Ncm 101 (continuation)postpartal Period And Pediatrics

POSTPARTAL PERIOD 1st 6 weeks following the birth of the infant. – Healing process, a time wherein maternal changes occur ○ Retrogressive – uterus to normal state ○ Progressive – production of milk, parenting role. A. Phases a. Taking – in phase i. “The time of reflection for a woman.” ii.The woman is passive, letting other people do things for her and make decisions for her. iii.Encourage her to talk about the wonderment of birth. b. Taking – hold phase i. “The woman begins to initiate action herself.” ii.The woman shows great interest on caring for the baby. iii.Woman may still feel insecure about her abilities in caring for the child iv.Praise the mother. c. Letting – go phase i. “The woman finally defines her new role.” ii.She gives up the fantasized image of her child for the real one. B. Physiologic Changes during Puerpuerium a. Reproductive Changes i. Uterus 1. Involution – the process whereby the uterus returns to it nonpregnant state. (1 cm or fingerbreadth per day). 2. Afterpains – are cramps similar to that felt with menstrual period, which is caused by the contractions of the uterus. (common in multiparous, large babies) 3. Lochia – uterine flow consisting of blood, fragments of deciduas, WBC, mucus and some bacteria. Type Color Duration Composition Rubra Red 1 – 3 days Blood fragments of deciduas and mucous. Serosa Pink / brown 4 – 10 Blood, mucus, and invading leukocytes. Alba White / cream 11 – 21 (even 6 weeks) Large mucuc, leukocytes count increase.

–

a.

b.

Volume i. Scant - < 5 cm (2”) = 10 mL ii.Small - < 10 cm (4”) = 10 – 25 mL iii.Moderate - < 15 cm (6”) = 25 – 50 mL iv.Large - > 15 cm (>6 “) – 50 – 80 mL

ii.Cervix 1. Soft and malleable post pregnancy. 2. Contractions begin at once. After 7 days, external os is narrowed and it feels firm and non – gravid again. 3. There is formation of new muscle cells. iii.Vagina 1. Soft and few rugae, diameter is considerable less than normal. 2. Hymen is permanently torn and heals in small separate tags of tissue. iv.Perineum 1. Portion may show ecchymosis from rupture of surface capillaries. 2. Labia majora and minora typically remain atrophic and softened. 3. Presence of episiotomy incisions. Systemic Changes i. Hormonal system 1. Pregnancy hormones produced by placenta is no longer present. 2. HCG in urine is negligible in 24 hours. 3. By week 1, progestin and estrogen are at pre – pregnancy level. ii.Urinary system 1. Pressure of the fetal head during childbirth may leave the bladder with a transient loss of tone. 2. Assess the woman’s bladder frequently immediate postpartum. 3. Positive excessive dieresis on immediate postpartum to excrete the excess fluids (2000 – 3000 mL). 4. Increased nitrogen – increase muscular activity during labor process. iii.Circulatory system

Audray Kyle Saydoven

Page 1

1. 2.

