Ncma219 Lec Final

Bachelor of Science in Nursing 2YB
NCMA219 PEDIA LEC: BSN 2ND YEAR 2ND SEMESTER FINAL 2022
Classification
Coverage for Final: - heterogenous group of disease
• Alterations with Infectious, Inflammatory and • Systemic arthritis is arthritis in one or more joints associated
Immunologic Responses/ Cellular Aberrations with at least 2 weeks of quotidian fever, rash,
• Alterations in Nutrition and Gastrointestinal, Metabolism lymphadenopathy, hepatosplenomegaly, and serositis.
and Endocrine • Oligoarthritis is arthritis in one to four joints for the first 6
• Alterations in Perception and Coordination months of disease.
• Life Threatening Conditions/ Acutely Ill/ Multi-organ - Persistent Oligoarthritis if it remains in four joints or
Problems/ High Acuity and Emergency Situations fewer
• Integrated Management of Childhood Illness (IMCI) - Extended Oligoarthritis if it involves more than four
joints after 6 months.
ALTERATIONS W/ INFECTIOUS, INFLAMMATORY & • Polyarthritis rheumatoid factor negative affects five or
IMMUNOLOGIC RESPONSES more joints in the first 6 months with a negative rheumatoid
Discussed by Prof. Carmencita Pacis factor.
Juvenile Rheumatoid Arthritis (Idiopathic) JRA • Polyarthritis rheumatoid factor positive also affects five or
- Chronic autoimmune inflammatory disease-causing more joints in first 6 months, but these children have a positive
inflammation of the joints and other tissue with an unknown rheumatoid factor.
cause. • Psoriatic arthritis is arthritis with psoriasis or an associated
- Idiopathic – hindi dactylitis, nail pitting, or onycholysis or psoriasis in a first-
- Inflammation of joints degree relative.
- Inflammation bec. of IgE, mga mass cells • Enthesitis-related arthritis is arthritis or enthesitis associated
- Peak: before 16 yr/old with at least two of the following: sacroiliac or lumbosacral
- Onset: bet. 1 and 3 yr/old pain, HLA-B27 antigen, arthritis in a boy older than 6 years,
- Twice as many girls as boys are affected acute anterior uveitis, inflammatory bowel disease, Reiter
- Cause: Unknown syndrome, or acute anterior uveitis in a first-degree relative.
Factors: • Undifferentiated arthritis fits no other category above or fits
- Immunogenic susceptibility – expose sa infection, para ma more than one category.
trigger mag release ng mga substances yung katawan Diagnostic Evaluation
- Environmental/ external triggers (can cause inflammation); • Diagnosis of Exclusion (no definitive test)
such as virus (e.g. rubella, Eptein-Barr virus, Parvovirus B19) - Arthritis one or more joints for 6 wks and longer are affected
– kapag mababa immune system mabilis mahawaan - Age of onset bef. age 16 years
- Genetic - Exclusion of other causes – walang ibang sakit, hindi
• HLA (Class I and II) gene nadulas, hindi kumakain ng foods na mataas sa uric acid
• PTPN22 gene • Laboratory tests (supporting evidence)
• IL2RA/CD 25 gene - ESR may elevated – inflammatory markers
- The genetic factor is complicated and well not understand - Plain radiographs – shows soft tissue swelling and joint
Pathophysiology space widening (bec. of high synovial fluid)
- Characterized by chronic inflammation of the synovium with - Films – can reveal osteoporosis, narrow joint-space,
joint effusion – synovitis (merong fluid sa gitna na pwedeng erosions, subluxation, and ankylosis)
ma fold yung mga joints, pero kapag may inflammation - Slit lamp eye (for uveitis) – inflammatory chamber of the
nauubos ang fluid, hindi maka flow ang fluid) eye this is most common in young girls with positive
- Eventual erosion, destruction, and fibrosis of the articular antinuclear antibody oligoarthritis
cartilage (because of the synovitis or pamamaga, nagiging - Antinuclear antibodies common but not specific for
manipis ang mga cartilage) arthritis – however can help to find who are at risk for
- If inflammatory process persists, adhesions bet. joints surface uveitis (present sya)
and ankylosis of joints occur. (kapag tuloy tuloy ang exposure - Leukocytosis – Presence of leukocytosis during
mo sa inflammation) exacerbations of systemic JIA (mataas ang WBC – may
- Ankylosis – unmovable joints or stiffness infection)
Clinical Manifestation - Radiographs (X – ray)
- Joint deformity – cannot open the hands may stiffness na Therapeutic Management
- Functional disability Major Goals:
- Children have most soft bones than the adult - Control pain or Relieve Pain – behavioral therapy and
Management relaxation technique.
- Physical therapy - Heat and exercises can help prevent deformity – moist heat
- Joint replacement – if needed in the future (bathtub with warm water), paraffin bath, hot packs.
- Chronic and Acute Uveitis – can cause permanent vision loss - Pool Therapy (swimming)
if – undiagnosed and not treated STAT - Preserve joint range of motion and function
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CARE OF MOTHER AND CHILD AT RISK OR PROBLEMS – LECTURE: BSN 2ND YEAR 2ND SEM FINAL 2022
- minimize effects of inflammation such as joint deformity -Profuse watery nasal discharge – coryza (tumutulo lang yung
- promote normal growth and development sipon)
- Non-pharmacologic modalities - Mucous membrane (pale)
Promote General Health - Nasal congestion
- Well balanced diet with sufficient calories – iwasan ang mga - Edematous
high in uric acid like oily foods or monggo kapag sa bata - Watery eyes
naman yung mga foods na nilalagyan lang ng mainit na tubig - Pruritic Conjunctivae
- Sleep and rest are essential - Cobble stoning – pebbly appearance
- Nighttime splints instructions to parents – immobilize ang - Allergic salute – rubbing the nose upward
mga area na pwedeng magalaw galaw - Dennie line pr crease in the nose
- Prevent URTI – mga sipon, sinusitis, tonsilitis - Allergic shiners – dark areas under the eyes
- Effective communication among family, primary care - Full frontal headaches (>6 years old) – sinusitis
provider and rheumatology team for care coordination - Exhausted and lethargic
Medications - Otitis media – swollen pharyngeal tissue
• Methotrexate Diagnosis Evaluation:
• Corticosteroids - Nasal smear – high eosinophil count (mataas sya ng 10%)
• Nonsteroidal inflammatory Drugs (NSAID) (Normal: <500 cells/mcL)
- Naproxen Therapeutic Management
- Ibuprofen - Pharmacologic Agents
- Tolmetin • Antihistamine – OTC (non-sedative)
- Indomethacin • Leukotriene inhibitors – nare release ng mga WBC na
- Celeboxib trigger the immune system to increase histamine pero
- Meloxicam kapag meron b block nya pag release ng histamine ng
- Aspirin katawan
Biologic Agents: • corticosteroids (Intranasal) – Antiviral
- Etanercept - Immunotherapy
- Adalimumab - W/ saltwater solution
- Abatacept - Environmental control (avoidance of allergen)
- Immunomodulator NOTE: Nasal Spray – do not give this for more than 3 days bec. of
Side effects: rebound effect, nasal mucosa will be more edematous and the
- Gastrointestinal irritation symptoms will worsen.
- Bruising
NOTE: Atopic Dermatitis – Eczema
• Naproxen – skin fragility (must taken w/ foods) - A type of pruritic eczema that usually begins during infancy
• Aspirin – once the DOC but replaced by NSAID bec. they and is associated with an allergic contact dermatitis with a
have fewer side effects and have easier administration hereditary tendency (atopy)
schedules. - chronic inflammatory disease
- inflammation of the skin
Allergic Rhinitis - will go on develop allergic rhinitis and asthma
- associated w/ an IgE – mediated inflammatory response to • Cause: Hereditary tendency
allergen exposure (magre release ng substance) o Sweating
- Caused by a type 1 or immediate hypersensitivity immune o Heat
response o Tight clothing
- Occurse in 10% to 40% in children o Contact irritants
Risk: Assessment
- development of asthma - Popular and vesicular skin eruptions
- sleep impairment - Erythema
Cause: - Vesicles Ruptured – Exudate Yellow Sticky Secretions
- Polens - Lesions Pruritic
- Molds - Secondary Infection:
- Irritants - Depigmented
- Dust - Lichenified
- Flakes of skin animals - Dry
NOTE: w/ upper respi. infection, the mucous membrane is more - Flakes Scales Form
apt to be reddened than pale, secretion = thick white or yellow - Low Grade Fever
Assessment - Pus-Filled Lesions
Main Symptoms: - Local Lymph Nodes Enlargement
- Congestion sneezing – yung pang filter is hindi na kaya e - Develops Dexterity
sala yung mga alikabok Forms of Eczema
- Nasal engorgement – mamumula at lalaki lalo Infantile Form (Eczema)
- Usually begins at 2 to 6 months of age
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- Undergoes spontaneous remission by 3 years of age • Prone to cold hands

(Spontaneous – makakarecover na yung katawan nya) • Pityriasis alba (small, poorly defined areas of
- Generalized, especially cheeks, scalp, trunk, and extensor hypopigmentation)
surfaces of extremities • Facial pallor (esp. Around nose, mouth and ears)
Childhood Form (Eczema) • Bluish discoloration beneath eyes (allergic shiners or eye
- May follow infantile form bags)
- Occurs at 2- 3 years of age (pwedeng bumalik sa gantong • Increased susceptibility to unusual cutaneous infection (esp.
age) Viral)
- 90% of children have manifestation by age 5 years Therapeutic Management
- Flexural areas (antecubital and popliteal fossae, neck), • Hydrate skin
wrists, ankles, and feet
• Relieve pruritus or itchiness
Preadolescent and Adolescent Form (Eczema)
• Reduce flare-ups or inflammation
- Begins about 12 years of age
• Prevent the illness and secondary infection – pwedeng mag
- May continue into the early adult years or indefinitely
sugat kapag kinamot ng kinamot
(may mga rashes pero hindi na ganun kadami)
- Face, sides of neck, hands and feet, face, and antecubital • Avoiding exposure to skin irritants or allergens
and popliteal fossae (to a lesser extent) • Avoiding overheating
Appearance of lesions - Fingernails/toenails are cute short
Infantile Childhood Adolescent Treatment:
Erythema Symmetric Same as childhood - Short, lukewarm showers and baths
involvement - Regular use of humectant moisturizer
Vesicles – Cluster of small Dry, thick lesions - OTC topical medications (typically in the form of ointments
fluid erythematous or flesh- (lichenified plaques) and creams)
colored papules or common confluent - Humidifiers
minimally scaling papules - Prescriptions
patches Older Children Management:
Papules – more Dry and may be Other physical - Application of hypo cortisones or phototherapy w/ ultra
on laman, hyperpigmented manifestation violet light for lesions
elevated ang Medications
skin or may • Antihistamine
bump • Topical Immunomodulators
Weeping Lichenification Intense itching • Topical Steroids
(thickened skin w/ • Mild Sedatives
accentuate crease) Nursing Care Management
Oozing – Keratosis pilaris Unaffected skin dry • Family history
paglabas ng (follicular and rough • History of previous involvement
fluid hyperkeratosis) • Environmental factors
common – chicken • Dietary factors
skin • These two are associated w/ previous and present
Crusting African – American exacerbations
children likely to • Prevent and minimize scratching
exhibit more popular - Cut fingernails and toenails short, keep it clean and filed
or follicular lesions - Gloves or cotton stockings can be placed overhands and
than are white children pinned to shirtsleeves
Scaling – - One-piece outfits with long sleeves and long pants
nagda dry, decrease direct contact with the skin
natutuklap - Remove woolen clothes or blankets, rough fabrics, and
Often furry stuffed animals from the child’s environment
symmetric - Proper dress for climatic conditions
• Risk Factors: - Prevent exposure to certain components of soaps,
- Drugs detergents, fabric softeners, perfumes, and powders
- Foods - Use soft cotton fabrics
- Vaccines • Prevent infections
- Peanut hypersensitivity - Tepid baths – slightly cooler to the body temp. 23 to 24
- Milk intolerance deg. C.
- Stinging insect hypersensitivity - Avoid bubble baths, oil, and powders
- Contact dermatitis - Skinfolds and diaper areas need freq. cleansing with plain
Manifestation water
• Lymphadenopathy, especially near affected sites - Room humidifier or vaporizer
• Increased palmar crease
• Atopic pleats (extra line or groove of lower eyelid)
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- Assess for signs of infection (honey-colored crusts or - NG decompression

pustules with surrounding erythema) – impetigo, a - Antibiotic
contagious skin dse. Surgery:
• Skin lesions: - Resection
- assess the; Nursing Management
! Type • Preoperative Preparation
! Distribution - NPO
! Evidence of secondary infection - Routine lab testing (CBC and Urinalysis)
NOTE: in older children they could swim in the chlorinated pool - Parental consent
and after swimming wash immediately and properly and apply - Preanesthetic sedation
emollient and skin moisturizer. In infants they should soak in the • Perforation:
bath for 15-30 minutes (NO SOAP) - IV Fluids
- Systemic antibiotic
Intussusception - Bowel decompression
- Intestinal obstruction in children bet. 3 and 6 yr/old - Fluid replacement
- common in males than females - restoration of electrolytes
- common in children younger than 2 yr/old - monitor VS
- can lead to:
o Polyp • Postoperative
o Lymphoma - monitor VS
o Meckel diverticulum - intact suture and dressing
• Cause: Unknown - return bowel sounds
- Idiopathic – caused by hypertrophy of intestinal lymphoid - passage of water-soluble contrast material
tissue secondary to viral infection - Stool pattern
Site: Pathophysiology
- Ileocecal valve (ileocolic) – ileum invaginates into the
cecum; then further into the colon Mesentery Invaginated (compressed and angled)
- Ileoileal (ileum)
- Colocolin (colon)
- Intussusception – area of the hepatic or splenic flexure or at
Lymphatic and obstruction (venous)
along the transverse colon
Manifestation (s/s)
• Sudden acute abdominal pain
• Child screaming and drawing the knees onto the chest (parang Increase edema
naka fetal like position sya)
• Child appearing normal and comfortable between episodes of
pain
• Vomiting increase intussusception
• Lethargy
• Passage of red, current jelly-like stools (stool mixed w/ blood
and mucus) pressure equals the arterial pressure
• Tender, distended abdomen
• Palpable sausage-shaped mass in upper right quadrant
• Empty lower right quadrant (dance sign – kapag pinalpate mo
sya parang umuusog yung organ na dapat ma palpate mo sa arterial blood flow stops
area na yun)
• Eventual fever
• Prostration
ischemia and pouring of mucus into the intestine
• Other sign of peritonitis
Diagnostic Evaluation:
• Ultrasonography – heterogenous mass and “bull’s eye”
• Rectal Exam – mucus, blood and occasionally a low venous engorgement
intussusception itself
Therapeutic Management
• Pneumoenema (air enema)
• Ultrasound – guided hydrostatic enema (saline) leaking of blood and mucus into the lumen
NOTE: Procedure should not be attempted w/ prolonged
intussusception, signs of shocks, peritoneal irritation or intestinal
perforation
currant jelly-like stool
- IV fluids administration
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CELLULAR ABERRATIONS (BASIC CONCEPTS OF • Exposure to sunlight

ONCOLOGY) • Altitude (living in an area that has low level of O2 and
Discussed by Prof. Carmencita Pacis humidity
- Mutation or growth in the cells Chemical Agents
- Simply termed as cancer • Smoking – biggest risk factor that could lead to cancer
Cancer specially kapag may lahi kang ganito at may physical
- Is a complex of diseases (includes more than 1 type of agents pa
symptoms it depends on what organ will this mutation will • Dietary ingredients – refers to the food that you eat,
occur) which occurs when normal cells mutate into abnormal mataas ba ung concentration or content ng preservatives.
cells (in the mitosis phase of our cell cycle this is where the Fund of eating foods that is not natural like canned foods
parents cell will divide into 2 daughter cell, but in the cell cycle and frozen foods. We have to eat nutritious foods
of a cancer cell they will undergo the same process but it would • Drugs – taking certain types of medication can trigger the
be much faster, mas mabilis silang manganak) that take over mutations in the genes
normal tissue, eventually harming and destroying the host. Genetics and Family History
- A large group of diseases characterized by: • Colon cancer
• Uncontrolled growth and spread of abnormal cells • Premenopausal breast cancer
• Proliferation (rapid reproduction by cell division, this is • Considered only as 10% factor causing cancer
the reason why they spread faster) • Kung maingat ka sa katawan mo kahit na may family
• Metastasis (spread or transfer of cancer cells from one history ka 10% lang possible cause para mag ka cancer ka.
organ or part to another not directly connected)
- ONCOLOGY – deals with study, detection, treatment, and
management of cancer and neoplasia
Characters of Neoplasia
Neoplasia
- abnormal or uncontrolled growth of cells or tissue
- Have 2 types: benign and malignant
Benign
• Well-differentiated – have smooth or regular shape. Madaling
Makita kung anong shape nya dahil encapsulated sila
• Slow growth Leukemia
• Encapsulated - Most commonly diagnosed pediatric malignancy in children
• Non-invasive under 14 years of age.
• Does NOT metastasize – do not migrate or enter other organs - Cancer of the blood-forming organs or tissues (bone marrow)
• Moveable and does not contain cancer cells characterized by a proliferation of abnormal white blood cells
Malignant in the body (abnormal na pag dami ng WBC)
• Undifferentiated – have uneven shape - Common type of cancer among children.
• Erratic and uncontrolled growth – mabilis silang lumaki - We have 4 types of leukemia but we will only focus on the 2
• Expansive and invasive – can transfer to other organs types only
• Secretes abnormal proteins – protein kase ay kailangan ng cell - Among the 3 blood components, leukaemia starts forming in
para sya ay lumaki, this helps cells to grow faster the WBC. WBC fights infection in our body it also have
• METASTASIZES components like lymphocytes and these lymphocytes have 3
• Not moveable classes T-cells (attacks bacteria or m.o), B-cells (increases the
production of antibodies) and natural killer cells (serves as a
guard and kills foreign bodies when they detected it harmful.
Lahat ng ito lumalabas or tumataas ang bilang kapag nag
kakaroon tayo ng infection.
Main types
• Acute lymphoblastic leukemia (ALL)
• Acute myelogenous leukemia (AML)
Etiology • Since we are talking about pedia we will only focus on these
Physical Agents two ↑
• Radiation • The problem with acute since they are present in early
• Exposure to irritants – like insecticides and chemicals childhood mabilis silang mag parami
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Causes of leukemia - Prognosis depends on the stage of disease progression, age

• unknown; group of 3 to 7 years seem to have the highest chance of
• exposure to infectious agents; complete recovery.
• genetic factors - WBC – have lymphocytes and myeloid cells. It depends what
component of WBC ang nag karoon ng abnormal mutation
meaning mabilis dumami pero puro abnormal sila they will not
serve the function of the WBC.
- They developed in the WBC. Specifically in the lymphocytes in
the bone marrow. If you look at the blood stem cell chart nag
focus ung type ng leukemia na ito sa lymphoid stem cell, which
is responsible in the formation of the lymphoblast, which is
also responsible in the creation of the B & T lymphocyte and
natural killer cell.
- It started in the lymphoid stem cell.
- Leukemia has 65% chance of survival. Sometimes even though
you have treatment there is still a remission that the cancer will
come back.
- If you have surpassed five years ago of having leukemia while
having continuous treatment mas tumataas ung chance na
makaka survive kana.
- You need to have continuous treatment kase nasa dugo ito.
- Occurs when the stem cells in the bone marrow produce
Acute Myelogenous Leukemia (Aml)
immature WBCs that cannot function normally → proliferate
- Refers to all leukemias from myeloid cells
rapidly by cloning causing bone marrow to fill with abnormal
- 17% of childhood leukemia
WBCs → abnormal WBCs spill out into circulatory system →
- Most common in children younger than 2 years of age and in
replace normal functioning WBCs → the protective
adolescents
lymphocytic functions (cellular and humoral immunity) are
- Mostly seen in the adolescent age. Doesn’t only focus on the
reduced → body vulnerable to infections
WBC
- Lahat ng cell ay dumadaan sa cell cycle kaya ung immature
- Myeloid stem cell in the chart is responsible in the formation of
WBC ay mangangaank rin ng mga immature WBC. Dahil dito
RBC, platelet and the myeloblast or the granulocyte
hindi na rin nila magawa ng maayos ung function nila na
- Have three problems: RBC, platelet and WBC
labanan ang mga infections. Mapupuno ung bone marrow ng
mga abnormal WBC. Madali ng mag karoon ng infection kase Causes
ung mga WBC ay hindi nag fa-function ng tama. • Ionizing radiation exposure when in utero (pinag bubuntis pa
- Malignant WBCs rapidly fill the bone marrow → replaces stem lng ni nanay na exposed na sa radiation)
cells that produce erythrocytes (RBCs) and other blood • Chemical agents (chemotherapy agents for other cancers)
products (platelets) → ↓ RBC and platelets in circulation (pwedeng ung bata ay exposed to medications for other type of
(anemia and abnormal bleeding) cancer pwedeng ma damage nya ung bone marrow nya that
- Later on pati ung ibang component inside the bone marrow will could lead to this type of cancer later)
be affected like the RBC and platelet. There will be anemia • Chromosomal and genetic abnormalities
since there will be a destruction of the RBC. There will also be
bleeding because there is a decrease amount of platelet dahil
they are replaced by abnormal WBC. Kaya magiging 3 na ung
problem ni patient: infection, anemia and bleeding. Ang tawag
dito ay pancytopenia – abnormal WBC, decrease RBC and
platelet.
Acute Lymphoblastic Leukemia (All) Assessment Findings

