Pedia Notes Physiologic wt loss – 5 – 10% wt loss few days after birth Small GA < (less) 10 Large GA > (more) 90 Physical Exam and Deviations fr Normal
1. if client is new born, cover areas not being examined 2. if clie client nt is is inf infan antt – the the 1st yr of life - get VS – take RR 1 st - begin fr least intrusive to the most intrusive area 3. if client is a toddler and preschool, let them handle an instrument like: - play syringe or stet, security blanket – favorite article. Let baby hold it. 4. Explain procedure and respect their modesty - school age and adolescent V/S: Temp: rectal- newborn – to rule out imperforate anus •
take it once only, 1 inch insertion
Imperforate anus 1. 2. 3. 4.
atre atreti ticc – no anal anal open openin ing g agen agenet etic ic – no no ana anall ope openi ning ng sten stenos os – has has open openin ing g memb membra rano nous us – has has open openin ing g
Earliest sign: 1. no mecomium 2. abd destention 3. foul odor breath 4. vomitous of fecal matter 5. can aspirate – resp problem Mgt:
Surgery with temporary colostomy Cardiac rate: 120 – 160 bpm newborn Apical pulse – left lower nipple Radial pulse – normally absent. If present PDA Femoral pulse – normal present. If absent- COA - coartation of aorta
Congenital Heart Dse Common in girls – PDA, ASD atrial septal Common in boys – TOGA ( transportation of great arteries) TA – tronchus arteriosus TOF – tetralogy of fallot Causes: 1.
familial 2. exposure to rubella – 1st month 3. failur failuree of of stru strucut cutee to to prog progres resss acyanotic L to R cyanotic R – L Acyanotic heart defects L to R
1.
ventricul ventricular ar septal septal defect defect - opening opening betwee between n 2 ventri ventricles cles S&Sx 1. systolic murmurs at lower border of sternum and no other significant sign
2. 3.
cardiac cardiac cathete catheterizat rization ion reveals reveals increa increased sed o2 saturat saturation ion @ R side side of heart heart ECG ECG revea reveals ls hyper hypertro trophy phy of R side side of of heart heart
Nsg Care: Cardiac catheterization: catheterization: site – Rt femoral vein 1. 2. 3.
NPO NPO 6 hrs hrs befo before re proc proced edur uree protect protect site site of catheter catheterizat ization. ion. Avoid Avoid flexion flexion of joint jointss proximal proximal to site. site. assess assess for complic complicatio ation n – infection, infection, throm thrombus bus formati formation on – check check pedal pulses pulses ( dorsalis pedis)
Mgt.
1. 2.
long term term antibi antibiotic otic – to prevent prevent subacu subacute te bacteri bacterial al endocard endocarditis itis open open hear heartt sur surge gery ry--
2.) ASD – failure of foramen ovale to close S&SX 1. 2.
systo systoli licc murmur murmur @ upper upper bord border er of sternu sternum m result result of cardiac cardiac cathete catheteriza rization tion & ECG same with VSD Mgt: open heart surgery
3.) endocardial cushion defects - atrium ventricular (AV) - affects both tricuspid and mitral valve Dx – confirmed by cardiac catheterization Mgt: - open heart surgery Antibiotics to prevent subacute bacterial endocarditis 4.) PDA - failure of ductus arteriosus to close - should close within 24 h -complete close – 1 month S&Sx 1.
cont contin inuo uous us mac machi hine nery ry like like murmurs
2. 3.
prom promin inen entt radi radial al puls pulsee ECGECG- hyper hypertro trophy phy Left Left ventri ventricle cle
Drug: 1. 2. 3.
endomethaz endomethazine ine – prostag prostagland landin in inhibito inhibitorr - facilit facilitate ate closing closing of of PDA liga ligati tion on of PDA PDA by by 3-4 3-4 yo thorac thoracoto otomy my proc procedu edure re-- nakada nakadapa pa child child
5.)Pulmunary Stenosis- narrowing of valve of pulmo artery
S &Sx: 1.) typical systolic ejection murmur 2. S2 sound widely split 3. ECG- Lt ventricular hypertrophy 6.)Aortic Stenosis – narrowing of valve of aorta S & Sx: 1. inactive, sx sme with angina
2. typical murmur 3. rough systolic sound and thrill 4. ECG- Left ventricular hypertrophy cardiac catheterizationcatheterizationMgt Pulmo Stenosis & Aortic Stenosis 1. 2.
ball balloo oon n ste steno nost stom omy y surgery
Duplication of Aortic ArchArch - doubling of arch of aorta causing compression to trachea and esophagus S&Sx : 1. dysphagia 2. dyspnea 3. left ventricular hypertrophy Mgt: - close heart surgery 8.) Coartation of Aorta – narrowing of arch of aorta outstanding Sx : absent femoral pulse BP increased on upper extremities and decreased on lower extremities ECG – hypertrophy Lft ventricle Mgt: close heart surgery CYANOTIC HEART DEFECTS R to L
1. Transportation of Great Arteries (TOGA) - aorta arising from Rt ventricle p u l m o a r t e r y a r i s
i n g f o r m L t v e n t r i c l e
Outstanding Sx:
1. cyanosis after 1st cry (due no exygenation) 2.
poly po lyccyth theemi miaa – increased RBC =compensatory due to O2 supply=viscous blood =thrombus = embolus = stroke
3.
