTION OR HIV EXPOSED

A young infant classified as CONFIRMED HIV INFECTION or HIV EXPOSED should return for follow-up visits regularly as per national guidelines.
Follow the instructions for follow-up care for child aged 2 months up to 5 years.
Annex:

Skin Problems

IDENTIFY SKIN PROBLEM

IDENTIFY SKIN PROBLEM

IF SKIN IS ITCHING
SIGNS CLASSIFY TREATMENT UNIQUE FEATURES IN HIV
AS:
Itching rash with small papules PAPULAR Treat itching: Is a clinical stage 2 defining case
and scratch marks. Dark spots ITCHING Calamine lotion
with pale centres RASH Antihistamine oral
(PRURIGO) If not improves 1% hydrocortisone
Can be early sign of HIV and needs assessment
for HIV

An itchy circular lesion with a RING Whitfield ointment or other antifungal cream if few Extensive: There is a high incidence of co
raised edge and fine scaly area WORM patches existing nail infection which has to be treated
in the centre with loss of hair. (TINEA) adequately to prevent recurrence of tinea
If extensive refer, if not give:
May also be found on body or infections of skin.
web on feet Ketoconazole
Fungal nail infection is a clinical stage 2
for 2 up to 12 months(6-10 kg) 40mg per day
defining disease
for 12 months up to 5 years give 60 mg per day
or give griseofulvin 10mg/kg/day
if in hair shave hair treat itching as above

Rash and excoriations on torso; SCABIES Treat itching as above manage with anti scabies: In HIV positive individuals scabies may
burrows in web space and 25% topical Benzyl Benzoate at night, repeat for 3 manifest as crust scabies.
wrists. face spared days after washing and or 1% lindane cream or
Crusted scabies presents as extensive areas
lotion once wash off after 12 hours
of crusting mainly on the scalp, face back and
feet. Patients may not complain of itching. The
scales will teeming with mites
IDENTIFY SKIN PROBLEM

IF SKIN HAS BLISTERS/SORES/PUSTULES

SIGNS CLASSIFY AS: TREATMENT UNIQUE FEATURES IN HIV
Vesicles over body. CHIKEN POX Treat itching as above Presentation atypical only if
Vesicles appear Refer URGENTLY if pneumonia or child is immunocompromised
progressively over jaundice appear Duration of disease longer
days and Complications more frequent
form scabs after they Chronic infection with
rupture continued
appearance of new lesions
for >1 month; typical vesicles
evolve into nonhealing ulcers
that become necrotic, crusted,
and hyperkeratotic.

Vesicles in one area HERPES Keep lesions clean and dry. Use local antiseptic Duration of disease longer
on one side of ZOSTER If eye involved give acyclovir 20 mg /kg 4 times daily for 5 days Haemorrhagic vesicles,
body with intense pain Give pain relief necrotic
or scars Follow-up in 7 days ulceration
plus shooting pain. Rarely recurrent, disseminated
Herpes zoster is or multi-dermatomal
uncommon in
children except where
Is a Clinical stage 2 defining
they are
disease
immuno-compromised,
for example
if infected with HIV

Red, tender, warm IMPETIGO OR Clean sores with antiseptic

crusts or small lesions FOLLICULITIS Drain pus if fluctuant
Start cloxacillin if size >4cm or red streaks or tender nodes or multiple
abscesses for 5 days ( 25-50 mg/kg every 6 hours)
Refer URGENTLY if child has fever and /
or if infection extends to the muscle.
IDENTIFY SKIN PROBLEM

NON-ITCHY
SIGNS CLASSIFY AS: TREATMENT UNIQUE FEATURES IN
HIV
Skin coloured pearly white papules with MOLLUSCUM Can be treated by various Incidence is higher
a central umblication. It is most CONTAGIOSUM modalities: Giant molluscum (>1cm in
commonly seen on the face and trunk in Leave them alone unless size), or coalescent
children. superinfected Pouble or triple lesions
Use of phenol: Pricking each lesion may be seen
with a needle or sharpened More than 100 lesions
orange stick and dabbing the lesion may be seen.
with phenol Lesions often chronic and
Electrodesiccation difficult to eradicate
Liquid nitrogen application (using Extensive molluscum
orange stick) contagiosum is a Clinical
stage 2 defining disease
Curettage
The common wart appears as papules WARTS Treatment: Lesions more numerous
or nodules with a rough (verrucous) Topical salicylic acid preparations ( and recalcitrant to
surface eg. Duofilm) therapy
Liquid nitrogen cryotherapy. Extensive viral warts is a
Electrocautery Clinical stage 2 defining
disease

Greasy scales and redness on central SEBBHORREA Ketoconazole shampoo Seborrheic dermatitis may
face, body folds If severe, refer or provide tropical be severe in HIV
steroids infection.
For seborrheic dermatitis: 1%
Secondary infection may
hydrocortisone cream X 2 daily
be common
If severe, refer
CLINICAL REACTION TO DRUGS

DRUG AND ALLERGIC REACTIONS

SIGNS CLASSIFY TREATMENT UNIQUE FEATURES IN HIV
AS:
Generalized red, wide spread with small bumps or blisters; or FIXED DRUG Stop medications give oral Could be a sign of reactions to
REACTIONS antihistamines, if pealing ARVs
one or more dark skin areas (fixed drug reactions)
rash refer

Wet, oozing sores or excoriated, thick patches ECZEMA Soak sores with clean water
to remove crusts(no soap)
Dry skin gently
Short time use of topical
steroid cream not on face.
Treat itching

Severe reaction due to cotrimoxazole or NVP involving the skin STEVEN Stop medication refer The most lethal reaction to
as well as the eyes and the mouth. Might cause difficulty in JOHNSON urgently NVP, Cotrimoxazole or even
breathing SYNDROME Efavirens
MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
Name: Age: Weight (kg): Height/Length (cm):
Ask: What are the child's problems? Initial Visit? Follow-up Visit?

ASSESS (Circle all signs present) CLASSIFY

CHECK FOR GENERAL DANGER SIGN General danger sign
NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS present?
VOMITS EVERYTHING CONVULSING NOW Yes ___ No ___
CONVULSIONS Remember to use
Danger sign when
selecting
classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes __ No __
For how long? ___ Days Count the breaths in one minute: ___ breaths per minute. Fast breathing?
Look for chest indrawing
Look and listen for stridor
Look and listen for wheezing
DOES THE CHILD HAVE DIARRHOEA? Yes __ No __
For how long? ___ Days Look at the childs general condition. Is the child:
Is there blood in the stool? Lethargic or unconscious? Restless and irritable?
Look for sunken eyes.
Offer the child fluid. Is the child:
Not able to drink or drinking poorly? Drinking eagerly, thirsty?
Pinch the skin of the abdomen. Does it go back:
Very slowly (longer then 2 seconds)? Slowly?
Yes __ No __
Decide malaria risk: High ___ Low ___ No___ Look or feel for stiff neck
For how long? ___ Days Look for runny nose
If more than 7 days, has fever been present every day? Look for signs of MEASLES:
Has child had measles within the last 3 months? Generalized rash and
One of these: cough, runny nose, or red eyes
Do a malaria test, if NO general danger sign in all cases in
Look for any other cause of fever.
high malaria risk or NO obvious cause of fever in low
malaria risk:
Test POSITIVE? P. falciparum P. vivax NEGATIVE?
If the child has measles now or within the Look for mouth ulcers. If yes, are they deep and extensive?
last 3 months: Look for pus draining from the eye.
Look for clouding of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM? Yes __ No __
Is there ear pain? Look for pus draining from the ear
Is there ear discharge? If Yes, for how long? ___ Days Feel for tender swelling behind the ear
THEN CHECK FOR ACUTE MALNUTRITION Look for oedema of both feet.
AND ANAEMIA Determine WFH/L z-score:
Less than -3? Between -3 and -2? -2 or more ?
Child 6 months or older measure MUAC ____ mm.
Look for palmar pallor.
Severe palmar pallor? Some palmar pallor?
If child has MUAC less than 115 mm or Is there any medical complication: General danger sign?
WFH/L less than -3 Z scores: Any severe classification? Pneumonia with chest indrawing?
Child 6 months or older: Offer RUTF to eat. Is the child:
Not able to finish? Able to finish?
Child less than 6 months: Is there a breastfeeding problem?
CHECK FOR HIV INFECTION
Note mother's and/or child's HIV status
Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN
Child's virological test: NEGATIVE POSITIVE NOT DONE
Child's serological test: NEGATIVE POSITIVE NOT DONE
If mother is HIV-positive and NO positive virological test in child:
Is the child breastfeeding now?
Was the child breastfeeding at the time of test or 6 weeks before it?
If breastfeeding: Is the mother and child on ARV prophylaxis?
CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next
BCG DPT+HIB-1 DPT+HIB-2 DPT+HIB-3 Measles1 Measles 2 Vitamin A immunization on:
________________
OPV-0 OPV-1 OPV-2 OPV-3 Mebendazole
(Date)
Hep B0 Hep B1 Hep B2 Hep B3
RTV-1 RTV-2 RTV-3
PCV-1 PCV-2 PCV-3
ASSESS FEEDING if the child is less than 2 years old, has MODERATE ACUTE MALNUTRITION, FEEDING
ANAEMIA, or is HIV exposed or infected PROBLEMS
Do you breastfeed your child? Yes ___ No ___
If yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes ___ No ___
Does the child take any other foods or fluids? Yes ___ No ___
If Yes, what food or fluids?
How many times per day? ___ times. What do you use to feed the child?
If MODERATE ACUTE MALNUTRITION: How large are servings?
Does the child receive his own serving? ___ Who feeds the child and how?
During this illness, has the child's feeding changed? Yes ___ No ___
If Yes, how?
ASSESS OTHER PROBLEMS: Ask about mother's own health
 TREAT
Remember to refer any child who has a danger sign and no other severe classification

Return for follow-up in ... days. Advise mother when to return immediately. Give any immunization and feeding advice needed today.
ART INITIATION RECORDING FORM
FOLLOW THESE STEPS TO INITIATE ART IF CHILD DOES NOT NEED URGENT REFERRAL
Name: Age: Weight (kg): Date:
ASSESS (Circle all findings) TREAT
STEP 1: CONFIRM HIV INFECTION YES ____ NO
Child under 18 months: Virological test positive Send tests that are required ____
Check that child has not breastfed for at least 6 weeks Send confirmation test
Child 18 months and over: Serological test positive If HIV infection confirmed, and child is in stable condition, GO TO STEP 2
Second serological test
positive
Check that child has not breastfed for at least 6 weeks
STEP 2: CAREGIVER ABLE TO GIVE ART YES ____ NO
Caregiver available and willing to give medication If yes: GO TO STEP 3. ____
Caregiver has disclosed to another adult, or is part If no: COUNSEL AND SUPPORT THE CAREGIVER.
of a support group
STEP 3: DECIDE IF ART CAN BE INITIATED AT FIRST LEVEL YES ____ NO
Weight under 3 kg If any present: REFER ____
Child has TB If none present: GO TO STEP 4
STEP 4: RECORD BASELINE INFORMATION
Weight: _____ kg Send tests that are required and GO TO STEP 5
Height/length _____ cm
Feeding problem
WHO clinical stage today: _____
CD4 count: _____ cells/mm3 CD4%: _____
VL (if available): _____
Hb: _____ g/dl
STEP 5: START ART AND COTRIMOXAZOLE PROPHYLAXIS
Less than 3 years: initiate ABC +3TC+LPV/r, or RECORD ARVS & DOSAGES HERE:
other recommended first-line regimen
1. ____________________________________________________________
3 years and older: initiate ABC+3TC+ EFV, or other
2. ____________________________________________________________
recommended first-line
3. ____________________________________________________________
PROVIDE FOLLOW-UP CARE Follow-up according to national guidelines NEXT
FOLLOW-UP
DATE:
_______
RECORD ACTIONS AND TREATMENTS HERE:
ALWAYS REMEMBER TO COUNSEL THE MOTHER AND PROVIDE ROUTINE CARE
FOLLOW-UP CARE FOR CONFIRMED HIV INFECTION ON ART: SIX STEPS
Name: Age: Weight (kg): Height/legth (cm): Date:
Circle all findings
STEP 1: ASSESS AND CLASSIFY RECORD
ASK: does the child have any problems? If yes, record here: ___________________________________________________ ACTIONS
ASK: has the child received care at another health YES ____ NO ____ TAKEN:
facility since the last visit?
Check for general danger signs:
NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING If general danger signs or ART severe side effects, provide pre-referral treatment
CONVULSIONS and REFER URGENTLY
LETHARGIC OR UNCONSCIOUS
CONVULSING NOW
Check for ART severe side effects:
Severe skin rash
Yellow eyes
Assess, classify, treat, and follow-up main symptoms according to IMCI guidelines.
Difficulty breathing and severe abdominal pain Refer if necessary.
Fever, vomiting, rash (only if on Abacavir)
Check for main symptoms:
Cough or difficulty breathing
Diarrhoea
Fever
Ear problem
Other problems
STEP 2: MONITOR ARV TREATMENT RECORD
Assess adherence: 1. REFER NON-URGENTLY IF ANY OF THE FOLLOWING ARE PRESENT: ACTIONS
TAKEN:
Takes all doses - Frequently misses doses - Not gaining weight for 3 months
Occasionally misses a dose - Loss of milestones
Not taking medication Poor adherence despite adherence counselling
Assess side-effects Significant side-effects despite appropriate management
Higher clinical stage than before
Nausea - Tingling, numb, or painful hands, feet, or
CD4 count significantly lower than before
legs - Sleep disturbances -
LDL higher than 3.5 mmol/L
Diarrhoea - Dizziness - Abnormal distribution of Triglycerides (TGs) higher than 5.6 mmol/L
fat - Rash - Other
2. MANAGE MILD SIDE-EFFECTS
Assess clinical condition:
3. SEND TESTS THAT ARE DUE
Progressed to higher stage
CD4 count
Stage when ART initiated: 1 - 2 - 3 - 4 - Unknown
Viral load, if available
Monitor blood results: Tests should be sent after LDL cholesterol and triglycerides
6 months on ARVs, then yearly. Record latest
OTHERWISE, GO TO STEP 3
results here:
DATE: _____ CD4 COUNT:________cells/mm3
CD4%: __________
Viral load: _________
If on LPV/r: LDL Cholesterol: _________ TGs:
____________
STEP 3: PROVIDE ART AND OTHER MEDICATION
ABC+3TC+LPV/r RECORD ART DOSAGES:
ABC+3TC+EFV 1. ____________________________________________________________
Cotrimaoxazole 2. ____________________________________________________________
Vitamin A 3. ____________________________________________________________
Other Medication COTRIMOXAZOLE DOSAGE:_______________________________________
VITAMIN A DOSAGE: _____________________________________________
OTHER MEDICATION DOSAGE:
1. __________________________________________________________
2. __________________________________________________________
3. ___________________________________________________________
STEP 4: COUNSEL DATE OF
Use every visit to educate the caregiver and provide RECORD ISSUES DISCUSSED: NEXT VISIT:
support, key issues include:
How is child progressing - Adherence - Support to
caregiver - Disclosure (to others & child) - Side-
effects and correct management
RECORD ACTIONS TAKEN:
MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS
Name: Age: Weight (kg):
Ask: What are the infant's problems?: Initial Visit? Follow-up Visit?
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION
Is the infant having difficulty in feeding? Count the breaths in one minute. ___ breaths per minute
Has the infant had convulsions? Repeat if elevated: ___ Fast breathing?
Look for severe chest indrawing.
Look and listen for grunting.
Look at the umbiculus. Is it red or draining pus?

Look for skin pustules. Are there many or severe pustules?

Movement only when stimulated or no movement even when
stimulated?
THEN CHECK FOR JAUNDICE
When did the jaundice appear first? Look for jaundice (yellow eyes or skin)
Look at the young infant's palms and soles. Are they yellow?
DOES THE YOUNG INFANT HAVE Look at the young infant's general condition. Does the infant: Yes ___ No ___
DIARRHOEA? move only when stimulated?
not move even when stimulated?
Is the infant restless and irritable?
Look for sunken eyes.
Pinch the skin of the abdomen. Does it go back:
Very slowly?
Slowly?
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
If the infant has no indication to refer urgently to hospital Determine weight for age. Low ___ Not low ___
Is there any difficulty feeding? Yes ___ No ___ Look for ulcers or white patches in the mouth (thrush).
Is the infant breastfed? Yes ___ No ___
If yes, how many times in 24 hours? ___ times
Does the infant usually receive any other foods or
drinks? Yes ___ No ___
If yes, how often?
What do you use to feed the child?
CHECK FOR HIV INFECTION
Note mother's and/or child's HIV status:
Mother's HIV test: NEGATIVE POSITIVE NOT DONE/KNOWN
Child's virological test: NEGATIVE POSITIVE NOT DONE
Child's serological test: NEGATIVE POSITIVE NOT DONE
If mother is HIV positive and and NO positive virological test in young infant:
Is the infant breastfeeding now?
Was the infant breastfeeding at the time of test or 6 weeks before it?
If breastfeeding: Is the mother and infant on ARV prophylaxis?
ASSESS BREASTFEEDING
Has the infant breastfed in the previous hour? If the infant has not fed in the previous hour, ask the mother to put her
infant to the breast. Observe the breastfeed for 4 minutes.
Is the infant able to attach? To check attachment, look for:
Chin touching breast: Yes ___ No ___
Mouth wide open: Yes ___ No ___
Lower lip turned outward: Yes ___ No ___
More areola above than below the mouth: Yes ___ No ___
not well attached good attachment
Is the infant sucking effectively (that is, slow deep sucks, sometimes
pausing)?
not sucking sucking effectively
effectively
CHECK THE CHILD'S IMMUNIZATION STATUS (Circle immunizations needed today) Return for next
BCG DPT+HIB-1 DPT+HIB-2 Hep B 1 Hep B 2 200,000 I.U immunization on:
OPV-0 OPV-1 OPV-2 vitamin A to ________________
mother (Date)
ASSESS OTHER PROBLEMS: Ask about mother's own health
 TREAT

Return for follow-up in ... days. Advise mother when to return immediately. Give any immunization and feeding advice needed today.
Weight-for-age GIRLS
Birth to 6 month s (z-sco res)

WHO Child Growth Standards

Weight-for-age BOYS
Birth t o 6 month s (z-scores)

WHO Child Growth Standards

Weight-for-Iength GIRLS
Birth to 2 years (z-scores)

WHO Child Growth Standards

Weight-for-Iength BOYS i i
Birth to 2 yea rs (z-scores)

W HO Child Growth Standards

Weight-for-Height GIRLS Work! Health
Organization
2 to 5 years (z-scores)

WHO Chi ld Growth Standards

Weight-for-height BOYS
2 to 5 yea rs (z-scores)

WHO Child Growth Standards

 GIVE GOOD H OME CARE FOR YOUR CHILD

._-
FOA ANY SICK Ctll.O .
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IMCI clinical guidelines are based on the following o Only a limited number of clinical signs are
principles: used. selected on the basis of theil' sensitivity and
o Examining all sick children aged up to five specificity to detect disease through
years of age fo r general danger signs and all classification .
young infants for signs of very severe disease .
These signs indicate sever e illness and the need A combination of individual signs leads to a child's
for immediate referral or admission to hospital. classification within one or m ore symptom groups
rather than a diagnosis. The classification of illness
f) The children and infants are then assessed for is based on a colou r -coded triage system :
main symptoms: • "PINK" indicates urgent hospital referral 01'
• In older children the main symptoms include: admission,
•
•
Cough o r difficulty breathing,
Diarrhoea.
• indicates in iti ation of s pecific
o utpatient treatment.
• Fever, and • "GREEN " indicates supportive home care,
• Ear infection.
• In young infants, the main symptoms include: o IMCI management procedUl'es use a limited
• Local bacterial infection, number of essential drugs and encourage
• Diarrhoea, and a ctive parti ci pation of caregivers in the
• Jaundice, treatment of their children.