- Most common type of childhood leukemia • Fever – since immune system is down, this is a sign of
- 25% of all childhood cancer and 78% of leukemias in children infection.
- Peak age at onset: 2 to 3 years • Pallor – because of decreased RBC
• Overt signs of bleeding – because of decreased WBC
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• Lethargy and Body Malaise – caused by decrease of O2, this is • This other lab finding is evident if the patients have already
related to the decrease of RBC started with the treatment.
• Anorexia – loss of appetite, kapag may sakit kase diba wala • The main diagnose here is for the doctor to identify if the
kang gana kumain. symptoms manifested by the patient is actually of leukemia will
• Large joint or bone pain – due to bleeding and inflammation be the rapid flow cytometric assay.
kase abnormal ung WBC niya
• Petechiae, frank bleeding, and joint pains – cardinal signs of
bone marrow failure. Pumapalya na ung bone marrow nya
• Hepatosplenomegaly (paglaki ng liver at spleen niya) and
lymphadenopathy (may namamagang lymph nodes)
• Headache, vomiting, papilledema, sixth cranial nerve palsy
(CNS involvement) – problem in the abducens nerve w/c is
responsible to the control movement of the eye kaya kapag may
6 cranial nerve palsy duling siya.
Treatment
- Treatment of cancer ay halos iisa lang
Radiation therapy
• Used for CNS disease, in T-cell leukemia, and for
Diagnostics testicular involvement.
- This is done to confirm kung may leukemia ba tlga. • May klase kase ng lukemia depende kung anong specific.
CBC – full blood count Pag kase sinabing lymphocyte may 2 types na affected T-
• and include differential (to identify the specific cell or B-cell kaya aalamin muna kung anong cell sa
component of the WBC are low in value kase meron itong leukemia ung affected t-cells ba or b-cells.
lymphocyte, neutrophil, eosinophil etc.) • Kapag B-cell leukemia iba ang approach dito
• Anemia, thrombocytopenia, neutropenia Chemotherapy
Bone marrow aspiration • Four phases:
• Reveals immature and abnormal lymphoblasts and 1. Induction – intensive phase of killing cancer cells. It is the
hypercellular marrow first phase and more aggressive, mataas na klase ng gamot
• Differential test ang ibibigay dahil gusto muna nating papatayin ung active
• Identifies the presence of the abnormal WBC cancer cells. Usually last for 1 month
Rapid flow cytometric assay 2. Consolidation – second phase, happens a month after
• Measures even very small numbers of leukemic cells induction. It takes several months of treatment.
• Used to establish the protocol for treatment 3. Delayed intensification – maintenance therapy. After 2
• If the patient will be positive for the rapid flow cytometric years they will give chemotherapy.
assay we need to start for the immediate treatment 4. Maintenance of remission – happens after 2 to 3 years
• Kapag kase CBC lang makikita lang na mababa ung RBC - Merong phase sa cell cycle na hindi mapapatay ung cancer cells
baka isipin na anemia lang at hindi siya specifically ito ung G0 phase.
madadiagnose na may leukemia tapos ung bone marrow - Sa cell cycle kase ntin may G1 ito ung opianka maatagal
aspiration it will identify immature WBC but will not wherein nag papalaki ung cell → G0 is the resting phase sa cell
indicate specifically if the patient already has leukemia cycle. Before the cell will enter the S phase mag papahinga
bali ang pinaka pang diagnose tlga is this rapid flow muna ito so kung cancer cell ung nandito ptotected siya hindi
cytometric assay to identify leukemic cells. siya tatablan, mapapatay or maaapektuhan ng mga
Other lab findings chemotherapeutic agents. After G0 either the cell will go back
• Elevated serum uric acid – mataas ang uric acid kass mataas to G1 or enter S phase → S phase nandito na ung DNA
ang break down ng mga cancer cell kaya once we started with replication → G2 continues growth or maturation of the cell →
the treatment ibe-break mo ung mga cancer cell so expect na M phase or mitosis phase, this is where the parent cell is ready
tataas din ung uric acid. Tatas serum uric acid bcs of the higher to divide into 2 daughter cell kaya pag abot ng M phase
level of cellular nucleic acid that is being breakdown bcs of the magiging 2 na sila at magkakaroon sila ng anak so each
cancer cells daughter cell will undergo their own cell cycle hanggang sa
• Hypocalcemia – side effect of chemotherapeutic kaya bababa dumami na sila.
ang kanyang calcium. Most of the anti-cancer drug that we - Pagpasok nya ng halimbawa natapos na nya ung consolidation
have, have side effects of hypocalcemia treatment at hindi na sya nag tuloy sa treatment tinigil na ung
• Elevated potassium and Phosphorus levels – mataas kase mag mga cells na nasa G0 mabubuhya ulit sila kaya mag kakaroon
kakaroon ng release of the intracellular potassium during blood ulit ng cancer kaya nga may tinatawag na maintenance
clotting.
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remission para sa mga cells na nakapasok sa G0 na hindi - Exhibits a variety of morphologic, cytochemical, and
napatay ng mga unang treatment. immunologic features similar to the diversity seen in leukemia.
- Hematopoietic stem cell transplant (HSCT) – or bone marrow - Multi organ thymus, liver, spleen, lymphatic system and the
transplant. Treatment for relapse of ALL; treatment option for bone marrow will be affected
AML. Could be from own bone marrow ni pt. or from a donor.
Treatment
• Prepare the child and family for diagnostic and therapeutic
procedures
• Relieve pain
• Prevent complications of myelosuppression – through treatment
dahil medyo aggressive ung gamutan pwedeng mag cause ito
ng myelosuppression hindi na mag foform ng blood products
ung bone marrow parang namatay na ung bone marrow
• Using precautions in administering and handling
chemotherapeutic agents – when u prepare this wear gloves and
think of ways we could prevent our self from being
Classification based on histologic pattern
contaminated of this medication. Pag hindi nag suot ng goggles
may fumes kase un at pati mga secretions ni pt. nung nag • Lymphoblastic – malalaki nag size ng mga lymph nodes
chemotherapy hindi dpt mahawakan. After 2 weeks of • Burkitt (have abnormal growth) or non-Burkitt (hindi
chemotherapy we need to protect the nurse and relatives of any masyadong lumalaki)
secretions coming from the patient. Pwede kase ma-absorb ng • Large cell
katawan antin ung chemotherapeutic agents that will trigger the - Clinical manifestations depend on the anatomic site and extent
abnormal mutations in our body kase ang chemotherapy drug of involvement (gaano ba kalaki ung bukol sa mga kulani niya).
na dadamay din ung mga normal cells kaya pwede dito na mag Enlargement of adjacent lymph nodes, intestinal or airway
start at magakroon ka ng cancer. obstruction, cranial nerve palsies, and spinal paralysis (kapag
• Manage problems of drug toxicity napunta na sa lumbar ang cancer cells). Since this is a non-
• Provide emotional support hodgkin that will damage the other organs magkakaroon din ng
Lymphomas intestinal or airway obstruction once na mamaga ang tonsil niya
- A group of neoplastic diseases that arise from the lymphoid and Therapeutic Management
hematopoietic systems. - Irradiation therapy
- 3rd most common group of malignancies in children and - Chemotherapy (induction, consolidation, and maintenance
adolescents phases, some with Intrathecal chemotherapy)
- Ang affected dito ay T-cells and B-cells at hematopoietic - Antineoplastic agents (vincristine, prednisone, Lasparaginase,
systems like RBC methotrexate, 6-mercaptopurine, cytarabine, cyclophosphamide,
- Magkakaroon ng mga kulani makakapa natin. anthracyclines, and teniposide or etoposide) – these drugs
Hodgkin lymphoma (HL) targets to kill specific phase of cell cycle.
- Prevalent in adolescence and young adult period (Between ages - Ex. Vincristine is an ex. of mitotic inhibitor ibig sabihin sa M
15 and 19 years). Have reed-sternberg cell. Have better survival phase ng cell cycle sya papatay ng cancer cell. Kase mitosis un
rate and health prognosis compared to non-hodgkin. Aggressive e mitotic inhibitor ito. Purpose nito is para hindi na managank
but easily treated compared to non-hodgkin. ung mga parent cancer cell or para hindi na mag hiwalay ung
- Originates in the lymphoid system and primarily involves the mga mitotic spindle
lymph nodes. Affected is lymph nodes. Wilms tumor
Symptoms - Also known as Nephroblastoma
• Asymptomatic enlarged cervical or supraclavicular - Most common malignant renal and
lymphadenopathy intra-abdominal tumor in children
• Systemic: cough, abdominal discomfort, and anorexia < 15 y/o (peak at 3 y/o)
Therapeutic Management • More common in blacks, inc
• Radiation therapy – to shrink cancer cell that is big. Parang males
sinusunog cancer cell para dna lumaki. Prevent growth. • Diagnosed at age < 5 y/o in
• Chemotherapy – kill cancer cells. 80% cases bcs as the child gets older the chance of
developing wilms tumor decreases
Nursing Care Management
• Error in DNA is the primary cause of wilms tumor this
• Preparation for diagnostic and operative procedures if there is a hase been transmitted from parent to child habang pinag
need to remove the organ that is being affected by the cancer bubuntis pa lang sya
cell. - Unknown
• Explanation of treatment side effects - Associated with mutations of the p53 tumor suppressor gene
• Child and family support (psychologic needs) chromosome 11.
Non-Hodgkin lymphoma (NHL) - p53 allows DNA to repair and activate the p53, once it is
- Prevalent in children younger than 14 years of age. No reed- activated it prevents the cells to get bigger kaya nga sya tumor
sternberg cell. More life threatening. suppressor genes kaso nag karoon sya ng mutations meaning
J.A.K.E 8 of 45
malfunctions si p53 so wala ng nag susupress sa cell para Treatment

lumaki kaya ang effect nito is it will: • Surgery & chemotherapy with or without radiation depending
• Form malignant undifferentiated cluster of primordial on histologic pattern and clinical stage
cells (mag kakaroon na ng bukol sa kidney) • Stage 1 – 3: tumors are treated with nephrectomy (removal of
• Associated with congenital anomalies – babies na may the kidney part lang ng kidney or buong kidney) and chemo
birth defect like: with or without radiation (after maalis mag undergo
o Hypospadia – nasa ilalim daanan ng ihi niya medications and radiations)
o Cryptorchidism – undescended testis, ung scrotum nya • Stage 4: treated with pulmonary irradiation and three-drug
nakadikit sa katawan nya combination chemo treatment in addition to the above. (meron
- Primary function of p53 is to prevent the development of tumor na siyang surgery-alisin, chemotherapy-gamutin, radiate-
kaya lang nag karoon ng mutation at hindi niya na prevent prevent lumaki at pulmonary irradiation. Tatlong
pagkakaroon ng tumor chemotherapeutic drug ang pag sasabay-sabayin) alkalating
Clinical manifestations drug pwede pumatay ng cancer cell kahit nasaang phase pa siya
• Abdominal swelling or mass (firm, non-tender, confined to one
side) bawal i-palpate bukol kase baka sumabog at kakalat ito
• Hematuria – bleeding in the urine
• Fatigue and malaise
• Hypertension (occasionally) – bcs we are talking about the
kidney and this filters the sodium, later on sodium will be
retained and it will result to inc. in the blood pressure
• Weight loss – r/t loss of appetite
• Schedule surgery asap after confirmation of abdominal mass
• Fever – sign of infection within 24 – 48 hours of admission. (kapag aalisin ung tumor
• (with lung involvement - metastasis) there will be symptoms of kasamang aalisin ung adjacent adrenal gland, kung right kidney
dyspnea, cough, shortness of breath, chest pain (sometimes)
ang may cancer pati si right adrenal na nasa ibabaw ng right
kidney aalisin na rin)
• Remove tumor, affected kidney, adjacent adrenal gland
• Keep encapsulated: tumor intact – rupture can seed cancer cell
throughout abdomen, lymphatic channel and bloodstream
• Inspect regional lymph node – do biopsy
• Any involved structures are removed – i.e. colon, diaphragm,
vena cava.
Diagnostic Evaluation • If both kidneys are involved
• Renal UTZ (makikita presence of tumor in the kidney) and CT o Radiotherapy &/or chemotherapy 1st before surgery to
• Hematology: polycythemia (inc. in RBC) if tumor secretes decrease the size of the tumor – allow conservative
excess erythropoletin surgery OR
• CXR and chest CT scan – for metastasis to the lungs o Partial nephrectomy on less affected kidney, total
• Urinalysis, IVP intravenous pyelogram (assess function of nephrectomy on opposite side OR
unaffected kidney) a dye will be injected to the vein and it will o If transplant is feasible – bilateral nephrectomy (last
be revealed papunta sa kidney. Para mamonitor ung pag travel option)
nung dye papunta sa kidney. Ex. Meron cancer right kidney so
i-moniter ung left kidney.
• Bone marrow aspiration to rule out metastasis to other organ.
• Post op radiation therapy: for large tumors, mets, residual post

op disease, unfavourable histology, recurrence
• Chemotherapy: for all stages
- DOC: Actinomycin D (most effective) chemotherapeutic
agent na protein synthesis inhibitor, vincristine (mitotic
inhibitor), Adriamycin (protein synthesis inhibitor)
- Advance disease: add cyclophosphamide ( 6 – 15 mos) ex.
of alkylating agent (non-cycle specific drug)
Prognosis
• 90% - stage 1 & 2 kase hindi pa ito kumalat sa ibang organ
• Survival rate: highest among all childhood CA
J.A.K.E 9 of 45
• Factors that favor success: Diagnostic Evaluation

o Initial treatment with only vincristine and dactinomycin. • MRI – identifies what specific part of the brain have the tumor
Mitotic inhibitor and protein synthesis inhibitor. Kapag • CT scan, angiography, EEG, Lumbar puncture – this is done if
mababa ang protein dec. ang growth ng cancer cell kapag there is already effect of tumor to other organs.
mitotic pine-prevent nya ung panganganak ng cell. • Brain tissue specimen (Histopathology) – definitive diagnosis
o Relapse to lungs only – pwede kase mag bigay ng Therapeutic Management
pulmonary radiation • Surgery (Complete surgical resection of tumor). Craniotomy –
o Relapse in abdomen on patient who receive no primary brain surgery
abdominal irradiation • Radiation therapy (avoided in children younger than 3 years of
o Relapse > 12 months after diagnosis (kase naka recovery na age) bcs it can cause long side effect of brain development that
ung body pwede na ulit mag undergo sa chemotherapy) is irreversible.
Nursing management • Chemotherapy
- Nursing care similar to CA patients treating with surgery, Symptoms
irradiation & chemotherapy • Vomiting
- Pre-op care • Mood swings
• Prepare child & parents for lab & surgical procedures • Hearing problems
within 24-48 hours of admission • Cognitive decline
• Special pre-op concerns • Speech problems
o Tumor not palpated unless absolutely necessary (bawal • Seizures
i-palpate kase baka pumutok at kakalat sa ibang organ) • Headache
o Manipulating of mass may disseminated CA cells to Nursing management
adjacent & distant site (explain sa pt. ano mga side • Establish baseline data to compare preoperative and
effect) postoperative changes
• Explain to parents what to expect – major benefits & side • Assess degree of physical incapacity and the family’s
effects of radiotherapy & chemotherapy emotional reaction to the diagnosis
• Nurse should be present during physician-parent • Monitor VS (BP and pulse pressure)
conferences to answer question as they arise • Routine neurologic assessment
o Alopecia: 2 weeks after initial treatment (explain after 2 • Observe for symptoms of increased ICP, bradycardia,
weeks malulugas ang buhok ni pt.) hypertension, irregular respirations, headache, vomiting, and
- Post-op care: same as any abdominal surgery any seizure activity. Note the location, severity, and duration of
• Careful monitoring of bowel movements, bowel sounds, headaches as well as its relationship to activity, time of day,
distention, vomiting, & pain and any associated factors.
• Increase risk for intestinal obstruction from vincristine- • Observe for behaviors, gait, head tilting while talking or
induced adynamic ileus radiation-induce edema & poor performing activity, and changes in posturing.
surgical adhesion formation Treatment Modalities
• Monitor BP, urine output, signs of infection Basic Cancer Management
- Family support • Surgery
• Post-op period: difficult for parents realization of o To remove or debulk (reduce the size) a solid tumor
seriousness of disease o May determine the stage and type of cancer. Malalaman
• Nurse should be with parents to assure them of child’s dito kung nag metastasize na bas a ibang organ ung bukol
recovery after surgery & assess parent’s understanding of nya.
total experience • Chemotherapy
o Administration of specific drugs that kill both normal and
Brain tumor cancerous cells.
- Most common solid tumor in o Administration is timed to achieve the greatest cellular
children and the second most destruction.
common childhood cancer
- A tumor that arises from any cell
within the cranium.
- Neuroblastoma
- Signs and symptoms related to
anatomic location and size and age.
(depende kung saan tumubo ung
bukol kung ang bukol sa brain ay
tumubo sa hypothalamus it will
suppress the functioning of the
hypothalamus w/c is to control the
release of the hormone) • Radiation therapy
o uses high-powered energy beams, such as X-rays or
protons, to kill cancer cells.
J.A.K.E 10 of 45
• Bone marrow transplant Atresia with proximal fistula

o also known as a stem cell transplant, can use your own - No distal fistula
bone marrow stem cells or those from a donor. - Small stomach, gasless abdomen
o Hematopoietic cell transplant - Often has a long gab between esophageal ends
• Immunotherapy - If the baby swallows milk or secretion, it will go to the
o also known as biological therapy, uses the body's immune esophagus and trachea going to the lungs. The baby will
system to fight cancer. experience severe aspirations and difficulty of breathing.
- 1% out of 100% cases
Esophageal Atresia with Tracheoesophageal Fistula
(Atresia with distal fistula)
- Most common
- The baby can aspirate the fluid because of the pharynx. And
when the baby inhales, some of the air will go to the lungs and
also to the stomach.
- Abdominal distension
Double Fistula
- The esophagus connected to the trachea and also the lower
portion of esophagus is connected to trachea.
- Halo halo mangyayari, when the baby swallows fluid, some of
• Cryoablation the fluid will go to lungs and since may fistula din sa lower
o kills cancer cells with cold. During cryoablation, a thin, portion, mapupunta rin un fluid sa stomach. And when the
wandlike needle (cryoprobe) is inserted through your skin baby inhales, some of the air will go to the lungs and also to
and directly into the cancerous tum or. A gas is pumped stomach.
into the cryoprobe in order to freeze the tissue. Then the - Not common, only 1% out of 100 cases
tissue is allowed to thaw. The freezing and thawing Tracheoesophageal fistula
process is repeated several times during the same - No atresia of the esophagus
treatment session in order to kill the cancer cells. - Congenital tracheoesophageal fistula
- H or N fistula
- When the baby swallows fluid, majority of the fluid will go to
the stomach and some of the fluid as the baby is inhaling, can
go also to the trachea.
• Radiofrequency ablation - Abdominal distention – majority of the air will go the trachea
o This treatment uses electrical energy to heat cancer cells, but some of the air will go the stomach because of fistula.
causing them to die. During radiofrequency ablation, a
doctor guides a thin needle through the skin or through an
incision and into the cancer tissue. High-frequency energy
passes through the needle and causes the surrounding
tissue to heat up, killing the nearby cells.
ALTERATIONS IN NUTRITION AND