ECG ECG – card cardio iome mega galy ly Cardiac cath – decreased O2 saturation Palliative repair – rashkind procedure Complete repair – mustard repair
2.) Total Anomalous Pulmonary venous return – pulmo vein instead of entering Lt atrium, enters Rt atrium or SVC Increased pressure on Rt so blood goes to Lft Outstanding Sx: Open foramen ovale Mild to moderate cyanosis Polycythemia Polycythemia = thrombus = embolus = stroke
asplenia- absent spleen Mgt: restructuring of heart 3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 1 single vessel or common trunk with VSD S & Sx 1. cyanosis 2. polycythemia – thrombus = embolus = stroke Mgt: Heart transplant 4.) Hypoplastic Left heart syndrome – non fx Left ventricle 1. cynosis 2. polycythemia – throm, emb, stroke Mgt: heart transplant
5.) Tricuspid atresia – failure of tricuspid valve to open S&SX: open foramen ovale (R to L shunting – goes to Lt atrium) cynosis, polycythemia polycythemia Mgt: fontan procedure – open tricuspid valve 6.) Tetralogy of Fallot P – pulmonary stenosis V – ventricular SD O – overriding or dextroposition of aorta R – Rt ventricular hypertrophy S &Sx: 1. 2. 3. 4. 5. 6. 7.
Rt ven ventr tric icul ular ar hype hypert rtro roph phy y high high degr degree ee of cyan cyanos osis is poly polyccythe themia mia severe severe dyspnea dyspnea – squatting squatting position position – relief , inhibit inhibit venous venous return facili facilitate tate lung expansio expansion. n. grow growth th ret retar arda dati tion on – due due no no O2 tet spell or blue blue spells spells-- short short episod episodes es of of hypoxia hypoxia syncope
8. clubbing clubbing of of fingern fingernails ails – due due to chronic chronic tissue tissue hypoxia hypoxia 9. mental mental reta retarda rdatio tion n – due decre decrease ased d O2 in brain brain 10. boot shaped shaped heart heart – x-ray x-ray Mgt: 1. 2. 3. 4. 5.
O2 no valsa valsalva lva mane maneuve uverr , fiber fiber diet diet laxat laxative ive morp morphi hine ne – hypo hypoxi xiaa propra propranol nolol ol – decrea decrease se hear heartt spasm spasmss pall pallia iati tive ve repa repair ir – BLT blalock taussig procedure Brock procedure – complete procedure
ACQUIRED HEART DSE 1. RHD Rheumatic Heart Disease - inflammation disease ff an infection acquired by group A Beta hemolytic strepto coccus Affected body – cardiac muscles and valves , musculoskeletal , CNS, Integumentary Sorethroat before RHD Aschoff – rounded nodules with nucleated cells and fibroblasts – stays and occludes mitral valve.
Jones Criteria
Major
Minor
1. polyarthritis – multi joint pain
1. arthralgia – joint pain
2. chorea chorea – – sydenhamms sydenhamms chores or
2. low grade fever
st. vetaus dance-purposeless involuntary hand and shoulder with grimace 3. carditis carditis
– tachycardia
3. all lab results
erythema marginatum - macular rashes
increase antibody
SQ nodules
" C reactive protein " erythrocyte sedimentation rate " anti streptolysin o titer (ASO)
Criteria:Presence Criteria: Presence of 2 major, or 1 major and 2 minor + history of sore throat will confirm the dx. Nsg Care: 1. 2. 3. 4.
CBR throat throat swab swab – cultur culturee and and sensi sensitiv tivity ity antibi antibioti oticc mgt mgt – to to preve prevent nt recu recurre rrence nce aspirin aspirin – anti-i anti-inflam nflammato matory. ry. Low Low grade grade fever fever – don’t don’t give aspirin. aspirin. S/E of aspirin:
•
Reyes syndrome – encephalopathy- fatty infiltration infiltration of organs such as liver and brain
Respiration Newborn resp – 30-60 cpm, irregular abd or diaphramatic with short period of apnea without cyanosis. < 15 secs – normal apnea –newborn Resp Check Newborn – 40 – 90 1 yr - 20 – 40 2-3yr 20 – 30 5 yrs 20 – 25 10 yrs 17 – 22 15 & above 12- 20 BREATH SOUNDS HEARD DURING ASCULTATION:
1.) VESICULAR – soft, low pitched, heard over periphery of lungs, inspiration longer then expiration -Normal
2.) BRONCHOVESICULARBRONCHOVESICULAR- soft, medium pitched, heard over major bronchi, inspiration equals exp. Normal 3.) BRONCHIAL SOUNDSSOUNDS- loud high pitched, heard over trachea, expiration longer than inspiration. Normal 4.) RHONCHI – snoring sound made by air moving through mucus in bronchi. Normal 5.) RALES-or crackles – like cellophane – made by air moving through fluid in alveoli. Abnormal- asthma, foreign body obstruction. 6.) WHEEZINGWHEEZING- whistling on expiration made by air being pushed through narrowed bronchi .Abnormal – asthma, foreign body obstruction 7.) STRIDOR- crowing or ropster life sound – air being pulled through a constricted larynx. Abnormal – resp obstruction Asthma- pathognomonic sign – expiratory – expiratory wheezing Pet – fish. Sport – swimming Drugs – amynophylline – monitor bp, may lead to hypotension Laryngo Tracheo Bronchitis LTB - inspiratory stridor – stridor – pathognomonic sign RDS respiratory dist synd or hyaline membrane dis Cause- lack of surfactant – for lung expansion Hypotonia, Post surgery, Common to preterm Fibrine hyaline
Sx – definite with in 1 st of life Increase RR with retraction Inspiratory grunting – grunting – pathognomonic 7 – 10 severe RDS (silvermenn Anderson index) cyanosis due to atelectasis Mgt: 1. 2. 3.
surfa surfacta ctant nt repl replac aceme ement nt and rescu rescuee pospos- head head elev elevat ated ed prop proper er suct suctio ioni ning ng
4. 5. 6. 7.
o2 with with increase increase humidi humidityty- to prevent prevent drying drying of mucosa mucosa moni monito torr V/S V/S skin skin col color or , ABG ABG CPAP CPAP-- cont continu inuous ous + a/w a/w pressu pressure re PEEP PEEP - + end expira expirator tory y pres pressur suree Purpose of #6-7- to maintain alveoli partially open and alveoli collapse
LARYNGOTRACHEOBRONCHITIS
LTB – most common Creup -viral infection of larynx, trachea & bronchi outstanding sx - croupy cough or barking pathognomonic - stridor • • •
labored resp resp acidosis end stage – death
Lab: 1. 2. 3.