€) The n in addition , all sick children are routinely at An essential component of IMCI is the
checked for: counselling of caregivers regarding h o me care:
• Nutritional and immunization status, • Appropr iate feeding and fluids ,
• HIV statu s in high HIV settings, and • When to retu rn to the clinic immediat ely, a nd
• When to retu rn for follow -up
• Other pote ntial pl'Oblems.
15610_Ch46.qxd 6/30/09 10:04 AM Page 1356

Chapter

46 Nursing Care of a Family When a

Child Has a Renal or Urinary
Tract Disorder
K E Y T E R M S Carol Hendricks is a

• Alport’s syndrome • hydronephrosis 4-year-old girl admit-

• azotemia • hypospadias ted to the hospital with
• Bowman’s capsule • nephrosis
• dialysis • patent urachus nephrotic syndrome.
• enuresis • polycystic kidney She has marked ascites and edema.
• epispadias • postural proteinuria
“I kept asking everyone why she was
• exstrophy of the bladder • prune belly syndrome
• glomerular filtration rate • vesicoureteral reflux gaining so much weight when she
• glomerulonephritis
doesn’t eat anything,” her grand-
mother tells you. “My daughter said
O B J E C T I V E S
this happened because she drank part
After mastering the contents of this chapter, you should be able to:
of a beer I left on the coffee table. Do
1. Describe common renal and urinary disorders that occur in children.
2. Identify National Health Goals related to renal or urinary tract you think that’s what caused it? What
disorders in children that nurses can help the nation achieve. if she needs a kidney transplant? Will
3. Analyze methods for making nursing care of the child with a renal
or urinary disorder more family centered. I be allowed to give a kidney to her?”
4. Assess a child for a renal or urinary tract disorder. Previous chapters described the
5. Formulate nursing diagnoses related to renal or urinary disorders in
children. growth and development of well chil-
6. Establish expected outcomes for a child with a renal or urinary dren and the nursing care of children
disorder.
7. Plan nursing care related to urinary or renal disorders in children. with disorders of other systems. This
8. Implement nursing care for a child with a renal or urinary disorder chapter adds information about the
such as preparing a child for peritoneal dialysis.
dramatic changes, both physical and
9. Evaluate expected outcomes for achievement and effectiveness of
care. psychosocial, that occur when children
10. Identify areas related to care of the child with a renal or urinary
develop urinary tract or renal disor-
disorder that would benefit from additional nursing research or
application of evidence-based practice. ders. This information builds a base
11. Integrate knowledge of renal and urinary tract disorders with the for assessment, care, and health
nursing process to achieve quality maternal and child health
nursing care. teaching.

How would you answer Carol’s grand-

mother? What information does she need
to better understand her grandchild’s
condition?

1356
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1357

Normally, the urinary system maintains the proper edema, or low-grade fever are subtle, parents may not
balance of fluid (water) and electrolytes in the blood. When bring their child for evaluation as early in the disease as
disease occurs, such as with structural abnormalities or they might if symptoms were more definite. School nurses
kidney malfunction, children may be left with excessive can play an important role in recognizing the seriousness
amounts of fluid in the body or with an imbalance of elec- of minor symptoms and making proper referrals for care.
trolytes essential to their body’s functioning. Disorders in- The ease with which parents and children can discuss
volving the kidneys and urinary tract often are long term. illnesses of the kidneys or urinary tract is culturally influ-
Urinary tract disorders can ultimately (if not originally) affect enced. As a general rule, because elimination functions are
the kidneys, resulting in kidney dysfunction, with potentially typically regarded as private, this is not a body system that
fatal consequences (Watnick & Morrison, 2009). people discuss as comfortably as they do illnesses of other
Unfortunately, because symptoms may be vague, or be- body systems. The more that modesty is stressed in a cul-
cause a child or parents do not realize the seriousness of uri- ture, the more difficult it may be for people to ask ques-
nary disease or are embarrassed to discuss it, children may tions about this system’s disorders. By being aware that
not be evaluated at the first sign of illness. Health education this is a difficult area for parents to discuss, health care
to increase the awareness of the symptoms of urinary tract personnel can better observe whether added health educa-
and kidney disorders is an important area of family health tion is needed when caring for a child with one of these
teaching. National Health Goals related to renal or urinary disorders.
tract disorders and children are shown in Box 46.1. A hallmark of kidney or bladder infection is pain. If chil-
dren have had bladder surgery, they also may experience
pain on urination or pain from bladder spasms. Be sure to
Nursing Process Overview assess the degree of any pain, including its location and in-
tensity, before administering an analgesic or antispasmodic.
For Care of a Child With a Renal or Urinary Tract Urine specimens also provide valuable assessment informa-
tion. Techniques for obtaining urine samples such as clean-
Disorder catch, catheterization, 24-hour collections, suprapubic aspi-
Assessment ration, and urinalysis are described in Chapter 37.
Because the symptoms of many urinary tract and renal
disorders such as mild abdominal pain, slowly increasing Nursing Diagnosis
Nursing diagnoses used with children with urinary tract
or renal disorders are related to the symptoms these disor-
ders cause. Some examples are:
• Pain related to bladder irritation from urinary tract
BOX 46.1 ✽ Focus on National infection
Health Goals • Excess fluid volume related to decreased kidney
function and fluid accumulation
Renal disease can lead to long-term illness, so pre- • Fear related to as yet unknown outcome of kidney
venting it is important to improving the health of the na- transplantation
tion. The following National Health Goals address this • Imbalanced nutrition, less than body requirements,
concern: related to effects of dietary restrictions
• Reduce the rate of new cases of end-stage renal dis-
• Social isolation related to immunosuppressant therapy
ease from a baseline of 300 per 1 million population
• Risk for injury related to body’s inability to excrete
to a target rate of 221 per 1 million population.
waste products properly
• Increase the proportion of patients with treated Because the entire family becomes involved in long-
chronic kidney failure who receive a transplant within term renal disease, other appropriate nursing diagnoses
3 years of end-stage renal disease (ESRD) from a might include:
baseline of 23.1 per 1000 to 30.5 per 1000
(http://www.nih.gov). • Interrupted family processes related to the effects and
stresses of child’s chronic illness
Nurses can help the nation achieve these goals by ed- • Compromised family coping related to the chronic
ucating parents to give antibiotics conscientiously for nature of child’s illness
streptococcal throat infections and being active advo-
cates for organ transplant procedures. Outcome Identification and Planning
Areas that would benefit from nursing research in- Be certain that outcomes established for care are relevant
clude: determining parents’ or children’s ability to accu- to a child’s age and condition. Because renal disease may
rately self-assess for proteinuria after streptococcal in- become chronic, expected outcomes may need to be mod-
fections, identifying the specific needs of children on ified frequently to meet changing needs.
ambulatory peritoneal dialysis, designing ways to make Planning for a child with a urinary tract or renal disor-
low-potassium diets more appealing to children with der often involves helping parents remember to give medi-
end-stage renal disease, or designing ways that organ cine. A child with nephrotic syndrome or a renal transplant,
donation can be presented to make it more appealing to for example, may take three or four different types of
potential donors. medicine every day at home. Be certain parents understand
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1358 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

the types of medicine prescribed and the expected action of may recall that a particular test involved an injection when
each. If school-age children cannot take medicine in school, it did not, making them worry needlessly unless their
they need a schedule that allows them to take medicine be- memories are refreshed. Parents wait anxiously for the re-
fore they leave home in the morning or after they return in sults of re-evaluation studies. Ensure they are given test
the afternoon. If a child’s school allows medication to be results as soon as a comprehensive opinion of the child’s
given during school hours, an order from the prescriber and progress is available. Be sure that all involved are aware of
the reason for the medication is usually required. how anxious a particular parent is to hear the results of the
If a child has severe renal impairment, parents may be re-evaluation.
asked to make decisions regarding kidney removal and Examples suggesting achievement of outcomes are:
transplantation. Provide them with ample time for discus-
sion. If a kidney donor is sought among relatives, the par- • Child reports pain is at a tolerable level and decreasing
ents must help decide whether the person whose tissue in intensity after treatment.
matches the child’s really wants to donate a kidney or is • Family members state they are able to cope with long-
being pressured to do so. Helping parents to schedule term illness in child.
times for hemodialysis or peritoneal dialysis or to supervise • Child states the purpose of a low-sodium diet and lists
continuous cycling peritoneal dialysis (CCPD), to care for the ingredients of a low-sodium meal.
their other children, and to provide a life apart from their • Child states she can accept the need for kidney trans-
child requires nursing planning. Referrals to support orga- plantation.
nizations such as the following may be helpful: National • Child states the precautions he must follow to reduce
Kidney Foundation (http://www.kidney.org) and Kidney possibility of infection while on immunosuppressive
Dialysis Foundation (http://www.kdf.org.sg/). therapy.
• Child remains free of any signs and symptoms of com-
Implementation plications related to accumulated waste products. ❧
Parents may or may not understand the function of the
urinary system because it is not a system that receives
much discussion. For example, they may confuse the ANATOMY AND PHYSIOLOGY OF
words “ureter” and “urethra.” A nurse can play a major THE KIDNEYS
role as a resource person, explaining anatomy and the tests
and procedures and why they are being done. Embryonic development of the urinary tract is discussed in
Many children with kidney disease take a cortico- Chapter 9. Figure 46.1 identifies the structures of the tract.
steroid for immunosuppression and so develop a typical Kidneys are located slightly lower in relation to the ribs than
cushingoid appearance. They may have edema or ascites, in adults. They also do not have as much perinephric fat to pad
which makes them appear obese. A child may be teased or them. This makes them more susceptible to trauma.
criticized by classmates because of this “different” appear-
ance. Contacting the school nurse or making the reason Nephron
for the child’s appearance known to the child’s teacher
may be necessary to help minimize this. Frequent contact A nephron, the functioning unit of the kidney, consists of a
and discussion with the child’s siblings are also important glomerulus (a filtrating unit) and a complex set of tubules
to help them understand the reason for so many tests and with accompanying blood supply (Fig. 46.2). Enclosed by a
health care visits and why their sibling is receiving so
much attention. Discussion also helps open up channels
of communication with all members of the family. Suprarenal
If kidney damage is extensive and the child’s kidneys fail (adrenal) gland
or a transplant is rejected, nursing care needs to be refocused
on helping the family to face the possibility of the child’s Left kidney
death. Nursing interventions can begin to prepare the child,
parents, and family for this event (see Chapter 56).
Ureter
Outcome Evaluation
Children with urinary or renal disease often need follow-
up care after their acute illness. Because they are followed
by a specialty renal group or clinic, parents may assume
that routine health maintenance care is being given as well.
Check to see that children are receiving routine childhood
immunizations (remember that children taking steroid or Urinary
other immunosuppressive therapy should not receive live bladder
virus immunizations) and that parents have their questions
about day-to-day childrearing concerns answered.
Children returning to health care agencies for re-
Urethra
evaluation usually need as much preparation for procedures
as those having them for the first time. Memory blurs
events and sometimes confuses children. For example, they FIGURE 46.1 The urinary system.
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1359

Bowman’s
capsule TABLE 46.1 ✽ Functions of the Nephron

Glomerulus
Peritubular capillary
Site Activity
Afferent arteriole
Proximal Glomerulus Secretion of water and all
Peritubular capillary solutes except protein
Macula densa from blood
Proximal Reabsorption of 80% of
convoluted glomerular filtrated water,
tubule all of glucose, amino acids,

Distal
vitamins, and proteins;
Efferent most of sodium, chloride,
arteriole and ascorbic acid;
To venous
secretion of creatinine
circulation
Descending Reabsorption of additional
and ascending water; fluid becomes
loop of Henle neutral in reaction; specific
gravity 1.010; additional
Collecting duct reabsorption of sodium
and chloride
Vasa Distal convoluted Reabsorption of water,
recta tubule sodium, chloride,
capillaries phosphate, and sulfate as
needed; secretion of
potassium, H" ions, and
ammonia (secretion of
NH4" and H" ions
conserves base because
H" ions are substituted for
Loop of Henle sodium ions; sodium is
reabsorbed as sodium
FIGURE 46.2 Basic structure of a nephron with its accompa- bicarbonate)
nying blood vessels.

double-walled chamber called a Bowman’s capsule, the portion of the tubule responds selectively to body needs. If
glomerulus is a capillary tuft supplied by a large afferent (in- necessary, Na" and HCO3! ions and additional water can
going) and a small efferent (outgoing) arteriole. It is invagi- be reabsorbed. The functions of nephron structures are sum-
nated within a tubule with a proximal and distal portion. In marized in Table 46.1.
the glomerulus, water and solutes are filtered from the blood.
This passage of water and solutes from the blood into the Urine
glomeruli is effective only as long as the blood pressure in
glomerular arteries exceeds that in the tubule. The smaller ef- The amount of urine excreted in a 24-hour period depends
ferent arteriole normally causes back-pressure in the on fluid intake, kidney health, and age. Approximate urine
glomerular arterioles, increasing the existing pressure and al- output from different age groups is shown in Table 46.2. A
lowing filtration to occur readily. If blood pressure in these significant decrease in urine production is oliguria; absence of
arterioles should fall below the tubular pressure or the tubu- urine production is anuria.
lar pressure should rise above that of the arterioles, little or no When renal disease occurs and glomerular or tubular
filtration will occur. For this reason, renal function must be function becomes impaired, nonprotein nitrogenous sub-
assessed carefully in children who are hemorrhaging or are in stances such as creatinine, urea, ammonia, and purine bodies
shock with lowered blood pressure for any reason. are retained in the blood rather than being excreted. Urea is
The solution that filtered into the tubule from afferent ar-
terioles passes through the proximal portion, the loop of
Henle, and then the distal portion. Beginning with the loop of TABLE 46.2 ✽ Child’s Average Urine Output in
Henle, water and electrolytes diffuse back into blood capillar- 24 Hours
ies, reducing the volume of the filtrate by approximately 90%.
The glomerular filtrate enters the proximal tubule at a rate
of approximately 120 mL/min. So much water is reabsorbed Age Amount of Urine (mL)
that the final end product (urine) left in the tubule is excreted 6 mo–2 yr 540–600
at a rate of only approximately 1 mL/min. The proximal por- 2–5 yr 500–780
tion of the tubules reabsorbs most of the water, glucose, 5–8 yr 600–1200
sodium chloride, phosphate (PO4!), sulfate (SO4!), and 8–14 yr 1000–1500
some bicarbonate (HCO3) ions. This is a passive process, not Over 14 yr 1500
particularly affected by body needs. In contrast, the distal
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1360 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

TABLE 46.3 ✽ Characteristics of Urine

Assessment Normal Finding Description/Implications

Color Pale yellow Color is influenced by urine concentration and ingredients; if fresh blood
is present, urine may be red; if old blood, it may be brown or black.
Appearance Clear Bacteria, excessive crystals, or cells cause cloudiness; if protein
content is high, it foams like beer when it is poured.
pH 4.6–8.0 Urine becomes alkaline (pH more than 7) with urinary tract infection or
severe alkalosis; urine left at room temperature also becomes alkaline.
Specific gravity 1.003–1.030 Specific gravity is elevated in dehydration as kidneys try to conserve
fluid, and decreased in overhydration as they try to rid the
body of fluid.
Protein 0 Due to inflammation, protein molecules pass into urine; in adolescent
girls, protein in urine may occur as a result of pregnancy; some
children have orthostatic proteinuria, slight to mild proteinuria
occurring only when they are standing.
Ketones 0 Ketones are released after breakdown of body protein, because of
starvation.
Glucose 0 Glucose in urine occurs most frequently as a symptom of diabetes
mellitus; in adolescent girls, glucosuria may occur with pregnancy.
Red blood cells Less than 1 per Blood may be present in urine as a result of such diseases as glomeru-
high-power field lonephritis, urinary tract infection, or trauma; may also suggest
Negative on dipstick systemic diseases such as leukemia or blood dyscrasias.
White blood cells Less than 5 per White blood cells are round, small configurations on a microscopic
high-power field slide; they are present with bacteriuria.
Casts 0 Casts (protein configurations) are found most often in concentrated urine
specimens; with cast formation, there is invariably proteinuria; casts
comprise red blood cells, white blood cells, or desquamated renal
epithelium; as an epithelial cast moves along the nephron, the cells
begin to disintegrate, leaving a coarse granular cast; some
disintegrate still further to become fine granular casts. The last stage
of the process is a configuration in the shape of the tubule, termed a
waxy cast (translucent and may be shiny and reflect light). The stage
of the cast is important in indicating the flow of urine through the
kidney. Hyaline casts are formations of protein appearing dull and
reflecting light poorly; fatty casts are casts caused by the degeneration
of tubular epithelial cells and are found in children with nephrosis.
Red blood cells, white blood cells, and fatty casts are evidence of
disease; other casts suggest urine stasis and probably proteinuria.
Crystals Possibly present or not Crystal formation is possibly indication of urine pH; uric acid, cystine,
and calcium oxalate crystals are examples of crystals found in acid
urine; phosphate crystals tend to be present in alkaline urine.
Infection (particularly Proteus infection) is the most usual cause of
alkaline urine. Sulfur crystals may be present if the child is
receiving a sulfa drug (such as sulfamethoxazole [Gantanol]).