Reduced blood volume as a result of blood loss. There is elimination of uteroplacental circulation reducing the maternal vasculature bed by 10 – 15 %. 3. Immediate after birth, pulse rate, stroke volume and cardiac output remain elevated for 30 – 60 per minute. *placenta – endocrine function – vasodilation. *V/S – Increases BP – 4 days; respiratory function – 6 months. *Blood components: a. Hgb and Hct – increase in 3rd to 7th day b. WBC – Normal c. Coagulation Factors – elevated immediate postpartum. C. Maternal Concerns and Feelings in the Postpartum Period a. Shifting of Role – maternal and child bonding b. Abandonment – family focus to newborn, abandonment feeling to the mother. c. Disappointment d. Postpartum blues – women experience a certain degree of overwhelming sadness, which they can’t account for during the postpartum period. *PPSR – Psycho – physiological somatic response. D. Postpartum Complications a. Postpartum Hemorrhage – any blood loss that is > 500 mL. i. Early PH – within the last days of 6 weeks postpartum. ii.Common causes 1. Uterine Atony a. Refers to the lack of muscle tone that results in failure of the uterine muscle fibers to contract firmly around blood vessels when the placenta separates. b. Predisposing factors: i. Overdistention of the uterus 1. Multiple pregnancy 2. Hydramnios 3. Large babies ii.Caesarean birth – trauma introduced iii.Pregnancies with placental anomalies. iv.General anesthesia 1. SAB – Bupivacaine HCL 2. Epidural – Lidocaine HCl 3. SAB + Epidural = CSEA (hypertensive women) v. Multiparity – more than 5 pregnancies c. Clinical Manifestation i. Gush of blood from the placental site. ii.Uterine fundus that is difficult to locate. iii.Uterine fundus located above the expected level. iv.Soft / boggy fundus. v. Excessive lochia. vi.Uterine becomes firm when massaged but losses its tone when massage is stopped. d. Management i. Apply uterine massage. ii.IV infusion of dilute oxytocin (PNSS, LRS) iii.Methergine (methylergonovine maleate) – acts directly to the uterus. iv.Prostaglandin (analogue of prostaglandin) – prolongs the contraction of the uterus. v. Bimanual massage. vi.Intravascular fluid replacement. 1. Blood transfusion. 2. Plasma expanders. vii.Hysterectomy. e. Nursing Considerations i. Gentle massage. ii.Close observation for the next 4 hours. iii.Encourage voiding. iv.Monitor signs and symptoms of hypovolemic shock.

Audray Kyle Saydoven

Page 2

2.

b.

Retained Placental Fragments a. Bleeding may persist when placenta is not completely delivered. b. Clinical manifestation i. Apparent bleeding on immediate postpartum. ii.Firmed and contracted uterus. iii.High HCG result. c. Management i. Remove retained fragments. ii.D & C may be indicated. iii.Methothrexate in cases of placenta accrete iv.Instruct the patient about normal lochia discharges. 3. Lacerations – episiorrhaphy 4. Hematomas – incision and drainage 5. DIC 6. Subinvolution 7. Sheehan’s syndrome ( atrophy of Adenohypophysis ) Puerperal Infection i. Bacterial infection after birth. ii.Fever of 38 °C or higher occulting at least 2 of the 10 days after the 1st 24 hours of postpartum (Joint Committee of Maternal Welfare). iii.Predisposing Factors 1. Caesarean Birth 2. Any trauma to maternal tissues. 3. Prolonged rupture of membranes 4. Postpartum hemorrhage. iv.Common Puerperal Infection 1. Metritis a. Metritis with pelvic cellulitis – involves deciduas, myometrium, parametrial tissue. b. Complications i. Oophoritis ii.Salphingitis iii.Peritonitis c. Clinical Manifestation i. Fever ii.Chills iii.Body malaise iv.Anorexia v. Abdominal pain and cramping vi.Uterine tenderness vii.Purulent foul smelling lochia. d. Diagnostics i. CBC – elevated WBC ii.Culture and sensitivity (E. coli, Staph. Aureus) iii.Urinalysis – increases pus cells e. Management i. IV administration of antibiotics 1. Mild to moderate infection a. Ampicillin – only drug approved for pregnant. b. cephalosporin 2. Prophylactic drugs for CS case. a. Clindamycin b. Gentamicin f. Nursing Considerations i. Fowler’s position. ii.Give medication as directed. iii.Comfort measures – use of abdominal binder. iv.Health teachings. 2. Mastitis a. Infection of lactating breast. b. Occurs most often during 2nd and 3rd week after birth. c. Clinical Manifestations

Audray Kyle Saydoven

Page 3

d. e.

f.

3.

i. Flu like symptoms ii.Fatigue iii.Aching muscles iv.Fever v. Chills vi.Headache Complications – breast abscess (normal – 15 – 25 lobules) Management i. Antibiotic therapy ii.Breast decompression 1. Breastfeeding 2. Breast pump manual extraction iii.Analgesic iv.Warm / cold compresses v. Breast support Nursing Considerations i. Provide adequate information 1. Correct positioning of the infant. 2. Avoid nipple trauma and milk stasis. a. Never apply oil b. Let the infant suck the nipple. c. Use plain water in cleansing. ii.Change nursing pads as necessary.