ABG neck neck and and thr throa oatt cul cultu ture re dx- neck neck x-ray x-ray to rule rule out epiglo epiglotit titis is
Nsg Mgt: 1. bronchodilators 2.increase o2 with humidity 3. prepair tracheostomy set BRONCHOLITIS- Inflammation of bronchioles – tenatious mucus
Causative agaent – RSV - Resp sincytial viruses Sx: flu like sx Increased RR Drug: Antiviral – Ribavirin End stage – epiglotitis
EPIGLOTITIS - infl of epiglottis
- emer. Condition of URTI
Sx: sudden onset Tripod position – leaning forward with tongue protrusion •
never use tongue depressor
prepare tracheotomy set < 5 yo – unable to cough out, put on mist tent (humidifier o2) or croupe tie Nsg Care: check edges tucked on mist tent Provide washable plastic material No toys with friction due O2 on No hairy toys – due moist environment medium for bacterial growth BP – 80/46 mmHg newborn BP after 10 days- 100/50 BP taking begins by 3 yo COA – take BP on 4 extremities SKIN:
Acrocyanosis BIRTHMARKS:
1. 2. 3. 4. 5.
Mongolian Mongolian spots spots – stale stale gray or bluish bluish discolor discoloration ation patche patchess commonly commonly seen across across the sacrum sacrum or buttocks due to accumulation of melanocytes. Disappear by 1 yr old MIlla MIlla – plugged plugged or unopened unopened sebace sebaceous ous gland gland . white white pin point point patches patches on nose, nose, chin chin or cheek. cheek. Lanug Lanugo o – fine, fine, downy downy hair hair – common common pre preter term m Desquama Desquamation tion – peeling peeling of newbor newborn, n, extreme extreme drynes drynesss that begin begin sole sole and palm. palm. Stork Stork bites bites (Talen (Talengeict geictasi asi nevi) nevi) – pink patches patches nape nape of neck neck
hair will grow as child grows old
1. Erythema Toxicum – (flea bite rash)- 1 st self limiting rash appear sporadically & unpredictably as 2.
to time & place. Harlequin Harlequin sign sign – depende dependent nt part is pink, pink, indepen independent dent part part is blue blue (side lying – bottom part is dependent pink)
3. 4.
Cutis Cutis Marmorato Marmorato – transit transitory ory mottli mottling ng of neonates neonates skin skin when when exposed exposed to cold. cold. Heman Hemangio giomas mas – vascul vascular ar tumor tumorss of the the skin skin
3 types Hemangiomas
a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can be removed surgically b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. Enlarges, disappears at 10 yo. c.) Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear with age. - MOST DANGERIOUS DANGERIOUS – intestinal hemorrhage Skin color blue – cyanosis or hypoxia White – edema Grey – inf Yellow – jaundice , carotene Vernix Caseosa – white cheese like for lubrication, insulator BURN TRAUMA – injury to body tissue caused by excessive heat.
INFANT ANTERIOR Head
POSTERIOR
9.5 Neck
5-9 yo Ant
9.5 1
Post
6 .5 1
6.5 1
1
Upper arm
2
2
2
2
Lower arm
1.5
1.5
1 .5
1.5
Hand
13
1.25
1.25
1.25
Trunk
13
13
Back
13
13
Genital
1
1
@ buttocks
2.5@
2.5 @
Thigh
2.75
2.75
4
4
Leg
2.5
2 .5
3
3
foot
1.75
1.75
1.75
1.75
DEPTH
1st degree – partial thickness – superficial epidermis - erythema, dryness, PAIN -sunburn, heals by regeneration from 1 – 10 days 2nd degree – epidermis & dermis- erythema, blisters, moist, extremely painful o
scalds
3rd degree – full thickness- epidermis, dermis, adipose tissue, fascia, muscle & bone o o
lethargy, white or black, not painful – nerve endings destroyed ex. lava burns
Mgt: 1.) 1st aid a.) put out flames by rolling child on blanket b.) immerse burned part on cold H2o c.) remove burned clothing of with sterile material d.) cover burn with sterile dressing 2.) a/w a.) suction PRN, o2 with increased humidity b.) endotracheal intubation c.) tracheostomy 3.) Preventiuon of shock & F&E imbalance a. colloids to expand bld volume b. isotonic saline to replace electrolytes c. dextrose & H2o to provide calories 4.) Tetanus toxoid booster 5.) Relief of pain – IV analgesic MORPHINE SO4 – needed for 2 nd degree – very painful 6.) 1st defense of body – intact skin prevention of wound infection
a. b. c.
clea cleani ning ng & debr debrid idin ing g of woun wound d open open or close close meth method od of of woun wound d care care whirlp whirlpool ool therap therapy y – drum drum with with solut solution ion
7.) skin grafting – 3 rd degree – thigh or buttocks (autograft), pigs/ animals – xenograft frozen cadaver – hallow graft 8,) diet – increase CHON, increase calories. ATOPIC DERMATITIS- infantile eczema (galis)
Papulo vesicular erythematus lesions with weeping & crusting Cause – food allergies: milk, citrus juice, eggs, tomatoes, wheat Sx: - extreme pruritus, linear excoriation, weeping crusting; scaly shiny and white – lechenification lechenification Goal of care: decrease pruritus – avoid food allergens
Diet: Prosobi or Isomil Hydrate skin, borow solution 1% hydrocortisone cream Prevent infection – proper handwahsing, trim nails IMPETIGO- skin disease.