formed from the breakdown of amino acids by the liver. The abnormal condition that causes the kidney tubule to become
amount of urea in urine is an indirect indication of kidney lined with protein formed from red and white blood cells,
and liver function. epithelial cells, or fatty cells that harden into the shape of the
Creatinine is a product released during muscle cell me- tubule. After urine washes the casts out, they can be detected
tabolism. The amount excreted in urine normally remains by microscopic examination of urine. As protein deposits in
constant, regardless of the amount of protein in the diet or this way only when fluid is slow-moving, their presence sug-
body processes. When it is less in amount, therefore, it gests slow filtration. Normal constituents of urine are shown
means that kidneys are not functioning as well as usual. in Table 46.3.
When kidney function is impaired, not only is creatinine
level reduced, but also some constituents that normally are
retained such as albumin, glucose, blood, bile pigments, and ASSESSMENT OF RENAL AND URINARY
casts will be allowed to enter the urine. Bile pigments that TRACT DYSFUNCTION
stain urine a green/yellow/brown color appear in the urine
when the child has elevated levels of indirect or direct biliru- Assessment of urinary or renal tract disorders is based on the
bin in the blood plasma (hemolysis of red blood cells or history, physical examination, and laboratory/diagnostic tests
jaundice will cause this). Casts are formed when there is an (Box 46.2).
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1361

from muscle contraction) excreted in 24 hours as determined

Box 46.2 Assessment by a 24-hour urine sample. A venous blood sample is taken
Assessing a Child for Renal during the 24-hour period and compared with the urine
and Urinary Tract Dysfunction findings (if urine creatinine is decreased, this will be in-
creased). A normal creatinine clearance rate is 100 mL/min.
A normal urine creatinine level is 0.7 to 1.5 mg/100 mL; cre-
History
Chief concern: Child reports burning or cries on urination; bloody or “dark” atinine in blood serum rarely exceeds 1 mg/dL (Watnick &
urine, frequency of urination; abdominal pain, flank pain, enuresis. Parents Morrison, 2009).
report increase in size of abdomen, periorbital edema, poor appetite,
frequent thirst, weight gain, strong odor to urine; diaper rash in infants. A
school-age child may be described as a behavior problem because he or
she frequently asks to use the bathroom.
Radioisotope Scanning
Family history: History of renal disease, such as polycystic kidney,
enuresis; hypertension. The administration of radioisotopes (a technetium scan) is a
Pregnancy history: Exposure to nephrotoxic drugs (antibiotics) during
pregnancy. Oligohydramnios at birth.
second way to assess glomeruli filtration ability.
Past illness history: Child recently had a throat or skin infection. Radioactively tagged substances are given intravenously (IV);
the rate at which these substances can be observed flowing
Physical assessment
General appearance
through the kidney and excreted in urine is then determined.
Fatigue, paleness The level of radioisotopes used in these studies is small, and
Growth restriction
Low-grade temperature urinating removes the substance from the body immediately
Head
Swelling around eyes afterward. Children do not remain radioactive, so parents
Mouth
Pale mucous Odd facies; beaklike should not be afraid to stay near them or to hold them after
nose, small chin,
membrane, caries
prominent epicanthal such a study.
folds, low-set ears
Cardiovascular
Hypertension
Chest
Gynecomastia
Urine Culture
Respiratory A urinary tract infection (UTI), the presence of bacteria
Rapid respirations
Abdomen in urine, is diagnosed by a urine culture. Because bladder
Back Tenderness over
Pain over kidney area bladder area catheterization can introduce bacteria into the bladder and
Abdominal mass
Genitals Slack abdominal also is painful and intrusive, most urine specimens in chil-
Reddened urethra muscles dren are obtained by a clean-catch procedure or sterile
Diaper area rash in infants Protuberant abdomen
Round urethra in males
suprapubic aspiration (see Chapter 37). Several instant-read
Constant dripping of urine commercial kits for culturing urine are available for use in
A stronger than usual arc
of urine in males ambulatory settings.
Displaced urethral opening
Extremities
Skin Bowed legs Blood Studies
Poor skin turgor
White crystals on skin Neurologic
Edema Confusion, muscle A blood urea nitrogen (BUN) test measures the level of urea in
twitching blood and is used to assess glomerular function, or how well
the kidneys can clear this from the bloodstream. However, this
level may not increase until approximately 50% of glomeruli
are destroyed, because the remaining glomeruli can increase in
size and function to accommodate urine production. A normal
Laboratory/Diagnostic Tests value is 5 to 20 mg/100 mL.
A variety of diagnostic tests may be performed, either in an Ultrasonography and Magnetic Resonance Imaging
ambulatory department or on an inpatient basis, to docu-
ment renal or urinary tract disease. An ultrasound or magnetic resonance imaging (MRI) can de-
tect differing sizes of kidneys or ureters and can differentiate
Urinalysis between solid or cystic kidney masses. They do not involve x-
rays and so may be repeated at frequent intervals for follow-
One of the most revealing tests of kidney function is also one up without danger of radiation exposure (Riccabona, 2007).
of the simplest: urinalysis. For best results, specimens col-
lected should be fresh because urine that stands at room tem- X-Ray Studies
perature for any length of time changes composition. Devices
used to collect urine specimens and the method for obtaining A plain flat-plate abdominal x-ray film can provide informa-
urine specimens from diapers are described in Chapter 37. A tion about the size and contour of the kidneys. This radi-
chemical reagent strip can be used to detect glucose, protein, ograph may be referred to as a KUB (kidney, ureters, and
and occult blood and to measure pH. Specific gravity is best bladder). A small kidney shown this way is generally a hy-
determined by use of a refractometer (requires only a single poplastic or an underdeveloped organ. A large kidney may
drop [see Chapter 37]). indicate hydronephrosis or a polycystic kidney.

Creatinine Clearance Rate Computed Tomography

Glomerular filtration rate is the rate at which substances are Computed tomography (CT) scans of the kidneys are used to
filtered from the blood to the urine. It is measured by the show the size and density of kidney structures and adequacy
amount of creatinine (the breakdown product of creatine of urine flow. Conscious sedation may be given before a CT
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1362 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

scan because a child must lie still for an extended time dur- the radiologic physician. A clean-catch urine specimen for cul-
ing the procedure, and the size of a CT scanner and the fact ture may be ordered before the VCUG to rule out infection.
that it surrounds the child may be frightening. Be sure to pre-
pare the child for this. A contrast medium may be injected ✔Checkpoint Question 46.1
before the procedure to better outline urine flow. If this
Carol had a voiding cystourethrogram last year to help diag-
medium is iodine based, be certain to ask about allergy to io-
nose a urinary tract infection. Why is a voiding cystourethro-
dine before the study. Because a support person is not al-
gram a difficult test for preschool children?
lowed to remain in the room during the procedure, thor-
oughly prepare children so they can comfortably remain still a. Reading the instructions for the test is difficult.
for the procedure. b. Lying in an MRI machine is dark and scary.
c. They feel uncomfortable voiding in public.
Intravenous Pyelogram. An intravenous pyelogram (IVP) is an d. The dye capsules may be too large to swallow.
x-ray study of the upper urinary tract. It used to be a mainstay
of diagnosis for kidney disorders but now is used less fre- Cystoscopy
quently because ultrasounds, MRIs, or CT scans reveal so
much information. For an IVP, a radiopaque dye is injected Cystoscopy, examination of the bladder and ureter openings
into a peripheral vein, circulates through the bloodstream, and by direct examination with a cystoscope introduced through
is almost immediately identified as a foreign substance by the the urethra, is done to evaluate for possible vesicoureteral re-
kidney and filtered out into the urine by the glomeruli. X-ray flux or urethral stenosis. Radiopaque dye may be introduced
films taken at frequent intervals show the outline of collecting into the bladder at the time of cystoscopy so the bladder can
systems in the kidney and of the ureters as the radiopaque dye be visualized on radiography (cystography). Small catheters
passes through them. also can be threaded into the ureters for the introduction of
In preparing children for an IVP, tell them that they will dye to outline them (retrograde pyelography). Because the
receive an injection. Say “medicine,” not “dye” (or compare procedure is painful and requires a child to lie still, it is usu-
coloring kidneys to coloring with crayons or coloring Easter ally done under conscious sedation. After the procedure, the
eggs), because the child may mistake “dye” for “die.” Be sure first voiding may be painful. Once allowed, urge children to
children know that, after this injection, they must lie still in drink plenty of fluids so they urinate frequently to flush out
whatever position they are placed until all films are taken. any pathogens introduced at the time of the procedure.
This may be difficult for young children because x-ray tables
are hard and cold and the x-ray camera overhead can be Renal Biopsy
frightening. When explaining the test, compare the x-ray ma-
chine to a camera. Caution children that they may experience Renal biopsy involves passing a thin biopsy needle into the
flushing of the face, warmth, and a salty taste in their mouth kidney through the skin over the kidney. The procedure is
after the injection of medicine. Because the dye used is iodine used to diagnose the extent of renal disease and thereby pre-
based, ask the parents if the child has a known allergy to io- dict disease outcome or progress or reveal beginning rejection
dine. This is rarely known in children because they may have of a transplanted kidney (Croker & Tisher, 2007). Renal
had no previous studies of this kind. biopsy may be done in an older child under only simple local
anesthesia, but conscious sedation may be necessary for a
Voiding Cystourethrogram. A voiding cystourethrogram younger child who cannot cooperate easily. The kidney is lo-
(VCUG), a study of the lower urinary tract, reveals the struc- cated first by ultrasound to accurately locate the place of the
ture of the urethra and bladder and the presence of reflux biopsy. The child lies prone with a sandbag under the ab-
into the ureters (Gomella & Haist, 2007). After bladder domen for firmness. If the procedure is done under a local
catheterization, a radiopaque dye is injected into the bladder, anesthetic, prepare children for the feel of a pinprick as the
and the catheter is then removed. The child is asked to void local anesthetic is injected; after this, they should not feel any
into a bedpan while serial x-ray films are taken. Although the further pain. What they will feel is pressure as the biopsy nee-
catheterization is unpleasant, being asked to void while they dle is inserted. Caution children that they need to lie still
are observed on an x-ray table may be the most stressful part while the biopsy specimen is taken (if the child moved sud-
of the procedure for most children because they have been denly, the needle might puncture a renal artery or vein or tear
taught that voiding is a private act. Be sure that children are vital glomeruli). Be certain children have support people to
told in advance that they will be asked to do this. Caution a accompany them for this procedure so that they have some-
child that a first voiding this way after catheterization may be one to hold their hand or comfort them when they feel the
painful. A few children have difficulty voiding a second time pressure of the needle.
later in the day because they worry that the second voiding After the biopsy, press a sterile gauze square against the
will also sting. Pouring warm water over the perineal area biopsy site for approximately 15 minutes to halt bleeding,
while sitting on a toilet or sitting in a bathtub of warm water and then apply a pressure dressing. Caution parents that a
and voiding into the water may help relieve pain. Most chil- large dressing will be used and that the size of this dressing
dren, once they void this second time and realize that it is not does not reflect the size of the specimen taken (the amount
painful, usually have no further difficulty. of tissue removed is no more than the lumen of the needle
A VCUG should not be done if a child has an active UTI used, or approximately the size of a pencil lead).
because there is danger that the radiopaque material injected If the procedure was done on an ambulatory basis, chil-
into the bladder could spread, carrying bacteria from the in- dren can be discharged 2 to 4 hours after the procedure if
fection into the ureters and kidneys. Report any symptoms of vital signs are stable and they have voided. Measure vital
UTI such as frequency, pain on voiding, or low back pain to signs and observe the biopsy site every 15 minutes for at least
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1363

the first hour. Do not lift the dressing to assess bleeding, be-
cause doing so destroys the protective function of the pres-
Skin
sure dressing. Encourage children to drink a considerable
Fat
amount of fluid (a glass every hour while awake) during the
first 24 hours to keep urine flowing freely and prevent blood Muscle
from clotting in the kidney tubules and blocking urine flow.
Play games with the child, if necessary, to encourage a high
fluid intake (the child must take a drink each time before a Peritoneal
turn at a game; play “Simon Says” and have Simon fre- cavity
quently say, “Drink”).
The first voiding after renal biopsy is invariably blood- Bowel
tinged. Advise parents to keep children on restricted activity
for 24 hours or until no more hematuria is present. Instruct
parents how to keep serial urine samples, comparing each FIGURE 46.3 Insertion site for peritoneal dialysis catheter.
specimen with the previous one, to detect whether hematuria
is becoming more or less marked. When urine no longer ap-
pears bloody, they can test it for occult blood to confirm that
catheterization may be necessary. Following this, the child’s
bleeding has stopped. A hematocrit may be ordered 24 hours
abdomen is cleaned just below the umbilicus with an anti-
after the procedure to ensure that no bleeding is continuing.
septic solution and covered with a sterile drape; a local anes-
thetic is injected into the abdominal wall, and a large-bore
What if... Carol’s grandmother telephones you after a needle is inserted into the peritoneal cavity. If ascites fluid
kidney biopsy and says Carol is voiding black urine? is present, a quantity of this fluid is removed and then a
Is there a possibility this is blood? What questions warmed hypertonic glucose solution (approximately 50 to
would you ask to elicit additional information? What 100 mL/kg of body weight) or a commercial dialysis solution
recommendations would you make to the grandmother? is infused by gravity flow into the peritoneal cavity. This dis-
tends the abdominal wall and allows safe insertion of a peri-
toneal catheter, which is sutured in place and covered with a
sterile dressing (Fig. 46.3). This catheter will remain in place
THERAPEUTIC MEASURES FOR THE for the duration of dialysis.
As for any procedure, children need to be well prepared
MANAGEMENT OF RENAL DISEASE for peritoneal dialysis but if the procedure is presented in a
As kidney function is necessary for life, if it deteriorates, matter-of-fact way, children usually accept it with no more
some method to replace function must be instituted. apprehension than IV therapy. Both procedures involve a
needle penetration. You can assure children that they will feel
the initial prick of the needle that administers the local anes-
Peritoneal Dialysis thetic but will feel only pressure after that as the peritoneal
Dialysis is the separation and removal of solutes from body needle or catheter is inserted. The procedure is intrusive,
fluid by diffusion through a semipermeable membrane. however, and frightening. Provide opportunities for thera-
Peritoneal dialysis uses the membrane of the peritoneal cavity peutic play such as letting the child handle a cloth doll, a
to do this. Hemodialysis uses an outside synthetic membrane dialysis tube, IV tubing, a doll’s bed, or syringes and needles.
to do this. Unlike hemodialysis, peritoneal dialysis does not With the dialysis tube in place, a prescribed amount of
require elaborate equipment or expense, but it does take dialysis solution is then infused into the peritoneal cavity by
more time. gravity drainage. This takes approximately 10 minutes and is
Peritoneal dialysis may be used as a temporary measure for recorded as inflow time. Be certain that the infusion fluid is
children who experience sudden renal failure caused by warmed to room temperature to prevent the child from be-
trauma or shock. It is used for fairly long periods with chil- coming chilled; warming the solution to near body tempera-
dren with chronic renal disease both in the hospital or at ture also appears to improve diffusion efficiency. It can be
home to allow them to live until a kidney transplantation can warmed in a basin of warm water or with the use of commer-
be arranged (Coe & Lail, 2007). It is usually begun when the cial warm packs at the child’s bedside. Heparin is generally
serum creatinine level reaches 10 mg/100 mL. Other indica- added at least to the first infusion to keep any initial bleeding
tions are congestive heart failure, BUN of more than from the abdominal puncture from plugging the tube.
100 mg/100 mL, hyperkalemia (potassium level of more Infused fluid is allowed to remain in the child’s peritoneal
than 6 mEq/L), and uremic encephalopathy (confusion or cavity for 15 to 60 minutes (called the equilibrium or dwell
coma). CCPD allows the procedure to be done at home be- time). Because the infused solution is hypertonic, fluid from
cause less rigorous monitoring of the procedure is necessary. extracellular spaces diffuses across the semipermeable peri-
toneal membrane to dilute the hypertonic solution (the law
Method for Performing Peritoneal Dialysis of osmosis). Urea and electrolytes diffuse with this fluid.
After this designated equilibrium time, drain the fluid from
Before peritoneal dialysis begins, a child’s weight and vital the peritoneal catheter into a collecting bottle (this takes ap-
signs are obtained to provide baseline information. Ask the proximately 10 minutes and is recorded as outflow time).
child to void to reduce bladder size so that the bladder occu- More fluid generally drains from the peritoneal cavity than
pies as little anterior space as possible. If a child cannot void, was infused, because excessive fluid has diffused across the
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1364 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

peritoneum, reducing peritoneal or ascitic fluid. After a cycle help with the procedure by doing such things as recording
of inflow, equilibrium, and outflow time, a new cycle is the amount of solution infused and drained, and allowing
begun. Peritoneal dialysis may be conducted continuously them to select liquids they like for meals.
for periods of 12 to 72 hours, depending on the effectiveness Peritoneal dialysis is a simple yet important concept. Help
of the procedure in restoring serum creatinine and BUN lev- parents understand its importance so they can demonstrate a
els to normal. positive attitude toward it. The parents’ acceptance of the
Monitor vital signs at least every hour while children are procedure helps the child accept it as well.
undergoing peritoneal dialysis. During each new infusion pe-
riod and while the solution is in the abdomen, carefully ob- Continuous Cycling Peritoneal Dialysis
serve for shortness of breath, because the fluid exerts upward
pressure on the diaphragm. Elevating the head of the bed helps CCPD allows a child to go to school or participate in other ac-
to increase breathing space and ease respirations. If tachycardia tivities while receiving dialysis. With CCPD, a permanent
or hypotension occurs, this suggests that hypovolemia is oc- dialysis catheter is inserted and sutured into place at the ab-
curring. An increasing temperature (after 24 hours) may indi- domen. Each day, the child or parent attaches a bag of dialysis
cate peritoneal infection, a serious complication (Auron et al., fluid and tubing to this and infuses a prescribed dialysis solu-
2007). Frequent blood studies are necessary during periods of tion by gravity drainage; the bag and tubing are then rolled
peritoneal dialysis to determine electrolyte concentrations. If into a compact square under the child’s clothes. The infused
electrolyte imbalances occur, electrolytes may be added to the solution remains in the child for 4 to 6 hours during the day
infusion solution or administered IV. (8 hours at night); the dialysate bag is then lowered and the so-
The longer the peritoneal catheter remains in place, the lution drains from the peritoneal cavity into it. The bag and
greater the risk of peritoneal infection at the catheter inser- fluid are then discarded and a new bag of dialysate solution is
tion site. Assess the insertion site daily for signs of infection, attached and raised, and new solution is infused.
such as redness or drainage. Obtain temperature about every CCPD requires careful monitoring and attention by the
4 hours. Ask children to report any abdominal pain or diar- child or family. They must keep accurate records of infu-
rhea. Assess for abdominal guarding or tenderness once daily sions. Children can participate in gym programs but should
by palpating the abdomen; a rigid abdomen suggest peri- not participate in contact sports or swimming. Teach parents
tonitis or infection. Follow the agency’s policy for cleaning to think ahead for holidays or family trips so they do not run
and covering the end of the peritoneal catheter if there are short of supplies.
periods when dialysis is halted (Fig. 46.4). Because CCPD is continuous, electrolytes in the blood-
Once cycles of dialysis begin, children often grow bored stream are maintained at more constant levels than when in-
lying in bed waiting for this procedure to be finished. They termittent dialysis is used although because a great deal of
need planned interaction for these times—perhaps a toy or potassium is removed, children may become hypokalemic
game that is allowed only during the procedure, so that it re- (Factor, 2007). CCPD also allows greater freedom because
mains special. Children generally do not feel hungry while children can return home and go back to school. There are
having peritoneal dialysis, because the bulk of peritoneal disadvantages, however. Infection can occur because of the
fluid causes pressure on the stomach and makes them feel un- long-term placement of the catheter. Dehydration or hyper-
comfortably full. They do well on a liquid diet or small fre- natremia may occur because of excess fluid removal. Because
quent feedings during this time. So that children can feel that the tube remains in place at all times and the peritoneal so-
they have a sense of control over what is happening, let them lution constantly distends the abdomen, the child appears
obese and clothing is difficult to fit, the child is frequently
reminded of the illness and may have difficulty accepting
this change in body image. Possible complications of CCPD
are summarized in Table 46.4.