GASTROINTESTINAL
Discussed by Prof. Francis Vasquez
 Esophageal Atresia (EA)/ Tracheoesophageal Fistula (TEF)
 Pyloric Stenosis
 Hirschsprung disease (Aganglionic Megacolon AMC)
 Cleft lip/ Palate
 Phenylketonuria
 Celiac Disease (Malabsorption Syndrome)
Esophageal Atresia (EA)/ Tracheoesophageal Fistula (TEF)

- Atresia – failure to develop; Fistula – abnormal connection
- Causes is unknown
Esophageal Atresia
- No connection between the esophagus and trachea. (closed
pouch)
- Atresia alone, no fistula
- Small stomach, gasless abdomen
- Usually has a long gab between the esophageal ends
- If the baby swallows the secretions or fluid, dederetso sa
esophagus pero hanggang doon lng. Walang pupuntahan, The
baby will experience vomiting.
- 8% out of 100% cases
J.A.K.E 11 of 45
- During embryonic development, the developing embryo - Weaning – ginagamit sa ventilator, breastfeeding (iniistop na
has 3 primary germs layer: sya) stop the TPN gradual (pag biglang mo inistop
1) Ectoderm – skin, hair, nails, nervous system magkakaroon sya ng hypoglycemia)
2) Mesoderm – cardio, renal - NPO – 10-14 days (the baby can forget how to suck, so u need
3) Endoderm – respiratory, digestive system to offer a pacifier)
- The different germ layers are responsible for the development - One piece pacifier – ung hindi nafofold, isang deretso lng
of body systems - Kapag gumaling na: clear fluid muna ibibigay sa baby then
- Endoderm – during the embryonic development, ung upon evaluation of the doctor, the baby can resume normal
respiratory tract at digestive tract appear as a single track. And diet. (Be sure alam mo un capacity ng stomach ni baby)
during embryonic to fetal development, this single tract should - Computation of Gastric Capacity:
split into two. • Age in month + 2 ounces
- Nagkaroon ng incomplete separation between the respiratory • 1 ounces = 30 ml
tract and digestive tract during the embryonic to fetal
development. Nagkaroon sila ng pagkadikit dahil same sila ng Pyloric Stenosis – Hypertrophic pyloric stenosis (HPS)
germ layer which is endoderm. - Occurs when the circumferential muscle of the pyloric
- Kaya kapag may problema sa respiratory system apektado din sphincter becomes thickened, resulting in elongation and
un kanyang feeding. Kung may problema naman sya sa narrowing of the pyloric channel.
digestive apektado din un respi, because of the pharynx, the - Cause is unknown
pharynx is both passageway of respiratory and digestive tract. - Narrow opening between stomach and duodenum
- Once the baby is delivered, asymptomatic pa sya. But as the - The purpose of pyloric sphincter is to prevent the duodenal
secretions are building up in the oral cavity and the moment content from going back to the stomach.
you start feeding the baby, then the baby becomes cyanotic. - The baby is not yet symptomatic at birth. The moment u feed
(Basta kapag lumulunok na sya) the baby, doon na magpapakita ng sign and symptoms.
- Cough – to remove the obstruction, kapag hindi nya nailabas - As the baby being fed, the milk accumulates in the stomach.
magkakaroon ka ng choking. Kapag nagkaroon ng choking, (Cardiac sphincter is not yet matured, it will start to mature
hindi papasok ang oxygen at hindi makakalabas un CO2, dahil when the baby can sit with support, 6 mos) and sa sobrang
dyan magkakaroon ng cyanosis. sikip ng pyloric canal, even fluid & milk is having hard time
- 3 C’s of the Tracheoesophageal Fistula – Cough, Choking, to flowing. = abdominal distention
Cyanosis. - Habang lumalaki un stomach ng baby, the pressure inside the
- Sign and symptoms: irritability, abdominal distension. stomach will be high. Un pressure biglang lalabas sa cardiac
- Nursing management: Suction, NPO, positioning sphincter kaya makaka experience si baby ng projectile
- Suction mouth first, para d madagdagan un aspiration. When u vomiting – malakas na suka.
suction the nose, you are also depleting the air/ oxygen from - Pyloric stenosis is located above the common bile duct. = non
the lungs, kaya kapag nag susuction ka sa nose, nababawasan bile-stained projectile vomiting. (bcz the bile will not mix with
ng hangin, un baby mapapa inhale sya. Kapag nag iinhale sya, the vomitus)
un secretions sa pharynx gagalaw, pupunta yan sa oropharynx - Kapag kumapal pa ung pyloric stenosis, pag pinalpate mo sya,
to pharynx, at maaspirate nya yon. may mafifeel kang bukol = olive shaped mass (right upper
- Kapag Nawala un airway obstruction, mawawala un cyanosis, quadrant)
mawawala ang choking, papasok ang oxygen and the baby - Mas makikita ung abdominal distention sa left upper quadrant.
will start to pink up. - Hard and dry stools – the baby can develop constipation and
- Several mins later, as the secretions are building up and the dehydration.
baby begins to swallow again, babalik ulit un 3 C’s. kaya baka Sign and symptoms:
may anatomical problem sya. • Non-bile-stained projectile vomiting
- Mas concern tau sa aspirations, because that can result to • Present of olive shaped mass on the right upper quadrant
respiratory distress. • Abdominal distention on the left upper quadrant
- NPO muna ang baby. No feeding • Dehydration
- During feeding, fluid returns through the infant’s nose and
• Constipation
mouth. Aspiration places the infant at risk for pneumonia.
Management
Depending on the type of defect, the infant’s abdomen may be
• Withhold feeding
distended because of air trapping.
• NPO
- Position the baby: elevate the head at least 30 degree angle,
para hindi umakyat un stomach content. • Elevate the head 30 degrees
- Surgery: Kapag may fistula, stomach decompression –
pinapasukan nila ng NGT
- The baby will be fed via:
• Gastrostomy feeding. Bubutas sa abdominal wall.
• Duodenostomy feeding – sa duodenum naman kinabit.
• TPN total parental nutrition – via IV – high in glucose – u
will start the feeding slow (kapag nagstart ka ng fast,
magkakaroon sya ng hyperglycemia)
J.A.K.E 12 of 45
- Before surgery, mag stomach decompression muna. (Gastric puputol ung part na yon = resection, then ikokonek na un
lavage) naputol = anastomosis
- Pyloromyotomy – to loosen the tight muscle causing the - Bago mag surgery, kailangan muna idecompress ung sigmoid
blockage. colon para mailabas un mga naipon stool = colostomy –
- After surgery, NPO muna ng 14 days. Para hindi makalimutan sinurture muna sa abdominal wall
paano mag suck, offer a pacifier.
- The baby will be fed via:
• Duodenostomy feeding
• TPN total parental nutrition
Hirschsprung disease (Aganglionic Megacolon AMC)
- Delikado na hindi ma- decompress ito dahil palaki ng palaki

un sigmoid colon, this portion can occupies the space in the
abdominal cavity at macocompress din un blood vessels, dahil
dyan, madedecrease ung blood supply sa organ at mamatay un
tissue, magkakaroon ng inflammation at lalambot ito = pwede
- Absence of ganglion cells that resulted in the megacolon. magkaroon un pasyente natin ng perforation
- Parasympathetic ganglion cells - Perforated colon – nabutas, kaya lalabas doon sa butas un mga
- Ganglion cells – promote peristalsis stools at ito ay kakalat sa abdominal cavity and this can result
- Wala sa sigmoid rectum. Kaya magiging narrow at walang to massive infection. = peritonitis – inflammation of peritoneal
peristalsis cavity. And the baby can die in septic shock
- Hindi gagalaw ang stool sa sigmoid rectum kaya maiipon un - Colostomy is temporary
stool sa sigmoid colon. - Surgical procedure: Soave with pull through procedure – pag
- Cause is unknown. But it affects more in the male than the putol, hinahatak pababa un sigmoid colon
female. - Resection – cut; anastomosis – reconnected
- May abdominal distension sa left lower quadrant. - Kapag lumaki na ung bata, at nakaramdam ng urge to defecate,
- At birth, no passage of meconium = Meconium ileus, so the kailangan nya pumunta agad sa CR kasi umiksi ng rectum nya
baby becomes irritable, and refusal to take fluid. kaya mabilis lalabas un stool nya. Kapag yan umutot, may
Sign and symptoms possible na kasama ung stool
• Meconium ileus - Need i- toilet train un bata kapag gumaling na un tahi sa
• Irritable sigmoid colon, bibigyan natin ng isotomic saline enema para
• Refusal to take fluid mag stimulate ng peristalsis. Tapos pag okay na, isasara na un
sa may colostomy.
• Bile stained non projectile vomit – because the defect is
- 3 operations:
located at below the bile duct.
1) Creation of colostomy
• Abdominal distension
2) Soave with pull through procedure
• Fecal odor breath – flatus (utot) d makalabas 3) Closure of colostomy
• Chronic constipation - Diet: Habang meron syang colostomy – low residue diet (low
• Mild to moderate AMC fiber but high caloric diet)
- Meconium (nagiging symptomatic sila when they reach - Low residue diet kasi meron syang colostomy appliances,
the age of 4-6 yrs old kasi mahilig sila maglaro at dahil masyadong magtutubig un lalabas doon sa colostomy pouch.
dyan nakakalimutan na nila uminom ng tubig)
- Ribbon-like stool – flat and wavy un stool Cleft Lip and Cleft Palate
- Pellet-like stool – kung kulang sya ng tubig, - Are one of the most common face malformations affecting
Management children
- Diagnosis: Isotonic saline enema – it will not cause fluid and - Disfiguring defect or disfiguring of the face
electrolytes imbalance, so there will be no fluid shifting. - Mas masakit na part to for the parents
- Enema – to stimulate peristalsis, pero dahil walang walang - Once the mother come to know that her baby has face defect
peristalsis, ang mangyayari sa enema ay hindi makakapasok. ang unang reaksyon ni mother is shock and denial
Kaya i- rectal biopsy ng doctor. - failure of maxillary and median nasal to fuse (4th to 10th wk of
- Rectal biopsy – kumukuha ng specimen para malaman kung embryonic development nagkakaproblema)
anong portion un walang ganglion cells. At pag nalaman na - This is either both or one defect only
kung saan at hanggang saan un walang ganglion cells, i- - Divided by primary and secondary
J.A.K.E 13 of 45
- Primary: • Nurse: “Misis itatabi na ho naming ang baby sainyo”

• Dapat it will merge completed by 7th WOA Mother: “ah wag muna masakit pa dd ko tsaka pagod pa
• Portion of alveolar ridge (central/lateral incisors) ako please wag muna”
• Medial portion of upper lip • Dito nagkakaroon ng problem sa bonding
- Secondary: - Nurse responsibility:
• Merge bet. 7th to 10th woa • bilang nurse you know the feeling to the baby towards the
• Hard palate cleft lip and palate, hindi kasalanan ng baby. As a nurse
• Soft palate do not show an easiness in taking care of the baby, show
- 2 Types (for both Cleft lip and palate) no discomfort side comments.
1) Unilateral – isang pingot lang • Focus on the good side (compliment the assessment
2) Bilateral – dalawa ang may pingot, mas wider ang canal results about the baby not about the disfigured face)
or roof. - If the mother asks you “maganda ba ang baby ko, cute ba ang
- Sa defect merong mga skin folds baby ko”?
- Problem: dentition (kase may sungki sungki kapag may palate • Therapeutic communication needed on this
pa yung bata) • Nurse: “Ay ma’am ang concern nyo ba ang problema po
sa labi nya?” Mother: “Ay oo naman, syempre paano pag
laki nyan tutuksuhin yan”
• To answer that question reassure the mother regarding the
past patient na nagkaroon ng ganung defect use image or
procedure of the past patient before and after surgery.
• No psychological effect if the child was undergone
- Predisposing factors: surgery in right age
• Inheritance combination of genetic and environmental Risk
• Alcohol What will be the problem if the child has cleft lip or cleft palate?
• Smoking • Feeding difficulty
• Anticonvulsants • Difficult to suck – cleft lip only
• Steroids • Difficult to swallow – cleft palate only
• Retinoids • Aspiration – both cleft lip and palate
• Folate deficiency • Respiratory infection – otitis media (particulary if the infant
• Infection has both defect) – mabilis mag dry ang mucus membrane and
- It cannot cause cleft lip and palate in trauma like Si nanay 1st less na yung cilia sa nose and dahil sa mga milk na nag a
trimester na buntis 2 and half month, nahulog sa hagdan. This accumulate doon sa folds
cannot lead it to cleft lip and palate. How to fed
- Teratogenic effect of drug - Painumin ng tubig or kuha ng malinis na towel or lampin
• Coumadin – crosses the placenta (can cause cranio face babasain ng warm water yun then rub yung part after feeding
malformation) - The number 1 cause of having repeated respiratory infection
• Heparin – hindi nagc-cross sa placenta kaya ito talaga with both defect = drying of mucus membrane
ang binibigay kay mother kesa kay coumadin - Feeding for cleft lip:
- If the pregnant woman will receive anticoagulant drug (both • Beck feeder
are anticoagulant), ang ibibigay lang ay Heparin. • Rubber tipped syringe (if wala ang beck feeder)
Shock and Denial • Medicine dropper
- Shocks and denial ang mamaging reaction ng nanay. - Feeding for Cleft Palate:
- 3 psychological adaptations during the postpartum period: • Large nipple
• Taking in – ito ang pinakamatagal at nagkaka problema sa • Wide bowl spoon
bonding - Both:
• Taking hold – dito na sya magtatanong about sa baby • Beck feeder or large nipple either the two
• Letting go – forgets the delivery experience and assumes
mother role. Diagnosis:
- Who is the primary concern of the mother during taking in? • Identified during oral examination – the examiner places
Herself or her baby? gloved finger directly on the palate
• Herself, focus nya maka pagpahinga, marecover sa pagod, • Unable to suction (cleft lip)
self-attention sya during taking in, kase sya ang nagdala • Unable to swallow (cleft palate)
ng 9 months sa baby, sya nag labor ng matagal at Management/ Surgery
ginupitan ng pwerta kaya gusto nya ma appreciate naman - Closure of the cleft
sya. - Prevention of complications
• Self-centered - Facilitation of growth and development
- Papaano mo malalaman nagkaroon ng shock and denial sa part - Surgery – Cleft Lip
ni mother? Ano ang mas nagging prolong? • Tennison – Randall Triangular Flap (Z plasty) – crosses
• Taking in the philtral line
J.A.K.E 14 of 45
•Millard Rotational Advancement Technique – advances a • Tyrosine is the precursor of 2 substance: thyroxine
triangle of tissue in the upper 3rd lip and does not cross the (metabolism and growth) and melanin (pigmentation)
midline
• Nasoalveolar
- Surgery – Cleft Palate
• Veau – ward ill – kilner (V-Y pushback)
• Furlow double – opposing Z plasty
- Secondary Procedures:
• Palate lengthening
• Pharyngeal flap
• Sphincter pharyngoplasty
• posterior pharyngeal wall augmentation
- Since there is no PHE hydroxylase what will happen to the
Cleft Lip Cleft Palate Both
phenylalanine coming from the milk, converted or not?
Boys Girls Boys
• not converted
Yung cleft lip • If the milk not converted into tyrosine
ang uunahing • The thyroxine will be affected as well as the melanin
Cheiloplasty Uranoplasty
sasara bago • Decrease in melanin prone to skin cancer, rashes, etc. and
ang cleft palate can affect the color of the eye and hair.
- If the phenylalanine not converted into tyrosine, what will it
Rule of 10: cause?
• 10 wks old (2 – 3 12 – 36 months • It can produce acid
months) before speech • Phenyl pyruvic acid – it is a musty odor ang amoy ng bata,
• 10 lbs development yung amoy ng basahan na nababad at na kulob ng ilang
• 10g hemoglobin araw ganun ang amoy
• Pyruvic acid will breakdowns the fats into fatty acids that
Postoperative: protect suture line (positioning) leads to production of ketones
Position: Lateral/Supine Prone never supine • Ketones = neurologic impairment (permanent)
Logan Bar (Doctor) – Signs and symptoms:
prevent stretching of the CODE: D.A.L.A.S
lip • Diarrhea
Minimize crying:primary • Anemia
Parents • Lethargy
care giver /Mother
Note: to minimize the cry of the infant’s nurses, PCG/Mother or • Anorexia
parents need to attend the needs of the infants • Skin rashes
Refer: Diagnosis:
- Speech Therapist • Guthrie blood test – it will determine if the phenylalanine is
- Child psychologist converted into tyrosine or not. Bago gawin kailangan muna
- Orthodendist dumede ni bby
- ENT (Ear, nose, throat) • Done for 24 – 48 hrs
o What will happen if the cleft palate repair after speech Management
development? - Phenylalanine – free diet for life
- Meron na syang speech defect - No phenylalanine in the first 6 to 8 yrs of life
- 36 months the child can subject into bullying - Bawal lahat na may gatas
- Lateral – pwedeng ma supine or ma prone to avoid it you - Formula: Lofenalac (for infants’ milk)
need to put pillow pero hindi aabot sa mukha - Preschool: kailangan kausapin ang teacher and classmates na
o How are you going to check if there is bleeding in clef palate? may ganong sakit yung anak para masabihan kung ano ang
- there is a frequent swallowing mga hindi pwedeng kainin ng bata during preschool even yung
sa canteen kailangan masabihan ang mga tindera. Kapag
Phenylketonuria (PKU) pwedeng baunan ng pagkain ang bata baunan nalang kesa
- Absence of phenylalanine hydroxylase (liver converting baunan ng pera.
enzyme) - Food: papatikimin ng isang teaspoon once in a while hindi
- Metabolic disorder araw araw, para lang malaman nya kung ano ang lasa.
- Nakukuha ang phenylalanine sa Amino acids that found in the
milk Celiac Disease
- Cause: possible hereditary - Atrophy intestinal villi due to gluten containing foods
- Pathophysiology: - Allergic reaction to gluten
• phenylalanine must be converted into tyrosine - Tumitigas ang intestinal villi
• substance that converts phenylalanine into tyrosine is - Intestinal villa = to absorb nutrients
PHE hydroxylase
J.A.K.E 15 of 45
- Sa lining ng intestine ang na absorb ay si fats hindi si ALTERATIONS IN METABOLISM AND ENDOCRINE
carbohydrates at protein DISORDERS
- Gluten that contains food – CODE: B.R.O.W Discussed by Prof. Carmencita Pacis
• Barley – beer Endocrine system
• Rye - A complex network of glands and organs.
• Oats - 3 vital functions:
• Wheat – flour • Makes hormones for mood, development, and growth
- Lahat ng process food bawal, kase may mga extender, even • Send hormones into the bloodstream
the street foods • Regulates the release of hormones.
- Ang mga pwede is rice, corn, puto na yari sa bigas.
Pathophysiology Hypopituitarism (Dwarfism)
- Diminished or deficient secretion of pituitary hormones
- Consequences depend on the degree of dysfunction
- The patient is smaller than in normal height
- There are 2 pituitary glands: Anterior & Posterior pituitary
gland. (Ex: they will secrete follicle stimulating hormone/
luteinizing hormone that will target the ovary to function
normally)
- This disease meaning the pituitary gland produce less hormone.
- 2 types: disproportion & proportion
- Gluten → Atrophy I.V → Malabsorption