Causative agent – grp A beta Hemolytic streptococcus streptococcus •
papulovesicular surrounded by localized erythema erythema –becomes purulent , oozes a honey colored crust
Pediculosiscapitis –"KUTO" •
Mgt: proper hygiene – wash soap and H2o, oral penicillin – bactroban ointment Can lead to acute glomerulonephritis AGN
ACNE- adolescent problem • •
self limiting infl dis – sebaceous gland comedones – sebum causing white heads sebum- lipids causing acne bulgaris
Mgt: - proper hygiene- mild soap or sulfur soap- antibacterial retin A or tretinoi
ANEMIA- pallor pallor
Causes: 1.)early cutting of cord – preterm – cut umb cord ASAP fullterm – cut umb cord when pulsation stops 2.) Bleeding disorders – blood dyscrasias HEMOPHILIA – deficiency of clotting factor. X linked recessive – inherited
If mom – carrier, son – affected If father carrier- transmitted to daughter Hemophilia A – deficiency of coagulation component factor 8 Hemophilia B –or christmas disease, deficiency of clotting factor 9 Hemophilia C – deficiency of clotting factor 11 Assessment: • • • •
umphalagia – earliest sign newborn receive maternal clotting factor newborn growing – sudden bruising on bump area- marks earliest sign continuous bleeding – hematrosis – damage or bleeding synovial membrane
Dx test : PTT. Partial thromboplastin time – reveals deficiency in clotting factor Long Term Goal- prevention of injury Nsg Dx- increase risk of injury HT: avoid contact sport, swimming only, don’t stop immunization – just change gauge of needle Falls – immobilized , elevate affected part, apply pressure-not more then 10 min cold compress -determine case before doing invasive procedure LEUKEMIA- grp of malignant disease • •
rapid proliferation of immature WBC WBC – protection from infection, soldiers of body
Classification :
1. 2. 3. 4.
Lympho – affects lymphatic system Myelo – affects bone marrow acute / blastic- affects immature cells chronic/ cystic- affects mature cells
MOST COMMON CANCER – (ALL) – Acute Lymphocytic Leukemia
S&Sx: 1. from invasion of bone marrow signs of infection a. b. b. c.
fever poor poor woun wound d hea heali ling ng bone bone wea weakn knes esss & caus causes es fra fract ctur uree
signs of bleeding a. b. c.
petecc petecchia hiae-s e-smal mall, l, round round,, flat, flat, dark dark red red spot spot epistaxis bloo blood d in in uri urine ne// eme emesi siss
signs of anemia a.
pallor pallor , body body malai malaise se , consti constipat pation ion
2. from invasion of body organ- hepato spenomegaly – abd pain , CNS affectation, increase ICP Dx Tests: 1. 2.
PBSPBS- periphe peripheral ral blood blood smear smear – deter determine mine immature immature RBC CBC – determ determine ine anemia, anemia, leukoc leukocytos ytosis, is, thromboc thrombocytope ytopenia nia neutrope neutropenia nia 3. lumbar puncture (LP) – determine CNS involvement. Before LP, fetal pos.- avoid flexion of neck – will cause a/w obstruction."C" position or shrimp position only. 4. bone marrow marrow aspir aspiration ation – determ determine ine blast blast cells, cells, • •
common site- iliac crest post BMA s/effect – bleeding
•
apply pressure. Put pt on affected side to prevent hemorrhage
1. 2.
Bone Bone scan scan – dete determi rmine ne bone bone invo involve lvemen mentt CT scan scan – deter determin minee organ organ involv involveme ement nt
Therapeutic Mgt: TRIAD:
1. 2. 3.
surgery irradiation chemo hemotther heraphy phy Focus Nsg Care: prevent infection
4 LEVELS OF CHEMOTHERAPHY
1. induction – goal of tx; to achieve remission meds: IV vincristine L- agpariginase Oral predinisone 2. Sanctuary- treat leukemic cells that invaded testes & CNS give: methotrixate- adm intrathecally via CNS or spine cytocine, Arabinoside, steroids with irradiation 3. maintenance- to continue remission give: oral methotrisate – check WBC -adm of methotrisate – do weekly WBC check 4. Reinductin – treat leukemic cells after relapse occurs. Meds – same as induction - give antigout agents: allopurinol or Zyloprim- treat or prevent hyperurecemic nephropathy. Nsg mgt: Outstanding nsg dx: alteration in nutrition less body requirement.
Based on Maslow’s heirarchy S/Effect of Chemotherapy
1. N/V – adm antiemetic drugs 30 mins before chemo until 1 day after chemo 2. Ulcerations / stomatitis / abscess of oral mucosa- (alteration nutrition less body req) - oral care – alcohol free mouthwash , betadine mouthwash - don’t brush – use cotton pledgets
- topical xylocaine before meals diet- soft, bland diet according to child’s preference Temporary S/E of chemo: Alopecia – altered body image Hirsutism – hair -give emotional support to parents ABO incompatibility –
Most common incompatibility – ( mom) O – ( fetus) A Most severe incompatibility (Mom) O– (Fetus) B Can affect 1st pregnancy
Hydrops (h20) Fetalis – edematous on lethal state with pathologic jaundice
Within 24 h Mgt: 1. 2.
initi initiate ate brea breastf stfeed eeding ing to get get colos colostru trum m Temp Temp susp suspens ension ion of breast breastfe feedi eding ng
•
content breast milk pregnanedioles – that delays action of glucoronil transferees liver enzymes converts in direct bilirubin to become direct bilirubin
1. 2.