Hemodialysis
Hemodialysis removes body wastes by using an external mem-
brane as the diffusion surface. For hemodialysis, a catheter is
inserted into an artery and blood is removed from the child
and circulated through a dialysis coil. Urea and electrolytes in
the blood diffuse into the surrounding fluid bath as the blood
passes through the coil (Ahmad et al., 2007). After diffusion
is complete, the blood is returned to the child’s venous cir-
culation (Fig. 46.5).
Hemodialysis can be done as a continuous process, but
it is so effective that 3 hours of hemodialysis accomplishes
as much as 12 hours of peritoneal dialysis. Children who
have renal failure or whose kidneys have been removed
FIGURE 46.4 Peritoneal catheter inserted into a child’s while they await a kidney transplant can be maintained al-
abdomen. A secure dressing surrounds the insertion site to most indefinitely by hemodialysis sessions two or three
prevent infection. (Courtesy of Karen M. Polise, MSN, RN, times a week or by continuous ultrafiltration or continuous
Division of Nephrology, The Children’s Hospital of arteriovenous hemofiltration (Schon et al., 2007). It can be
Philadelphia.) used in infants as well as older children (Sousa et al., 2008).
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1365

TABLE 46.4 ✽ Possible Complications of Continuous Ambulatory Peritoneal Dialysis

Assessment Problem Interventions

Redness or pain or swelling Infection Take culture at site; administer antibiotics as
at tube insertion site prescribed; continue site care as ordered;
notify physician.
Abdominal pain, increased Peritonitis Notify physician; administer antibiotics as
temperature, nausea and prescribed; auscultate for bowel sounds.
vomiting, cloudy return
in drainage solution
Cramps as fluid is infused Irritation of peritoneal cavity Infuse solutions more slowly; warm temperature of
solution to body temperature.
Difficulty with infusion or Kinked or clotted tubing; Assess tubing for kinking; change position of
drainage of fluid malpositioned catheter child; ask child to cough to increase abdominal
pressure; add prescribed amount of heparin to
dialysate bag (prevents clotting).
Weight increase; moist Fluid overload Decrease sodium and fluid oral intake; assess
cough, shortness of blood pressure and weight; use 4.25% exchange
breath solution until weight is again decreased.
Weight loss, hypotension, Fluid loss Increase fluid and sodium intake; assess blood
poor skin turgor, pressure and weight; do not use 4.25% solution.
tachycardia
Blood-tinged dialysis return Ruptured blood vessel Assess pulse and blood pressure; observe for
further bleeding in drainage; flush catheter with
prescribed amount of heparin to keep clots from
forming.

To establish a site for initial blood removal, children may two venipunctures, one from a low point in the shunt to re-
have a double-lumen central catheter inserted into a central move blood and one high in the shunt to return it, are nec-
vein, such as the subclavian or internal jugular vein. essary for dialysis (use lidocaine or EMLA cream to reduce
A permanent technique is subcutaneous anastomosis of a pain). The ability to feel a thrill (vibration) or hear a bruit
vein and artery, creating an arteriovenous fistula (usually the over the fistula or graft site is proof that it is open.
brachial artery and brachiocephalic vein; Fig. 46.6A) or in- The risks of hemodialysis include infection introduced
ternal anastomosis of the artery and vein using a subcuta- with venipuncture (severe because the infection automati-
neous graft (see Fig. 46.6B). The possibility of infection is cally is septicemia) and clotting of the access site, which can
reduced with internal anastomosis, although, unfortunately, lead to emboli. During hemodialysis, children may begin to
show signs of confusion, vomiting, visual blurring, or hallu-
cinations from a dialysis disequilibrium syndrome. This occurs
because the hemodialysis is removing urea from the blood at
too rapid a rate—faster than urea can be shifted from the
brain to the blood. This causes fluid to shift into the brain,
resulting in cerebral edema. The procedure must be tem-
porarily halted to allow equalization to return. Muscle
cramping may occur from sodium depletion. A “first use”
syndrome or symptoms such as dizziness or muscle cramping
may occur from a reaction to the fibers in the dialysis ma-
chine coil.
Children grow bored during hemodialysis as they do dur-
ing peritoneal dialysis. They need entertainment so the pro-
cedure remains acceptable. Help parents provide stimulating
activities such as a play board, a ball to throw, or rings to
stack for the infant. Parents may envision the infant as so ill
that lying still without an activity would be best. Children
need stimulation and play to avoid missing normal develop-
mental milestones, however, even during a long therapy such
FIGURE 46.5 An adolescent receiving hemodialysis. A
catheter from the child is connected to the hemodialysis
as dialysis.
equipment (in the background). Blood flows from the child When children’s kidneys are removed prior to transplan-
through the catheter to the hemodialysis equipment for waste tation so they must remain on a continuous program of he-
removal and is then returned to the child’s venous circulation. modialysis, they may come to resent a machine as “owning”
(Courtesy of Karen M. Polise, MSN, RN, Division of or “controlling” them. They become aware that they cannot
Nephrology, The Children’s Hospital of Philadelphia.) exist apart from it. Allowing them to plan special activities to
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1366 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

A B
FIGURE 46.6 (A) An internal arteriovenous fistula. (B) An internal arteriovenous graft.

do during hemodialysis time can help to give them a feeling Exstrophy of the Bladder
of control.
Exstrophy of the bladder is a midline closure defect that oc-
curs during the embryonic period of gestation (first 8 weeks).
As a result, the bladder lies open and exposed on the ab-
HEALTH PROMOTION AND RISK domen. It occurs more frequently in males than females at a
MANAGEMENT ratio of 2:1 (Atala, 2007).
Several important interventions can help prevent urinary Assessment
and renal disease in children. The first intervention is to ed-
ucate parents and caregivers about wiping from front to Exstrophy is often revealed by fetal ultrasound as there is no
back when changing diapers of female infants. The second anterior wall of the bladder and no anterior skin covering on
intervention is to prevent urinary tract infection in girls by the lower anterior abdomen (Fig. 46.7A). The bladder ap-
beginning education about perineal hygiene measures from pears bright red and continually drains urine from the open
the time they are first toilet-trained. Remind parents of
simple ways to prevent UTI, such as not allowing children
to bathe with bubble bath. Teach parents to recognize the
normal appearance of urine (clear and yellow) so that they
can recognize abnormalities, such as red, black, or cloudy
urine and the signs and symptoms of UTI, such as urgency,
frequency, and pain.
Educating parents about the importance of giving the full
course of antibiotics prescribed for UTI can help prevent
reinfection. Also important is educating parents about the
importance of giving the full course of antibiotics after a strep-
tococcal infection to prevent acute glomerulonephritis.

STRUCTURAL ABNORMALITIES OF
THE URINARY TRACT A
Because the urinary tract is a system of hollow tubes, con-
genital disorders can rise from faulty recanalization in in-
trauterine life.

Patent Urachus
When the bladder first forms in utero, it is joined to the um-
bilicus by a narrow tube, the urachus. When this fails to close
properly during embryologic development, a fistula is left
between the bladder and umbilicus (patent urachus). This
occurs more commonly in males than in females. Nurses are
frequently the ones to discover this condition as they notice
clear fluid draining from the base of the umbilical cord while
changing a newborn’s diaper. If you test the fluid with
Nitrazine paper for pH, its acid content will identify it as
urine. An ultrasound will confirm the patent connection. B
A few patent urachus abnormalities heal spontaneously, FIGURE 46.7 Bladder exstrophy. (A) Prior to surgical
but most require surgical correction to prevent pathogens reconstruction. Note the bright-red color of the bladder.
from entering the fistula site and causing persistent bladder (B) Following surgical reconstruction. (Courtesy of Karen M.
infection. This can be done in the immediate neonatal period Polise, MSN, RN, Division of Nephrology, The Children’s
using only a small subumbilical incision (Ashley, 2007). Hospital of Philadelphia.)
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1367

surface. In males, the penis is often unformed or malformed. osteotomy to hold the pubic bones in approximation until
In females, the urethra may also be abnormally formed. they fuse (4 to 6 weeks).
Pelvic bone defects, particularly nonclosure of the pubic After the second-stage urethra repair, children can be ex-
arch, and urethral defects such as epispadias—opening of the pected to experience some stress incontinence (loss of urine
urinary meatus on the dorsal or superior surface of the on physical exertion) from the constructed urethra. When
penis—may be present. The skin around the bladder quickly they are older, Kegel exercises can help strengthen the per-
becomes excoriated because of constant exposure to acid ineal muscles.
urine. Untreated bladder exstrophy leads to kidney infection Surgical repair may be limited if inadequate bladder tissue
from ascending organisms. When children with this disorder is present. For this reason, in some instances, the bladder is
begin to walk, they may demonstrate a “waddling” gait from surgically removed and a ureterocecal implantation (ureters
the effect of the nonfused pubic arch. directed into the small intestine) or a continent urinary reser-
voir (an artificial bladder) is constructed (Fig. 46.8).
To construct a continent urinary reservoir, a small seg-
Therapeutic Management ment of the intestine, usually the cecum, is separated from
The treatment of bladder exstrophy begins with surgical clo- the intestinal tract. The intestinal tract is then anastomosed
sure of the bladder and, if necessary, the anterior abdominal so that a normal gastrointestinal (GI) tract is maintained.
wall and construction of a urethra (Gearhart, Baird, & The separated segment is attached to the internal abdominal
Nelson, 2007; see Fig. 46.7B). wall using the appendix to create an artificial urethra. The
ureters are anastomosed to this segment.
Preoperative Interventions. To minimize the possibility of Urine drains from the kidneys into the ureters, and then
infection in the bladder while the infant is waiting for initial into the collecting bowel segment. The parent or child
surgery, keep the exposed bladder covered by a sterile plastic catheterizes the abdominal urethra three or four times daily to
bowel bag. This prevents the bladder surface from adhering empty urine. The procedure is theoretically simple, but it is
to bedclothes or diapers and the mucosal surface from being technically difficult to accomplish. Parents need a good review
injured. To prevent the skin of the abdomen from excoria- of anatomy to aid their understanding of the procedure. As
tion due to the constant irritation of urine, protect it with a the child reaches school age and begins school activities, such
substance such as A&D ointment, Karaya Gum, or Maalox. as showering, that exposes the condition to others, adjusting
Consult a wound, ostomy, continence nurse for the best ap- to a continent urinary reservoir can be difficult. Ensure that
proach. To reduce pressure and prevent further separation of the child has a plan for follow-up care during the school years
the symphysis, the orthopedic physician may ask that the in- and in adolescence so the function of the reservoir and also
fant’s legs be flexed, brought together, and wrapped in Ace the child’s adjustment can continue to be assessed.
bandages to hold them in that position. If this is done, do
not separate the infant’s legs to apply diapers; just place
them under the child instead. Be certain to change diapers
promptly after defecation so feces are not brought forward to
the open bladder. Position the infant on the back, the same
as for all infants, so urine drains freely. Sponge bathe rather
than tub bathe the infant to prevent water from entering the
ureters and becoming a source of infection.
Parents often need support to view their child as normal
in all other ways but the unusual bladder formation. In some
instances, the bladder repair will not be done immediately, so Ureters
parents will need instructions on how to care for the child at
home while waiting for surgery.
Postoperative Interventions. Surgery may be completed
either as a one-step or two-step procedure. In the first step,
the bladder tissue is reconstructed; in the second, a ure- Cecum
thra is created. After bladder construction, the surgical
Stoma
incision over the bladder area must be kept free of infec-
tion. Position the infant on the back or in an infant chair
to prevent feces from coming forward and contaminating
the incision line. A suprapubic or indwelling urethral
catheter for urine drainage will be in place to allow the
newly constructed bladder to rest. Immediately after
surgery, urine draining from the catheter may be blood-
stained, but this should clear after the first few hours.
Children may notice sharp painful bladder contractions for
the first few days after surgery. Analgesics and antispas-
modics may be needed to keep the child comfortable. To
prevent the nonfused pubic bone from separating and FIGURE 46.8 A continent urine reservoir. A portion of intes-
putting stress on the suture line, at the time of surgery, the tine is isolated; the attached ureters drain into it. The appendix
child may be fitted with an external fixation device after an creates an abdominal stoma for catheterization.
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1368 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

FIGURE 46.9 Urethral defects.

(A) Hypospadias. (B) Epispadias.
A B C (C) Hypospadias with chordee.

Hypospadias penis growth and make the procedure easier, the child
may have testosterone cream applied to the penis or receive
Hypospadias is a urethral defect in which the urethral open- daily injections of testosterone. It is important that hy-
ing is not at the end of the penis but on the ventral (lower) pospadias be corrected before school age so the child looks
aspect of the penis (Fig. 46.9A). The meatus may be near the and feels like other children (Dodson et al., 2007). If left
glans, midway back, or at the base of the penis (Hutton & uncorrected, in later years, a meatal opening at an inferior
Babu, 2007). This anomaly is fairly common, occurring in penile site may interfere with fertility, because it does not
approximately 1 in 300 male newborns. It tends to be famil- allow sperm to be deposited close to the female cervix dur-
ial or may occur from a multifactorial genetic focus. ing coitus. Repair must be made before this time to pre-
Epispadias is a similar defect in which the opening is on the vent subfertility.
dorsal surface of the penis (Fig. 46.9B); this is corrected the After surgical repair, a urethral urinary drainage catheter
same way. will be inserted to allow urine output without putting ten-
sion against the urethral sutures. The child may notice
Assessment painful bladder spasms as long as the catheter is in place (3 to
Be certain to inspect all male newborns at birth for hypospa- 7 days). An analgesic such as acetaminophen (Tylenol) and
dias or epispadias as part of the routine physical examination. an antispasmodic medication such as oxybutynin (Ditropan)
The degree of hypospadias may be minimal (on the glans but may be prescribed for pain relief.
inferior in site) or maximal (at the midshaft or at the penal- After hypospadias repair, children can be expected to have
scrotal junction). Many newborns with hypospadias have an usual urinary and reproductive function unless accompany-
accompanying short chordee—a fibrous band that causes the ing anomalies of the penis were present.
penis to curve downward (often called a cobra-head appear-
ance; Fig. 46.9C). Also inspect carefully for cryptorchidism ✔Checkpoint Question 46.2
(undescended testes), often found in conjunction with hy- The appearance of a child with hypospadias is:
pospadias.
If the penis defect is so extensive that sex determination is a. The urethra opens on the underside of the penis.
unclear, sex cell karyotyping (see Chapter 7) will be done. b. The bladder opens on the surface of the abdomen.
Hypospadias can be a difficult medical diagnosis for parents c. Urine drains into the rectum and is excreted with stool.
to accept because they may view it as a threat to the child’s d. The child is unable to void, as there is no urethral meatus.
masculinity. This may cause them to have difficulty dis-
cussing this defect with relatives or health care personnel.
Help parents work through these feelings by allowing them INFECTIONS OF THE URINARY SYSTEM
to talk about the disorder and by answering their questions AND RELATED DISORDERS
honestly and openly.
As the urinary system drains to the outside of the body, in-
Therapeutic Management fection can easily spread to the bladder or kidneys.
Children with hypospadias should not be circumcised be- Urinary Tract Infection
cause, at the time of the repair, the surgeon may wish to
use a portion of the foreskin for the repair. In the newborn, UTI occurs more often in females than in males at a rate of
a meatotomy—a surgical procedure in which the urethra is about 8% to 2% (Lum, 2008). Pathogens appear to enter the
extended to a normal position—may initially be performed urinary tract most often as an ascending infection from the per-
to establish better urinary function. When the child is ineum. Most urinary pathogens are gram-negative rods. E. coli
older (age 12 to 18 months), adherent chordee may be re- is a frequent offender. UTIs also are a common cause of noso-
leased. If the repair will be extensive, all surgery may be de- comial or health care–acquired infections in children with uri-
layed until the child is 3 to 4 years of age. To encourage nary catheters.
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1369

UTIs tend to occur more often in girls than in boys be- reflux that causes recurrent urinary stasis. A secondary prob-
cause the urethra is shorter in girls and because it is located lem is more likely in boys with a UTI.
close to the vagina (allowing the spread of vulvovaginitis) and
close to the anus, from which E. coli spread. Changing dia- Assessment
pers frequently can help reduce the risk for infection in in-
fants. Girls should be taught early (when they are toilet- Although it may be possible to locate a UTI precisely as ure-
trained) to wipe themselves from front to back after voiding thritis, cystitis, ureteritis, or pyelonephritis, the signs and
and defecating to avoid contaminating the urethra. There is symptoms in young children often are not clear-cut. When
a suggested correlation between the use of products such as the exact location or extent of the infection is unknown, it is
bubble bath, feminine hygiene sprays, and hot tubs and UTI referred to simply as a UTI. The typical symptoms that occur
in girls so use of these should be discouraged or minimized in older children or in adults—pain on urination, frequency,
(Schilling McCann et al., 2007). Infection also often occurs burning, and hematuria—may not be present. If the infec-
after sexual intercourse. Teach both adolescent males and fe- tion is confined to the bladder (cystitis), the child may have
males to void after sexual intercourse. Additional measures to a low-grade fever, mild abdominal pain, and enuresis (bed-
prevent UTIs are summarized in Box 46.3. wetting). If the infection is a pyelonephritis, the symptoms
UTIs need vigorous treatment in childhood so they do not generally are more acute, with high fever, abdominal or flank
spread to involve the kidneys (pyelonephritis). Girls who have pain, vomiting, and malaise. Any child with a fever and no
more than three UTIs or boys with their first UTI should demonstrable cause on physical examination should be eval-
be referred to a urologist to determine whether they have a uated for UTI (Wan, Liu, & Chen, 2007).
congenital anomaly such as urethral stenosis or bladder–ureter Urine for culture can be collected by a clean-catch tech-
nique, suprapubic aspiration, or catheterization, so that bacte-
ria from the vulva or foreskin do not contaminate the sample
and give a false reading. Suprapubic aspiration is generally lim-
ited to infants because the sight of the syringe is so frightening
BOX 46.3 ✽ Focus on to older children; plus, the procedure can introduce infection.
Family Teaching The use of catheterization, also frightening and a potential
source of infection, is limited in children of all ages.
Preventing Urinary Tract Infection (UTI) in Females Urine obtained from suprapubic aspiration is generally
Q. Carol’s grandmother tells you, “Carol had a urinary sterile, so any growth from this source is significant. A clean-
tract infection last year. How can we prevent that catch urine specimen is said to be positive for bacteriuria if
from happening again?” the bacterial colony count is more than 100,000/mL. A
A. Here are some important tips to help prevent UTI: count of less than 10,000/mL is considered a negative cul-
ture. Counts between 10,000 and 100,000/mL are repeated.
• Encourage your granddaughter to drink periodically Usually, the urine also is positive for proteinuria (because of
during the day, especially in warm weather or during the presence of bacteria). Microscopic examination may in-
exercise, to keep urine flowing freely and prevent dicate the presence of red blood cells (hematuria) because of
stasis of urine in ureters. mucosal irritation. The presence of red or white blood cells
• Urge her to urinate at least every 4 hours to prevent and bacteria tends to make urine more alkaline, so the pH
stasis of urine in the bladder. will be elevated (greater than 7).
• Teach her not to bathe with bubble bath; this can
cause vulvar and urethral irritation. Therapeutic Management
• Help your granddaughter learn to wipe from front to
back after moving her bowels or urinating, to prevent The medical treatment for UTI is the oral administration of
moving rectal contamination forward to the urethra. an antibiotic specific to the causative organism that is cul-
• Have your granddaughter wear cotton, not synthetic, tured (Lum, 2008).
underwear to decrease perineal irritation. In addition to the antibiotic, a child needs to drink a large
• Instruct your granddaughter to wash her vulva daily quantity of fluid to “flush” the infection out of the urinary
to lower the bacterial count on the perineum. tract. Cranberry juice is often recommended as being highly
• When your granddaughter begins menstruating, en- effective in acidifying urine and making it more resistant to
courage her to change sanitary pads at least every 4 bacterial growth. In actual practice, there is little proof of its
hours to reduce the possible growth of bacteria near effectiveness, so offer any fluid the child drinks readily. If the
the urethra. child experiences moderate to severe pain on urination that
• If symptoms of UTI should occur (pain on urination, interferes with the ability to void, suggest that the child sit in
frequency, blood in urine), call your primary health a bathtub of warm water and void into the water. A mild
care provider. If an antibiotic is prescribed, make sure analgesic, such as acetaminophen (Tylenol), may help reduce
that your granddaughter takes it for the full prescribed pain enough to allow voiding.
course, so all bacteria are completely eradicated. With a UTI, treatment with antibiotics must be contin-
Otherwise, after a short time, bacteria will proliferate, ued for the full prescription or the infection will return.
and the infection will recur. Create a reminder sheet for parents to post in a readily visi-
• When your granddaughter becomes sexually active, ble location, such as on the refrigerator door, to help ensure
teach her to urinate immediately after intercourse to re- adherence. A repeat clean-catch urine sample is usually ob-
move any bacteria forced into the urethra by pressure. tained at 72 hours to assess the effectiveness of the antibiotic
treatment.
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1370 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

After antibiotic therapy is stopped, it is helpful if parents

obtain another clean catch urine specimen to be tested to
prove that bacteria are not still present. After recurrent UTIs,
children may be prescribed a prophylactic antibiotic for 6
months. At periodic health checkups for the next few years,
a child should void a clean-catch specimen for culture or mi-
croscopic analysis.