UTI

a. Urinalysis b. Antibiotic therapy c. Hygiene 4. Wound infection a. Episiotomy b. Antibiotic therapy 5. Septic Pelvic Thrombophlebitis a. Pain in groin, flank area, iliac. b. Less common c. Antibiotic c. Deep Vein Thrombosis i. Thrombus - collection of blood factors on a vessel wall. ii.It affects the veins from the foot to ileofemoral region. iii.Complication – Pulmonary embolism (sudden sharp chestpain, tachycardia) iv.Causes 1. Venous stasis 2. Hypercoagulability 3. Injury to the intima (inner lining) of the blood vessel v. Risk Factors 1. Inactivity 2. Obesity 3. Caesarean birth 4. Smoking 5. Varicose veins vi.Diagnostics 1. Doppler ultrasonography 2. Impedance plethysmography 3. Venography – note for shellfish allergy vii.Management 1. Prevent thrombus formation a. Early and frequent ambulation b. Use of antiemboli socks c. Stirrup should be padded during childbirth 2. IV infusion of Heparin 3. Warfarin (oral) E. The Newborn (Extrauterine Adaptation) a. Neonatal Transition

Audray Kyle Saydoven

Page 4

i. Refer to the 1st few hours after birth wherein the newborn makes vital changes to maintain extrauterine life and stabilizes respiratory and circulatory changes. ii.Initiation of Respiration 1. Causes a. Physical factors i. Mechanical factors 1. Chest Compression – small amount of lung fluid is forced into the upper air passages and expelled during birth. 2. Chest Recoil – creates negative intrathoracic pressure as the pressure against the chest is released. b. Chemical factors i. Transitory Asphyxia – lowered PaO2 and pH, increased PaCO2 1. Cord clamping c. d.

Thermal Factors i. Decrease of more than 20 °F from intra to extrauterine life ii.Cold stress and respiratory depression result from excessive cooling. Sensory Factors i. Auditory stimuli ii.Visual stimuli iii.Tactile stimuli Brain (MO); Carotid & aortic Chemoreceptors

Decreased O2 & pH; Increased CO2

Diaphragm stimulated

Internal Stimuli

Cold air/ touch/ noise, etc

1 st Breath

External Stimuli

iii.Cardiovascular Adaptation 1. Transition from fetal to neonatal circulation. 2. Shunts close and pulmonary vessels dilate at birth. 3. Transition occurs simultaneously within the first few minutes after birth. a. Pulmonary blood vessels i. Dilation of these vessels begins with the 1st breath taken by the newborn resulting in lower pulmonary resistance which allows the blood to freely circulate through the lungs to be oxygenated. b. Ductus Arteriosus i. Increases pressure in the aorta and oxygen in the blood cause a reversal of blood flow in the ductus arteriosus resulting in more blood flowing through the pulmonary arteries for oxygenation. ii.Functional closure occurs within 15 – 24 hours and is permanent by 3 – 4 weeks. (ligamentum arteriosum) c. Foramen Ovale i. Closes within minutes after birth because of the higher pressure in the left than to the right. ii.Increased blood flow in the lungs and decreased pressure in the right atrium and the return of the blood from the lungs increases pressure in the left atrium. iii.Closure is permanent in approximately 3 months. (fossa ovale) d. Ductus Venosus i. Blood ceases flowing through the umbilical vein to the ductus venosus and into the inferior vena cava. ii.Blood now flows through the liver and is filtered as in adult circulation.

Audray Kyle Saydoven

Page 5

iii.Fibrosis occurs by the end of the 1st week of life (ligamentum venosum).