Need Needss pho photo toth ther erap apy y need needss exch exchan ange ge ther therap apy y
Hyperbilirubinemia Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term
Normal – 0-3 mg/dL • •
bilirubin encephalopathy Kemicterus - > 20 mg/dL among full term & >12 mg /dl of indirect – preterm =can lead to cerebral palsy-
Physiologic jaundice – jaundice within 48 -72 h (2-3 days) expose morning sunlight
Pathologic Jaundice – within 24h. Jaundice during delivery. Breastfeeding jaundice – caused by pregnanediole Assessment of Jaudice : 1. Blanching neonates forehead, nose or sternum - yellow skin & sclera - color of stool – light stool - color of urine – dark urine Mgt: Phototheraphy – photo oxygenation Nsg Resp: 1. 2. 3. 4. 5. 6.
cover cover eye eyess – pre preven ventt retin retinal al dama damage ge cover cover genitals genitals – preven preventt priapism priapism – painf painful ul continuou continuouss erectio erection n change change positio position n regular regularly ly – even exposed exposed to to light light incre increase ase fld fld intak intakee – due pron pronee to dehy dehydra dratio tion n moni monito torr I&O I&O – wei weigh gh baby baby monitor monitor V/S V/S – avoid avoid use of of oil or or lotion lotion duedue- heat heat at phototh phototherap erapy y = bronze baby syndrome-transient syndrome-transient S/E of phototherapy
weigh diaper 1gm = 1cc Head – largest part of baby ¼ of its length Craniostenosis or craniosinustosis – premature closing of fontanel
Hydrocephalus – ant fontanel open after 18 mos Microcephaly – small growing brain due- alcohol & HIV mom Anencepahly – absence of cerebral hemisphere
Craniotabes – localized softening cranial bone. Common – 1 st born child -due early lightening (2 weeks prior to EDD) Rickets of Vit B deficiency – soft cranial bone in older children Caput Succedaneum – edema of scalp due prolonged pressure at birth Char: 1. 2. 3.
pre presen sent at at bir birth th cros crosse sess sutu suture re line liness disa disapp ppea earr aft after er 2-3 2-3 day dayss
Cephalhematoma- collection of blood due to rapture of pericostal capillaries
Char : 1. 2. 3. 4.
pre presen sent af after ter 24 24 h neve neverr cro cross ss sutu suture re line line disa disapp ppea earr afte afterr 4-6 4-6 week weekss monito monitorr for develo developin ping g jaundi jaundice ce
Seborrheic Dermatitis – ‘craddle cap"
Scaling, greasy appearing salmon colored patches – seen on scalp behind ears and umbilicus Cause: - improper hygiene Mgt: 1. 2. •
prop propeer hygie giene put put oil oil nig night ht bef befor oree sham shampo poo o baby oil
Hydrocephalus – excessive accumulation of CSF
1. 2.
communica communicating ting – extra extra ventricul ventricular ar hydroceph hydrocephalus alus non-commu non-communica nicatingting- intrave intraventri ntricular cular hydroce hydrocephalu phaluss or obstructi obstructive ve hydrocephal hydrocephalus us due to tumor obstruction
Sx – ICP – abnormally large head, bulging fontanel •
cushings triad
•
high pitched cry
older child – diplopia – eye deviation, projectile vomiting • • •
fontanel bossing – prominent forehead - prominent skull vein sunset eyes
Mgt: position to lessen ICP – low semi-fowlers 30 degree angle Administer- osmotic diuretic Mannitol/ Osmitrol , Diamex- Azetam Decrease CSF production Shunting – AV shunt or Vp shunt (ventriculoperitoneal shunt) Shave hair – in OR – to prevent growth of micro org. Nsg Care: 1.) post VP shunt – side lying on non operated site - to prevent increase ICP monitor for good drainage - sign – sunken fontanel bulging fontanel – blocked shunt change fontanel as child is growing SENSES
EYES: Assessment 1. 2.
chec check k for for symm symmet etry ry sclera sclera – normal normal color – light light blue blue then then become become dirty dirty white white pupil – round- adult size coloboma- part of iris is missing sign: key hole pupil
whiteness & opacity of lens congenital cataract cornea – round & adult size large – congenital glaucoma Test for blindness common tests
1. newborn – general appearance - can only see 10 – 12 " - visual acuity 20 /200 to 20/ 800 Doll’s eyes test- test for blindness • •
done 10th day pupil goes opposite to direction when head is moved
Globellars test – test for blink reflex. Points near nose – baby should blink
2. Infant & children - appearance - ability to follow object past midline 3. 3 yrs – school age - general appearance Allen cards – test for visual acuity. Show picture 20 ft away Ishiharas plates – test for color blindness Prechool E chart - test for stereopsi of depth perception Cover testing test – cover 1 eye for 10 – 15 min. Then remove. Test for strabismus 4. School age – adult - general appearance - snellens test Retinobastoma – malignant tumor of retina Outstanding sign : oat’s eye reflex-whitish reflex-whitish glow of pupil • •
red painful eye blindness
surgery – Enucliation – removal of eyeball put artificial aye NOSE:
1. 2.
flar flarin ing g alen alenas asee – cas casee of RDS RDS cyanosis cyanosis at rest rest – choanal choanal atresia atresia - post post nares nares obstructe obstructed d with bone bone or membran membranee
1. 2.
resist resistanc ancee during during cath cathete eterr inser insertio tion n emer emer.. Sur Surge gery ry with within in 24 h
Sx:
normal color nasal membrane – pinkish rhinitis – presence of creases & pale check sense of smell – blindfold – smell Hair in nose – cilia Adolescent no hair with ulceration of nasal mucosa suspect cocaine user Epistasis – nosebleed • •
sit upright, head slightly forward to facilitate drainage cold compress , apply gentle pressure, epinephrine
most developed sense of newborn – newborn – sense of touch 1st sense to develop & last to disappear – – hearing EARS:
1.