“Honeymoon” Cystitis
Honeymoon cystitis refers to lower UTI seen in young women
shortly after they initiate a first sexual relationship. Such in-
fections occur in connection with the local irritation and in-
flammation caused by initial coitus.
Like most UTIs, these respond quickly to antibiotic ther-
apy. Voiding as soon as possible after coitus may help to flush
pathogenic organisms from the urethra and prevent such in-
fections. When cystitis is seen in adolescent girls, it should alert A
health care providers to the possibility that a girl may be sexu-
ally active. In addition to needing counseling about personal
hygiene measures to prevent UTI, the girl may need informa-
tion on sexually transmitted infections, reproductive planning,
and her responsibility for her maturing body. Recurrent UTIs
in a school-age or preschool girl may suggest sexual abuse.

Vesicoureteral Reflux
Normally, urine flows from the ureters into the bladder, with
almost no flow re-entering the ureters from the bladder. This B
is because the ureters enter the bladder obliquely, and a blad- FIGURE 46.10 Vesicoureteral reflux. (A) Normal voiding
der skin flap or “valve” obscures the end of the ureter, pre- pattern. (B) Reflux into ureters with voiding.
venting backflow. Vesicoureteral reflux refers to retrograde
flow of urine from the bladder into the ureters (Watnick &
Morrison, 2009). This reflux occurs because the valve that
guards the entrance from the bladder to the ureter is defec- growth occurs, however, the condition must be rigorously
tive, either from birth or because of scarring from repeated treated to decrease the possibility of glomerular scarring from
UTIs, bladder pressure that is stronger than usual, or ureters infection or back-pressure. Teaching double voiding (having
that are implanted at abnormal sites or angles. This backflow the child void, then in a few minutes attempt to void again)
of urine happens at micturition (voiding) when the bladder may help to empty the bladder and prevent recurrent infec-
contracts (Fig. 46.10). tion from urinary stasis. Some girls need to remain on pro-
Reflux leads to bladder infection because urine is retained phylactic antibiotics to prevent bladder infection. Long-term
in the ureters after voiding, and stasis of any fluid is subject maintenance with antibiotics may be as effective as surgery in
to infection. It also appears that the capacity for normal blad- reducing renal scarring from recurrent urinary tract infection
der tissue to lyse bacteria becomes reduced due to the large in lower grades of reflux (Hensle, Grogg, & Eaddy, 2007).
residual urine volume that is always present. In addition, re- If continuous antibiotic therapy does not prevent recur-
flux is a potentially serious condition because it can lead to rent UTIs, reflux can be corrected by cystoscopy. Under gen-
back-pressure on the kidneys, possibly leading to nephron eral anesthesia or conscious sedation, a cystoscope is passed,
destruction and, subsequently, hydronephrosis or dilatation and an agent such as Deflux (dextranomer–hyaluronic acid)
of the renal pelvis. As it is prone to appear in families, it is is injected to stabilize the ureter valves (Sutherland et al.,
most likely a heterogeneous disorder (Kelly et al., 2007). 2007). Laparoscopic surgery to correct the placement of
ureters may be scheduled to reinsert the ureters at a more
Assessment oblique angle, creating the usual valve effect.
A child with reflux is usually first seen by health care person- After surgery, a suprapubic catheter remains in place to
nel because of a history of repeated UTI. A voiding cys- keep the bladder empty and prevent pressure against the sur-
tourethrogram, CT scan, cystoscopy, or cystography with gical area. Two ureteral catheters (stents), threaded into the
contrast material will show the ureteral reflux. Based on di- ureters to drain urine directly from the kidney pelvis, also
agnostic studies, reflux is graded from I to V by degree of re- exit at the suprapubic tube site. Tubes are attached as a closed
flux, with V being the most serious. drainage system to collecting bags. Sterile gauze dressings and
antibiotic cream are placed around the tube insertion sites.
Therapeutic Management In preparing children for this type of surgery, be certain to
prepare them for the number of tubes that will be inserted.
The majority of instances of vesicoureteral reflux resolve with Explain that even with the tubes in place, the child will be al-
maturity without a need for surgery. Until this normal lowed to walk and move about soon after the operation (and
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1371

should do this). Be sure that the child and parents under- detect in a child this age except as general irritability or crying
stand the importance of keeping the urine collection bags on voiding). Elevated blood pressure caused by increasing
below the level of the child’s bladder to prevent urine from tubular pressure (which activates the renin-angiotensin sys-
flowing back into the bladder. Caution them not to raise the tem) may be detected on a routine health assessment, al-
bags above the child’s bladder level when helping the child though blood pressure is not taken routinely in a child of this
out of bed. age. With severe back-pressure, the infant experiences flank or
Observe the catheter drainage tubes closely, every hour for abdominal pain. Abdominal palpation may reveal an abdom-
the first 24 hours and then at least every 4 hours. Note the inal mass (the dilated kidney pelvis). An IVP or ultrasound
color and the amount of drainage (urine), and carefully mea- will show the enlarged pelvis and the point of obstruction.
sure and record it. Initially, drainage will be bloody, but this Hydronephrosis is a serious disorder because, if the pres-
should clear in 1 or 2 days. Assess drainage for clots (should sure in the pelvis becomes too acute, back-pressure on the
not be over pinpoint in size). The stents should drain an kidney will interfere with tubular function or destroy the
equal amount, to ensure that kidney production is equal on nephrons. The treatment is surgical correction of the ob-
both sides. Urine will drain primarily from the stents for ap- struction before glomerular or tubular destruction occurs.
proximately the first 3 days after surgery; thereafter, drainage
will flow around the stents and will be mainly from the
suprapubic tube. DISORDERS AFFECTING NORMAL
Be sure that the ends of the catheters do not become con-
taminated, because then infection can spread to the surgical URINARY ELIMINATION
area or the kidneys. An antiseptic solution may be ordered Interferences with urine elimination can arise from innocent
placed in the drainage bags to limit the growth of bacteria in conditions such as enuresis or extremely serious disorders
the collecting urine. Be certain any amount added is sub- such as kidney agenesis.
tracted from the output amount. As soon as urine drainage
from the stent catheters has decreased and blood has cleared, Enuresis
the stent catheters will be removed. To show that urine is
clearing of blood, obtain serial urine specimens each time Enuresis is involuntary passage of urine past the age when a
collecting bags are emptied and label it with the time of re- child should be expected to have attained bladder control
moval. Comparing the color of these samples will show that (Weaver & Dobson, 2007). Because this is expected at age 2
urine is clearing of blood. School-age children can help label to 3 years of age for daytime and age 4 years for nighttime,
the containers, which can help to add to their sense of ac- enuresis is said to occur at approximately 5 to 7 years.
complishment and control over the situation. Many children Enuresis may be nocturnal (occurs only at night), diurnal
become frightened when they learn the stent catheters will be (occurs during the day), or both. It is primary if bladder
removed. Assure them that this will not be painful and can training was never achieved, acquired or secondary if control
be done at an ambulatory visit without anesthesia. was established but has now been lost.
Incisional pain and painful bladder spasms may occur for Most enuresis is nocturnal; daytime enuresis occurs only
the first 3 days after surgery, so antispasmodics may be pre- rarely, except during naptime. Functional nocturnal enuresis
scribed to reduce bladder spasm. Also, not touching or not (that with no known cause) occurs in approximately 8% to
moving the suprapubic tube helps to reduce spasms because 12% of children age 8 years or younger. It is found more fre-
this limits bladder irritation. The suprapubic tube is removed quently in boys than in girls. It also tends to be familial (if it
between 4 and 7 days after surgery (again, a nearly painless is present in a child, one of the parents probably experienced
procedure). There may be slight urine leakage from the it, too).
puncture site of the tube for 1 or 2 days after removal of the
tube. Keep a sterile dressing in place to absorb the leaking Assessment
urine. Remind the child and parents to avoid tub baths until
Children with enuresis who are older than 5 years of age need
the suprapubic tube site has closed completely.
an evaluation to determine whether there is an organic cause
A few children continue to have bladder reflux after ureter
for the disorder. During the history, ask how parents have
reimplantation. All children need follow-up care such as re-
tried to correct the problem; identify whether it is primarily
peated urine cultures or perhaps an IVP or ultrasound at a
a problem for the child or the parents (treatment will be most
later date to establish that surgery was effective in halting the
effective if the child wants the situation corrected). Assess
reflux.
whether there are stresses in the family, such as parents who
Hydronephrosis expect more mature behavior of a child than the child can
handle such as the introduction of a new brother or sister, an
Hydronephrosis is enlargement of the pelvis of the kidney uncomfortable school situation such as being assigned to a
with urine as a result of back-pressure in the ureter (Watnick “shouting” teacher, or marital discord.
& Morrison, 2009). The back-pressure is generally caused by If they wet only on nights when they are exceptionally
obstruction, either of the ureter or of the point where the tired or troubled, a functional rather than an organic cause is
ureter joins the bladder, as with vesicoureteral reflux. Although suggested. If children wet only when they are engrossed in an
this may occur at any age, it occurs most often in the first interesting activity, they may simply need more reminders to
6 months of life. If it occurs during intrauterine life, it will be empty their bladder. If children have symptoms other than
revealed by fetal ultrasound (Hubert & Palmer, 2007). bedwetting, such as abdominal pain, burning, or frequency,
Children with hydronephrosis are usually asymptomatic. UTI is suggested. It is a common practice for many parents
They may have repeated UTIs from urinary stasis (difficult to to get children out of bed every night and take them to the
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1372 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

bathroom. At any point parents stop this practice, children

may begin bedwetting because they have been conditioned to BOX 46.5 ✽ Focus on
empty their bladder at that time of night. Pharmacology
Some children with enuresis have abnormal electroen-
cephalographic patterns. Other children with the same ab- Desmopressin acetate (DDAVP)
normal patterns do not have enuresis, however, so this by it- Classification: A synthetic form of human antidiuretic
self is not a sufficiently specific finding to be helpful. In hormone
others, bedwetting seems to occur as children pass from a pe- Action: Promotes resorption of water in the renal tubule
riod of rapid eye movement sleep pattern to a type IV level, or decreases bladder filling; drug of choice for
or it is primarily a sleep disorder. It may be associated with enuresis (Karch, 2009)
small bladder capacity (which would explain why the condi- Pregnancy Risk Category: B
tion is familial). Dosage: In children 6 years of age and older, 20 #g
Although usually not necessary to aid diagnosis, an IVP, (0.2 mL) intranasally at bedtime, possibly increasing
VCUG, or ultrasound may be done to rule out organic dis- the dose up to 40 #g if necessary; or 0.2 mg orally at
ease. A clean-catch urine specimen should be collected to rule bedtime, titrated up to 0.6 mg to obtain the desired
out bacteriuria. Specific gravity is assessed to rule out a defect response
in urine concentration. Protein and glucose levels are evalu- Possible Adverse Effects: Transient headache, nau-
ated to determine evidence of kidney disease. sea, flushing, mild abdominal cramps, fluid retention
Nursing Implications
Therapeutic Management
• Instruct parents and child that child should restrict
The treatment of enuresis may be complex because the fluid after dinnertime in addition to taking medication.
cause is generally unknown. If stress factors have been • If given intranasally, advise parents to refrigerate the
identified, an attempt should be made to correct these. solution.
Some stress factors, such as birth of a new sibling, cannot • Teach parents and child the proper method for in-
be changed, but frank discussion with children regarding tranasal administration.
what causes the stress and attempts to help children cope • Caution child and parents that nasal administration is
better with their daytime activities may improve enuresis less effective if the child develops a cold with drain-
(Box 46.4). ing rhinitis.
In many children, it helps to limit fluids after dinner.
Urge parents to exercise common sense in this area. Remind
them that a child may not be able to go every night without
a drink from dinner until breakfast. Caution parents of chil-
dren with sickle-cell anemia not to restrict fluid this way be- Alarm bells that ring when children wet at night are effec-
cause increased sickling of cells occurs with dehydration. tive in some children. This type of system does not actually
stop bedwetting. The alarm wakes the child, the child stops
voiding, and then gets up and uses the bathroom. Over time,
this type of conditioning may be effective, but once the urine
alarm is removed, children may relapse. Bladder-stretching
BOX 46.4 ✽ Focus on Evidence- exercises—drinking a large quantity of water and then re-
Based Practice fraining from voiding as long as possible—to increase the
functional size of the bladder can be helpful in some children.
Does bedwetting (nocturnal enuresis) affect the quality A bladder that can hold 300 to 350 mL of fluid will generally
of life of families? be large enough to contain urine during a night’s sleep.
For this study, 28 women who reported that their child If these measures are not effective, synthetic antidiuretic
had nocturnal enuresis and 38 women whose child had hormone (ADH; desmopressin [DDAVP]) administered in-
no urinary symptoms were asked to fill in three separate tranasally or orally is the drug of choice to reduce urinary out-
questionnaires: one on general health, one on risk of de- put and enuresis (Glazener, Evans, & Peto, 2009; Box 46.5).
pression, and one on risk of anxiety. Results of the inven- Enuresis is not a minor problem for either parents or for
tories showed that the mothers of children with nocturnal the child. As a general measure, children who wet their beds
enuresis had significantly lower quality-of-life scores re- need to take baths in the morning rather than at bedtime to
lated to bodily pain and emotional well-being than did minimize urine odor and avoid teasing. Parents may find
mothers whose child was symptom-free. They also planning a vacation with hotel stays difficult. They may re-
scored significantly higher on a depression scale. sent the daily linen washing. Children may exclude them-
selves from activities such as slumber parties or camping trips
Suppose a parent tells you that her child has nocturnal
with friends to avoid embarrassment.
enuresis but she knows it is only a stage of growth so
Enuresis may occur in hospitalized children because of
she is not worried. Based on the above study, would you
the stress of their new surroundings. Preschool children may
ask any further questions?
experience it because they are uncomfortable using strange
Source: Egemen, A., et al. (2008). An evaluation of quality of life bathrooms or do not understand which bathroom is theirs
of mothers of children with enuresis nocturna. Pediatric to use. As a rule, place as little stress or importance on enure-
Nephrology, 23(1), 93–98. sis as possible during an illness, and encourage parents to do
the same.
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1373

Postural (Orthostatic) Proteinuria such resistance to blood circulation that systemic hypertension
often results by school age.
A few children will spill albumin into the urine when they In many children, the liver is filled with identical cysts.
stand upright for an extended period (postural proteinuria, This is most evident later in life when increased difficulty
also called postural albuminuria). The amount of spilling de- with portal circulation occurs (blood cannot perfuse the cys-
creases when they rest in a supine position. Children with tic liver structures either).
this condition have no apparent damage to glomeruli; the The treatment for polycystic formation is surgical removal
phenomenon is apparently attributable to the effect of grav- of a kidney if only one is cystic. If both kidneys are cystic,
ity on glomerular function. treatment is renal transplantation (difficult in the young
To determine whether postural proteinuria exists, urine is child, because few infant kidneys are available for transplan-
collected after the child has been recumbent during the night tation and because of the technical challenge presented by
(a first-voided specimen) and then again after the child has such small blood vessels).
been up and active for several hours. Make certain when col- Because this kidney disease is inherited, parents, and chil-
lecting these urine specimens to record the child’s activity ac- dren at adolescence, need genetic counseling to inform them
curately. If the child stood by the crib rail crying for a parent that future children may also have this problem.
or was held in a nurse’s lap for most of the night, the urine
may show protein in the morning specimen because it is not
truly a “resting specimen.” Likewise, for the specimen to be
Renal Hypoplasia
collected after the child has been active, make certain that the Hypoplasia means reduced growth. Hypoplastic kidneys con-
child is up and active, not lying in a supine position reading tain fewer lobes than normal kidneys and are small and un-
a book for most of the time. Play a game if necessary, such as derdeveloped. The child with hypoplastic kidneys, in addition
follow the leader, so the child is active. to having poor kidney function, may develop hypertension
Postural proteinuria needs no therapy. However, be sure from stenosis of the renal arteries. If hypoplasia is bilateral, the
to document the condition because some of these children child may need a kidney transplant in later life to maintain
develop some form of kidney disorder later in life. kidney function and prevent extreme hypertension.