- Malabsorption
• LHON wasted buttocks
• Fats (steatorrhea) turn into fatty acids lead to ketones then
neurological impairment
- Since protein did not absorb, anong mangyayyari sa batang
may celiac disease?
• The body will use the stored protein, na nasa muscle kaya
magkakaroon sya ng wasted buttocks manipis ang pwet
- If the fats did not absorb in the stool what will happen?
• magkakaroon ng steatorrhea
• ADEK (vitamins) – deficiency
• in the pancreatic duct there are TLA that needed to pass
through in the pancreatic duct but if this duct is barado
hindi makakadaan ang TLA hindi makakapunta sa
duodenum kaya hindi ma a-absorb ang fats
- Hormones: Go Look For The Adenoma Please
• pwedeng magkaroon ng celiac crisis – because of the fats
pwede magkaroon ng diarrhea and dehydration • Growth hormone
Symptoms: • Luteinizing hormone
• Steatorrhea (fatty, foul, frothy bulky stools) • Follicle stimulating hormone
• General malnutrition • Thyroid stimulating hormone
• Abdominal distention • Adrenocorticotropic hormone
• Secondary vitamin deficiency • Prolactin function
Management - Ang cause ng pagbaba ng hormones dahil may presence ng
• low fat diet Adenoma
Types:
• kaya need kumain bago umalis ng bahay
• Congenital hypopituitarism
- Seen in newborn after birth trauma
- Natagalan ilabas un baby or naipit na nag cause ng
hemorrhage sa brain.
• Idiopathic hypopituitarism
- Related to GH deficiency
- Unknown, d malaman kung ano ang cause.
• Normal proportions with short stature

J.A.K.E 16 of 45
- Maliit ang height, maliit din lahat ng organs nya • NGT or gastrostomy feeding to maintain adequate hydration
- Cause by a tumor and nutrition (with infants with coexisting brain damage)
- Adenoma or tumor will cause the decrease in production • Child should always wear a medical alert ID (tag, bracelet, or
of the pituitary hormones necklace) to indicate the presence of the disorder
- Ex: 10 yearr old girl with short stature • Unrestricted access to toilet facilities and water in school
• Short stature
• Normal birth weight Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
• Poor growth since aged 3 year - Results from excessive amount of serum ADH (produced by
• Reduced appetite hypersecretion of the posterior pituitary)
• HV 3.0 cm/ year - Associated with CNS infections, brain tumors, brain trauma,
Sign and symptoms pulmonary disorders (pneumonia, asthma, or cystic fibrosis),
Anterior Pituitary Gland receiving positive-pressure ventilation, medications (diuretics
and chemotherapy)
• GH – growth hormone
- Mataas ang ADH = low urine production
- Hypoglycemia (infancy)
- Ang antidiuretic hormone, pineprevent nya lumabas ang tubig.
- Growth failure (childhood)
So kung mataas ang hormone nato, mababa ang urine
• ACTH – Adrenocorticotropic hormone
production. Pero kung mababa naman ang hormone nato,
- Hypoglycemia
mataas ang urine production.
- Hypotension (kasi ung ACTH, responsible for regulation
- Mostly sa brain dahil andyan si pituitary gland, sila un may
of cortisol – nagreregulate ng BP and glucose sa katawan)
responsible para regulate un endocrine system.
• LH – luteinizing hormone (responsible for sexual hormone) Causes of SIADH
- Micropenis/ undescended testes
- Failure of puberty
• TSH – thyroid stimulating hormone
- Jaundice (unconjugated) – hindi nacoconjugate un
bilirubin
- Coarse facial features – lacks muscle tone
- Poor growth
- Tiredness, dry skin, hair loss
Posterior pituitary gland
• ADH – Anti Diuretic hormone
- Cranial diabetes insipidus (magkakaroon sya ng polyurea
and polydipsia)
- Kapag mababa ang ADH, iihi ka ng marami. (kasi kapag
diuretic – iihi ka, kapag may anti diuretic – hindi ka
makakaihi, so sabi dito decrease antidiuretic – hindi nya
mapigilan un pagiihi)
Treatment
• GH (recombinant) – SC injections OD (once a day)
- Medyo safer na sya kasi combination na
• Hydrocortisone – oral TDS or QDS (3 or 4 times a day)
• Levothyroxine – oral OD
- Kapag affected sa Thyroid stimulating hormone
• Testosterone injections, topical gel (neonatal, pubertal)
- Kapag un luteinizing hormone un mababa 7 S’s
• Oestrogen (oral patches) 1) Stops urination (low urine output)
• LF and FSH (recombinant) injections 2) Sticky and thick “urine” high sp. Gravity 1.030 + (mataas ung
• DDAVP (oral, sublingual, nasal) specific gravity ng urine dahil hindi sya umiihi, naiipon,
- Kapag affected un ADH nagiging concentrated)
Nursing Management 3) Soaked inside “low and Liquidy” Labs
• Accurate I & O (kasi kapag hindi pa natitreat un pasyente • Hypoosmolality (Low)
natin, mas marami un output kaysa input) • Hyponatremia below 135 Na + (Low)
• Weight monitoring (everyday, same time) 4) Sodium low (headache early sign)
• Observe for signs of dehydration (maraming output kaya 5) Seizures
pwede ma dehydrate) 6) Severe high blood pressure
• Fluid intake adjusted to prevent dehydration: Cold fluids are 7) Stop all fluids + give salt + diuretics (No IV drinking) + (IV
preferred to relieve thirst (dahil may polydipsia) 3% saline + Eat Salt) (we have to give hypertonic solution kasi
• Avoid excessive intake of fluids with DDAVP treatment (this mas mataas ang sodium concentration compare to physiologic/
DDAVP will increase the ADH, kaya kapag nagiistart na tau normal saline = 0.9 % - isotonic solution) hypertonic solution
sa tx na to, kailangan na mag limit ng fluid kase masosobrahan – shrink cell, it will draw fluid out of the cell, ang effect kasi
naman = fluid retention)
J.A.K.E 17 of 45
neto ay hahatakin nya ung fluid palabas sa cell para ma substances such as lithium that interfere with thyroid
prevent nya ung cerebral edema. hormone synthesis
Laboratory findings - Normal syang pinanganak with normal thyroid function
• Urinalysis but bcz of the following conditions naging abnormal ang
- High osmolality pag produce ng kanyang thyroid hormone.
- High urine sodium Assessment
• Serum electrolytes Congenital hypothyroidis:
- Low serum osmolality • Jaundice
- Low serum sodium • Thick tongue (bcz of hypotonia, lacks of muscle tone)
• Decreased BUN • Hypotonia
Management: • Umbilical hernia
• Fluid restriction • Hoarse cry
• Medications: • Dry skin
- Diuretics – para umihi • Constipation
- Demeclocycline – block action of ADH at the renal • Large fontanelles
collecting tubules = iihi na ng marami (Tetracycline Acquired hypothyroidism:
antibiotic – iniinhibit nya ung ADH renal action of the • Decreased appetite
antidiuretic hormone) • Dry, cool skin
• Hypertonic Saline IV fluid = 3% and 5% NaCl • Thinning hair or hair loss
Nursing Management: • Depressed deep tendon reflexes
• Monitoring fluid balance • Bradycardia
• Strict I & O, fluid restrictions • Constipation
• Monitor Labs • Sensitivity to cold temperatures
• Preventing injury • Abnormal menses
• Administering medications • Goiter
• Managing nutritional intake Unique Manifestations to children:
• Educate about fluid restrictions and hidden sources of water • Change in past normal growth patterns with a weight
and fluids in foods to help avoid excessive fluid intake. increase (bibigat sya pero d na tatangkad)
• Daily weights (kasi kapag nag weight gain un pasyente natin, • Decreased height velocity
ibigsabihin may water gain sya ulit) • Delayed bone and dental age
• Hypotonia with poor muscle tone
DISORDERS OF THYROID FUNCTION
• Delayed or precocious puberty
Hypothyroidism: Cretinism
Diagnostic findings:
- A disorder in which levels of active thyroid hormones are
• Newborn screening
decreased (reduced circulating levels of T3 and T4)
- 3 basic concepts of thyroid function • Serum T3, T4, TSH
- Mild = Decreased T4, normal T3, and elevated TSH
1) ↓ T3 = ↓ metabolic rate (normal pa si T3 kasi si T4 is primary, thyroxine, si T4 it
2) ↓ T4 = ↓ body heat production will indicate underactive thyroid, nacoconvert ito to T3,
kaya pwedeng si T4 will replace the amount the T3 kaya
3) ↓ Thyrocalcitonin = ↑ calcium (nagiging mababa din
nadedect pa rin na normal ang T3)
ang parathyroid) - Elevated TSH level indicates that the disease originated in
- Congenital hypothyroidism occurs in approximately 1 in 3000 the thyroid, not the pituitary
to 4000 live births worldwide
- 2x common in females as it is in males
2 types:
1) Congenital hypothyroidism
- Usually caused by a spontaneous gene mutation, an
autosomal recessive genetic transmission of an enzyme
deficiency, hypoplasia or aplasia of the thyroid gland,
failure of the CNS-thyroid feedback mechanism to
develop, or iodine deficiency
- Intellectual disability is irreversible if not treated
- Inborn
- May thyroid gland pero hindi normal functioning
2) Acquired hypothyroidism Management
- Idiopathic or result from autoimmune thyroiditis, late- • Levothyroxine (DOC) – recommended starting dose is 10-
onset thyroid dysfunction, isolated thyroid stimulating 15mcg/kg per day and gradually increased as the child grows
hormone (TSH) deficiency caused by pituitary or to ensure thyroid hormones in appropriate balance (euthyroid)
hypothalamic dysfunction, or exposure to drugs or • Periodic evaluation of T4 and TSH serum levels, bone age,
Growth parameters
J.A.K.E 18 of 45
- Detect thyroid autoantibodies anti-TG (antithyroglobulin)

and anti-TPO (antiperoxidase) – kapag nag positive sya
dyan, ibigsabihin ang cause ng hyperthyroidism is
autoimmune
• Thyroid scan
- Identify nodules or to confirm the high uptake of
Nursing Management radioactive iodine associated with Graves disease
• Monitor vital signs
• Be alert for signs and symptoms of cardiovascular disorders
(kasi ang thyroid hormone natin affected ang cardiovascular
function, kapag mababa ito magkakaroon ng bradycardia,
kapag nasobrahan ka naman tachycardia, arrythmia)
• Monitor the weight daily
• Diet:
- Low calorie
- High fiber (constipation – kasi there are responsible for
metabolism, bumabagal ang elimination) Complications
• Provide warm environment during cold climate (ginawin un • Severe Thyrotoxicosis
pasyente natin) - Also called thyroid crisis or thyroid storm
• Provide health education - A life-threatening emergency resulting rom extreme
- Medication administration hyperthyroidism, in which elevated circulating levels of
- Side effects TH result in a hypermetabolic state
- Signs to watch out if drug overdose - Unusual in children
- Binibigay sa morning - Symptoms: Muscle weakness, Diaphoresis, Tachycardia,
- Kapag gabi mo binigay, hindi makakatulog un pasyente Tremor, Palpitations, Diarrhea, Irritability, Nervousness,
anxiety
Hyperthyroidism (Graves’ Disease/ Hashimoto) - May be precipitated by infection, surgery, or
- Occurs when thyroid hormone levels are increased, resulting discontinuation of antithyroid therapy
in excessive levels of circulating thyroid hormones. Management
- Common cause of hyperthyroidism in childhood • Goal of therapy: to inhibit excessive secretion of thyroid
- Occurs more in females and in ages 11-15 years hormones (dapat mapigilan ang pag produce ng T3 and T4)
- Causes: High familial incidence, thyroiditis and thyroid • Medication therapy
hormone producing tumors. - Antithyroid drugs:
- 3 basic concepts: o Methimazole (Tapazole) – DOC for children
• ↑ T3 = ↑ metabolic rate o Propylthiouracil (PTU)
• ↑ T4 = ↑ body heat production - Beta-adrenergic blocking agents – relieve symptoms of
tremors, tachycardia, eyelid lag, and excessive sweating.
• ↑ Thyrocalcitonin = ↓ calcium (Beta – stimulating hormone, B1 – heart kaya ireregulate
- Mag dadiarrhea ka, mainit ang katawan kaya gusto mo lagi ni beta blocker ung heartbeat)
nasa aircon, hindi ka makatulog, hindi ka tumataba, palagi o Propanolol or atenolol
kang nagugutom • Radiation therapy – will kill some of the cells that are
Assessment findings: encouraging the thyroid gland to produce more thyroid
Caused by hyperactivity of the sympathetic nervous system: hromone
• Enlarged, non tender thyroid gland (goiter) • Surgery: Thyroidectomy – provides immediate cure
• Prominent or bulging eyes (exophthalmos), Eyelid lag - May result to hypothyroidism
• Tachycardia, Nervousness - Complications: hemorrhage, hypocalcemia, damage to the
• Increased appetite with weight loss laryngeal nerve paresis
• Emotional lability, moodiness, behavioral problems,
easily frustrated
• Heat intolerance
• Hypertension
• Hyperactivity, difficulty concentrating, declining
performance in school
• Irregular menses
• Insomnia
• Tremor, muscle weakness, fatigue
Diagnostic Studies Nursing management
• Serum studies (TSH, T3 and T4 levels) • Teaching child and parents about the disorder and its treatment
- Elevated T3 and T4 • Promote rest
- Decreased TSH • Provide emotional support
J.A.K.E 19 of 45
• Provide preoperative and postoperative teaching and care • Abnormal glucose tolerance test (papainumin ka ng glucose
• Promote increased caloric intake – 5 or 6 moderate meals per solution, they will identify after 1 hour, ano na ang level ng
day (madalas pero konti lng) glucose in the body, and after 2 hours ichecheck ulit, kasi
• Encourage to express feelings and concerns about the disorder dapat after 2 hours dapat maging normal)
Cushing Syndrome
- Also called Adrenocortical hyperfunction (mataas ang ACTH,
ang ACTH nagreregulate ng cortisol - stress hormone, nag
reregulate ng BP and sugar, kaya kapag mataas si ACTH,
tataas ang cortisol at tataas din ang BP at sugar level)
- Characterized by a group of manifestations resulting from
excess blood levels of glucocorticoids (especially cortisol)
- Cause: Excessive or prolonged administration of
glucocorticoid hormones or steroid therapy
- Condition is reversible once steroids are discontinued
- Abrupt withdrawal of steroids may precipitate acute adrenal
• Adrenal-suppression test using an 11pm dose of
insufficiency.
Dexamethasone reveals that adrenal cortisol output is not
suppressed overnight as would normally in children
- Cushing Disease: • CT scan and MRI – to detect specific location of tumors in the
adrenal and pituitary glands
• Endogenous type is caused by a pituitary tumor
Management
(adenoma) in children older than 7 years old
• Surgery:
• Tumor secretes excessive ACTH which leads to bilateral
- Removal of the pituitary adenoma (pituitary adenoma
adrenal hyperplasia
causing excessive releasing of ACTH)
- Bilateral removal of adrenal glands
• Irradiation of the pituitary
• Lifelong hormone replacement therapy (when bilateral adrenal
glands are removed)
- Replacement of growth hormone, ADH, TH,
gonadotropins, and steroids
Nursing management:
• VS; I & O
• Nutritional status, weight monitoring
• Monitoring muscle strength and endurance
• Good skin care
• Teach client and family about the disorder and its treatment
• Provide preoperative and postoperative teaching and care
• Provide emotional support
DIABETES MELLITUS
Assessment findings: Discussed by Prof. Carmencita Pacis
• Obesity, excessive weight gain followed by slowed linear - Most common metabolic disease in children
growth - A disorder of hyperglycemia resulting from defects in insulin
• Cushingoid feature: Rounded (moon) face with prominent secretion, insulin action, or both, leading to abnormalities in
cheeks carbohydrate, protein, and fat metabolism
• Hirsutism – pagtubo ng buhok sa excessive - Commonly type 1 sa bata
• Acne - It could be of Insulin secretion or Insulin resistance from
• Deepening of voice muscles and fats, but there will be hyperglycemia for both bcz
• Hypertension if there is decrease amount of insulin, glucose cannot enter the
• Older children: cell, on the other hand, if the muscles resist or refuse will enter
- Delayed puberty, irregular menstrual periods (kasi mataas the insulin, pati glucose maiiwan = insulin resistance, kaya
ang adrogen level) maraming maiiwan na glucose sa blood.
- Headaches - Normal blood glucose: 70-11 0mg/dL
- Weakness
- Pathologic fractures Type 1 DM (Insulin Dependent)
- Emotional problems - Characterized by destruction of pancreatic islet beta cells,
- Hyperglycemia (kasi mataas ang sugar level) which fail to secrete insulin.
Diagnostic findings: - Alpha cell = produce glucagon – production of glucose
• 24-hour Urinary levels of free cortisol - Beta cell = insulin – decreasing the amount of glucose in the
• Elevated nighttime salivary cortisol level blood (beta cell tau mag fofocus here)
J.A.K.E 20 of 45
- If there is destruction in beta cell, the amount of insulin on the Clinical manifestations
body will be decrease. Type 1 DM (Insulin Dependent)
- Early onset = 4 years old; common age = 11-13 years old • Polyuria, polydipsia
- Onset in childhood and adolescence, but it can occur at any • May have polyphagia
age • Weight loss
- Juvenile onset DM • Ketoacidosis may be present at diagnosis, at continued risk for
- 90% are caused by immune system destroying the beta cell; ketoacidosis
10% genetic • Short duration of symptoms
- Without the insulin, glucose cannot enter the cell, mag stestay • Need insulin for survival
lng sila sa blood. Type 2 DM
• Obese, little or no weight loss, or may have significant weight
loss
• Acanthosis nigricans
• Long duration of symptoms
• Polyuria, polydipsia, may be mild or absent
• Glycosuria with or without ketonuria
• Ketoacidosis may be present
• Lipid disorders, hypertension (more viscous – mas mabagal
Type 2 DM ang circulation kaya kailangan mo ng mataas na pressure para
- Arises because of insulin resistance in which the body fails to maideliver sya sa buong circulation)
use insulin properly combined with relative insulin deficiency • Androgen-mediated problems such as acne, hirsutism,
- Onset usually after age of 45 menstrual disturbances, PCOS (Kapag babae nagka DM, pag
- Adult-onset DM taas ng androgen; Kapag lalaki naman nagkaDM, mababa ang
- Common cause: Obesity androgen)
- Kapag nagkaroon ng resistance, hindi tinanggap si insulin, • Excessive weight gain and fatigue due to insulin resistance
hindi rin makakapasok un glucose kaya the glucose remain in
the blood resulting to hyperglycemia Diagnostic tests:
• Random Blood Sugar (RBS)
- Blood specimen is drawn without preplanning
- >200mg/dL + symptoms is suggestive of DM
- It could be taken anytime, walang preparation
• Fasting blood sugar (FBS)
- Blood specimen after 8 hours of fasting
- No DM (70-110mg/dL), preDM (>110 but <126 mg/ dL)
DM (>126mg/dL)
• Postprandial Blood sugar
- Blood sample is taken 2 hours after a high CHO meal
- No DM (70-110mg/dL), DM (>140 but <200 mg/ dL)
• Oral Glucose Tolerance Test (OGTT)
- Diet high in CHO is eaten for 3 days
- Client then fast for 8 hours. A baseline blood sample is
drawn & a urine specimen is collected
- An oral glucose solution is given and time of ingestion
recorded
- Blood is drawn at 30 mins & 1, 2, 3 hours after the
ingestion of glucose solution.
- Urine is collected
- No DM (glucose returns to normal in 2-3 hours & urine is
negative for glucose)
- DM (blood glucose returns to normal slowly; urine is
positive for glucose
- Normally, after 2 hours of eating, babalik na dapat ung
normal value ng glucose natin sa dugo
Impaired nerve function – kapag mataas ang glucose level, it will

be affected the ability of nerve that can send signal – bumababa
(kaya minsan namamanhid)
J.A.K.E 21 of 45
Patient Education: DM and Insulin Therapy