Prope Properly rly alig aligned ned with with oute outerr cantu cantuss of eyes eyes
low set ear – kidney malformation ex. Renal aginesis – absence of kidney sign in uterus : oligohydramnios oligohydramnios sign in newborn: 2 vessel cord failure to void within 24 h Mgt: kidney transplant
Chromosomal aberrations : -advance maternal age
1. non disjunction – uneven division Trisomy 21 - down syndrome - extra chromosome
47xx + 21 - related to advance paternal age Sx: Mongolian slant Broad flat nose Protruding neck Puppy’s neck Hypotonic – prone to resp problem Simean crease – single transverse line on palm. Trisomy 18 – "endvard syndrome" Trisomy 13- patau syndrome Turner – Monosomy of X synd. • • • • •
45x0 affected girls signs evident during puberty has poorly developed 2dary sexual char. Sterile
Klinefelters Syndrome- has male genitalia - 47 XXY
- poorly devt secpndary sexual characteristics - no deepening of voice -small testes, penis -sterile Klinefelter – Calvin Kline – male Turner – Tina Turner – female
Otitis Media – inflammation of middle ear. Common children due to wider & shorter Eustachian tube
Causes 1. 2.
bott bottlle pr proppi oppin ng Clef Cleftt lip lip// cle cleft ft pala palate te –
Sx: Otitis 1. 2. 3. 4.
bulging bulging tympa tympanic nic membrane membrane,, color color – pearly pearly gray abse absenc ncee ligh lightt ref refle lex x observe observe for passa passage ge of milky, milky, purule purulent nt foul foul smelling smelling odor discha discharge rge obse obserrve for for UR URTI
Nsg Care: 1. 2.
position position side side lying lying on affec affected ted aside aside – to facil facilitat itatee drainage drainage suppor supportiv tivee carecare- bedrest bedrest,, increas increasee fld intake intake
Med Mgt: 1. Massive dosage antibiotic Complication – bacterial bacterial meningitis 2. Apply ear ointment School age – up and down < 3 yo – down & back > 3 yo – up & back Small child – down & back ( no age) surgery (to prevent permanent hearing loss)– otitis media – myringotmy with tympanostomy tube post surgery – position affected side for drainage both – put ear plug if tympanous tube falls – healed na Bells Palsy- facial nerve #7 paralysis R/T forcep delivery
Sx. 1. 2.
Cont Contin inuo uous us dro drool olin ing g sali saliva va inabil inabilit ity y to open open , eye & close close eith either er eye eye
Mgt: Refer to PT TEF (Tracheoesophageal Fistula)-TEAFistula)-TEA- no connection bet esophagus and stomach Outstanding Sx – Coughing Choking Continuous drooling Cyanosis Mgt: Emergency surgery Epstein pearl – white glistering cyst at palate & gums related to hypercalcemia Hypervitaminosis
Natal tooth – tooth at birth. Move with gauze Neonatal tooth – tooth within 28days of life Moniliasis – oral candidiasis • • •
white cheese like, curd like patches that coats tongue oral thrush Nsg Care – don’t remove, wash with cold boiled H2o
Meds – nystatin / Mysnastatin – antifungal Kawasaki Dse--strawberry --strawberry tongue - originated in Korea
- Dr. Kawasaki discovered it - common in Japan - "mucocutaneous Lymphnode Syndrome" Sx: -persistent fever – 5 days -strawberry tongue , -desquamation of palm & sole
- lymph adenopathy > 1.5 cm Drug: aspirin Can lead to MI LIPS- symmetrical Cleft lip – failure of median maxillary nasal process to fuse by 5-8 wks of pregnancy • •
common to boys unilateral
Cleft Palate- Failed palate to fuse by 9 – 12 wks of pregnancy
•
common to girls unilateral or bilateral
1. 2. 3.
evide vident nt at bir birtth milk milk escap escapes es to nostri nostrill during during feed feeding ing frequ frequent ent colic colic & otit otitis is med media ia or URTI URTI
•
Sx:
Mgt: 1. Surgery cleft lip repair – Cheiloplasty =done 1-3 months to save sucking reflex (lost in 6 months ) Cleft Palate- uranoplasty = done 4-6 months to save speech Pre op care
1. 2. 3.
emotio emotional nal suppor supportt espec especial ially ly to to mom mom prop propeer nutr nutrit itio ion n prevent co colic feed – upright seating or prone pos burp frequently 2x at middle and after feeding-lower to upper tap
4.
orient orient parent parentss to to type type of feed feeding ing rubber tipped syringe – cheiloplasty paper cup/ soup spoon/ plastic cup – urano plasty
5.
apply apply rest restrai raints nts – elbow elbow rest restrai raints nts so baby can adjust post op
Condition that warrants suspension of operation •
colds & pharyngitis = can lead to generalized infection – septicemia
Post Op Nsg Care :
1. airway – positon post cheilopasty – side lying for drainage post uranoplasty (tonsillectomy)- prone 2. assess for RDS sx bleeding 3. assess for bleeding – freq swallowing. 6-7 days after surgery – bleeding 4. proper nutrition • •
clear liquids- ( gelatin except red or brown color due may mask bleeding) ( popsicle- not ice cream) full liquid soft diet regular diet
5. Maintain integrity of suture line such as: Logan bar – wash ½ strength Hydrogen Peroxide & saline solution- Bubbling effect traps microorganism microorganism - prevent baby form crying for pain- analgesic
NECK-
1.
check heck symmet mmetrry
Congenital torticolis- " wryneck"-burn injury of sternocleidomsstoid muscle during delivery – due to excessive traction at cephalic delivery Mgt: passive stretching exercise , Surgery Complication – scoliosis THYROID gland – for basal metabolism
Congenial cretinism – absence or non functioning thyroid glands reasons for delaying dx: 1. 2. 3.
Thyroid Thyroid glands glands covere covered d by sternocl sternocleidom eidomastoi astoid d muscles muscles in in newborn newborn baby baby rece receive ived d mater maternal nal thyrox thyroxine ine baby baby slee sleeps ps 16 – 20 20 h a day day
earliest sign: 1. 2. 3. 4. 5.
chang hangee in in cr crying ing chang hangee in in suc sucki king ng slee sleep p exce excess ssiv ivel ely y constipation edema dema – moo moon n fa face
late sign 1.
ment mental al reta retard rdat atio ion n
prognosis : mental retardation preventable when Dx is early Dx: 1. 2. 3.