iv.Neurologic Adaptation (Thermoregulation) 1. Maintenance of body temperature must begin at birth. 2. Factors affecting thermoregulation a. Heat production i. Newborn produces heat through general metabolism, muscular activity and nonshivering thermogenesis. ii.Brown fat – special fat found only in newborns utilized during nonshivering thermogenesis. It can be found in the adrenal, around the kidneys, axilla, abdomen, back of neck, in between scapula, etc. b. Heat retention i. Staying in flexed position which reduces the area of skin exposed to the environmental temperature. ii.Peripheral vasoconstriction. c. Heat loss i. Newborn has thin skin with blood vessels close to the surface and little subcutaneous fat to prevent heat loss. ii.Cold stress – excessive heat loss. iii.Methods of losing heat 1. Evaporation → body to air 2. Conduction → body to solid objects (cold compress) 3. Convection → body to a cooler surrounding object (fever, aircon) 4. Radiation → body to a cold subject not in contact with the body (thermal shift) i. Hepatic Adaptation 1. Newborn’s liver is immature at birth. 2. Liver conjugates bilirubin for excretion. 3. Jaundice – staining of the skin first seen in the head and face. a. Physiologic – after 24 hours of life. b. Pathologic – within 24 hours of life (correlated with sickle cell anemia) B. Immediate Care of Newborn a. Goals: i. Establish, maintain and support respiration. ii.Promote warmth and prevent hypothermia. iii.Ensure safety and prevent injury and infection. iv.To identify actual or potential problems that may require immediate attention. b. APGAR Scoring System (Virginia Apgar) i. A quick method of assessing the newborn adjustment to extrauterine life and general condition. ii.Take I minute and 5 minutes after birth. 1. < 120 – asphyxiated (excessive oxygen could result to retrolental fibroplasia) 2. >160 – distress 3. Newborns are nose breathers for 2 – 3 weeks. iii.Factors that affect the APGAR score 1. Degree of physiologic maturity 2. Fetal cardiorespiratory and neurologic condition (e.g. cleft palate, PDA) 3. Maternal perinatal therapy such as use of analgesia during labor. Special Consideration • 1st 1 minute → determines general coneral condition of the baby Next 5 Minute → determines the capability of the baby to adjust extrauterinely (most important) • Next 15 minutes → optional → depndent on the 5 minutes apgar score Components A ppearance P G A R

ulse Rate rimace ctivity espiration

Color upon birth is slightly cyanotic After first cry baby will be pink Take apical pulse at the lower left nipple Determines reflex irritability using tangential foot slap and catheter insertion To determine the degree of muscle tone

Newborns will cry within 30 seconds upon expulsion

Audray Kyle Saydoven

Page 6

ASPHYXIA NEONATORUM → failure to cry within 30 seconds because mother received Demerol NARCAN → antidote of Demerol APGAR SCORING Criteria 0 Heart Rate Absent Respiratory Effort Absent Muscle Tone Flaccid Extremities Reflex Irritability Catheter No Response Tangential FS No Response Color Blue / Pale • High score means healthy baby

Score 1 < 100 Slow RR/ Weak Some reflexes

2 > 100 Good strong cry Well Flexed

Grimace Grimace Acrocyanosis

Cough or sneeze Cry Pink

Interpretation 0-3 • Severely depressed • Needs CPR • Admission at NICU 4-6 • Moderate depression • Additional suctioning 7 – 10 •

Good and healthy

CARDIOPULMONARY RESUSCITATION • CPCR → cardiopulmonary and cerebral resuscitation • 5 minutes of 02 deprivation will cause irreversible brain damage • Priority: Airway, Breathing, Circulation a. Establish respiration and maintain clear airway i. Measures to establish and maintain normal respiration. 1. Wipe secretion from the mouth and nose after delivery using sterile gauze. 2. Suction secretions from the mouth and nose. a. Gently suction to prevent: i. Irritating the mucous membrane ii.Mucosal edema iii.Reflex bradycardia from vagal stimulation. iv.Laryngospasm v. Cardiac arrhythmias. 3. A crying infant is a breathing infant. Stimulate baby to cry if the baby does not cry spontaneously or if cry is weak. a. Normal infant cry: loud and lusty. b. Abnormal manifestation i. High pitched cry – hypoglycemia and increased ICP ii.Weak cry – prematurity iii.Hoarse cry – sign of laryngeal stridor iv.Grunting respirations – respiratory distress syndrome v. Unable to initiate to maintain respiration 1. Neonatal asphyxia requiring resuscitation vi.Cardinal signs of newborn’s RDS 1. Tachypnea 2. Nasal flaring 3. Grunting 4. Intercostal retraction 5. Cyanosis 4. Oral mucous may cause the NB to choke, cough or gag during the 1st 12 hours of life. a. Trendelenburg or sidelying position. 5. Proper positioning a. Right sidelying after feeding