• Nature of the disease
• Meal planning
• Insulin therapy: types of insulin, duration, onset and peak
action, mixing and administration of insulin, rotation of
injection sites (kapag isang site ka lng nag iinject,
magkakaroon ng trauma, lipodystrophy, maninigas un fats and
d na sya magaabsorp ng insulin)
• Insulin pump therapy in some cases
• Glucose monitoring
Complications
• Nephropathy – kidney damage
• Retinopathy – eye damage
• Neuropathy – nerve damage
Management • Hypertension – cardiovascular
Type 1 DM (Insulin Dependent) • Atherosclerotic cardiovascular disease – pwede mastroke
• Blood glucose monitoring • Hyperglycemia
• Insulin • Limited mobility of small joints of the hand
• Dietary management, balancing carbohydrate intake to insulin
(rapid/ short acting – dapat nakakain ka na)
• Exercise – will be more sensitive to insulin
Causes of Hypoglycemia
• Blood glucose level is less than 80mg/dL
• Insulin dose too high for food eaten
• Insulin injection into muscle
• Too much exercise for insulin dose
• Too long between meals/ snacks
• Too few carbohydrates eaten
• Illness, stress
• Blood glucose level is more than 200mg/dL
• Insulin dose too low for food eaten
• Illness or injury, stress
• Too many carbohydrates eaten
• Meals/ snacks too close together
• Insulin injected just under skin or injected into hypertrophied
Type 2 DM areas
• Diet with decreased calories and low-fat foods • Decreased activity
• Decrease sedentary activity time or increase routine physical
activity Clinical Manifestation
• Blood glucose monitoring Hypoglycemia
• Oral medication (metformin) to improve insulin sensitivity • Rapid onset
(OHA = Oral Hyperglycemic Agent) • Irritability, nervousness, tremors, shaky feeling, difficulty
• May need insulin concentrating or speaking, behavior change, confusion,
repeating something over and over
• Unconsciousness, seizure, shallow breathing, tachycardia
• Pallor, sweating
• Moist mucous membranes, hunger
• Headache, dizziness, blurred vision, double vision,
photophobia
• Numb lips or mouth
Hyperglycemia
• Gradual onset
• Lethargy, sleepiness, slowed responses, or confusion
• Deep, rapid breathing
• Flushed skin, dry skin
• Dry mucous membranes, thirst, hunger, dehydration
• Weakness, fatigue
J.A.K.E 22 of 45
• Headache, abdominal pain, nausea, vomiting - Seizures are classified not only according to type but also
• Blurred vision according to etiology:
• Shock • Acute symptomatic seizures are associated with an acute
• Blood sugar (if high, u will feel hot and dry, but if low, u feel insult such as head trauma or meningitis. (immediate na
cold and clammy) pwede magcause ng seizure)
*mas delikado ang hypoglycemia – rapid onset, like nawalan • Remote symptomatic seizures are those without an
ka ng malay; usually sa hyper, ang ikamamatay mo dyan ay immediate cause but with an identifiable prior brain injury
complication. such as major head trauma, previous history of meningitis
or encephalitis, hypoxia, stroke, or a static encephalopathy
Management such as cognitive impairment or cerebral palsy.
Hypoglycemia • Cryptogenic seizures are those occurring with no clear
• If conscious, give 15g of carbohydrate. Wait 15 minutes and cause.
recheck blood glucose level. Give another 15g of carbohydrate • Idiopathic seizures are genetic in origin.
if 70mg/dL or below. Recheck the blood glucose level in 15 - Regardless of the etiologic factor or type of seizure, the basic
minutes. mechanism is the same. Abnormal electrical discharges:
• If unconscious, give glucagon by injection. • May arise from central areas in the brain that affect
Hyperglycemia consciousness
• Give additional insulin at usual injection time • May be restricted to one area of the cerebral cortex,
• Give correction scale insulin doses for specific blood glucose producing manifestations characteristic of that particular
levels when ill or injured. anatomic focus. (biglang napatulala, mental block etc)
• Give extra injections if hyperglycemia and moderate to large • May begin in a localized area of the cortex and spread to
ketones other portions of the brain and, if sufficiently extensive,
• Increase fluids produce generalized seizure activity.
Diabetic Ketoacidosis (DKA) Pathophysiology
- Complication of DM that develops when severe insulin - Seizure activity begins with a group of neurons in the CNS
deficiency occurs (wala ka ng insulin production) that because of excessive excitation and loss of inhibition
- Life threatening condition amplify their discharge simultaneously.
- Hyperglycemia that progresses to metabolic acidosis - Physiologic stimuli, such as cellular dehydration, severe
- Develop over a period of several hours or days; kaussmaul’s; hypoglycemia, electrolyte imbalance, sleep deprivation,
frothy breath emotional stress, and endocrine changes, these hyperexcitable
- Urine and serum ketone test are (+) cells activate normal cells in surrounding areas and in distant,
- KETONES acts as CNS depressant and may decrease brain pH synoptically related cells.
leading to COMA - Excessive excitation and loss of inhibition of a group of
Intervention neurons in the CNS
• Restore circulating volume - Amplify electrical discharge of the neurons resulting to
• Correct dehydration 0.9% or 0.45% saline seizures
• Correct hyperglycemia = give insulin • Partial seizures, which have a local onset and involve a
• O2, monitor blood glucose frequently relatively small location in the brain.
• Monitor for potassium level; for sign of fluid overload • Generalized seizure (naeexcite na lahat) develops when
the neuronal excitation from the epileptogenic focus
ALTERATIONS IN NEUROLOGIC AND COGNITIVE spreads to the brainstem, particularly the midbrain and
DYSFUNCTION reticular formation.
Discussed by Prof. Melanie Cambel
 Seizure disorders
 Febrile seizures
 Epilepsy
 Status epilepticus
 Neural tube defects
 Hydrocephalus
Seizures Disorders
- Seizures are the most common pediatric neurologic disorder.
- Caused by excessive and disorderly neuronal discharges in the
brain.
- Symptoms of an underlying disease process. (Ex: central
nervous system infection, when to much inflammation at the
brain of the client, it can seizure the person)
- Causes of seizures may be infectious, neurologic, metabolic,
traumatic, or related to ingestion of toxins.
- Children may have a single seizure without the cause ever
being known.
J.A.K.E 23 of 45
Partial seizures • May be confused

- Which have a local onset and involve a relatively small • May perform purposeless, complicated activities in a
location in the brain. repetitive manner (automatisms), such as walking,
Simple Partial Seizures with Motor Signs running, kicking, laughing, or speaking incoherently, most
- Characterized by: often followed by postictal confusion or sleep; may
• Localized motor symptoms exhibit oropharyngeal activities, such as smacking,
• Somatosensory, psychic, autonomic symptoms chewing, drooling, swallowing, and nausea or abdominal
• Combination of these pain followed by stiffness, a fall, and postictal sleep;
• Abnormal discharges remaining unilateral rarely manifests actions such as rage or temper tantrums;
- Manifestations: aggressive acts uncommon during seizure
Generalized seizures
• Aversive seizure (most common motor seizure in
- Which involve both hemispheres of the brain and are without
children) – Eye or eyes and head turn away from the side
local onset.
of the focus, awareness of movement or loss of
consciousness. (Ex: they are trying to look left side, pero Tonic-Clonic Seizures (Formerly Known as Grand Mal)
nag tuturn away, sa right sya tumitingin) - Most common and most dramatic of all seizure manifestations.
• Rolandic (Sylvan) seizure – Tonic-clonic movements (dahil andami nangyayari sa pasyente, biglaan nlng)
involving the face, salivation, arrested speech; most - Occur without warning
common during sleep (tonic – naninigas; clonic – like - Tonic phase lasts approximately 10 to 20 seconds
jerking movements) - Manifestations:
• Jacksonian march (rare in children) – Orderly, sequential • Eyes roll upward
progression of clonic movements beginning in a foot, • Immediate loss of consciousness
hand, or face and moving, or “marching,” to adjacent • If standing, falls to floor or ground
body parts • Stiffens in generalized, symmetric tonic contraction of
entire body musculature (bigla nlng tumigas buong
Simple Partial Seizures with Sensory Signs katawan)
- Uncommon in children younger than 8 years of age • Arms usually flexed
- Characterized by various sensations, including: • Legs, head, and neck extended
• Numbness, tingling, prickling, paresthesia, or pain • May utter a peculiar piercing cry
originating in one area (e.g., face or extremities) and • Apneic, may become cyanotic
spreading to other parts of the body • Increased salivation and loss of swallowing reflex
• Visual sensations or formed images - Clonic phase lasts about 30 seconds but can vary from only a
• Motor phenomena such as posturing or hypertonia few seconds to a half hour or longer
Complex Partial Seizures (Psychomotor Seizures) - Manifestations:
- Observed more often in children from 3 years through • Violent jerking movements as the trunk and extremities
adolescence undergo rhythmic contraction and relaxation
- Characterized by: • May foam at the mouth
• Period of altered behavior • May be incontinent of urine and feces
• Amnesia for event (no recollection of behavior) • As event ends, movements less intense, occurring at
nakalimutan nya na gnawa nya yon longer intervals and then ceasing entirely
• Inability to respond to environment - Status epilepticus – Series of seizures at intervals too brief to
allow the child to regain consciousness between the time one
• Impaired consciousness during event
event ends and the next begins. (kakatapos lng ng seizure, nag
• Drowsiness or sleep usually following seizure
seizure na ulit)
• Confusion and amnesia possibly prolonged
• Requires emergency intervention
• Complex sensory phenomena (aura) – Most frequent
• Can lead to exhaustion, respiratory failure, and death
sensation is strange feeling in the pit of the stomach that
- Postictal state: (after a seizure)
rises toward the throat and is often accompanied by odd or
• Appears to relax
unpleasant odors or tastes; complex auditory or visual
hallucinations; ill-defined feelings of elation or • May remain semiconscious and difficult to arouse
strangeness (e.g., déjà vu, a feeling of familiarity in a • May awaken in a few minutes
strange environment); strong feelings of fear and anxiety; • Remains confused for several hours
a distorted sense of time and self; and in small children, • Poor coordination
emission of a cry or attempt to run for help • Mild impairment of fine motor movements (hindi kaya
- Patterns of motor behavior: mag grasp ng bagay)
• Stereotypic • May have visual and speech difficulties
• Similar with each subsequent seizure • May vomit or complain of severe headache
• May suddenly cease activity (biglang hihinto), appear • When left alone, usually sleeps for several hours
dazed, stare into space (luting, nakatitig lng), become • On awakening, is fully conscious
confused and apathetic, and become limp or stiff or • Usually feels tired and complains of sore muscles and
display some form of posturing headache
J.A.K.E 24 of 45
• No recollection of entire event (d nila alam ano nangyari) - Numerous seizures during the day without postictal
Absence Seizures (Formerly Called Petit Mal or Lapses) drowsiness or sleep
- Characterized by: - Poor outlook for normal intelligence
• Onset usually between 4 and 12 years of age - Manifestations:
• More common in girls than boys • Possible series of sudden, brief, symmetric, muscular
contractions
• Usually cease at puberty
• Head flexed, arms extended, and legs drawn up
• Brief loss of consciousness
• Eyes sometimes rolling upward or inward
• Minimum or no alteration in muscle tone
• May be preceded or followed by a cry or giggling
• May go unrecognized because of little change in child’s
behavior • May or may not include loss of consciousness
• Abrupt onset; suddenly develops 20 or more attacks daily • Sometimes flushing, pallor, or cyanosis
- Infants who are able to sit but not stand:
• Event often mistaken for inattentiveness or daydreaming
• Sudden dropping forward of the head and neck with trunk
• Events possibly precipitated by hyperventilation,
flexed forward and knees drawn up—the salaam or
hypoglycemia, stresses (emotional and physiologic),
jackknife seizure Less often: alternate clinical forms
fatigue, or sleeplessness
- Manifestations: • Extensor spasms rather than flexion of arms, legs, and
trunk, and head nodding
• Brief loss of consciousness
• Lightning events involving a single, momentary, shock-
• Appear without warning or aura
like contraction of the entire body
• Usually last about 5 to 10 seconds
• Slight loss of muscle tone may cause child to drop objects Febrile Seizure
• Ability to maintain postural control; seldom falls - Convulsion triggered by a rise in body temperature
• Minor movements such as lip smacking, twitching of - One of the most common neurologic conditions of childhood
eyelids or face, or slight hand movements - Affects 2% to 5% of children between the ages of 6 and 60
• Not accompanied by incontinence months.
• Amnesia for episode - Peak incidence: 18 mos of age
• May need to reorient self to previous activity - Twice as common in boys as in girls
Atonic and Akinetic Seizures (Also Known as Drop Attacks) - Do not cause brain injury
- Biglang nagugulat, bumabagsak - Usually last less than 5 mins
- Characterized by: - Do not occur frequently
• Onset usually between 2 and 5 years of age - Do not increase the risk of epilepsy
• Sudden, momentary loss of muscle tone and postural Classification
control • Simple febrile seizures
• Events recurring frequently during the day, particularly in - Occur in children between the ages of 6 months and 5
the morning hours and shortly after awakening years.
- Manifestations: - No preexisting neurologic abnormality (walang problema
• Loss of tone causing child to fall to the floor violently sa kanyang brain, bigla lng sya nagkaroon)
• Unable to break fall by putting out hand - Consist of a general tonic-clonic seizure that occurs with a
fever (>38.0° C)
• May incur a serious injury to the face, head, or shoulder
- Resolves within 15 minutes
• Loss of consciousness only momentary
- Return to alert mental status after the seizure
Myoclonic Seizures - No further seizure occurring within a 24-hour period.
- A variety of seizure episodes - Risk factors: viral infection, family history
- May be isolated as benign essential myoclonus • Complex febrile seizures
- May occur in association with other seizure forms - Can occur in children of any age
- Characterized by: - With a previous neurologic impairment
• Sudden, brief contractures of a muscle or group of - Prolonged seizure lasting more than 15 minutes that can
muscles reoccur within 24 hours
• Occur singly or repetitively - Can result in neurologic deficits after the seizure.
• No postictal state Management
• May or may not be symmetric - Medication:
• May or may not include loss of consciousness • Acetaminophen/ ibuprofen
Unclassified Epileptic Seizures • IV or rectal Diazepam
- Seizures that lack sufficient information to classify • If the seizure continues, treatment consists of controlling
Infantile Spasms the seizure with IV or rectal diazepam and reducing the
- Also called infantile myoclonus, massive spasms, temperature with acetaminophen or ibuprofen.
hypsarrhythmia, salaam episodes, or infantile myoclonic Antiepileptic prophylaxis is usually not indicated.
spasms Antipyretic therapy may lower the child’s temperature
- Most commonly occur during the first 6 to 8 months of life and provide symptomatic relief but will not prevent a
- Twice as common in boys as girls seizure.
J.A.K.E 25 of 45
- Tepid sponge baths are not recommended for several reasons: - Ethosuximides/ valproic acids (absence Sz)
they are ineffective in significantly lowering the temperature, - Single meds preferred to minimize adverse effects
the shivering effect further increases metabolic output, and - (+) continuous Sz – multiple anti-convulsants
cooling causes discomfort to the child. Its okay to give BUT - Other drugs: phenobarbital, diazepam, lorazepam
dina-dry dapat agad. Nursing care management
- Parental education and emotional support are important - Care of the child with epilepsy involves physical care and
interventions, and information may need to be repeated instruction regarding the importance of the drug therapy and,
depending on the parents’ anxiety and education level. probably more significant, the problems related to the
emotional aspects of the disorder. Nursing care is directed
Epilepsy toward educating the child and family about epilepsy and
- Characterized by two or more unprovoked seizures helping them develop strategies to cope with the psychologic
- Caused by a variety of pathologic processes in the brain. and sociologic problems related to epilepsy.
- A single seizure event should not be classified as epilepsy and • Assist client with ketogenic diet (high fat, low
is generally not treated with long-term antiepileptic drugs. carbohydrates, and low protein diet). Potential side effects
Diagnosis of the diet are constipation, weight loss, lethargy and
• Through history – After the child’s first seizure, a thorough kidney stones
history is taken from the parent, primary caretaker, or • Observe the seizure episode and accurately document the
witnesses to the event. The description and length of the event
seizure, presence or absence of an aura, and whether the child • Administer anti-epileptic drug
lost consciousness, this information helps to identify the type • Educate family and child, as appropriate, the purpose of
of seizure AEDs, expected response and action, potential side effects,
• Skilled observation - Clinical entities that mimic seizures timing, dosage, route of administration and how to
include migraine headaches, toxic effects of drugs, syncope monitor effects
(fainting), breath-holding spells in infants and young children, • Monitor sides effects of AED s and therapeutic levels
movement disorders (tics, tremor, chorea), prolonged QT according to child’s growth, illness factors that affect
syndrome, sleep disturbances (night terrors), psychogenic metabolism and effects of drugs.
seizures, rage attacks, and transient ischemic attacks (rare in • Stress importance of adherence to medication regimen
children). event if child has no evidence of seizures activity
• Diagnostic tests – include a complete blood cell count, blood • Teach patient and family to identify and avoid situations
chemistry, and urine toxicology. A urine culture, blood culture, that are known to precipitate a seizure (e.g., blinking
and lumbar puncture are performed if meningitis is suspected. lights, sleep deprivation, excess activity or exercise,
A lead level and tests for inborn errors of metabolism may be physical factor
considered. Radiologic tests such as CT scanning or MRI and • Initiate seizure precautions in the hospital: pad side rails
angiography may be performed to identify a cerebral lesion or of bed, crib or wheelchair, keep bed relatively free of
metabolic disorder in the brain. An Electroencephalogram objectives
(EEG) is often performed at a follow-up visit between seizures. • Educate family to initiate seizure precaution at home
If the child is taking any anticonvulsants, a serum drug level is - Discharge plan
obtained.
• Help the child to lie down if having an attack
Management
• Remove glasses or other harmful objectives in the area
• Emergency Therapy
• Do not try to put anything in the child’s mouth. In doing
- Airway management
so, you may injure the child or yourself.
- Supplemental oxygen
- Intravenous benzodiazepines • After the seizure ends, place the child on one side aand
- VS monitoring stay with the child until fully awake, observe the child for
- Labs monitoring (Serum electrolytes, glucose, and blood breathing
gases) • If the child has a fever, acetaminophen (such as Tylenol)
- The postictal period ranges from 30 minutes to 2 hours. may be given rectally (hindi mouth dahil baka maaspirate)
When the child’s seizure does not stop as expected with • Do not try to give food, liquid, or medications by mouth
emergency intervention, treatment for status epilepticus is to a child who has just had seizure
initiated.
• Drug therapy Status Epilepticus
- Most seizure disorders are treated with antiepileptic drugs - Refers to a seizure that lasts continuously for longer than 30
(AEDs). minutes or a series of seizures from which the child does not
o A single (monotherapy) AED is preferred for seizure return to the previous level of consciousness. (derederetso ung
control to minimize the side effects such as sleepiness, pag seseizure un pasyente natin)
decreased attention and memory, difficulty with - This is an emergency requiring immediate treatment.
speech, ataxia, and diplopia. A low dose is used - Complications: exhaustion, respiratory failure, permanent
initially and gradually increased until seizures are brain injury, or death.
controlled.
- Carbamazepine, phenytoin, valproic acids (partial and
generalized Sz)
J.A.K.E 26 of 45
Management: directions—caudally and cephalically—until by the end of