Kidney Agenesis Prune Belly Syndrome

Agenesis means lack of growth (literally, lack of a beginning) Prune belly syndrome is severe urinary tract dilation that
or that no organ formed in utero. Absence of kidneys in a develops as early as intrauterine life from an unknown cause.
newborn is suggested when the volume of amniotic fluid on Occurring mainly in boys, the severe dilation causes back-
ultrasound or at birth is less than normal (oligohydramnios). pressure and destruction of kidneys. The infant is born with
This occurs because urine normally adds to the volume of oligohydramnios and pulmonary dysplasia because of the
amniotic fluid in utero. The infant with kidney agenesis lack of amniotic fluid in utero (Woods & Brandon, 2007).
often has Potter’s syndrome or accompanying misshapen, The condition is marked by the presence of three symp-
low-set ears and hypoplastic (stiff, inflexible) lungs from the toms: deficiency of usual abdominal muscle tone, bilateral
lack of amniotic fluid in utero. Without kidneys, the fetus undescended testes, and the dilated faulty development of
cannot void urine. Bilateral absence of kidneys this way is the bladder and upper urinary tract. The infant’s abdomen
obviously incompatible with life unless a renal transplanta- appears wrinkled (like a prune) because of the poorly devel-
tion can be accomplished, but the associated condition of oped abdominal muscles (Fig. 46.11). Without surgical re-
nonfunctioning lungs makes a successful transplantation modeling, the infant will develop repeated UTIs, leading
highly unlikely. eventually to end-stage renal disease. Teach parents to pro-
tect their child’s abdomen from trauma such as can happen
from lap belts or baby walkers because their child lacks ab-
Polycystic Kidney
dominal support. Some children need kidney transplants as
Polycystic kidney means that large, fluid-filled cysts have
formed in place of normal kidney tissue. The most frequent
type of polycystic kidney seen in children is inherited as an
autosomal recessive trait. A more rare form is inherited as an
autosomal dominant trait (Boyer et al., 2007). With either
type, there is abnormal development of the collecting
tubules. The kidneys are large and feel soft and spongy. If the
disorder is bilateral, an infant will not pass urine. The mother
will have had oligohydramnios during pregnancy. Children
often have a typical appearance (hypertelorism—wide-spaced
eyes, epicanthal folds, flattened nose; or micrognathia—small
jaw), the findings of Potter’s syndrome. Either transillumina-
tion or ultrasound will show the fluid-filled cysts.
If the condition is unilateral, urine production will be de-
creased (oliguria), not absent. Because kidneys are difficult to
locate in newborns, a unilateral polycystic kidney may be FIGURE 46.11 Prune belly syndrome. (Courtesy of Karen M.
missed until later in life, when, with increased kidney growth, Polise, MSN, RN, Division of Nephrology, The Children’s
an abdominal mass can be palpated. The cystic growth offers Hospital of Philadelphia.)
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1374 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

they reach school age because of destruction of glomeruli serum complement will be present, and, as the blood vol-
from back-pressure (Kamel et al., 2007). ume expands, a mild anemia also will occur. As in all in-
flammatory diseases, the erythrocyte sedimentation rate will
Acute Poststreptococcal Glomerulonephritis increase. Because the glomeruli cannot filter properly, con-
centrations of urea, nonprotein nitrogen (BUN), and creati-
Glomerulonephritis, inflammation of the glomeruli of the nine in blood will increase. The antistreptolysin O
kidney, may occur as a separate entity but usually occurs as (anti–DNase B) titer or antibody formation against strepto-
an immune complex disease after infection with nephrito- cocci is generally elevated.
genic streptococci (most commonly subtypes of group A If blood pressure reaches 160/100 mm Hg as part of the
beta-hemolytic streptococci). Tissue damage occurs from a acute process, encephalopathy may occur, with symptoms of
complement fixation reaction in the glomeruli (complement is headache, irritability, seizures, vomiting, coma or lethargy,
a cascade of proteins activated by antigen–antibody reactions and perhaps transitory paralysis. This extreme elevation in
and actually plugs or obstructs glomeruli). IgG antibodies blood pressure is probably related to the expanded circula-
against streptococci may be detected in the bloodstream of tory volume. The cerebral symptoms are caused by cerebral
children with acute glomerulonephritis, proof that the illness ischemia (vasoconstriction of cerebral vessels to reduce cranial
follows a streptococcal infection (Sinha et al., 2007). pressure).
Intravascular coagulation occurs in the minute renal
vessels. Ischemic damage leads to scarring and decreased Therapeutic Management
glomerular function. This results in a reduction in the
glomerular filtration rate, leading to an accumulation of The course of acute glomerulonephritis is 1 to 2 weeks.
sodium and water in the bloodstream. Inflammation of the During this time, there is little therapy specific for the disor-
glomeruli increases permeability, allowing protein mole- der. Antibiotics usually are ineffective because the disease is
cules to escape into the filtrate. caused not by an active infection but by an antigen–antibody
inflammatory response to a past infection. Diuretics are of
Assessment little value because obstructed glomeruli bases cannot be
made to function; a course of ethacrynic acid or furosemide
Acute glomerulonephritis is most common in children be- (Lasix) may be tried. If heart failure occurs, specific measures
tween the ages of 5 and 10 years, the age group most suscep- such as placing the child in a semi-Fowler’s position, digital-
tible to streptococcal infections. Boys appear to develop the ization, and oxygen administration may be necessary. If dias-
disease more often than girls; it occurs more often during the tolic blood pressure rises to more than 90 mm Hg, antihy-
winter and spring, as do pharyngeal streptococcal infections. pertensive therapy with a calcium channel blocker may be
The child typically has a history of a recent respiratory infec- necessary. Phosphate binders, such as aluminum hydroxide
tion (within 7 to 14 days) or impetigo (within 3 weeks). All to reduce phosphate absorption in the GI tract, or a potas-
children who have had a “strep” throat, tonsillitis, otitis sium-removing resin agent, such as sodium polystyrene sul-
media, or impetigo caused by streptococcal infection, ideally, fonate (Kayexalate), may be necessary in children who have
should have a urinalysis 2 weeks after the infection to evalu- rising phosphate and potassium levels.
ate that glomerulonephritis is not occurring. Many children Bedrest is unnecessary, although children should be en-
do not receive this follow-up step, however, because of lack couraged to participate in quiet play activities. They can at-
of health insurance coverage or compliance. tend school and engage in normal activities after 1 or 2 weeks,
Acute glomerulonephritis is characterized by a sudden onset but competitive activity is limited until kidney function has
of hematuria and proteinuria. The protein content both of in- returned to normal to avoid overstressing the kidneys.
dividual urine specimens and of total 24-hour urine volume Diet is controversial. Although limiting protein intake re-
is measured. Testing a single specimen will show 1" to 4" duces the amount of protein lost in urine, many children
protein; a 24-hour urine specimen may contain as much as 1 g who are losing large quantities of protein need high-protein
protein (normally, urine contains none). diets to supplement this loss. Salt restriction may be needed
The hematuria associated with acute glomerulonephri- to reduce severe edema. Most children do well on a normal
tis is usually so gross that the child’s urine appears tea- diet for their age, however, with normal salt and protein con-
colored, reddish-brown, or smoky. Urinary sediment will tent. Weighing the child every day and calculating intake and
contain white blood cells, epithelial cells, and hyaline, output are important assessments in following the course of
granular, and red blood cell casts. After these initial urine the disease.
changes, the child develops oliguria. Specific gravity of In most children, acute glomerulonephritis runs a limited,
urine is elevated. Hypertension from hypervolemia occurs. benign course. After most symptoms fade, proteinuria and
The child may have abdominal pain, a low-grade fever, impaired clearance of urea and creatinine may remain for as
edema, anorexia, vomiting, or headache. There may be car- long as 2 months, however. Caution parents that the results
diac involvement related to the difficulty in managing the of a urine protein test may remain abnormal for up to a year;
excessive plasma fluid. Such children show signs of or- caution them that, if their child has this test as a routine
thopnea, cardiac enlargement, enlarged liver, pulmonary screening procedure at a health checkup, they should not
edema, and a galloping heart rhythm. Electrocardiographic worry that this finding means reinfection or the beginning of
changes such as T-wave inversion and prolongation of the further disease.
P-R interval may be seen. Heart failure may occur from A few children will not completely recover from acute
circulatory overload. glomerulonephritis but will develop chronic nephritis. These
Blood analysis will indicate a lowered blood protein level children appear to suffer destruction from the initial inflam-
(hypoalbuminemia) caused by the massive proteinuria. Low mation that results in chronic renal insufficiency.
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1375

✔Checkpoint Question 46.3

Nursing Diagnoses and Related What is typically the first symptom of acute glomerulonephritis?
Interventions
a. Low blood pressure from excessive aldosterone
✽ b. “Old blood” in urine from kidney bleeding
Nursing Diagnosis: Situational low self-esteem, re-
c. Dependent edema from protein accumulation
lated to feelings of responsibility for onset of serious
d. Pain on urination from urethra inflammation
illness
Outcome Evaluation: Child (parent) admits guilt Chronic Glomerulonephritis
about inadequate treatment of initial infection; dis-
Although chronic glomerulonephritis occasionally follows
cusses plans and ways to maintain health; partici-
acute glomerulonephritis or nephrotic syndrome, it also oc-
pates in care.
curs as a primary disease (or after acute glomerulonephritis
Glomerulonephritis is a frightening disease for both that was clinically so mild it was undiagnosed). The child is
children and their parents. Children may be frightened found to have proteinuria at a routine checkup. Further in-
by the initial hematuria. They may be upset at the ap- vestigation may indicate hypertension and the presence of
pearance of periorbital edema, which makes their re- red cell or white cell casts and occult blood in urine. The spe-
flection in the mirror so strange to them. Children as cific gravity of the child’s urine is below normal (below
young as early school age are aware that kidneys are 1.003). Blood studies may indicate an increased BUN or cre-
necessary for life, and this means they recognize the atinine level. A renal biopsy will show permanent destruction
seriousness of kidney disease. of glomeruli membranes.
If children were prescribed penicillin for pharyngi- Chronic glomerulonephritis may result in either diffuse or
tis 2 weeks before the development of the nephritis local nephron damage. The remaining functioning nephrons
but refused to take it, they may believe that they increase their glomerular filtration rate to compensate for
caused this disease. The parents may feel guilty be- those that are damaged. At some point in this chronic disease
cause they did not insist the child take the medicine. destruction process, however, compensatory mechanisms
They worry that their child will develop chronic fail, and renal insufficiency or failure will result. Alport’s
glomerulonephritis or die during the acute phase of syndrome that also includes hearing loss and ocular changes
this attack. These parents and children need to talk is a progressive chronic glomerulonephritis inherited as a X-
about their feelings openly. Provide frequent reports linked or autosomal recessive disorder (Shaw et al., 2007).
of subtle positive changes in a child’s condition such During the illness, if the child has acute symptoms of
as “His blood pressure is staying down by itself now; edema, hematuria, hypertension, or oliguria, bedrest may be
he does not need medicine for that anymore.” “He necessary. If children have only a chronic manifestation, such
weighs 2 pounds less today than 4 days ago; that as proteinuria, and if they feel well, they can maintain nor-
generally means his kidneys are beginning to func- mal activity, including attending school. Children should
tion more efficiently again.” not engage in competitive activities such as contact sports,
Be certain that parents know the date and place of however, because of the risk of kidney injury.
a return visit for follow-up care. Because this is a per- Therapy is nonspecific and directed at symptom relief
plexing disease, be sure they have a telephone num- rather than the disease process itself, because the cause of the
ber to call if they have questions about their child’s disease is unknown. Therapy with antihypertensive drugs
care or condition. such as hydralazine (Apresoline) or with diuretics to increase
The most frequent type of acute glomerulonephritis urine output such as ethacrynic acid (Edecrin) may be neces-
can be avoided by the prevention or effective early sary. Corticosteroid therapy may reduce or halt the progress
treatment of group A beta-hemolytic streptococcal in- of the disorder by reducing inflammation. Children have dif-
fections. Acute glomerulonephritis tends not to recur ficulty accepting long-term corticosteroid therapy because of
with subsequent streptococcal infections, so prophy- the side effects, in particular a typical “moon face” and extra
lactic penicillin to prevent further streptococcal infec- body hair (Cushing’s syndrome). Talk with them about these
tions is unnecessary. body changes and assure them that these changes will reverse
when the drug is discontinued.
Children receiving corticosteroids are at an increased risk
for infection because of the immunosuppressive activity of
IGA Glomerulonephritis these drugs. They need to be shielded from other children
Acute glomerulonephritis may occur when there is no evi- and health care personnel with infection. Parents need to
dence of a prior infection (Watnick & Morrison, 2009). In learn to take their child’s temperature and recognize and re-
these children, immunoglobin A is elevated. The gross port the earliest signs of infection.
hematuria resolves within a few days and is not apt to pro- Generally, the prognosis for children with chronic
duce serious sequelae. Because of the benign course of the glomerulonephritis is poor. Although the illness may run a
illness, no therapy is indicated except for careful observation long-term course, eventually it leads to renal insufficiency
for more serious signs such as severe proteinuria, hyperten- and renal failure. Children may be maintained for long peri-
sion, or renal insufficiency. If these symptoms occur, corti- ods by peritoneal dialysis or hemodialysis. Kidney transplan-
costeroids will halt the disease process. Omega-3 fatty acids tation is a possibility.
present in fish oils may be prescribed but their use is not well Because children as young as early school age are aware of
established. the importance of kidney function to life, most children with
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1376 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

chronic renal disease are aware of the likely outcome of their

disease. Most children are adolescents or young adults before Autoimmune process
the disease runs its ultimate course. They indicate that they
appreciate having health care personnel face this outcome Increased glomeruli permeability
with them honestly if kidney transplantation cannot be per-
formed to prolong their life. Increased albumin in urine

Nephrotic Syndrome (Nephrosis) Hypoalbuminemia

Nephrosis, altered glomerular permeability due to fusion of
the glomeruli membrane surfaces, causes abnormal loss of Edema
protein in urine. Immunologic mechanisms are involved in
instigating the process. The cause may be hypersensitivity to Hyperlipidemia
an antigen–antibody reaction or an autoimmune process. A
T-lymphocyte dysfunction may be responsible. The highest FIGURE 46.12 The process that results in the signs and
incidence is at 3 years of age, and it occurs more often in boys symptoms of nephrotic syndrome.
than in girls (Lum, 2008).
Nephrotic syndrome in children occurs in three forms: (a)
congenital, which occurs as an autosomal recessive disorder;
(b) secondary, as a progression of glomerulonephritis or in pale, stretched, and taut. In boys, scrotal edema becomes ex-
connection with systemic diseases such as sickle cell anemia tremely marked. Ascites may become so extensive that the re-
or systemic lupus erythematosus (SLE); or (c) idiopathic (pri- sultant pressure on the stomach leads to anorexia or vomit-
mary). The congenital form is rare; in children, the idio- ing. Children may have diarrhea caused by intestinal edema
pathic form is most common (Tkaczyk et al., 2008). and poor absorption by the edematous membrane. Because
Nephrosis can be further classified according to the of poor nutrition, growth may stop. The child may become
amount of membrane destruction. Minimal change nephrotic malnourished but yet appear deceptively obese because of the
syndrome (MCNS) is the type most often seen in children extensive edema (Fig. 46.13). When the ascites becomes even
(80%). As the name implies, with this type, little scarring of more extensive, children may have difficulty breathing as the
glomeruli occurs. Children with this degree of scarring re- abdominal fluid presses against the diaphragm, decreasing
spond well to therapy. Other types are focal glomerulosclero- lung expansion. Parents report that children are irritable and
sis (FGS) and membranoproliferative glomerulonephritis fussy, probably from the feeling of abdominal fullness and
(MPGN). Both of these types involve scarring of glomeruli, generalized edema. An increased risk for clotting can occur
and these children will have a poorer response to therapy from the decreased intravascular fluid volume.
(Lu et al., 2007). Laboratory studies will reveal marked proteinuria. A sin-
The four characteristic symptoms of nephrotic syndrome gle test will show a 1" to 4" protein; a 24-hour total urine
are proteinuria, edema, hypoalbuminemia (low serum albu- test will show up to 15 g protein (normally urine contains no
min level), and hyperlipidemia (increased blood lipid level). protein). The protein loss with nephrotic syndrome is almost
Proteinuria occurs because increased glomerular permeability entirely albumin, differentiating it from the proteinuria of
leads to protein loss in the urine and, subsequently, hypoal- glomerulonephritis, in which protein loss tends to be non-
buminemia. With a low level of protein in the bloodstream,
osmotic pressure causes fluid to shift from the bloodstream
into interstitial tissue, causing edema. As the blood volume
decreases, the kidneys begin to conserve sodium and water,
adding to the potential for edema. The hyperlipidemia oc-
curs because the liver increases production of lipoproteins to
try to compensate for protein loss. Lipids are too large to be
lost in urine, so they rise to high levels in the blood serum.
Some children have such high lipid levels that, when blood is
drawn and placed into a test tube, a circle of white fat forms
on the top of it. Figure 46.12 illustrates the process that leads
to these common symptoms.