Audray Kyle Saydoven

Page 7

b. Supine during sleep (prevent SIDS) Make sure diapers, clothing and blankets are loose enough a. Allow maximum lung expansion b. Avoid overheating 7. Keep nares/nose patent a. Obligatory nose breather for 2 – 3 weeks old. 8. In some hospital, a catheter is passed into the stomach to remove amniotic fluid, blood, and mucus. a. Normal in newborn i. Short periods of apnea, periodic respiration without cyanosis. ii.Rapid respiration up to 80 that slows down to 30 – 60 bpm iii.Irregular respiratory depth, rate, rhythm. Provide warmth and maintain normal body temperature i. Principles for preventing hyporthermia in NB. 1. Delivery in a warm room. 2. Drying thoroughly after birth. 3. Wrapping in a dry warm cloth while keeping the baby out of draughts on a warm surface. 4. Giving the baby to the mother asap after birth. ii.Measures to prevent heat loss and maintain normal temperature 1. Dry the NB’s head and body immediately after birth. 2. Wrap with dry and warm blanket before giving to the mother to hold. 3. Place NB in a pre heated environment. (radiant warmer.) 4. Perform any extensive examination or procedure under radiant warmer to prevent heat loss. 5. Keep NB away from air conditioning vents that can promote heat loss. 6. Maintain ambient temperature of DR and nursery at 24 degrees celcius. 7. Delay initial feeding for at least 2 hours or until temp is stabilized. 8. Warm objects that will be used to examine or cover the NB. Prevent infection i. Principles of cleanliness at birth 1. Clean hands 2. Clean perineum 3. Nothing unclean to be introduced into the vagina. 4. Clean delivery surface. 5. Cleanliness in cutting the umbilical cord. 6. Cleanliness for cord care of the NB. ii.Care for the eyes (Crede’s prophylaxis) 1. It is part of the routine care of the NB to give prophylactic eye treatment a. Within the 1st hour after delivery. b. Gonorrheal conjunctivitis c. Opthalmia neonatorum 2. Eyes should be cleaned at birth and once everyday. a. Use cotton swab soaked in PNSS. 3. Sticky eyes are managed by frequent cleansing or instillation of 10 % sulphacetamide eyedrops every 2 – 3 hours. 4. Instillation of human colostrums for sticky eyes may be indicated. iii.Opthalmia neonatorum 1. Any conjunctivitis with discharge occurring during the 1st 2 weeks of life. 2. Typically appear 2 – 5 days after birth but may appear as early as 1st day or as late as 13th day. 3. Most often, eyelids become swollen an red with purulent pus. 4. Corneal damage with ulceration perforation synechiae and panopthalmia develop if there is delayed treatment. iv.Using erythromycin/tetracycline ointment (commonly used) 1. Don’t cause much irritation as silver nitrate 2. More effective to chlamydial conjunctivitis. 3. Apply ointment over lower eyelids then manipulate to spread medication over the eyes. 4. Wipe excess ointment after 1 minute with sterile cotton ball moistened with sterile water. 5. Don’t rinse eyes. v. Measures to prevent infection. 1. Proper hand washing technique. 2. Hand washing by health personnel. a. Before entering the nursery/caring for the baby. 6.

b.

c.

Audray Kyle Saydoven

Page 8

d.