• Oxygen may be necessary to relieve cyanosis. the fourth week of gestation, the ends of the neural tube,
• IV benzodiazepine such as diazepam (Valium) or lorazepam the anterior and posterior neuropores, close.
(Ativan) halts seizures dramatically. Types of Spina bifida
• IV phenobarbital or phenytoin (Dilantin). Diazepam must be • Spina bifida occulta
administered with extreme caution because the drug is - Hidden spina bifida
incompatible with many other medications, and any accidental - Covered neural tube defect
infiltration into subcutaneous tissue causes extensive tissue - 15% of patients
sloughing. When a benzodiazepine (diazepam or lorazepam) is - RARE neurological problems
ineffective, fosphenytoin followed by phenobarbital is given - Refers to a defect that is not visible externally.
as the next line of treatment. This combination of therapy - It occurs most frequently in the lumbosacral area (L5 and
places the child at high risk for apnea; therefore, respiratory S1).
support is generally necessary. - SB occulta may not be apparent unless there are
• Children may also receive an antiepileptic medication, IV associated cutaneous manifestations or neuromuscular
valproate, which does not cause respiratory compromise. disturbances.
Children who continue to have seizures despite this drug • Spina bifida cystica
treatment may require general anesthesia with a continuous - Refers to a visible defect with an external saclike
infusion of midazolam, propofol, or pentobarbital. In this protrusion.
situation, the patient may need to be intubated. - The two major forms of SB cystica:
• EEG monitoring is typically done to monitor for and treat o Meningocele
electrographic seizures. - Only spinal fluid in sac
Nursing care management - No nerve tissues
• Maintain airway, breathing, circulation suppoer - Fer or no symptoms to paralysis
• VS monitoring - which encases meninges and spinal fluid but no
- During the first 30 to 45 minutes of the seizure, the blood neural elements.
pressure may be elevated. Thereafter, the blood pressure o Myelomeningocele (or meningomyelocele)
typically returns to normal but may be decreased - Most severe
depending on the medications being administered for - Both fluid and nerve tissue in sac
seizure control. - Exposes nerves
- Hyperthermia requiring treatment may occur because of - Partial or complete paralysis
increased motor activity. - which contains meninges, spinal fluid, and
nerves.
Spina Bifida (SB)
- Latin: Split or Open Spine
- Refers to a defect in one or more vertebrae that allows spinal
cord contents to protrude.
- Can occur anywhere along the vertebral column.
- Most common at the lumbar or sacral portion of the spine.
- This is categorized into two types, SB occulta and SB cystica.
- The cause of spina bifida is unknown.
Clinical Manifestations based on location of defect
Rise factors:
- The clinical manifestations (paralysis, weakness, and sensory
• Chemicals (excessive use of alcohol), loss) depend on the location of the defect. The higher the
• Medications (e.g., valproic acid and carbamazepine used for defect on the spinal cord, the greater the neurologic
seizures, isotretinoin for acne) dysfunction
• Genetic factors 1) Thoracic level – paralysis of the legs, weakness and
• Maternal health conditions (diabetes mellitus, gestational sensory loss in the trunk and lower body region
diabetes, folic acid deficiency, and maternal obesity). 2) Lumbar 1–2 level – some hip flexion and adduction,
Pathophysiology cannot extend knees
Embryo stage → spinal cord development → 36 days since LMP 3) Lumbar 3 level – can flex hips and extend the knees:
almost close → small openings near head and bottom → 46 days paralyzed ankles and toes
since LMP completely close → neural tube → neural tube defect 4) Lumbar 4–5 level – can flex hips and extend the knees,
→ weak or absent ankle extension, toe flexion, and hip
Spina bifida extension
- At approximately 20 days of gestation, a decided 5) Sacral level – mild weakness in ankles and toes
depression, the neural groove, appears in the dorsal Complications
ectoderm of the embryo. • Sensory loss is more pronounced on the back of the legs
- During the fourth week of gestation, the groove deepens • Loss of lower extremity motor and sensory functioning may
rapidly, and its elevated margins develop laterally and not be symmetric
fuse dorsally to form the neural tube.
- Neural tube formation begins in the cervical region near
the center of the embryo and advances in both
J.A.K.E 27 of 45
• Bowel and bladder incontinence occurs with all but the sacral • Diet (adequate calcium and vit. D / dietary fiver) to prevent
level lesions, but bowel and bladder function may still be constipation
affected at the sacral level. • Weight bearing activities
• Renal damage may result from neurologic impairment and • Clean intermittent catheterization (every 3-4 hours)
urinary retention (neurogenic bladder). • Stool softeners and glycerin or bisacodyl suppositories /
• Hydrocephalus is usually present in children with a enema
myelomeningocele defect above the sacral level, along with Nursing consideration
the Arnold Chiari type II malformation. • Assess the sac and measure the lesion
• Children with myelodysplasia have mobility problems, • Assess neurological system
intellectual disability, and visual impairment. Additional • Measure head circumferences
complications include spinal curvatures, musculoskeletal and • Protect the sac, cover with a sterile, moist (normal saline),
joint abnormalities, skin sores, precocious puberty, and sexual nonadherent dressing and change the dressing every 2-4 hours.
dysfunction. • Place the patient in prone position and head to one side.
Diagnostic Evaluation • Assess and monitor the sac for redness, clear or purulent
• Clinical manifestations and examination of the meningeal sac. drainage, abrasions, irritation and signs of infection.
• MRI • Administer medication: antibiotics, anticholinergics and
• Ultrasonography laxatives as prescribed.
• CT scan.
• Neurologic evaluation will determine the extent of Hydrocephalus
involvement of bowel and bladder function as well as lower - A condition caused by an imbalance in the production and
extremity neuromuscular involvement. Flaccid paralysis of the absorption of CSF in the ventricular system.
lower extremities is a common finding with absent deep - When production is greater than absorption, CSF accumulates
tendon reflexes. within the ventricular system, usually under increased pressure,
• Ultrasonographic scanning of the uterus and elevated maternal producing passive dilation of the ventricles.
concentrations of α-fetoprotein (AFP, or MS-AFP), a fetal - The condition may be congenital or acquired as a result of
specific γ-1-globulin, in amniotic fluid may indicate intraventricular hemorrhage, meningitis, traumatic brain injury,
anencephaly or myelomeningocele. The optimum time for or brain tumor.
performing these diagnostic tests is between 16 and 18 weeks - An estimated 1 to 2 infants per 1000 are born with
of gestation before AFP concentrations normally diminish and hydrocephalus
in sufficient time to permit a therapeutic abortion. It is - CFS volume child = 60-100 ml
recommended that such diagnostic procedures and genetic Types of Hydrocephalus
counseling be considered for all mothers who have borne an • Communicating hydrocephalus
affected child, and testing is offered to all pregnant women. - Impaired absorption within the subarachnoid space
Prevention - Interference of CSF within ventricular system does not
• Increase folic acid in diet occurs
- Dietary supplement with folic acid - Obstructive
- Whole grains - CSF flows freely among normal channels and pathways,
- Fortified breakfast cereal but CSF absorption in the subarachnoid space and the
- Dried beans arachnoid villi is impaired.
- Green leaf vegetables and fruits - It may be acquired or caused by a congenital
Management malformation in the subarachnoid spaces. (ang problema
• Management of the child who has a myelomeningocele lng dito absorption)
requires a multidisciplinary team approach involving the • Noncommunicating hydrocephalus
specialties of neurology, neurosurgery, pediatrics, urology, - Obstruction of CSF flow within ventricular system
orthopedics, rehabilitation, physical therapy, occupational - Obstructive
therapy, and social services, as well as intensive nursing care - For most cases in children.
in a variety of specialty areas. - It results from a blockage in the ventricular system that
• Surgical repair (within 24 to 72 hours after birth) prevents CSF from entering the subarachnoid space,
- If sac is leaking, surgical closure within the first 24 hours. resulting in enlargement of one or more ventricles. This
(we try to prevent it from drying, get a sterile gauze, wet it obstruction can be caused by infection, hemorrhage,
with sterile saline solution and cover the sac) tumor, surgery, or structural deformity.
- VP shunt procedure - Congenital structural defects include the Chiari type II
- Mitrofanoff procedure (creates a reservoir for urine and a malformation (found in children with myelomeningocele),
stoma for catheterization in the umbilicus may be aqueduct of Sylvius stenosis, and the Dandy-Walker
performed.) syndrome (includes hydrocephalus, a posterior fossa cyst,
• Antibiotic therapy (if associated with infections) and hypoplasia of the cerebellum).
• Braces (used to support joint position and mobility) Clinical manifestations
• Assistive devices (such as walkers, crutches, and wheelchairs • Head grows at an abnormal rate
are used to enhance mobility) • Fontanels are bulging
• Tense anterior fontanelle (often bulging and non-pulsatile)
• Scalp veins are dilated, especially when the infant cries;
J.A.K.E 28 of 45
• Skull bones are thin with separated sutures, causing a cracked- • Assess for signs of increased ICP and check for the: Head
pot sound (Macewen sign) when palpated. circumference (daily), anterior fontanelle for size and
• In severe cases, infants display frontal protrusion (frontal fullness and behavior.
bossing), • Administer prescribed medication which may include
• Eyes depressed and rotated downward (setting-sun sign), antibiotics to prevent infection and analgesics for pain
• sluggish pupils. • Provide shunt care:
• Irritability and lethargy with varying LOC o Monitor for shunt infection and malfunction which
• Abnormal infantile reflexes may be characterized by rapid onset of vomiting,
• Possible cranial nerve damage severe headache, irritability, lethargy, fever, redness
• The signs of increased ICP, along the shunt tract and fluid around the shunt valve
- Headaches on awakening with improvement after emesis o Prevent infection (usually from staphylococcus
- Papilledema epidermis or aureus)
- Strabismus • Monitor for shunt over drainage (headache, dizziness and
- Ataxia nausea) – may lead to slit ventricle syndrome whereby the
- Irritability ventricle become accustomed to a very small or slit like
- Lethargy configuration, limiting the buffering ability to increased
- Apathy ICP variations
- Confusion Complications
Diagnostic Evaluation • Infections and malfunction (shunt)
• Level II ultrasonography of the fetus will allow a prenatal • Subdural hematoma (too rapid reduction of CSF)
diagnosis (Transuterine placement of ventriculoamniotic • Peritonitis
shunts during late pregnancy is still being developed as a • Abdominal abscess
treatment modality) • Perforation of organs
• Physical examination (HC) • Fistulas
• CT scan (diagnose most cases postnatally) • Hernias
• MRI (if complex lesion is suspected) • Ileus
- Hydrocephalus in infants is based on head circumference
that crosses at least one percentile line on the head
measurement chart within 2 to 4 weeks. ALTERATIONS IN MUSCULOSKELETAL AND
- In evaluation of a preterm infant, specially adapted head NEUROMUSCULAR DYSFUNCTION
circumference charts are consulted to distinguish Discussed by Prof. Melanie Cambel
abnormal head growth from normal rapid head growth.  Soft tissue injury
- The primary diagnostic tools to detect hydrocephalus in  Fractures
older infants and children are CT and MRI.  Developmental dysplasia of the hip
- Diagnostic evaluation of children who have symptoms of  Scoliosis
hydrocephalus after infancy is similar to that used in those  Cerebral palsy
with suspected intracranial tumor. In neonates,  Congenital clubfoot
echoencephalography is useful in comparing the ratio of
lateral ventricle to cortex. Soft Tissue Injury
Treatment (Surgical intervention) Contusion (Bruise)
• VP shunt – remove CSF from ventricles to peritoneal cavity - Damage to the soft tissue, subq. structures, and muscles
• VA shunt – to the right atrium - Tearing of these tissues and small blood vessels and the
• Ventriculopleural shunt – pleural cavity inflammatory response led to hemorrhage, edema, and
• Ventriculostomy – non shunting procedure associated pain when the child attempts to move the injured
• Surgical removal of obstruction (if cause is removable such as part
tumor/ hematoma) - The escape of blood into tissues is observes as ecchymosis, a
• DOC: Acetazolamide black-and-blue discoloration
Nursing management - Include strain and sprain
- Preoperative care: - Large contusions cause gross swelling, pain, and disability and
usually receive immediate attention from health personnel
• Assess head circumference, fontanelles, cranial sutures,
(hindi nya pa ma move)
and LOC; check also for irritability, altered feeding habits
- Smaller injuries may go unnoticed, allowing continued
and a high-pitched cry
participation (maliliit na pasa due to banga banga)
• Firmly support the head and neck when holding the child
- Treatment
• Provide skin care for the head to prevent breakdown
• cold application
• Give small, frequent feedings to decrease the risk of
• rest of affected part
vomiting
Dislocation
• Encourage parental-newborn binding
- Occurs when the force of stress on the ligament is so great as
- Postoperative care: (after the VP shunting)
displace the normal position of the opposing bone ends or the
bone end to its socket
J.A.K.E 29 of 45
- Common sa mga bata to - Childhood is a time of rapid bone growth the patterns od
- Predominant symptoms: treatment differ from the children and adults kase mas bata pa
• pain that increases with attempted passive or active sila they heal much faster than adults
movement of the extremity - Most often a result of traumatic incidents at home, at school,
• An obvious deformity and inability to move the joint in a motor vehicle, or in association with recreational activities
• ito yung mga batang nahahatak - Most common fracture in children:
- Subluxation – partial dislocation (di pa ganun nadi dislocate) • Distal forearm – radius or ulna
- Types: • Clavicle – younger than 10 of age
• Phalanges (most common type in children – school age) - Fracture line:
• Elbow • Transverse – cross wise at right angles to the long axis of
• Shoulder (more common in adolescent) – wag bone
masyadong binubuhat gamit yung kamay yung sa mga • Oblique – slanting but straight between a horizontal and a
bago pa lang naglalakad na mga bata perpendicular direction
- Diagnosis: • Spiral – slanting and circular, twisting around the bone
• X-ray shaft
• MRI - Diagnosis:
- Management • X-ray is most useful diagnostic tool
• RICE (Rest, Ice {10-20 min only}, Compression, Types of fracture:
Elevation) • Plastic Deformation – occurs when the bone is bent but not
• Repositioning broken. A child’s flexible bone can be bent 45 deg. or more
• Splint or cast – immobilize bef. breaking (di pa nakakatayong baby/bata. Mababalik pero
• Pain relievers (Acetaminophen or Ibuprofen) di totally ma s straight, sa ula or radius)
• Traction – trauma or vehicular accident. It is an act of • Buckle, or torus, fracture – produced by compression of the
pulling and drawing which is associated with counter porous bone; appears as a raised or bulging projection at the
traction fracture site (parang nagkaroon ng growth)
- Purpose: • Greenstick fracture – occurs when a bone angulated beyond
• P-Prevent & correct deformity the limits of blending (Incomplete fracture)
• R-Reduce pain & muscle spasm • Complete fracture – divides the bone fragments
• I-Immobility
• S-Support affected extremities
Assessment
• M-Maintain body alignment
• Loss of function
- Surgery – combined with other musculoskeletal dysfunction
• Deformity
Strain
• Erythema
- Injury to tendon and muscle
- Overstretching • Edema
Sprain • Muscle spasm
- Injury to the ligaments • Impaired sensation
- Twisting • The 6 P’s
- Active masyado sa sports 1) Pain and point of tenderness
- Assessment 2) Pulse – distal to the fracture site
• Pain = principal complaint 3) Pallor – affected ang blood vessels
• (+) swelling 4) Paresthesia – sensation distal to the fracture site
- Therapeutic Management 5) Paralysis – movement distal to the fracture site
6) Pressure – involved limb may feel tense and warm
• Within 12 – 24 hrs
4 Rs of Treatment
- CODE: R.I.C.E.S
• Recognition
• R - Rest
• Reduction-restore proper alignment
• I – Ice (<30 minutes at a time)
• Retention – memaintain muna di muna gagalawin
• C – Compression (bandaging)
• Rehabilitation – fraction yung may mga bakal bakal
• E – Elevate
Common site
• S – Support
• Clavicle
- NOTE: kapag may iba pang bleeding need ma assess ng
• Humerus
doctor yun
• Radius & Ulna
Fractures • Femur
- Occur when the resistance of bone against the stress being Causes
exerted yield to the stress point • Results of trauma
- More likely to occur in children and older adults • Motor vehicle accidents
- Heal much faster than in adults • Falls
• Child abuse
J.A.K.E 30 of 45
Stages of Bone Healing - Growth Categories

• Physiological factor – maternal hormone secretion and
intrauterine positioning
• Mechanical Factor – breech presentation, multiple fetus,
oligohydramnios, and large infant size)
• Genetic Factor
Degree
• Acetabular Dysplasia
- Mildest form in which there is neither subluxation nor
dislocation
- Delay acetabular development
• Subluxation
- Largest percentage
- Incomplete dislocation of the hip and is sometimes
regarded as an intermediate state in the development from
Bone healing primary dysplasia to complete dislocation femoral head
• Neonate (2 to 3 weeks) remains partially in contact with the acetabulum
• Early childhood (4 weeks) • Dislocation
• Late childhood (6-8 weeks) - Severe form
• Adolescence (8-12 weeks) - Femoral head losses contact with the acetabulum and is
displaced posteriorly and superiorly over the
• Thicken periosteum& generous blood supply
fibrocartilaginous rim. The ligamentum teres is elongated
- Apply cold to injured area
and taut.
- Limitation of complication
o Idiopathic
- Control of pain, hemorrhage & edema
o Teratologic
Nursing Management
Diagnosis
• Immobilize
• Galeazzi Test
• Cover with sterile gauze (open)
• Ortolan’s test
• Elevate part
• Barlow Test
• Prevent complications:
• Ultrasonography (<4 mon)
- Compartment syndrome – may pressure sa loob napupuno
ng blood. Check the capillary refill kase hindi nakaka • Radiographic examination (>4 mon)
daloy ng maayos ang dugo. manlalamig, mamumula or • CT scan
poor ang capillary refill. Pwede magkaroon ng ischemia - hindi agad nakikita to sa baby
and lead to ischosis
- Infection
- Renal calculi
- Fat metabolism (72 hours after fracture)
Developmental Dysplasia of the Hip

- A spectrum of disorders related to abnormal development of
the hip that may occur at any time during fetal life, infancy, or
childhood
- Incidence of hip instability is approximately 1.5 per 1000 live
births, and approx.. 15% to 50% of infants with DDH are born
breech.
- Girls are affected more commonly (80%) and there is a
positive family history in approx.. 12% to 33% of affected
individuals
Treatment
- Condition in which the head of the femur is seated improperly
- Initiated before 2 months
in the acetabulum, or hip socket of the pelvis
- By 6 months –Ortolani (-)
• Females
- Goal: Maintain hip joint so that femoral head and acetabulum
• Range from mild to severely dislocated can develop properly
• Can be congenital or can be develop after birth - < 6 months
- Causes: Unknown
• Splinting the hip with Pavlik Harness (6-12wks) to
- Predisposing Factors:
maintain flexion & abduction & external rotation
• Family history
• Bryan Traction (adduction contracture)
• Intrauterine position
• Hip spica Cast (difficulty maintaining stable reduction)
• Delivery type - 6 to 24 months
• Joint laxity • Close reduction –Spica cast (12 weeks)
• Post-natal positioning
J.A.K.E 31 of 45
- 6 months –2 years old 4 Common types of curves:

• Open surgical reduction - Curves of <25 deg. Considered as mild and required more
- Older Children observation for growth and development
• Operative reduction - Pag more than naman kailangan ng intervention talaga
• preoperative traction - Thoracic – 90% on R side
• tenotomy of contracted muscles - Lumbar – 70% on L side
• innominate osteotomy procedures combined with - Thoracolumbar – 80% on R side
proximal femoral osteotomy – naglalagay ng opening - Double major – Curve that occur left to right side; Not all
• casting curvature of spine is Scoliosis
• ROM exercises (after casting) • <10 degrees = postural variation (tinuturuan lang paano
- Following surgery ang tamang posture, exercises lang katapat)
• Position & immobilization in Spica cast until healing is • 25-50 degrees = bracing
achieved, then abduction splint • 25-51 >45 degrees = surgical (nilalagyan ng mga pins)
• Don’t double or triple diaper Intervention
• Put undershirt • Monitor curvature
• Diaper under straps • Prepare use of braces/ surgery
• Feed football/ supine (when in cast) • Braces
• Look for location of marking in harness when adjusting - Worn 16-23 hours/ day
- Inspect skin breakdown
• Place baby on back when asleep = supine
- Keep skin clean & dry
Nursing Management
- Inconvenient (but beneficial)
• Early detection and assessment (nakikita din to sa CP)
- 15-16 years old cessation of bracing (tapos na yung
• Maintenance of the device and adaption of nurturing activities
bracing)
to meet the patient’s need (para iwas compartment syndrome,
- ex. sa 15 – 16 years papalitan na ang braces and magu
sa pagkamot naman blower na malamig na hangin para
undergo na sila ng surgery to prevent further curvature
mawala ang kati sa loob
• Not curative; compliance
• Skin care
- inislow lang yung progress
• Health teaching
• Surgery (Rods are left in spine throughout life)
• Public harness (<6 months) - May return to school after 1 month
• Check freq. At least 2 or 3x a day lalo na yung sa bandang - 5-7 day = discharge
strap - After 2 days = ROM, log roll, elevate head
- Diet – mataas ang calcium at vitamin E
Scoliosis
• Physiotherapy
- Lateral curvature of the spine
- Gives more emphasis on posture
- Surgical & non-surgical intervention are used
- Strengthening the muscles
- Treatment depends on age, degree of curvature, & amount of
- Correction of muscle in balance
growth that is anticipated
- Long term monitoring
Cerebral Palsy
- Complex spinal deformity in 3 planes, usually involving
- A group of disabilities caused by injury or insult to the brain
lateral curvature, spinal rotation causing rib asymmetry, and
either before or during birth, or in early infancy
thoracic hypokyphosis
- Most common permanent disability of childhood
- Most common spinal deformity
- Cerebral = refers to cerebrum
- Classification
- Palsy = refers to disorder of movement
• Infantile (0-3 yr/old) - Caused by damage to the motor control centers of the
• Childhood or juvenile (4-10 yr/old) developing brain and can occur during pregnancy (75%),
• Adolescent (10 years or later) childbirth (5%) or after birth (15%) up to age 3.
- Causes Etiology
• Congenital infantile - Prenatal brain abnormalities
• Paralytic - Brain anoxia
• Idiopathic/ adolescent - Prematurity
Assessment - Twin births
- Visible curve fail to strengthen when child bends forward & - Other prenatal or perinatal risk factors
hang arms toward feet • Aspyxia
- Asymmetry –hips, shoulder, ribs (Adams forward bend test) • Ischemia
- Leg length discrepancy • Perinatal trauma
- Scoliometer – head and hips are not aligned • Congenital and Perinatal infections
- Diagnosis: • Perinatal metabolc problems such as hyperbilirubinemia
• radio graphs – chinecheck din ang growth ng bone ng bata and hypoglycemia
• use of cobb technique - Infection, trauma and tumors can cause CP in early infancy
• riser scale - Unknown (24%)
J.A.K.E 32 of 45
Types - Mental retardation, seizures, attention deficit disorder and