PPI-protein radi radioi oimm mmun unoa oass ssay ay test test radi radioa oact ctiv ivee iodi iodine ne upt uptak akee
Mgt: synthroid – sodium Levothyrosine -synthetic -synthetic thyroid given lifetime check pulse rate before giving synthroid tachycardia – Sx of hyperthyroidism hyperthyroidism
• •
CHEST
1. 2.
symmetry breast breast - transpar transparent ent fluid fluid coming coming out from from newborn newborn relate related d to hormonal hormonal change changess3. chest has retroactive – RDS 4. sternum sunken – pectus excavation
ABDOMEN (in order)
1. 2. 3. 4.
inspection I Auscu usculltati tatio on A percussion P Palpatio Palpation n P= W Will ill change change bowel bowel sounds, sounds, so do last Normal contour of abd – slightly protruding
Sunken abd- diaphramatic hernia – protrusion of stomach content through a defective diaphragm due to failure of puroperitoneal canal to close. Sx: 1. 2. 3.
sunken ab abd Sx of RDS R to to L shunting
Mgt: Emergency surgery within 24h Omphalocele – protrusion of stomach contents in between junction of abd wall and umbilicus. Mgt- very small surgery If large – suspension surgery Nsg Mgt: protect sac- sterile wet dressing Gastrochisis – absence of abd wall
Nsg Mgt: sterile wet dressing Fx of GIT
1. 2. 3.
assist assistss in mainta maintaini ining ng F&E F&E & acid acid base balan balance ce Processe Processess & absorbs absorbs nutrie nutrients nts to maintain maintain metabol metabolism ism & support support G & D excret excretee waste waste produc products ts from from digest digestive ive proce process ss
Recommended Daily Allowance Calories : 120 cal / Kbw/day (kilo body wt) 360 – 380 cal/ day CHON_ 2.2g /Kbw/day Principles in Supplementary Feeding
Supplementary Feeding usually – 6 mos Supplementary feeding given – 4 mos. a.) solid food offered to ff sequence! 1. cereals – rich in iron
2. fruits 3. veg 4. meat b.) begin with small quantities c,) finger foods – offered 6 months d.) soft table food – "modified family menu" given 1 yr e.) dilute fruit juices – 6 mos f.) never give half cooked eggs – usually causes of salmoneliosis g.) don’t give honey – infant botulism h.) offered new food one at a time – interval of 4 – 7days or 1 week – determines food allergens Total Body Fluids- comprises 65 - 85% of body wt of infants & children
Where fluids are greater in infants Extracellular fld – prone to develop dehydration Acid Base Balance dependent on the ff: a. b. c.
chem hemical ical buf bufffers renal ren al & resp resp sy syste stem m invo involve lvemen mentt diluti dilution on of of stron strong g acids acids and bases bases in in bld bld
Resp Acidosis – carbonic acid excess • • • •
hypoventilation RDS COPD Laryngotracheobronchitis Laryngotracheobronchitis (LTB)
Resp Alkalosis – carbonic acid deficit • • •
hyperventilation fever encephalopathy
Met. Acidosis – base HCO3 deficit • • •
diarrhea severe dehydration malnutrition
•
ciliac crisis
Met Alkalosis – base HCO3 excess • • •
uncontrolled vomiting NGT aspiration Gastric lavage
PROBLEMS LEADIING TO F&E IMBALANCE 1. vomiting – forceful expulsion of stomach content
Sx: 1. 2. 3. 4.
nausea dizziness facia aciall flu flusshing hing abd cramping
assess: amt, freq, force projectile vomiting= increase ICP or pyloric stenosis Mgt: BRAT diet - banana, rice – cereal, apple sauce, toast 2. Diarrhea – exaggerated excretion of intestinal contents
Types: Acute diarrhea – related to gastroenteritis, salmoneliosis • •
dietary indiscretions antibiotic use
Chronic non specific diarrhea Cause: 1. 2. 3.
food food into intole lera ranc ncee exce excess ssiv ivee fld fld inta intake ke CHO, CHO, CHON CHON mala malabs bsor orpt ptio ion n
Assess: freq, consistency, appearance of given colored stool.
Best criteria to determine diarrhea : consistency Complication = dehydration Mild dehydration 5% wt loss Moderate dehydration 10% wt loss Severe dehydration 15 % wt loss Earliest sx of dehydration
tachycardia increase temp weight loss tachypnea sunken fontanel & eyeballs scanty urine hypotension absence of tears Severe dehydration:
Oliguria , Prolonged capillary refill time Mgt: Acute – NPO ( rest the bowel ) • •
with fluid replacement – IV prone to Hypokalemia – give K chloride before adm of K chloride – check if baby can void, if cant void – hypokalemia
Drug: Na HCO3 – adm slowly to prevent cardiac overload
Gastric Motility Disorder: HIRSCHPRUNGS DISEASE – congenital aganglionic megacolon
Aganglionic – absence of ganglion cells needed for peristalis Earliest sign 1. 2. 3.
failur failuree to pass pass mecom mecomium ium after after 24h abd dist istensi ension on vomi vomitu tuss of of fec fecal al mate materi rial al early childhood – ribbon like stool foul smelling stool
constipations diarrhea Dx: 1. 2. 3. 4.
Barium Barium enem enemaa – reveals reveals narr narrowe owed d portion portion of of bowel bowel Rectal Rectal Biopsy Biopsy – reveal revealss absence absence of ganglio ganglionic nic cells cells abd x-ra x-ray y – reveal revealss dilate dilated d loops loops on inte intesti stine ne rectal rectal manomet manometry ry – revels revels failur failuree of intesti intestine ne sphincte sphincterr to relax relax
Therapeutic Mgt/Nsg care 1. 2.