b. In between NB handling. c. Before treating the cord. d. After changing soiled diapers. e. Before preparing formula milk. 3. Always use a single use tube pack of eye ointment. 4. Each NB should have her own bassinet and individual supplies to prevent cross infection. 5. NBs should be handled with gloves until after 1st bath. 6. Persons with infectious diseases should not be allowed in the nursery. 7. Used bulb syringe should be replaced every 24 hours and boiled for 10 minutes before reuse. Prevent Hemorrhage i. Hemorrhagic disorder of the NB 1. Self limited hemorrhagic disorder of the 1st 3 days of life. 2. Onset a. Early – 0 – 24 hours b. Classic – 2 – 5 days c. Late – 1 – 12 weeks 3. Clinical manifestation a. Spontaneous bruising or excessive bleeding after minor injury. b. Nose bleeds c. Oozing or bleeding from the umbilicus. d. Dark vomit e. Black tarry stools. f. Blood in the diaper from hematuria. g. Excessive bleeding from skin lesions. h. Less specific warning signs: pallor, irritability, jaundice. 4. Prevention: a. Vitamin K administration i. Vitamin K1 – green leafy vegetables ii.Vitamin K2 – microorganisms iii.Vitamin K3 – synthetic vitamin K. iv.Known as aquaMEPHYTON, phytomenadione, konakion. v. Administered prophylactically to prevent a transient deficiency of coagulation factors II(prothrombin), VII(proconvertin), IX(plasma thromboplastin), X (stuart-prower factor). vi.0.5 to 1 mg is injected IM in the lateral anterior aspect of the mid thigh within the 1st hour of life. vii.Oral vitamin K 1. 1st dose – 1st hour of life. 2. 2nd dose – 1 – 2 weeks of age 3. 3rd dose – 1 month of age b. Cord care i. The cord is clamped and cut in the delivery room about 8 inches from the abdomen. ii.Check the number of blood vessel. (1 artery = esophageal atresia) iii.Another clamp is applied ½ - 1 inch from the abdomen then cut above the clamp. iv.Clean the cord with antiseptic. v. Cord clamp is removed after 48 hours when the cord has dried. vi.Instruction to mothers 1. No tub bathing until cord falls off. 2. Do not apply anything on the cord except prescribed antiseptic. 3. Avoid wetting the cord. 4. Leave cord exposed to air. 5. Monitor for bleeding. 6. Report signs of infection. a. Foul odor in the cord. i. Presence of discharge. ii. Redness around the cord. iii.The cord remains wet and does not fall off within 7 – 10 days.

Audray Kyle Saydoven

Page 9

iv.fever Newborn Identification i. Important to prevent switching of babies. ii.Done in the delivery room after the mother or parents have had chance to meet and inspect their infant. iii.Identification or band 1. Placed around the infant’s wrist or ankle. 2. Around mother’s wrist. 3. Information: a. Mother’s maiden b. Date and time of delivery. c. Hospital/admission number of the mother d. Sex of baby e. Physician’s name 4. Traditional ID band a. Consists of plastic bracelet with permanent locks. iv.Foot prints 1. Considered permanent and fool proof method of newborn identification. v. Finger prints vi.Colored photograph of the newborn. vii.Storage of blood (DNA genptyping). f. Immunization i. BCG, OPV, Hep B B. Newborn Screening a. RA 9288 / Newborn Screening Act of 2004 i. Testing every NB for certain harmful or potential fatal disorders that are not apparent at birth. b. Disorders that can be detected: i. Congenital Hypothyroidism 1. Congenital metabolic disorder characterized by insufficient thyroid hormones that result in retarded growth and brain development. 2. 3 thyroid hormones: a. T4 – thyroxine b. T3 – triiodothyronine c. Thyrocalcitonin 3. Terms: Cretinism (infant); myxedema (adult) 4. Causative factors a. Congenital absence or underdevelopment of the thyroid glands. b. Hereditary condition c. Maternal iodine deficiency. d. Maternal intake of anti – thyroid drugs during pregnancy. 5. Clinical manifestations: a. Lowered v/s b. Changes in skin color c. Poor weight gain and growth. d. Delayed milestone (sitting, walking, talking) e. Mental retardation. *Adult – Hashimoto’s syndrome – autoimmune disease attacking the thyroid gland. 6. Management a. Replacement therapy i. Synthroid ii.Levothroid *Check the pulse rate before administering. *Withhold if PR = >80 – 100 (adult)/ >120 (infant); then refer. b. Warm environment. * Thyroidectomy Nx Considerations A – irway - positioning: sandbag on both head sides. - observe for stridor – airway problem - tracheostomy set is ready at bedside. B – leeding - check for the nape (external bleeding) e.