• Spastic Cerebral Palsy sensory impairment
- Affected area: cortex Diagnosis
- Tense, contracted muscles • Prenatal, birth and postnatal history
- Walks on his toes with scissor gait, crossing one foot in • Neurologic examination
front of the other • Assessment of muscle tone, behaviour or abilities
- Hypertonic, flexion, underdeveloped upper limbs • Other disorders: metabolic disorders, degenerative disorders
- Most common type (70%) and may involve one or both and early slow-growing tumors are ruled out
sides of the body Nursing Care Management
o Hemiparesis • Prevent physical injury by providing the child with a safe
o Quadriparesis environment, appropriate toys, and protective gear (helmet,
o Diplegia kneepads) if needed
• Dyskinetic/Athethoid Cerebral Palsy • Prevent physical deformity by ensuring correct use of
- Affected area: basal ganglia prescribed braces and other devices and by performing ROM
- Constant, uncontrolled motion of limbs, head, and eyes exercises
- Involves abnormal involuntary movements that disappear • Promote mobility by encouraging the child to perform age and
during sleep and increase with stress condition-appropriate motor activities
- Major manifestations are athetosis (worm-like • Promote adequate fluid and nutritional intake
movements), dyskinetic movement of mouth, drooling
• Foster relaxation and general health by providing rest periods
and dysarthria
• Administer prescribed medication which may include
- kapag natutulog relax lang ang muscle pero kapag na s
sedatives, muscle relaxants and anti-convulsant
stress ang bata galaw ng galaw ang muscles
• Encourage self0care by urging the child to participate in
• Ataxic Cerebral Palsy
activities of daily living (ADL)
- Poor sense of balance, often causing falls and stumbles
• Appreciate the activities na mga natapos nila
- Manifested by a wide-based gait, rapid repetitive
movements performed poorly, and disintegration of • Facilitated communication
movement of the upper extremities when the child reaches - Talk to the child deliberately and slowly, using pictures to
for objects reinforce speech when needed
- Encourage early speech therapy to prevent poor or
- To keep her balance the child with ataxia walks bent
maladaptive communication habits (mga computer pwede
forward with feet wide apart. She takes irregular steps,
nila magamit para masabi nila ang gusto nila)
like a sailor a rough sea or someone who is drunk
- Provide means of articulate speech such as sign language
- Kapag gumagalaw hindi kayang masabay ang dalawang
or a picture board
extremities. One extremity at a time
- Technology such as computer use may help children with
• Mixed /Dystonic Cerebral Palsy
severe articulation problems
- Manifested by a combination of the characteristics of
• As necessary, seek referrals for corrective lenses and hearing
spastic and athetoid CP
devices to decrease sensory deprivation related to vision and
- Delayed gross motor development – eating/swallowing is
hearing loss
difficult
• Help promote a positive self-image in the child
- mga soft food nalang and promotion not to aspirate
Pathophysiology - Praise him accomplishments (have patience teaching the
patient kase hindi isang turo lang nakukuha agad)
- Disabilities usually result from injury to the cerebellum, the
- Set realistic and attainable goals
basal ganglia or the motor cortex
- Encourage an appealing physical appearance
- Difficult to establish the precise location of lesions
- Encourage his involvement with age and condition-
- Some cases, brain has gross malformations; in others, vascular
appropriate peer group activities
occlusion, atrophy, loss of neurons and degeneration may be
evident • Promote optimal family functioning
- Non-progressive but become more apparent as child grows - Encourage family members to express anxieties,
older frustrations and concerns and to explore support networks
- Provide emotional support and help with problem solving
- During pinapanganak ang baby nagkaroon na sila ng vascular
as necessary
occlusion lead to atrophy to loss of neurons
- Refer the family to support organization such as the
- hindi naman lumalala pero nakikita mo yung disability nya
United Cerebral Palsy Association
Clinical Manifestation
- Delayed gross motor development
Congenital Clubfoot
- Abnormal motor performance (eg. Early dominant hand
- Congenital malformation of the lower extremities
preference, abnormal and asymmetrical crawl, poor sucking,
- Boys
feeding, problems or persistent tongue trust)
- Unilateral/bilateral
- Alteration of muscle tone
- Defect are rigid and cannot be manipulated into a neutral
- Abnormal posture (eg. Scissoring legs or persistent infantile
position
posturing)
- Long term follow up is required until the child reaches skeletal
- Reflex abnormalities (eg. persistent primitive reflexes – tonic
maturity
neck of hyperreflexia)
J.A.K.E 33 of 45
Common foot malformation LIFE-THREATENING CONDITIONS/ ACUTELY ILL/

• Talipes Varus – Inversion or bending inward MULTI-ORGAN PROBLEMS/ HIGH ACUITY AND
• Talipes Valgus – Eversion or bending outward EMERGENCY SITUATIONS
• Talipes Equinus – Plantar Flexion, toes are lower than the Discussed by Prof. Melanie Cambel
heel Life threatening illness or injury
• Talipes Calcaneus – Dorsi-flexion, toes are higher than the • Chronic illness or progressive disabling disease
heel • Child may die prematurely
• Talipes Equino-Varus – Toes are lower than the heel and Acute illness
facing inward • Unintentional injury
Categories • Unanticipated nature of event
• Positional – Stretching, casting, exercise Emergency situation
• Teratologic/ Syndromic – Surgical • Admission for an acute illness or unintentional injury that
• Congenital – Surgical if (+) bone involvement brings sudden stressors and faced with uncertain outcome.
• Goal: Painless, plantigrade, and stable foot
Therapeutic Management Child’s experience
- Correction of deformity • Appears extremely anxious and fearful or withdrawn, solemn,
- Maintenance of correction and preoccupied with their own physical condition. (ano ung
- Follow-up observation nakikita, nararamdaman nila)
- Ponseti method • Brings pain, decreased energy and changes to level of
- Begins soon after birth (paunti unti lang) consciousness.
- weekly gentle manipulation and serial long-leg casting (6- • May be unable to understand what is happening (once na
10 wks) naadmit sila sa hospital, d na nila ala mano nangyayari dahil sa
- Percutaneous heel tenotomy performed at the end of serial dami ng tao, maraming kumikilos at marami din silang hindi
casting then a long-leg cast is applied (3 wks) alam na bagay)
- Dennis Browne Splints • Responses to stress are influenced by their developmental
Nursing Care Management levels, past experiences, types of illness, coping mechanism,
• Observation of skin and circulation and available emotional support.
• Cast care health teachings • An unanticipated admission places the child at emotional risk
because of the lack of preparation for the experience, the
Septic Arthritis uncertainty and unpredictability of events that follow, the
- Condition in which bacteria invade the joint space (hip) unfamiliarity of the environment and heightened anxiety of
- <10 years old (3-7 y/o) parents.
- Bacteria access
• Direct puncture/ wound infection Coping mechanisms
• Seeding from distal infection site - Refers to the cognitive and behavioral responses that help a
person manage specific internal and external demands that a
• Compression of joint capsule from adjacent osteomyelitis
person manage specific internal and external demands that
- Causative agents:
exceed personal resources, enabling the persong to solve
• Staphylococcus Aureus
problems and to respond appropriately (paano nila
• Haemophyllus Influenza type B malalagpasan ang problema)
• Streptococci (most common) - Child’s temperature, previous coping experiences and
- Goal: Prevent destruction of the joint cartilage and maintain availability of support systems influences the child’s ability to
function, motion and strength cope with the current experience
- Treatment - Defense mechanisms: regression, denial, repression
• point aspiration or orthrotomy followed by IV antibiotics (involuntary forgetting), postponement, and bargaining
• Oral antibiotics
- Assessment Nursing assessment
• Fever to moderate severe pain • Subjective data: health history
• Refusal to bear weight - Should include the child’s response to illness, the
• Limited range of motion environment, coping strategies and the need for
• Affected joint is warm and swelling information and support.
- Management - Includes: birth history, immunization
• Assess signs of infection • Objective data:
• Resolution of fever - Physiologic parameters (head to toe)
• Analgesics - Skilled observation of the child’s psychosocial and
• Codeine or morphine emotional needs.
• Antibiotics
• Assistive devices Physical assessment
1) Vital Signs
• Temperature
• Radial Pulse: rate, volume, rhythm
J.A.K.E 34 of 45
• Respirations: rate, depth, rhythm

• Blood Pressure: Korotkoff’s sounds
2) State of comfort: location and intensity of pain, response to
medications given.
3) Emotional responses: patient behavior, reactions and
demeanor, and general mood (crying/ depressed)
4) Skin: presence/ absence of abrasions, contusions, erythema,
decubitus ulcers, incision line, color, turgor, temperature.
5) Musculoskeletal: activity level, general mobility, gait, range
of motion
6) Neurological: pupil (size, response, equality), hand grip
strength and sensation of all extremities; ability to follow
commands; level of consciousness.
7) Respiratory: breath sounds; sputum color and consistency;
cough (productive/ non-productive)
8) Cardiovascular: heart sounds; presence of pulses; edema
9) Gastrointestinal: bowel pattern and sounds; presence of
nausea/ vomiting; abdominal distention; consumption of diet
10) Genitourinary: voiding, color, odor, and consistency of urine,
dysuria; vaginal drainage discomfort; penile discharge
Diagnostic/ laboratory tests
Glassgow Coma Scale (GCS)/ Level of consciousness • Arteriography/ angiogram
- In this test of baseline mental status, a score of 15 indicates - Evaluating the patency of the blood vessels and blood
that the patient is alert, can the follow simple commands, and flow towards the other parts of the body.
is oriented to person, place and time. - Cardiovascular problems
- A decreased score in one or more categories may signal an • Barium or contrast enema
impending neurologic crisis. A score of 7 or less indicates - Gastrointestinal system
severe neurologic damage. - Administered via a tube through the rectum towards the
colon.
• Biopsy
- Removal and examination of tissues from the body organs
- To detect the malignancies
• Bone marrow aspiration
- To take a sample of the liquid part of your bone marrow.
- Your bone marrow is the spongy tissue inside of your
bones that produces blood cells.
- Hematologic problems
• Bronchoscopy
- Bronchoscopy is a procedure that lets doctors look at your
lungs and air passages. It's usually performed by a doctor
who specializes in lung disorders (a pulmonologist).
- During bronchoscopy, a thin tube (bronchoscope) is
passed through your nose or mouth, down your throat and
into your lungs.
• Cardiac catheterization
- Used to study the various functions of the heart or to
obtain diagnostic information about the heart or its vessels.
- A small incision is made in an artery or vein in the arm,
neck, or groin. The catheter is threaded through the artery
or vein into the heart.
- Femoral vein or artery ang ginagamit
- Congenital heart defects
• Computed tomography (CT) scan
- a medical imaging technique used in radiology to obtain
detailed internal images of the body noninvasively for
diagnostic purposes.
- To screen for head, liver, abdominal, renal, tumors, edema,
abscess, bone destruction
• Cultures
- Whether that is blood, urine, etc
- To identify microorganism.
J.A.K.E 35 of 45
• Echocardiography - This information can help your healthcare provider

- Checks how your heart's chambers and valves are diagnose and decide the treatment of certain lung
pumping blood through your heart. disorders.
- An echocardiogram uses electrodes to check your heart • Pulse Oximetry
rhythm and ultrasound technology to see how blood - Used to measure the oxygen level (oxygen saturation) of
moves through your heart. An echocardiogram can help the blood.
your doctor diagnose heart conditions. - Normal: 95 – 100 %
• Electrocardiography (ECG or EKG) • Radiograph (x-ray)
- Records the electrical signal from the heart to check for - It is used to diagnose or treat patients by recording images
different heart conditions. of the internal structure of the body to assess the presence
- Electrodes are placed on the chest to record the heart's or absence of disease, foreign objects, and structural
electrical signals, which cause the heart to beat. damage or anomaly.
- The signals are shown as waves on an attached computer - During a radiographic procedure, an x-ray beam is passed
monitor or printer. through the body.
• Electroencephalogram (EEG) • Tympanogram
- A test that measures electrical activity in the brain using - A tests how well your eardrum moves. The audiologist
small, metal discs (electrodes) attached to the scalp. will put a small probe, which looks like an earphone, into
- Brain cells communicate via electrical impulses and are each ear. A small device attached to the probe will push
active all the time, even during asleep. This activity shows air into your ear.
up as wavy lines on an EEG recording • Ultrasound
• Esophagogastroduodenoscopy/ esophagogastroscopy - An imaging method that uses sound waves to produce
- EGD is an endoscopic procedure that allows your doctor images of structures within your body.
to examine your esophagus, stomach and duodenum (part - The images can provide valuable information for
of your small intestine). diagnosing and directing treatment for a variety of
- EGD is an outpatient procedure, meaning you can go diseases and conditions.
home that same day. It takes approximately 30 to 60
minutes to perform. Nursing diagnoses
• GI series • Anxiety (child) related to separation from parents, unfamiliar
- The esophagus, stomach, and duodenum (first part of the environment, strangers as caretakers, invasive procedures
small intestine) are made visible on X-ray film by a liquid • Powerlessness related to inability to communicate, and control
suspension. This liquid suspension may be barium or a relinquished to the healthcare team.
water-soluble contrast. • Acute pain related to injuries, invasive procedures, surgery.
• Intravenous pyelogram • Impaired verbal communication related to the effects of
- Also called an excretory urogram, endotracheal intubation and mechanical ventilation
- An X-ray exam of your urinary tract. An intravenous • Spiritual distress related to crisis of illness or suffering.
pyelogram lets your doctor view your kidneys, your • Disturbed sleep pattern related to circadian asynchrony,
bladder and the tubes that carry urine from your kidneys excessive stimulation, pain and anxiety caused by the critical
to your bladder (ureters). care unit environment
• Lumbar puncture • Deficient diversional activity related to forced inactivity.
- can help diagnose serious infections, such as meningitis;
other disorders of the central nervous system, such as Planning and implementation
Guillain-Barre syndrome and multiple sclerosis; bleeding; • Provide psychosocial care for the child
or cancers of the brain or spinal cord. - Touch and talking to child
• Magnetic resonance imaging (MRI) - Build trusting relationship
- Uses a large magnet and radio waves to look at organs - Minimize stressors experienced by the child
and structures inside your body. - Promote coping
- Health care professionals use MRI scans to diagnose a • Promote sense of security
variety of conditions, from torn ligaments to tumors. - Parental presence
MRIs are very useful for examining the brain and spinal - Consistency of staff
cord. - Personalizing the child’s beside
• Positron Emission Tomography (PET) scan and Single • Provide education and prepare the child for procedures
Photon emission Computed Tomography (SPECT) - Help younger children to understand that illness and
- Provide a means of examining regional cerebral blood hospitalization are not punishment
flow, metabolism, and pharmacology in vivo under both - Preparation for procedures is important
resting and activating conditions. - Toddlers need to be talked to, soothed, and touched
• Pulmonary function tests (Spirometry) during and after the procedure
- Are noninvasive tests that show how well the lungs are - Explain sensations that they can expect to experience
working. • Facilitate use of play
- The tests measure lung volume, capacity, rates of flow, - To alleviate stress and help prepare for procedures
and gas exchange. - Assess child’s developmental level
J.A.K.E 36 of 45
- Therapeutic play diminishes negative fantasies, provides Basic Cardiac Life support (BCLS)
motor activity and help cope with stressors - Provided by trained responders in the absence of advanced
- Facilitate coping by assisting in preparation for medical care.
procedures and provide distraction - Does not include the use of drugs or invasive skills
Pharmacological therapeutics
• Dosage calculations
- Based on weight (common)
- Based on body surface area (BSA)
• Two nurses are required to check dosages on several
medications (insulin, narcotics, digoxin, chemotherapeutic
drugs and anticoagulants)
• Special considerations:
- Oral medications
o Check gag reflex
o Use calibrated spoons, syringes, and cups
o If medication needs to be crushed, administer in
nonessential food
o Do not crush sustained release capsules or tablets
o Verify placement of feeding tubes by both aspirations
and auscultation before administering medication.
• Injections
- Eutectic mixture of local anesthetics (EMLA) numbs the Pediatric Advanced Life Support (PALS)
skin at a depth of 0.5 mm and used before needlesticks. Precautions
Apply only to intact skin, contraindicated in children with • Do not leave victim alone.
methemoglobinemia • Do not chest compressions if the victim has a pulse. Chest
- Use the vastus lateralis as the site of choice of IM compression when there is normal circulation could cause the
injections for all children younger than 3 years of age. heart to stop beating.
Never use the gluteus until the child is walking well. • Do not give the victim anything to eat or drink.
• Ophthalmic medication • Avoid moving victim’s head or neck if spinal injury is a
- Gently pull the lower lid down. possibility. The person should be left as found if breathing
• Otic medication freely. To check for breathing when spinal injury is suspected,
- Pull the pinna up and back for children older than age 3 the rescuer should only listen for by the victim’s mouth and
years watch the chest for movement.
- Down and back for children younger than 3 years. • Do not slap the victim’s face, or throw water on the face, to try
and revive the person.
• Do not place a pillow under the victim’s head.
J.A.K.E 37 of 45
IMCI
Discussed by Prof. Melanie Cambel
- Simply the umbrella program through which all community
health intervention can be delivered to children under 5 years
of age.
- IMCI is an integrated approach to child health that focuses on
the well-being of the whole child. (holistic)
- IMCI aims to reduce death, illness and disability, and to
promote improved growth and development among children
under five years of age.
- IMCI includes both preventive and curative elements that are
implemented by families and communities as well as by health
facilities.
- Age categories of IMCI:
• Children age 2 months up to 5 years
• Young infants aged 1 week up to months
- Focus of IMCI in the Philippines (PD2M3)
• Pneumonia
• Dengue
• Diarrhea
• Malaria
• Measles
• Malnutrition
Brief history of IMCI
• 1992 – 1st developed by: UNICEF (United Nations Children’s
Emergency fund) and WHO)
When to Stop CPR
• 1995 – Introduced in the Phil as a strategy to reduce child
• Victim’s revives (regains pulse and breathing). Though most death and promote growth and development.
victims also require advanced cardiac procedures before they
• 1997 – implementation started and was expanded to all regions
regain their heart and lung functions.
• 2002 – a memorandum of agreement between DOH, ADPCN
• Replaced by either another trained rescuer or EMS system. and APSOM (Association of Phil school of Midwifery) was
• Too exhausted to continue made to include in the curriculum
• Scene becomes unsafe • 2008 – Medical schools integrated IMCI strategy in their
• A physician tells you to stop curriculum
When Not to Start CPR Assess the child
• Severe injury and/ or decapitation - By checking first the danger signs (or possible bacterial
• Rigor mortis (stiffness of the muscles which sets in after infection in a young infant)
death) • Asking questions about common conditions
• Evidence of tissue decomposition • Examining the child
• Lividity (purple-reddish color showing on parts of body • Checking nutrition and immunization status
closest to ground) • Includes checking the child for other problems
• Obvious massive head or trunk trauma which is incompatible Classify a child illness using colored coded triangle system
with life (provided the patient does not have vital signs). • Pink – urgent pre-referral treatment and referral
Do not start CPR • Yellow – Specific medical treatment and advice
• When DNR “do not resuscitate” orders apply usually in • Green – simple advice on home management
writing and decided upon by the victim’s family. Elements of IMCI
• In an unsafe environment or situation. In such cases if possible, • Identify specific treatments for the child
move the victim to a safe location and then begin CPR. - If requires urgent referral, give essential treatment before
Rescue breathing mistakes the patient is transferred
• Inadequate head tilt - If the child requires treatment at home, develop an
• Failing to pinch nose shut integrated plan for the child and give the 1st dose of drugs
• Not giving slow breaths in the clinic
• Failing to maintain tight seal around victim’s mouth and/ or - If a child should be immunized, give immunization.
nose • Provide practical treatment instructions
- Teaching the caretaker on oral drug administration
- How to feed and give oral fluids during illness
- How to treat local infections at home
- Ask the caretaker to return for follow up on a specific date
J.A.K.E 38 of 45
- Teach the caretaker on how to recognize signs that Counsel

indicate that the child should be return immediately in the - Providing health education to clients promotes health and
facility. avoid risk of infection.
• Assess feeding, including breast feeding practices. Counsel to - These are important for parents/caregivers especially who lack
solve any feeding problem found. Then counsel the mother knowledge on health practices and risks factors that contribute
about her own health to disease ailments.
• When a child is brought back to the clinic as requested, give - Recommendations on feeding, fluids and when to return are
follow up care and if necessary, reassess the child for new given on the chart titled COUNSEL THE MOTHER.
problems - For many sick children, you will assess feeding and counsel
the mother about any feeding problems found. For all sick
Steps in IMCI case management process children who are going home, you will advise the child’s
Assess caretaker about feeding, fluids and when to return for further
- Taking the history of the patient is one way of getting care.
information about the disease condition. Follow Up
- This can be done by asking and observing the patient’s - Several treatments in the ASSESS AND CLASSIFY chart
condition to explore the possible causes. include a follow-up visit.
a) Check for General Danger Signs: - At a follow-up visit you can see if the child is improving on
C - convulsion the drug or other treatment that was prescribed. The GIVE
U - unable to drink or breastfeed FOLLOW-UP CARE section of the TREAT THE CHILD
V - vomiting chart describes the steps for conducting each type of follow-up
A - abnormally sleepy/ Lethargic visit.
C - Chest indrawing
S – Stridor
b) Assess for Main Symptoms:
C - cough/ difficulty breathing
D - diarrhea
F - fever
E - ear problem
c) Assess nutrition and immunization status and
potential feeding problems
d) Check for other problems
Classify
- A thorough assessment supported with laboratory results is
necessary for classification of illnesses and confirmation of the
disease.
Cough Or Difficult Breathing