Assessment
Symptoms usually begin insidiously. Children develop
edema around the eyes (periorbital edema), most noticeable
when they wake in the morning from a head-dependent po-
sition. Parents may notice that clothing no longer fits a child
around the waist, because edematous fluid is beginning to
collect in the abdominal cavity (ascites). It is easy to dismiss FIGURE 46.13 A 2-year-old with nephrotic syndrome. Note
these first symptoms as those of an upper respiratory tract in- the extensive edema of the face and hand. (From B. J. Zitelli &
fection and the normal “paunchy” belly of a toddler or H. W. Davis [1997]. Atlas of pediatric physical diagnosis [3rd
preschooler. As edema progresses, the child’s skin becomes ed.]. St. Louis: Mosby–Year Book, Inc.)
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1377

TABLE 46.5 ✽ Comparison of Features of Acute Glomerulonephritis and Nephrotic Syndrome

Factor Acute Glomerulonephritis Nephrotic Syndrome

Cause Immune reaction to group A beta-hemolytic Idiopathic; possibly a hypersensitivity reaction
streptococcal infection
Onset Abrupt Insidious
Hematuria Profuse Rare
Edema Mild Extreme
Hypertension Marked Mild
Hyperlipidemia Rare or mild Marked
Peak age frequency 5–10 yr 2–3 yr
Interventions Limited activity; antihypertensives as needed; Corticosteroid administration; cyclophosphamide
symptomatic therapy for congestive heart administration; possibly a diuretic and
failure potassium supplement
Diet Normal for age High-protein, low-sodium diet
Prevention Prevention or thorough treatment of group A None known
beta-hemolytic streptococcal infections

specific. Some children with nephrotic syndrome exhibit extra fat at the base of the neck, and increased body hair.
hematuria at the onset, but it is minimal in contrast to that Urge parents to plan ahead when getting pharmacy refills so
seen with acute glomerulonephritis. The erythrocyte sedi- that the prednisone therapy is not stopped abruptly because
mentation rate (demonstrating the inflammation of the they ran out of medication; an abrupt stop can lead to
glomeruli membrane) is elevated. Features of acute glomeru- adrenal insufficiency.
lonephritis and nephrotic syndrome are compared in Table Diuretics are not commonly used to reduce the edema
46.5. A renal biopsy may be done to determine whether there because they tend to decrease blood volume, which is al-
is scarring of the glomerular membrane and document the ready decreased. This could lead to acute renal failure.
type of nephrotic syndrome present. Children who respond poorly to prednisone alone, however,
may need diuretic therapy with a drug such as furosemide
Therapeutic Management (Lasix). When children are taking furosemide for extended
periods, there is always a danger that too much potassium
Therapy for a child with nephrotic syndrome is directed to- will be excreted, causing hypokalemia. Children on long-
ward reducing the proteinuria and subsequently the edema term diuretic therapy usually need frequent blood studies to
with a course of corticosteroids, such as IV methylpred- determine that electrolyte levels, especially potassium, are
nisolone or oral prednisone, and keeping the child free of in- adequate. They may need supplemental potassium and
fection while the immune system is suppressed. An initial should eat foods high in potassium. IV albumin may be ad-
dose of prednisone is given until diuresis without protein loss ministered to temporarily correct hypoalbuminemia. As the
is accomplished; the dosage is then reduced for maintenance serum albumin level rises, fluid shifts from subcutaneous
and continued for as long as 1 to 2 months. spaces into the bloodstream. Children are then administered
Instruct parents to test the first urine specimen of the day a rapidly acting diuretic to remove the extra fluid. It is im-
for protein with a chemical reagent strip and keep an accu- portant that the diuretic be administered after the albumin
rate chart showing the pattern of protein loss. Approximately infusion or the child could develop a fluid overload and,
once a week, they are usually asked to collect a 24-hour urine subsequently, heart failure.
specimen so total protein loss can be measured. Some children are prednisone resistant or do not respond to
After the initial 4 weeks, prednisone is generally given corticosteroid therapy. A course of cyclophosphamide
every other day rather than every day. Prednisone has the po- (Cytoxan), cyclosporine (Sandimmune), or mycophenolate
tential to halt growth and to suppress adrenal gland secre- mofetil (CellCept), stronger immunosuppressant agents, may
tion. However, growth is apparently not delayed when the be effective in reducing symptoms or preventing further re-
drug is given on alternate days and there is less alteration of lapses of the disease in these children (Pena et al., 2007). It is
adrenal steroid production (Karch, 2009). Parents may need important to ensure adequate fluid intake with these drugs to
to be assured that alternate-day therapy is best to keep them prevent bladder irritation and bleeding. Cyclophosphamide is
from changing the schedule to every day or giving twice the also used in chemotherapy for malignancy (see Chapter 53).
calculated dose by adding extra tablets on alternate days. To Be certain that parents are not misled into believing that their
help parents remember to give medication on alternate days, child has cancer because their child is receiving a chemothera-
have them choose either even or odd calendar days as the day peutic drug.
of administration. Help them design a reminder chart. The prognosis for children with nephrotic syndrome
Prednisone tastes bitter, so parents may welcome suggestions varies. Almost all children with MCNS respond initially to
regarding how to disguise the taste, such as by mixing it with steroid therapy. Although they may have a relapse, they will
applesauce. then remain free of the disease. Those with FGS and
Be certain both the parents and the child are aware that MPGN types will have relapses at frequent or infrequent
prednisone causes a cushingoid appearance or a “moon face,” intervals over the next several years. Children who have
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1378 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

frequent relapses have a relatively poorer chance of ever Parents need to weigh children daily to detect fluid
being free of the disorder. Many develop renal failure later. accumulation (use the same scale with the child in the
Kidney transplantation may be necessary to sustain life. All same clothing at the same time of day), and they also
children and families need emotional support while the dis- must measure intake and output accurately. If the
ease runs a long-term course. child is hospitalized, taking pulse rate and blood pres-
sure every 4 hours will help detect hypovolemia from
✔Checkpoint Question 46.4 excessive fluid shifts to interstitial tissue.
What is an important nursing intervention for children with Nursing Diagnosis: Risk for impaired skin integrity re-
nephrotic syndrome? lated to edema
a. Caution them not to eat salt, as salt irritates the bladder. Outcome Evaluation: Child’s skin is intact without
b. Encourage them to walk a mile daily for exercise. erythema.
c. Teach them to test their urine for proteinuria. The edematous skin of children with nephrotic syn-
d. Teach them to take their temperature daily. drome tends to break down easily, so they need fre-
quent position changes while in bed. Check clothing
to make certain that the elastic band at the waist of
Nursing Diagnoses and Related pajamas or other constricting parts is not tight. Soft
Interventions gauze placed between skin surfaces, especially
around the scrotum, tends to prevent skin irritation
✽ and breakdown. Edematous tissue does not heal well,
Nursing Diagnosis: Imbalanced nutrition, less than so breaks in the skin easily become secondarily in-
body requirements, related to poor appetite, re- fected. The child who is not toilet-trained needs fre-
stricted diet, and protein loss quent diaper changes and thorough cleaning at each
Outcome Evaluation: Child follows normal growth change to prevent skin breakdown in the diaper area.
curve on standard growth chart. Generally, children are more comfortable if they
For children with nephrosis, a good protein intake is sleep with their head elevated in a semi-Fowler’s po-
necessary to offset protein loss. A good potassium in- sition rather than a supine or prone position because
take through consumption of fruits and fruit juices, this reduces periorbital edema. If children sleep in a
particularly bananas, is necessary to maintain suffi- head-flat position, edema can be so severe by morn-
cient serum potassium levels, especially if the child is ing that their eyes are swollen completely shut; their
receiving a potassium-losing diuretic (Table 46.6). tongues are also swollen, so they cannot speak. At
This may be difficult for children, however, because home, parents can provide a semi-Fowler’s position
they have poor appetites. During acute phases of the by placing extra pillows on the child’s bed or slipping
disease, fluid or sodium may be temporarily a cardboard box under the head of the mattress to
restricted. If this is so, most children are happiest with raise the end of the mattress.
many small glasses of fluid spaced throughout the Because medications are poorly absorbed from
day, rather than several large drinks. It helps to make edematous skin areas, intramuscular (IM) injections
a chart showing the amount of fluid a child is allowed should be kept to a minimum. Medication should be
each day. As fluid is given, color in a portion of the administered orally if possible (see Focus on Nursing
chart corresponding to the amount given. This allows Care Planning, Box 46.6).
the child to tell from the uncolored portion how much Nursing Diagnosis: Knowledge deficit related to
more fluid is allowed that day. This is easier for tod- chronic illness
dlers and preschoolers (the age group usually Outcome Evaluation: Parents describe course and na-
affected by this disease) to understand rather than ture of nephrosis and their role in care of child at home.
talking in terms of milliliters or even glassfuls.
Parents often need support to manage children with a
chronic illness at home. They need clear instructions
about their responsibilities, including keeping their
TABLE 46.6 ✽ Foods High in Potassium child free of infection, perhaps by limiting exposure to
friends, and giving prednisone or oral diuretics and a
Food Group Examples potassium supplement. Review medication instructions
with parents and have them repeat the instructions.
Fruits Bananas, peaches, prunes, raisins, Make certain they understand where and when they are
oranges, and orange juice
to return for a follow-up visit and make certain they have
Vegetables Carrots, celery, lima beans,
potatoes, collards, dandelion
a telephone number to call if they have questions or
greens, spinach concerns about their child’s care or health.
Meat Nuts, peanuts, red meat
Dairy products Milk, whole or skim; low-sodium
milk What if... You need to give an IM injection to Carol,
Miscellaneous Salt substitutes, chocolate and who has extensive dependent edema from nephrotic
cocoa, bran syndrome? Would it be best to give it in a thigh or del-
toid muscle, and why?
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1379

BOX 46.6 ✽ Focus on Nursing Care Planning

A Multidisciplinary Care Map for a Child With Nephrotic Syndrome

Carol is a 4-year-old girl admitted to the hospital with grandmother tells you. “My daughter said this hap-
nephrotic syndrome. She has marked ascites and pened because Carol drank part of a beer I left on the
edema. “I kept asking everyone how she could be gain- coffee table. I didn’t give her the beer; she just picked it
ing so much weight, yet she doesn’t eat anything,” her up and drank it. Do you think that’s what caused this?”

Family Assessment ✽ Child lives with grandparents in last 2 weeks. States she’s “always full.” Marked depen-
a trailer park while mother is incarcerated on a drug dent edema (4" over tibia) present. Urine tested and
charge. Grandparents are both retired. Grandfather found to be 4" for protein.
rates finances as, “Okay. I saved some money and we
both get Social Security.” Nursing Diagnosis ✽ Excess fluid volume related to de-
creased kidney function and fluid accumulation
Client Assessment ✽ Child began “gaining weight” and
becoming irritable a week ago. Yesterday, her face ap- Outcome Criteria ✽ Child’s edema decreases; urine
peared “very puffy.” Appetite has declined sharply in proteinuria is less than 2".

Team Member
Responsible Assessment Intervention Rationale Expected Outcome

Activities of Daily Living

Nurse Assess whether child is Review with grandpar- Child’s mobility may in- Child and grandparents
able to carry out ents advantage of terfere with physical state that child can
routine activities allowing child to tasks; other children continue with usual
with ascites or continue usual may make fun of activities.
edema. activities. her appearance at
nursery school.
Consultations

Physician Assess whether grand- Contact renal service Nephrotic syndrome is Grandparents state they
parents have legal and suggest child a chronic disorder have or will obtain
guardianship for be admitted to ser- that requires consci- legal guardianship;
child and can give vice for evaluation. entious, specialized renal service person-
permission for health supervision. nel meet with child
health care. and grandparents for
consultation.

Procedures/Medications

Nurse Assess if child has ex- Administer oral pred- Prednisone, a cortico- Child accepts oral
perience with oral nisone as steroid, reduces im- prednisone and
medication. prescribed. mune response and helps make out
proteinuria. reminder sheet.
Nurse Assess if grandparents Observe grandparents’ Testing for protein in Grandparents state
have experience technique for dip- urine will reveal ex- they feel able to test
with dipstick urine stick urine testing tent of protein loss. and collect urine
testing and 24-hour and urine collection conscientiously and
urine collection. and recording record results in
results. diary.

Nutrition

Nurse/ Assess child’s typical Suggest grandmother Ascites crowds Child describes yester-
nutritionist food intake for last monitor child’s stomach, so it can day’s intake; grand-
24 hours. intake to be certain give a feeling of mother voices intent
it includes all food fullness and cause to supervise child’s
groups daily. undernutrition. intake to be certain
it is nutritious.
(continued)
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1380 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

BOX 46.6 ✽ Focus on Nursing Care Planning (continued)

Patient/Family Education

Nurse Assess grandparents’ Teach grandparents Understanding disease Grandparents state

knowledge about about kidney func- process can help they understand
kidney function and tion and disease grandparents to why edema has oc-
kidney disease. process as needed. better carry out curred and describe
therapy. action of medicine
to reverse this.

Psychosocial/Spiritual/Emotional Needs

Nurse Assess whether grand- Review natural Grandparent states she Grandparent states that
parents are having inquisitiveness of didn’t supervise although caring for a
childrearing preschool children, child well so child preschooler is
concerns. which can lead them drank beer off difficult, she feels
into unsafe areas. coffee table. adequate to give care.

Discharge Planning

Nurse Assess if grandparents Schedule return As nephrotic syndrome Grandparents state

have transportation appointment for is a long-term disor- they are aware of
to return for follow- 1 week at kidney der, child will need long-term nature of
up appointment. clinic. continued follow-up disorder and will
for years to come. keep follow-up
appointments.

Henoch-Schönlein Syndrome Nephritis likely source of the E. coli is undercooked hamburger, be-
cause E. coli is found in the intestine of beef cattle. It occurs
Henoch-Schönlein purpura is discussed in Chapter 44. more frequently in infants who have their initial E. coli in-
Approximately one quarter of the children who develop this fection treated with an antibiotic than those who are not
type of purpura develop renal disease as a secondary compli- treated (Raffaelli et al., 2007).
cation. The renal involvement becomes apparent within a
few days after the manifestations of purpuric symptoms. Assessment
Children may show only urinary abnormalities such as pro-
teinuria or may have a rapidly progressing glomerulonephri- The syndrome occurs most often during the summer and in
tis. Fortunately, most children recover completely. Only a children 6 months to 4 years of age. Children usually develop
few develop chronic symptoms, but in those who do, long- only a transient diarrhea, although this can progress to severe
term kidney disease can develop (Ambruso, Hays, & fluid loss and bowel wall necrosis. Fever may be so elevated
Goldenberg, 2008). that the child experiences stupor and hallucinations. Oliguria
accompanied by proteinuria, hematuria, and urinary casts in
Systemic Lupus Erythematosus urine follows. The oliguria will lead to increased serum crea-
tinine, BUN, and extensive edema. Children appear pale
SLE is an autoimmune disease in which autoantibodies and from anemia; easy bruising or petechiae may be present from
antigens cause deposits of complement in the kidney glomeru- thrombocytopenia (reduced platelet level). Laboratory studies
lus (see Chapter 20). Because of this, some children with SLE will show fibrin split products in the serum as the fibrin de-
develop symptoms of acute or chronic glomerulonephritis, the posits in glomerular vessels are degraded. Thrombocytopenia
ultimate cause of death in many adults with SLE (Hellmann is present because platelets are damaged by the irregular
& Imboden, 2009). Therapy with corticosteroids or cytotoxic blood vessels. An increased reticulocyte count indicates that
agents may be effective. If kidney transplantation is required, red blood cells are rapidly being replaced.
the same damage rarely occurs in the transplanted kidney.
Therapeutic Management
Hemolytic-Uremic Syndrome
The child needs supportive therapy to maintain kidney and
With hemolytic-uremic syndrome, the lining of glomerular heart function. The extreme oliguria can be treated with peri-
arterioles becomes inflamed, swollen, and occluded with par- toneal dialysis; anemia can be corrected by careful transfu-
ticles of platelets and fibrin. The child’s red blood cells and sion of packed red cells. Peritoneal dialysis can be extremely
platelets are damaged as they flow through the partially oc- frightening to parents and the child because it involves pen-
cluded blood vessels. As the damaged cells reach the spleen, etration of the child’s abdomen. Be certain they understand
they are destroyed by the spleen and removed from circula- that the actual dialysis procedure is not painful and they can
tion. This leads to hemolytic anemia. hold the child during infusion.
Ninety percent of children who develop this syndrome Ensure that parents understand the importance of follow-
have recently experienced an E. coli GI infection. The most up care and have an appointment for this. Help them begin
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1381

to view the child as well again so they do not continue to Therapeutic Management
shelter the child unnecessarily but allow for normal growth
and development. Because acute renal failure is a reaction to body stress caused
Despite the extent of the illness, most infants with he- by acute disease or insult, attempts to treat it focus on sup-
molytic-uremic syndrome recover completely. Some chil- porting the child’s body systems while correcting the under-
dren, however, die of the acute illness or continue to have lying condition. If the child is dehydrated (as with diarrhea
chronic renal involvement. or hemorrhage), IV fluid is needed to replace plasma volume.
Administer such fluid slowly enough to avoid heart failure;
extra fluid cannot be removed by the kidneys because they
Acute Renal Failure are not functioning. The fluid should not contain potassium
Renal failure occurs in either an acute or chronic form. The until it is established that kidney function is adequate;
acute form most often occurs because of a sudden body in- buildup of potassium may otherwise cause heart block.
sult, such as severe dehydration. The chronic form results Potassium levels greater than 6 mEq/L are corrected by the
from extensive kidney disease, such as hemolytic-uremic syn- IV administration of calcium gluconate (as the glucose moves
drome or glomerulonephritis (Reddy & Murra, 2009). into cells, it carries potassium with it), by the oral adminis-
Other causes of acute renal failure include prolonged tration of a cation exchange resin such as Kayexalate, or by
anesthesia, hemorrhage, shock, severe diarrhea, or sudden dialysis. Administering sodium bicarbonate may cause a shift
traumatic injury. It also can occur in children who are placed of potassium from the bloodstream into cells, temporarily re-
on cardiopulmonary bypass while undergoing heart surgery, ducing the circulating potassium level. Administration of a
who receive common antibiotics (aminoglycosides, peni- combination of IV glucose and insulin may also be effective
cillin, cephalosporins, and sulfonamides), who swallow a poi- (insulin helps glucose move into cells).
son such as arsenic (found in rat poison), or who are exposed A diuretic such as furosemide (Lasix) may be ordered in an
to industrial wastes such as mercury. All of these conditions attempt to increase urine production. Diet should be low in
appear to lead to renal ischemia, which ultimately leads to protein, potassium, and sodium and high in carbohydrate to
acute renal failure. supply enough calories for metabolism yet limit urea produc-
tion and control serum potassium levels. Fluid intake may be
Assessment limited to prevent heart failure due to accumulating fluid that
cannot be excreted. Weigh children daily (same scale, same
One of the first symptoms noted with acute renal failure is clothing, same time of day) and maintain accurate intake and
oliguria, a urine output of less than 1 mL/kg of the child’s body output recordings to evaluate fluid status. If children are so ill
weight/hour. An indwelling urinary catheter may be inserted that they cannot eat, total parenteral nutrition may be neces-
to rule out the possibility that urinary retention in the bladder sary. Regulate amounts carefully to prevent fluid overload (see
rather than kidney dysfunction is causing the severe oliguria. Chapter 37 for administration techniques).
Azotemia (accumulation of nitrogen waste in the blood- When recovery from acute renal failure begins, children
stream) will occur because of the oliguria. Uremia (extra ac- generally have a degree of diuresis as the extra fluid accumu-
cumulation of nitrogen wastes in the blood, with additional lated by the body is cleared. The increase in urine must be
toxic symptoms such as cerebral irritation) also may occur. noted, because children may need additional fluid intake at
The BUN rises progressively as renal insufficiency continues this point to prevent hypovolemia, which could lead once
and the breakdown products of protein cannot be excreted. more to renal failure. Parents usually remain anxious for an
A BUN level greater than 80 to 100 mg/100 mL is toxic and extended period after an episode of acute renal failure be-
needs correction, usually by dialysis. Urine creatinine is an- cause they fear that the restoration of kidney function is only
other measure that can be used as an indicator of function, temporary. Reassure them that urine output is remaining at
because it is normally excreted at a uniform rate. A rate of less a normal level. This helps them to relax and interact effec-
than 10 mg/100 mL indicates severe renal failure. As the kid- tively with their child.
neys become unable to dilute or concentrate urine, the spe-
cific gravity of urine often becomes “fixed” at 1.010.
Hyperkalemia (elevated potassium level) may occur if Chronic Renal Failure
potassium cannot be excreted. Hyperkalemia is manifested Chronic renal failure results from developmental abnormali-
by a weak, irregular pulse, abdominal cramps, lowered blood ties, when acute failure becomes long term, or when chronic
pressure, and muscle weakness. Acidosis will follow shortly kidney disease has caused extensive nephron destruction
with acute renal failure from the inability of H" ions to be (Lum, 2008). The nephrons that are not destroyed by long-
excreted. As total output decreases, phosphorus levels will term disease appear to function normally; they simply are in-
rise in the bloodstream. A high serum phosphorus level leads adequate in number to sustain kidney function. Glomeruli
to a low calcium serum level (recall that phosphorus and cal- can adjust so that kidney functions continue normally until
cium have an inverse proportional relationship). Severe 50% of nephrons are destroyed. After this point, kidney
hypocalcemia can lead to muscle twitching and seizures function diminishes by degrees until the child develops end-
(tetany); chronic hypocalcemia can lead to withdrawal of cal- stage kidney disease, where the kidneys cannot maintain nor-
cium from bones (osteodystrophy). mal function.
An IVP or radioactive uptake scan may be ordered to sub-
stantiate the lack of kidney function. Parents and children Assessment
need support for this type of study, because the results may
be disappointing and so different from what they hoped they With loss of nephron function, kidneys cannot concentrate
would be. urine. This results in polyuria, possibly manifested as enuresis.
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1382 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