Audray Kyle Saydoven

Page 10

- frequent swallowing ( Internal Bleeding) C – alcium check - check for tetany (muscle constricture) - give 10 % calcium gluconate D – etermine the voice of the patient - may indicate destroyed laryngeal nerve. - hoarseness of voice - aphonia E – mergency - monitor / be prepared for assessing thyroid storm - increased v/s – palpitation; hyperthermia - icebath / thermal blanket. ii.Congenital Adrenal Hyperplasia 1. Autosomal recessive disease resulting from mutations of genes fro enzymes mediating the biochemical steps of production of cortisol from cholesterol by the adrenal glands. (steroidogenesis) 2. Clinical manifestation: a. Poor feeding b. Vomiting c. Diarrhea d. Metabolic acidosis 3. Management: a. Replacement therapy (hydrocortisone) b. Corrective surgery for enlarged clitoris (1 – 3 y/o) * Addison’s syndrome, Cushing, Hirsutism iii.Phenylketonuria 1. Metabolic disorder characterized by lack of enzyme phenylalanine hydroxylase 2. Clinical manifestation a. Delayed milestone b. Mental retardation 3. Management: a. Low phenylalanine diet (lofenalac) b. Foods to be avoided i. Milk and all dairy products ii.Meat and poultry iii.Fish iv.Eggs v. Nuts and peanut butter vi.Dried beans vii.Regular flour viii.Aspartame / artificial sweeteners iv.Galactosemia 1. Rare genetic metabolic disorder characterized by lack of the enzyme galactose – 1 – phosphate uridyl transferase. 2. Clinical manifestation a. Failure to gain weight b. Poor feeding c. Lethargy d. Irritability 3. Management a. Lactose free formula b. Calcium and vitamin D supplements c. Foods to be avoided i. Milk and all dairy products ii.Processed and pre – packaged foods iii.Tomato sauce iv.Some candies v. Certain meds vi.Some fruits and vegetables v. G6PD Deficiency 1. X – linked recessive hereditary disease characterized by abnormally low levels of G6PD enzymes

Audray Kyle Saydoven

Page 11

2.

Clinical manifestations: a. Paleness b. Rapid heartbeat c. Rapid breathing/ shortness of breath d. Dark tea colored urine e. Jaundice f. Spleenomegaly Management: blood transfusion

3. C. Newborn Assessment a. Gestational Age i. Measured from the 1st day of the mother’s LNMP ii.Assessment of birth weight 1. Appropriate for gestational age (AGA) a. When NB’s weight falls between the 10th and 90th percentiles expected for GA. 2. Large for GA (LGA) a. Above the 90th percentile expected for GA. 3. Small for GA (SGA) a. NB’s weight is below 10th percentile expected for GA. *Nx Alert: body weight and GA iii.Ballard Scoring System – assesses physical and neuromuscular maturity b. Physical Assessment i. Vital signs 1. Temperature a. Axillary – 36.5 – 37.5 b. Rectal – 36.6 – 37.2 – i. initially to rule out imperforated anus 1. clinical manifestation a. no meconium : earliest sign b. abdominal distention c. foul odor breath d. vomitus of fecal matter e. can apirate – respiratory problem 2. management: surgery with temporary colostomy ii.taken once iii.1 inch insertion. *Atretic – no anal opening *Agenetialism – no genital *Stenos – has opening 2. Heart Rate a. 120 – 160 bpm b. Apical pulse – left lower nipple c. Radial pulse – if present = PDA d. Femoral pulse – if absent = COA e. Murmur – an extra unusual sound heard during heartbeat. 3. Respiration a. 30 – 60 bpm b. Count for 1 full minute c. May want to do before waking up the infant. d. Rate will be elevated with crying / fever. e. Signs of potential distress or deviation from expected findings: i. Persistent fine crackles ii.Asymmetrical chest movements iii.Apnea (15 seconds) iv.Tachypnea (> 60bpm) v. Excessive mucus vi.Retractions vii.Nasal flaring viii.Stridor ii.General managements 1. Head circumference – 33 – 35 cm (2 – 3 cm larger than the chest) 2. Chest circumference – 30.5 - 33 cm

Audray Kyle Saydoven

Page 12

3. 4. iii.Skin 1. 2. 3. 4. 5.