- Respiratory infections can occur in any part of the respiratory
tract such as the nose, throat, larynx, trachea, air passages or
lungs.
- A child with cough or difficult breathing may have pneumonia
or another severe respiratory infection.
Identify The Treatment - Pneumonia is an infection of the lungs. Both bacteria and
- Write the treatments identified for each classification on the viruses can cause pneumonia. In developing countries,
reverse side of the case recording form. pneumonia is often due to bacteria.
Treatment - The most common are Streptococcus pneumoniae and
- A curative method of treating diseases. This vary on the Hemophilus influenzae. Children with bacterial pneumonia
condition of the patient. may die from hypoxia (too little oxygen) or sepsis (generalized
- The IMCI chart titled TREAT THE CHILD shows how to do infection).
the treatment steps identified on the ASSESS AND - Two clinical signs of pneumonia:
CLASSIFY chart. TREAT means giving treatment in clinic, • Fast breathing – PNEUMONIA
prescribing drugs or other treatments to be given at home, and • Chest indrawing – SEVERE PNEUMONIA
also teaching the caretaker how to carry out the treatments.
J.A.K.E 39 of 45
Assess 2) Is there blood in the stool?

1) > 30 days = chronic cough - Diarrhea with blood in the stool, with or without mucus is
2) Fast breathing: called dysentery
• Count the breath in one minute – Respiratory rate - The most common cause of dysentery is Shigella bacteria
• cut-off for fast breathing: 3) Check for signs of dehydration
If the child is: Fast breathing is: - Restless and irritable
2 months up to 12 months 50 breaths/ minute or more - Abnormally sleepy or difficult to awaken
- Sunken eyes
12 months up to 5 years 40 breaths/ minute or more
- Child is not able to drink or drinking poorly or drinking
3) Chest indrawing – the lower chest wall goes IN when the child eagerly, thirsty
breaths IN - Slowly Pinch the skin of the abdomen. Does it goes back:
4) Look or listen for stridor. Very slowly (longer than 2 seconds);
- Stridor – harsh noise made when the child breaths IN that Classification
happens when there is swelling of the larynx, trachea, or
• All children with diarrhea are classified for dehydration
epiglottis.
• If the child has had diarrhea for 14 days or more, classify the
Classification
child for persistent diarrhea
Severe Pneumonia or Very Severe Disease (PINK)
Signs – at least one sign to classify it under the pink category or • If the child has blood in the stool, classify the child for
severe classification. dysentery
- Any general danger sign:
• Chest indrawing
• Stridor in calm child
- Treatment:
• Give the first dose of an appropriate antibiotic (give an
intramuscular antibiotic: ampicillin (50 mg/kg) and
gentamicin (7.5 mg/kg)
• IF REFERRAL IS NOT POSSIBLE OR DELAYED,
repeat the ampicillin injection every 6 hours, and the
gentamicin injection once daily
• Refer URGENTLY to hospital
Pneumonia (YELLOW)
- Signs
• Fast breathing – 2 months up to 12 months (50 breaths/
minute or more) • Classification of dehydration: at least two signs should be
• 12 months up to 5 years (40 breaths/ minute or more) present
- Treatment: • For diarrhea 14 days or more
• Give an appropriate oral antibiotic for 5 days - Severe Persistent Diarrhea (Pink) – dehydration present
o First line antibiotic: Amoxicillin - Persistent Diarrhea (Yellow) – no dehydration
o Second line antibiotic : Cotrimoxazole • Dysentery (Yellow)
• Soothe the throat and relieve the cough with safe remedy - Signs: blood in the stool
o Breastmilk for exclusive breastfed infant - Treatment:
o Tamarind, calamansi and ginger o Treat for 5 days with oral antibiotic recommended for
shigella in your area.
• Advise mother when to return immediately
o First line antibiotic for shigella: COTRIMOXAZOLE
• Follow up in 2 days
o Second-line antibiotic for shigella: NALIDIXIC
No Pneumonia: Cough or colds (GREEN)
ACID
- Signs
o Follow up in 2 days
• No signs of pneumonia or very severe disease Treatment
- Home management: Treat for severe dehydration quickly (PLAN C)
• If coughing for more than 30 days, refer for assessment If you can give Intravenous fluid immediately:
• Soothe the throat and relieve the cough with safe remedy • Start IV fluid immediately
• Advice mother when to return immediately • If the child can drink, give ORS by mouth while the drip is set
• Follow up in 5 days if not improving up.
• Give 100 ml/kg Ringer’s Lactate Solution (or, if not available,
Diarrhea normal saline), divided as follows:
Assessment o Infants (under 12 mos.)
1) How long the child has diarrhea ? - Give 30ml/ kg in 1 hour
- To determine the type of diarrhea - Then give 70ml/ kg in 5 hours
- Acute Diarrhea- diarrhea lasts for less than 14 days o Children (12 months to 5 years)
- Persistent Diarrhea- diarrhea last for 14 days or more - Give 30ml/ kg in 30 minutes
- Then give 70ml/ kg in 2 1/2 hours
J.A.K.E 40 of 45
• Reassess the child every 1- 2 hours. If hydration status is not Treat for Diarrhea at Home (PLAN A)
improving, give the IV drip more rapidly. Counsel the mother on the 4 Rules of Home Treatment:
• Also give ORS (about 5 ml/kg/hour) as soon as the child can 1) Give Extra Fluid (as much as the child will take)
drink: usually after 3-4 hours (infants) or 1-2 hours (children). - Tell the mother:
• Reassess an infant after 6 hours and a child after 3 hours. • Breastfeed frequently and for longer at each feed
Classify dehydration. Then choose the appropriate plan (A, B, • If the child is exclusively breastfed, give ors or clean
or C) to continue treatment. water in addition to breast milk
If IV treatment available nearby within 30 minutes: • If the child is not exclusively breastfed, give one or
• Refer URGENTLY to hospital for IV treatment. more of the following: food-based fluids (such as
• If the child can drink, provide the mother with ORS solution soup, rice water, and yoghurt drinks), or ors
and show her how to give frequent sips during the trip or give • It is especially important to give ors at home when:
ORS by naso-gastic tube. o The child has been treated with plan b or plan c
Is the health care provider trained to use NGT for rehydration/ Can during this visit
the child drink o The child cannot return to a clinic if the diarrhea
• Start rehydration by tube or mouth with ORS solution : give gets worse
20 ml/kg/hr for 6 hrs ( total of 120 ml/kg) - Teach the mother how to mix and give ors. Give the
• Reassess the child every 1-2 hours while waiting for transfer: mother 2 packets of ors to use at home.
o If there is repeated vomiting or abdominal distension, give - Show the mother how much fluid to give in addition to
the fluid more slowly. the usual fluid intake:
o If the hydration status is not improving after 3 hours, send • Up to 2 years: 50 to 100 ml after each loose stool
the child for IV therapy. • 2 years or more: 100 to 200 ml after each loose stool
• After 6 hours reassess the child. Classify dehydration. Then - Tell the mother to:
choose the appropriate plan (A, B, or C) to continue treatment. • Give frequent small sips from a cup.
Treat for Some Dehydration with ORS (PLAN B) • If the child vomits, wait 10 minutes then continue -
In the clinic, give recommended amount of ORS over 4-hour but more slowly
period • Continue giving extra fluid until the diarrhea stops
• Determine amount of ors to give during first 4 hours 2) Give Zinc Supplements (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
• Use the child’s age only when you do not know the weight. • Older children - tablets can be chewed or dissolved in
The approximate amount of ORS required (inml) can also be a small amount of clean water in a cup
calculated by multiplying the child’s weight in kg times 75. 3) Continue Feeding (exclusive breastfeeding if age less than 6
• If the child wants more ORS than shown, give more. months)
• For infants below 6 months who are not breastfed, also give 4) When to Return
100-200ml clean water during this period
• Show the mother how to give ors solution: Fever (Malaria)
- Give frequent small sips from a cup - A child with fever may have the following conditions: Malaria,
- If the child vomits, wait 10 minutes then continue - but Measles, Dengue Hemorrhagic Fever (DHF), another severe
more slowly disease, and simple cough or cold or another viral infection
- Continue breastfeeding whenever the child wants - Malaria is caused by parasites in the blood called “plasmodia”.
• After 4 hours: - It is transmitted through the bite of anopheles mosquitoes.
- Reassess the child and classify the child for dehydration - Four species of plasmodia can cause malaria, but the only
- Select the appropriate plan to continue treatment dangerous one is Plasmodium Falciparum.
- Begin feeding the child in clinic - Fever is the main symptom of malaria. Other signs of
• If the mother must leave before completing treatment: falciparum malaria are shivering, sweating, and vomiting.
- Show her how to prepare ORS solution at home - In most areas in the Philippines where there is malaria
- Show her how much ORS to give to finish 4-hour transmission, malaria is a significant cause of death of children.
treatment home - The child is considered to be MALARIA RISK if the child
- Give her instructions how to prepare salt and sugar visited or stayed overnight in a malaria area in the past 4
solution for use at home weeks.
- Explain the 4 Rules of Home Treatment: High Malaria Risk
1) Give extra fluid Very Severe Febrile Disease (PINK)
2) Give zinc (age 2 months up to 5 years) - Signs
3) Continue feeding (exclusive breastfeeding if age less • Any danger sign
than 6 months) • Stiff neck
4) When to return
J.A.K.E 41 of 45
- Treatment No Malaria Risk

• In giving the first dose of Quinine it should be under
medical supervision or if a hospital is not accessible
within 4 hours
• Give first dose of an appropriate antibiotic.
• 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 breastmilk or breastmilk substitute
• If neither of these is available, give sugar water
- Give 30-50 ml of milk or sugar water before
departure
Fever (Measles)
• If the child is not able to swallow
- Signs and symptoms include generalized rash, cough, runny
- Give 50 ml of milk or sugar water by NGT
nose, red eyes and corneal clouding due to vitamin A
• If the child is difficult to waken or unconscious, start IV deficiency that may lead to blindness.
infusion
- Give 5 ml/kg of 10% of dextrose solution ( D10) over
a few minutes
- Or give 1 ml/kg of 50% (D50) by slow push
• Give one dose of paracetamol in clinic for high fever
(38.5 C or above)
• Refer URGENTLY to hospital.
• Send a blood smear with the patient
Malaria (YELLOW)
- Signs – Fever (37.5 C or above)
- Treatment
• If no cough with fast breathing, treat with oral Ear Problem
antimalarial - A child with ear problem may have ear infection. The main
• If cough with fast breathing, treat with cotrimoxazole for cause of deafness in low-income area which leads to learning
5 days problems.
• Give one dose of paracetamol in clinic for high fever Assessment
(38.5 C or above) • Tender Swelling behind the ear - this is a manifestation of
• Advise mother when to return immediately deep infection in the mastoid bone in infants can also be above
• Follow up in 2 days if fever persists the ear
• If fever is present every day for more than 7 days, REFER • Ear pain - can be seen in early stage of acute otitis causing the
for assessment. child to become irritable and rub ear
Low Malaria Risk • Ear discharge or pus - check for pus drainage from the ears.
Find out how long the discharge has been present.
Classification
Mastoiditis (PINK)
- Signs: Tender swelling behind the ear
- Treatment
• Give the first dose of an appropriate antibiotic
• Give the first dose of paracetamol for pain
• Refer URGENTLY to hospital
Acute ear infection (YELLOW)
- Signs
• Ear pain
• Pus is seen draining from the ear, and discharge is
reported for less than 14 days.
- Treatment
• Give an antibiotic for 5 days
• Give paracetamol for pain
• Dry the ear by wicking
• Follow up in 5 days
• Advise mother when to return immediately
J.A.K.E 42 of 45
Chronic ear infection (YELLOW) • In all other situations, here is a good rule to follow:
- Signs - There are no contraindications to immunization of a sick
• Pus is seen draining from the ear, and discharge is child if the child is well enough to go home
reported more than 14 days. Aged 1 Week Up To 2 Months
• No antibiotic must be given - Young infants have special characteristics that must be
- Treatment considered when classifying their illnesses.
• Dry the ear by wicking - They can become sick and die very quickly from serious
• Follow up in 5 days bacterial infections.
• Advise mother when to return immediately - They frequently have only general signs such as few
• Check immunization and vitamin status movements, fever, or low body temperature.
No ear infection (GREEN) - In the first week of life, newborn infants are often sick from
- Signs: No ear pain and no ear discharge seen draining from the conditions related to labor and delivery or have conditions
ear which require special management.
- Treatment: No treatment, Move to the next assessment - Newborns may be suffering from asphyxia, sepsis from
premature ruptured membranes or other intrauterine infection,
Malnutrition and Anemia or birth trauma.
- Look for visible wasting in the child. - Or they may have trouble breathing due to immature lungs.
• A child with visible wasting has Marasmus, a form of For all these reasons, management of a sick newborn is
severe malnutrition. somewhat different from caring for a young infant age 1 week
up to 2 months.
• The child is very thin, has no fat, and looks like skin and
bones.
Check for serious bacterial infection
• The face of the child with visible severe wasting may still
Assessment
look normal. The child’s abdomen may be large or
- Ask: Has the infant had convulsions
distended.
- Look: Count the breaths in one minute, repeat the count if
- Check also if the child has for edema of both feet.
elevated.
• A child with edema of both feet may have Kwashiorkor,
• The breathing rate of a healthy young infant is commonly
another form of severe malnutrition.
more than 50 breaths per minute.
• Signs of kwashiorkor include thin, sparse and pale hair
• Therefore, 60 breaths per minute or more is the cutoff
which easily falls out; dry, scaly skin especially on the
used to identify fast breathing in a young infant
arms and legs; and a puffy or “moon” face.
• If the first count is 60 breaths or more, repeat the count.
- Look for palmar pallor.
This is important because the breathing rate of a young
• Pallor is unusual paleness of the skin. It is a sign of
infant is often irregular.
anemia.
- Determine weight for age. • The young infant will occasionally stop breathing for a
few seconds, followed by a period of faster breathing.
• Weight for age compares the child’s weight with the
• If the second count is also 60 breaths or more, the young
weight of other children who are of the same age.
infant has fast breathing.
- Look for severe chest indrawing
• Look for chest indrawing as you would look for chest
indrawing in an older infant or young child.
• However, mild chest indrawing is normal in a young
infant because the chest wall is soft.
• Severe chest indrawing is very deep and easy to see.
Severe chest indrawing is a sign of pneumonia and is
serious in a young infant.
- Look for nasal flaring
• Nasal flaring is widening of the nostrils when the young
infant breathes in.
- Look and listen for grunting
Immunization Status - Grunting is the soft, short sounds a young infant makes
Observe Contraindications to Immunization when breathing out. Grunting occurs when an infant is
• There are only three situations at present that are having trouble breathing
contraindications to immunization: - Look and feel for bulging fontanelle
- Do not give BCG to a child known to have AIDS. • The fontanelle is the soft spot on the top of the young
- Do not give DPT 2 or DPT 3 to a child who has had infant’s head, where the bones of the head have not
convulsions or shock within 3 days of the most recent formed completely.
dose. • Hold the young infant in an upright position.
- Do not give DPT to a child with recurrent convulsions or • The infant must not be crying.
another active neurological disease of the central nervous • Then look at and feel the fontanelle. If the fontanelle is
system. bulging rather than flat, this may mean the young infant
has meningitis.
J.A.K.E 43 of 45
- Look for pus draining from the ear

• Pus draining from the ear is a sign of infection.
• Look inside the infant’s ear to see if pus is draining from
the ear.
- Look at the umbilicus—is it red or draining pus? Does the
redness extend to the skin?
• There may be some redness of the end of the umbilicus or
the umbilicus may be draining pus.
• The cord usually drops from the umbilicus by one week of
age.
• How far down the umbilicus the redness extends,
determines the severity of the infection
• If the redness extends to the skin of the abdominal wall, it
is a serious infection.
- Feel: measure temperature (or feel for fever or low body
temperature)
• Fever (axillary temperature more than 37.5 °c or rectal Diarrhea
temperature more than 38 °c) is uncommon in the first - Assessment
two months of life. • Ask: Does the young infant have diarrhea?
• If a young infant has fever, this may mean the infant has a • If yes: assess and classify the young infant’s diarrhea.
serious bacterial infection. • Then check for feeding problem or low weight,
• In addition, fever may be the only sign of a serious immunization status and other problems.
bacterial infection.
• Young infants can also respond to infection by dropping
their body temperature to below 35.5 °c (36 °c rectal
temperature). Low body temperature is called
hypothermia. If you do not have a thermometer, feel the
infant’s stomach or axilla (underarm) and determine if it
feels hot or unusually cool.
- Look for skin pustules. Are there many or severe pustules?
• Examine the skin on the entire body. Skin pustules are red
spots or blisters that contain pus. A severe pustule is large
or has redness extending beyond the pustule. Many or
severe pustules indicate a serious infection.
- Look: see if the young infant is lethargic or unconscious
• A lethargic young infant is not awake and alert when he
should be. He may be drowsy and may not stay awake
after a disturbance. An unconscious young infant cannot
be wakened at all. He does not respond when he is
touched or spoken to.
- Look at the young infant’s movements. Are they less than
normal?
• A young infant who is awake will normally move his
arms or legs or turn his head several times in a minute if
you watch him closely. Observe the infant’s movements
while you do the assessment.
Feeding and determine weight for age

Assessment
- Ask: is there any difficulty feeding?
• Any difficulty mentioned by the mother is important.
• This mother may need counselling or specific help with a
difficulty.
• If a mother says that the infant is not able to feed, assess
breastfeeding or watch her try to feed the infant with a
cup to see what she means by this.
J.A.K.E 44 of 45
• An infant who is not able to feed may have a serious

infection or other life-threatening problem and should be
referred urgently to hospital
- Ask: is the infant breastfed? If yes, how many times in 24
hours?
• The recommendation is that the young infant be breastfed
as often and for as long as the infant wants, day and night.
This should be 8 or more times in 24 hours.
Naway pumasok to lahat sa utak natin HAHAHA

Gooood luuuckk Future Nursess!! – Aki
J.A.K.E 45 of 45

Ncma219 Lec Final

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Bachelor of Science in Nursing 2YB

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Naway pumasok to lahat sa utak natin HAHAHA

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