Destruction of glomeruli foods such as lunch meats, potato chips, or pretzels). Other
children may actually need additional salt because, due to
poor tubular reabsorption, they dump sodium in urine. Low-
Retention of blood Retention of Decreased red sodium formulas such as Lonalac are recommended for chil-
urea nitrogen, urine blood cell production
creatinine, potassium,
dren with heart failure who need a low-sodium intake. Use
phosphorus them cautiously in children with renal insufficiency, because
Edema Anemia their high potassium content can lead to toxic potassium
blood levels. Diuretics may be ordered to help children reg-
Hyperkalemia and ulate sodium and fluid levels and prevent edema.
Hypertension
hypocalcemia As renal failure becomes prolonged, a child may need sup-
plemental calcium to prevent muscle cramping, rickets,
Bone growth tetany, or seizures. As hypertension becomes more and more
arrest acute from the accumulating blood volume, a daily antihy-
pertensive drug may be prescribed. A blood transfusion may
Body growth be needed to correct anemia, but it must be given cautiously
arrest so volume overload does not occur. Recombinant human
FIGURE 46.14 Pathology of chronic renal failure. erythropoietin may be prescribed to stimulate red blood cell
formation. Effective excretion of urea can be accomplished
by dialysis or by replacing the nonfunctioning kidneys with
kidney transplantation. Growth hormone may increase
The few functioning nephrons present cannot reabsorb height in some children who have fallen behind in stature
enough sodium to maintain a functioning level of body fluid, (Vimalachandra et al., 2009).
so dehydration occurs. As additional nephrons are lost, oliguria
and anuria occur. Inability to excrete H" ions leads to acido-
sis. Hypocalcemia and hyperphosphatemia occur from the Nursing Diagnoses and Related
kidney’s inability to excrete phosphate. Osteodystrophy occurs
as calcium is withdrawn from bones to compensate. Kidneys Interventions
are responsible for synthesizing vitamin D to its active form. ✽
With poor kidney function, vitamin D cannot be used. Nursing Diagnosis: Risk for interrupted family
Without this, calcium cannot be absorbed from the GI tract processes related to chronically ill family member
and deposited in bones. Bones become so calcium depleted Outcome Evaluation: Family members express feel-
that growth halts and the bones lose strength (renal rickets). ings about illness to each other and to health care
Erythropoietin, formed by the kidneys, stimulates red cell providers; participate in care of ill member.
production. With decreased erythropoietin production, ane-
mia develops. Pruritus may be present from skin irritation Children with renal failure grow poorly because of the
due to excretion of nitrogenous wastes in sweat from high alteration in calcium metabolism. It is easy for them to
levels of BUN and serum creatinine. These changes are sum- become depressed because of chronic fatigue and
marized in Fig. 46.14. an unappetizing diet. If children are taking cortico-
steroids or other immunosuppressive drugs because
Therapeutic Management of glomerulonephritis, they may be angry or disheart-
ened about their change in appearance. Help them
Children with chronic renal failure are generally placed on stay as active as possible by doing age-appropriate
a low-protein, low-phosphorus, low-potassium diet to pre- activities.
vent rapid urea and phosphate buildup. Children may take Caring for a child with chronic renal disease is not
aluminum hydroxide gel with meals to bind phosphorus in only time-consuming but also financially and socially
the intestines and prevent absorption. Milk usually is not devastating for parents. Parents caring for such chil-
given because it is high in sodium, potassium, and phos- dren at home need opportunities at periodic health
phate—electrolytes children may have difficulty clearing. assessments to voice their frustrations, fears, and anx-
Meat is restricted and even beans are high enough in pro- ieties. They need time to do those things important to
tein to be eliminated from the diet. This can be difficult for them as individuals, whether taking a weekend trip or
parents and children to understand because they are taught attending an evening show or program. Ask parents at
that meats are high in protein but vegetables are not. clinic or follow-up visits, “Do you ever get out of the
Letting children have some choice about what foods they house or have the opportunity to do anything for your-
eat each day helps to promote adjustment to this restricted self?” “What can we do for you ?” Help of this kind ulti-
diet. Whoever prepares meals needs good instructions on mately improves children’s care, because it improves
selecting low-protein foods. Low-electrolyte, low-protein the lives and mental attitudes of those around them.
formulas are commercially available for infants with renal
failure.
Total daily fluid intake may need to be restricted, al- KIDNEY TRANSPLANTATION
though restriction should be as minimal as possible or it can
present an area of tremendous conflict between the child and The ultimate possibility for prolonging the life of children
parents. Many children need sodium intake restricted, and with renal failure is kidney transplantation. With complete
others need a normal sodium intake (but no excessively salty renal failure, children who have extensive hypertension may
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1383

have their damaged kidneys removed and may be placed on Children who receive pretransplantation blood transfu-
hemodialysis or CCPD to await kidney transplantation. sions have an improved chance of transplant success
Kidney removal this way is an important step for parents and (Suthanthiran, Hartono, & Strom, 2007). Most children,
the child. Although parents realize that their child’s kidneys therefore, receive at least five blood transfusions while
are no longer functioning, this step removes all hope that a awaiting surgery. The mechanisms by which this oper-
miracle might happen and make them function once more. ates are unclear, but transfusion-induced production of
Parents may ask whether it is possible to leave one of the antibodies or immune complexes appears to mediate graft
child’s kidneys, because only one kidney will be transplanted survival.
(this is not recommended, because the hypertension would
continue). Parents need a thorough explanation of why hy- Human Leukocyte Antigen Typing
pertension is destructive, that is, it could lead to cerebrovas-
cular accident or coronary artery disease. They must under- HLAs are a group of antigens found on the surfaces of all
stand that renal biopsy shows that, short of a miracle, their cells with a nucleus, including blood components such as
child’s kidneys will not function again, so that removal of leukocytes and platelets. The name is derived from the fact
them is not a loss but only recognition of a loss. that they were first identified on white blood cells. Such
antigens are inherited from both parents and are specific for
Preoperative Care each individual. They denote tissue type or determine
which tissue the immune system identifies as foreign tissue.
Kidney transplantation is most effective (the kidney is less They are carried on the short arm of chromosome 6 in each
likely to be rejected) if the kidney is taken from a living twin, cell.
parent, or sibling (Lim, 2007). In these instances, the success Such antigens also serve as the basis for paternity typing.
rate is as high as 90% (Chan et al., 2007). Rejection occurs They may cause reactions to blood product transfusions and
at a higher incidence if a kidney comes from a cadaver or re- bone marrow and organ transplants. When two people have
cently deceased child. Most people consider that children like HLA antigens, they are said to be histocompatible.
should be of legal age to give consent to supply a kidney for Identical twins have complete histocompatibility and family
transplantation, so few children have a sibling who is eligible members have partial histocompatibility; any two people can
to donate a kidney. Tissue studies done to determine the best have histocompatibility at least on one antigen site.
donor (matched for human leukocyte antigens [HLA]) may Children who are awaiting kidney transplantation are tis-
show that the person in a family most willing to donate a kid- sue typed, and this information is circulated to major med-
ney is not the best person in terms of tissue compatibility. ical centers. When a kidney is available for transplantation,
This can cause bitterness and hopelessness in the family, the child’s tissue type is compared with the donor kidney.
compounding an already stressed family life. Many children For tissue typing, lymphocytes from both a donor and recip-
anticipate that the characteristics of the donor will be trans- ient are grown together in a culture medium and then exam-
mitted to them by the kidney, so they are reluctant to accept ined for like characteristics. With new immune suppressive
the kidney of a family member with a character trait they do drugs, however, even unmatched donor kidneys have a
not like (perhaps a bad temper). They need to be assured that chance to successfully graft.
transplanted organs do not carry this type of problem with
them. Adult-sized kidneys may be transplanted into children, Postoperative Care
although if the child weighs less than 10 kg, a kidney this
large may lead to hypertension, excessive diuresis, and ab- After renal transplantation, children are cared for in an envi-
dominal complications because of the lack of space. ronment that is as sterile as possible. They are placed on im-
Transplanted kidneys are placed in the abdomen, not the munosuppressive therapy such as cyclosporine, azathioprine
usual kidney space. [Imuran], and methylprednisolone [Solu-Medrol]) to reduce
People who cannot donate a kidney include those with the possibility of kidney rejection. Antilymphocyte globulin
multiple bilateral small renal arteries, bilateral renal disease, and antithymocyte globulin may be added to aid immuno-
renal infection, advanced medical illness, severe obesity, or suppression.
hypertension. Although kidney removal can be done by la- Although some transplanted kidneys begin to function
paroscopy, donors must understand that removal of a kidney immediately, hemodialysis may be continued until the im-
involves major surgery. Tests that kidney donors can expect planted kidney can fully function after the insult of trans-
to have preoperatively include HLA typing, electrolyte blood plantation. Be prepared to help a child and parents through
analysis, complete blood count, bleeding time, urinalysis and a “honeymoon” period after the transplantation.
urine culture, 24-hour urine sample for protein, a renal arte- Help children understand that acceptance or rejection of
riogram, and IV pyelography. They will have urine samples a kidney depends on a multitude of factors—the condition of
collected after surgery to assess that their remaining kidney is renal veins and arteries, the transplanted kidney, or anti-
capable of maintaining full function and they are still in good gen–antibody formation—but none of these factors is related
health. to whether the child is good or bad or deserves or does not
Before surgery, children who are to receive a transplant deserve to have the transplantation work (Box 46.7).
may be dialyzed to clear their body of excessive potassium Children with end-stage renal disease usually fail to grow
and fluid. If the donated kidney will be from a relative, there despite treatment. Although the rate of growth is improved
is adequate time for thorough preoperative preparation. If after kidney transplantation, they will probably never reach
the donor kidney is from a cadaver, the announcement of full height. Part of this growth restriction is related to the
surgery will be sudden and time for preoperative instruction need for corticosteroid maintenance therapy to continue
and procedures may be limited. immunosuppression.
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1384 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders

the long-term immunosuppression (Villeneuve et al., 2007).

BOX 46.7 ✽ Focus on Communication The original disease for which the child underwent trans-
plantation may recur in the transplanted kidney. This is most
Carol’s grandmother tells you Carol has “changed com- apt to occur in glomerulonephritis. During adolescence, typ-
pletely” since she became ill. ically an age of poor adherence to medication regimens, kid-
ney recipients need to be followed closely to be certain they
Less Effective Communication are taking their immunosuppressive therapy. Parents cannot
Nurse: Mrs. Hendricks, in what way has Carol changed? help but overprotect the child; they worry that a rough-hous-
Mrs. Hendricks: She used to whine all the time, and ing session with a sibling or playing a game such as baseball
constantly ask for things. Now she entertains may injure the transplanted kidney. The child may be afraid
herself. It’s like heaven. to engage in any activity for the same reason unless you help
Nurse: That sounds wonderful. Let’s review her medi- a family fully adjust to this major life change.
cine routine to be sure that’s going well.
Mrs. Hendricks: That’s another thing she does perfectly: ✔Checkpoint Question 46.5
never fusses a bit about anything she has to take.
How would you best explain kidney transplantation to a child?
More Effective Communication
a. A new kidney will be placed in your abdomen.
Nurse: Mrs. Hendricks, in what way has Carol changed?
b. The new kidney will be placed in your bladder.
Mrs. Hendricks: She used to whine all the time, and
c. You must never eat eggs after a kidney transplant.
constantly ask for things. Now she entertains
d. Your urine will be brown for the rest of your life.
herself. It’s like heaven.
Nurse: Do you think she’s acting a little too perfect?
Mrs. Hendricks: Well, it does seem a bit strange for her.
Nurse: Do you think she could be worrying that if she
misbehaves, her medicine won’t work? Key Points for Review
Mrs. Hendricks: I never thought of that. I would feel
better if she started to act like her old self.
● Many urinary tract disorders, such as polycystic kidneys,
What the grandmother above is describing is a “honey- urethral obstruction, and bladder exstrophy, are evident
moon” period that children may pass through after on a fetal ultrasound. Early identification this way allows
being told their kidneys are important for life. Parents therapy to begin in utero or immediately at birth.
often need help seeing this for what it is so they can ● Many urinary tract disorders, such as polycystic kidneys
begin to reassure children that behaving perfectly will
or chronic renal failure, are long-term conditions requir-
not influence the outcome of their illness and that, be-
cause they loved them as they were, they will continue
ing years of therapy. Be certain that parents are well in-
to love them regardless. formed about their child’s condition so they can continue
to participate in planning their child’s care.
● Congenital structural abnormalities of the urinary tract
include patent urachus, exstrophy of the bladder, hy-
Transplant Rejection pospadias, and epispadias. Surgical correction is required
for all of these.
Acute transplant rejection, if it occurs, usually develops ● Urinary tract infection tends to occur more often in girls
within the first 3 months after transplantation. Children than boys. “Honeymoon cystitis” refers to a urinary tract
begin to develop fever, proteinuria, oliguria, weight gain, infection occurring with first-time sexual intercourse.
hypertension, and tenderness over the kidney. Serum creati-
nine and BUN levels will rise. Increasing the dose of im- ● Vesicoureteral reflux is the backflow of urine into ureters
munosuppressants may be effective in relieving this type of with voiding. It occurs because the valve that guards the
rejection. entrance to the ureters is lax or misplaced. Surgical cor-
Rejection may also be chronic, in which the transplanted rection may be necessary to prevent repeated urinary tract
kidney gradually loses function after the first 6 months. infection.
Hypertension and anemia result. A biopsy will show vascular ● Kidney dysfunction can occur for structural reasons such
changes such as narrowing of arterial lumens and interstitial as kidney agenesis, polycystic kidney, and renal hypoplasia.
changes such as fibrosis and tubular atrophy. This type of re- ● Acute poststreptococcal glomerulonephritis is inflamma-
jection is difficult to halt, although it may be such a slow, tion of the glomeruli after a streptococcal infection. It is
steady process that it is 2 or 3 years before the kidney fails. If characterized by an acute episode of hematuria and
a kidney is rejected, it is removed and a child is returned to a proteinuria.
program of hemodialysis. Because one kidney was rejected
does not mean that a second transplant will be rejected also. ● Nephrotic syndrome is an immunologic process that re-
Unfortunately, however, the number of kidneys available for sults in altered glomerular permeability.
transplantation is limited, so kidney rejection becomes an ● Diminished kidney function leads to both fluid and
ominous sign for the child’s long-term survival. electrolyte imbalances. Creative techniques are necessary
Malignant disease is more common in transplantation re- to encourage children to continue to ingest a restricted-
cipients than in the normal population, probably because of protein diet.
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CHAPTER 46 Nursing Care of a Family When a Child Has a Renal or Urinary Tract Disorder 1385

● Renal failure can be acute or chronic. Peritoneal dialysis Ashley, R. A., (2007). Urachal anomalies: a longitudinal study of urachal
or hemodialysis may be used to remove body wastes until remnants in children and adults. Journal of Urology, 178(4.2),
kidney function can be restored. 1615–1618.
Atala, A. (2007). Congenital urologic anomalies. In R. W. Schrier (Ed.).
● Kidney transplantation may be an option for some chil- Diseases of the kidney and urinary tract. Philadelphia: Lippincott Williams
dren with kidney disorders. This is extensive surgery and & Wilkins.
requires the child to remain on immunosuppressive ther- Auron, A., et al. (2007). Prevention of peritonitis in children receiving peri-
apy to counteract transplant rejection. toneal dialysis. Pediatric Nephrology, 22(4), 578–585.
Boyer, O., et al. (2007). Prognosis of autosomal dominant polycystic kid-
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CRITICAL THINKING EXERCISES tion. In R. W. Schrier (Ed.). Diseases of the kidney and urinary tract.
Philadelphia: Lippincott Williams & Wilkins.
1. Carol is the preschooler with nephrotic syndrome Coe, K., & Lail, C. (2007). Peritoneal dialysis in the neonatal intensive care
unit: management of acute renal failure after a severe subgaleal hemor-
whom you met at the beginning of the chapter. Her rhage. Advances in Neonatal Care, 7(4), 179–186.
grandmother asked you whether a sip of beer could have Croker, B. P., & Tisher, C. C. (2007). Indications for and interpretation of
caused Carol’s kidney disease. What would you tell her the renal biopsy. In R. W. Schrier (Ed.). Diseases of the kidney and uri-
is the cause of nephrosis? What discharge instructions nary tract. Philadelphia: Lippincott Williams & Wilkins.
can you anticipate you will need to review with Carol’s Dodson, J. L., et al. (2007). Outcomes of delayed hypospadias repair: im-
plications for decision making. Journal of Urology, 178(1), 278–281.
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2. Carol’s grandmother is afraid Carol will need a kidney dren with enuresis nocturna. Pediatric Nephrology, 23(1), 93–98.
transplant. Carol tells you she hopes she has been good Factor, K. F. (2007). Potassium management in pediatric peritoneal dialy-
enough to deserve being chosen for a transplant. What sis patients: can a diet with increased potassium maintain a normal
would you want to teach this family about the trans- serum potassium without a potassium supplement? Advances in
Peritoneal Dialysis, 23(2), 167–169.
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3. Suppose Carol receives continuous ambulatory peri- reconstruction after newborn complete primary repair of exstrophy.
toneal dialysis and wants to go to her church camp this Journal of Urology, 178(4.2), 1619–1622.
summer. Her grandmother asks you whether this would Glazener, C. M. A., Evans, J. H. C., & Peto, R. E. (2009). Drugs for noc-
be a good experience for her. What factors would you turnal enuresis in children (other than desmopressin and tricyclics).
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want to know about the camp? About Carol? About her Gomella, L. G., & Haist, S. A. (2007). Clinician’s pocket reference (11th
procedure? ed.). Columbus, OH: McGraw-Hill.
4. Examine the National Health Goals related to renal dis- Hellmann, D. B., & Imboden, J. B. (2009). Musculoskeletal disorders. In
orders and children. Most government-sponsored funds S. J. McPhee & M. A. Papadakis (Eds.). Current medical diagnosis and
for nursing research are allotted based on these goals. treatment. Columbus, OH: McGraw-Hill.
Hensle, T. W., Grogg, A. L., & Eaddy, M. (2007). Pediatric vesicoureteral
What would be a possible research topic to explore per- reflux: treatment patterns and outcomes. Nature Clinical Practice
tinent to these goals that would be applicable to Carol’s Urology, 4(9), 462–463.
family and also advance evidence-based practice? Hubert, K. C., & Palmer, J. S. (2007). Current diagnosis and management
of fetal genitourinary abnormalities. Urologic Clinics of North America,
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Hutton, K. A., & Babu, R. (2007). Normal anatomy of the external ure-
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CRITICAL THINKING SCENARIO International: British Journal of Urology, 100(1), 161–163.
Kamel, M. H., et al. (2007). Deceased-donor kidney transplantation in
Open the accompanying CD-ROM or visit http:// prune belly syndrome. Urology, 69(4), 666–669.
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