NGT feedin feeding g – measure measure tube fr nose nose to ear ear to midline midline of xypho xyphoid id & umbilicu umbilicuss surgery
a. b.
temp emp colos olosto tom my anasto anastomos mosis is & pull pull throu through gh proc procedu edure re Diet: Increase CHON, increase calories , decrease residue – pasta GER- Gastroesophageal Reflux
Chalasia – presence of stomach contents to esophagus Will lead to esophagitis complication – aspiration pneumonia
Esophageal cancer
Assessment : 1. 2. 3. 4.
chron hronic ic vom vomiitin ting fait faitur uree to thri thrive ve syn syndr drom omee orga organi nicc – orga organ n aff affec ecte ted d melena melena or hema hematem temesi esiss – esophag esophageal eal blee bleedin ding g
Dx procedure 1. 2. 3.
barium barium esopho esophogra gram m – reveal revealss reflu reflux x esophageal esophageal manom manometry etry – reveals reveals lower lower esophage esophageal al sphincter sphincter pressure pressure intra intra esophage esophageal al pH content content – reveals reveals pH of distal distal esophagus. esophagus.
Meds of GERD
Anti-cholinergic a. b.
Betanico Betanicoll ( urecholine urecholine)) – increase increase esophage esophageal al tone & perist peristaltic altic activ activity ity Metachlop Metachloporomi oromide de (Reglam) (Reglam) – decrease decrease esophagea esophageall pressure pressure by relaxing relaxing pyloric pyloric & duodenal segments
•
increase peristalsis without stimulating secretions
a.
H2 Histami Histamine ne Receptor Receptor Antag Antagonist onist – decre decrease ase gastric gastric acidity acidity & pepsin pepsin secretion secretion
•
Zimetidine, Ranitidine Ranitidine (Zantac) – take 30 min before meals
a.
antacid antacid – neutraliz neutralizes es gastric gastric acid between between feeding feedingss - Maalox Maalox
Surgery: Nissen funduplication : Chronic vomiting – • • •
thickened feeding with baby cereals - effective if without vomiting feed slowly, burp often every 1 ounce positioning < 9 months – infant sit with infant supine > 9 months – prone with head of mattress slightly elevated 30 degree angle
OBSTRUCTIVE DISORDERS
A. PYLORIC STENOSIS STENOSIS – hypertrophy of muscles muscles of pylorus causing causing narrowing narrowing & obstruction. 1.) outstanding Sx- projectile vomiting - vomiting is an initial sx of upper GI obstruction - vomitus of upper GI can be blood tinged not bile streaked. (with blood) - vomitus of lower GI is bilous ( with pupu) - projectile vomiting – increase ICP or GI obstruction - abd distension – major sx of lower GIT obst 2.) met alk 3.) failure to gain wt 4.) olive shaped mass – on palpation
5.)serum electrolyte – increase Na & K, decrease chloride 6.) ultrasound 7.) x ray of upper abd with barium swallow reveal "string sign" Mgt: 1. 2.
Pyler leromy omyotom otomy y Fred Fredet et Ram Ramst sted edtt proc proced edur uree
INSTUSSUSCEPTION- invagination or telescoping of position of bowel to another
Common site – ilio-secal junction Prone pt: person who eats fat Complication – peritonitis – emergency Sx: 1. 2. 3. •
persis persisten tentt paro paroxy xysma small abd pain pain vomiting currant currant jelly jelly stoolstool- dye bleeding bleeding & inflammat inflammation ion palpate sausage shaped mass
Mgt: 1. 2.
Hydro Hydrosta static tic redu reducti ction on with with bariu barium m enema enema Anasto Anastomos mosis is & pull pull thru thru proc procedu edura ra
Inborn Errors of Metabolism- deficient liver enzymes PHENYLKETONURIA (PKU) – deficiency of liver enzymes (PHT)
Phenylalaninehydroxylase Phenylalaninehydroxylase Transferase – liver enzyme that converts CHON to amino acid 9 amino acids: valine isolensine tryptophase lysine phenylalanine Thyronine – decrease malanine production 1. 2. 3.
fair air com compl pleexion xion blond ha hair blue eyes
Thyroxine – decrease basal metabolism - accumulation of Phenyl Pyruvic acid 4.) Atopic dermatitis 5.) musty / mousy odor urine 6.) seizure – mental – mental retardation Test – GUTHRIE TEST – specimen – blood • •
preparation increase CHON intake test if CHON will convert to amino acid
specimen and urine mixed with pheric chloride, presence of green spots at diaper a sign of PKU DIET:
Low phenylalanine diet- food contraindicated- meats, chicken, milk, legumes, cheese, peanuts Give Lofenalac Lofenalac-- milk with synthetic protein Galactosemia – deficiency of liver enzyme • •
GUPT – Galactose Urovil Phosphatetranferase Converts galactose to phosphate tranferace glucose
Galactose – will destroy brain cells if untreated – death within 3 days Dx: Beutler test – get blood -done after 1st feeding presence of glucose in blood – sign of galactosemia galactose free diet lifetime neutramigen – milk formula CELIAC DISEASE – gluten enteropathy
Common gluten food: Intolerance to food with brow B- barley
R- rye O- oat W- wheat Early Sx: 1. 2. 3.
diarrh diarrhea ea – failur failuree to gain gain wt ff diarr diarrhea heall episode episodess constipation vomiting
Late Sx: 1. 2.
abd pain pain – protrub protruberan erantt abd even if with with muscle muscle wasting wasting steatorrhea
Celiac Crisis- exaggerated vomiting with bowel inflammation Dx: 1. 2.
lab lab stud studie iess – stoo stooll anal analys ysis is serum serum antig antiglya lyadin din – confi confirma rmator tory y of diseas diseasee
gluten free diet – lifetime all BROW – not allowed ok – rice & corn Mgt: 1. 2. 3.
vita vitami min n supp supple leme ment ntss mine minera rall supp supple leme ment ntss steroids