Weight – 2500 – 4000 gm (5lbs8oz – 8 lbs13oz) Length – 48 – 53 cm (19 – 22 inches)

Acrocyanosis Pinkish Cyanosis Vernix caseosa – whitish cheese – like substance Lanugo a. Moderate in full term b. Abundant in preterm c. Absent for post term 6. Mongolian spots a. Slate gray or bluish discoloration patches commonly seen across the sacrum or buttock due to accumulation of melanocytes. b. Disappear by 1 y/o 7. Milia a. Plugged or unopened sebaceous glands b. White pinpoint patches on nose, chin cheeks. c. Disappear in 1st 2 – 3 weeks of life. 8. Erythema toxicum a. Common rash in newborn composed of small pustular lesions. b. Newborn rash/ fleabite dermatitis. c. Peak incidence is 24 – 48 hours of life d. Cause is unknown and no treatment. 9. Harlequin’s Sign a. Color of the NB’s body appears to be half pale and half red. b. This condition is transitory and usually occurs with lusty cry. 10. Jaundice a. Refer to the yellow color of the skin and whites of the eyes caused by excess bilirubin in the blood. b. Management: Phototherapy (neon – blue light) – consists of exposing an infant’s skin to light which breaks bilirubin down into its part that is easier to excrete in stool and urine. c. Nx considerations: i. Cover eyes ii.Cover genitals – prevent priapism iii.Change position regularly iv.Increase fluid intake v. Monitor I&O and v/s. 11. Birth Marks a. Telangiectic nevi (stork bites) i. Appears as pale pink or red spots ii.Due to stretching (dilation) blood vessels. iii.Most stork bites on the face eventually go away completely in about 18 mos. Stork bites on the back of the neck /nape usually don’t go away. b. Hemangiomas – simply a collection of extra blood vessels in the skin. i. Types: 1. Nevus flameus (port wine stain) a. Birthmark in which swollen blood vessels create a reddish – purplish discoloration of the skin. 2. Strawberry hemangiomas / nevus vasculosus a. Dilated capillaries in the entire dermal or subdermal area. b. Disappear at 10 years of age. 3. Cavernous hemangioma a. Communication network of venules in the subQ tissue that never disappear with age – most dangerous – intestinal hemorrhage. iv.Head 1. Assess fontanels and sutures – observe for signs of hydrocephalus and evaluate neurologic status. 2. Craniosynostosis: premature fusing of the sutures 3. Micro and macrocephaly 4. Cephalhematoma (weeks) – blood in the subperiosteal area

Audray Kyle Saydoven

Page 13

5. 6. v. Eyes 1. 2. 3.

4. 5. 6. vi.Ears 1. 2. 3. vii.Nose 1.

Caput succedaneum – fluid accumulation Molding Visual acuity – 20/150 – 20/190 Optimal visual field – 8 – 12 inches Reflexes a. Red eye reflex – may indicate blindness, cataracts, congenital infection (rubella), calcium metabolism abnormality. b. Blink reflex c. Corneal reflex d. Papillary reflex Tears – 3 – 4 mos. Opthalmia neonatorum – STI Doll’s eye – disappear in 10 days Pinna – in line with outer canthus If lower – low set ears = trisomy 21/Down Syndrome Startle reflex – upper & lower extremities toward chest.

Congenital choanal atresia a. Blocked posterior nasal passage b. Emergency case 2. Excessive discharge – congenital syphilis viii.Mouth and throat 1. Epstein pearls a. Accumulation of epithelial cells usually found on the palate. b. Disappear within 2 weeks. 2. Reflexes: a. Rooting reflex b. Sucking reflex c. Gagging reflex d. Extrusion reflex 3. Abnormalities a. Cleft lip (cheiloplasty)/ palate(uranoplasty) i. Use small spoon (cleft lip); bigger spoon (cleft palate) ii.Rule of ten before surgery 1. 10 weeks 2. 10 lbs 3. 10 hgb b. Macroglossia – premature baby c. Protruding tongue – Down syndrome d. Oral thrush – oral candidiasis/moniliasis ix.Neck 1. Short for chubby 2. Tonic neck / fencing reflex 3. Short neck may indicate the possibility of Kippel – feil syndrome 4. Abnormalities a. Congenital torticollis / wryneck i. Shortening of the sternocleidomastoid muscle (normally or by injury); spasm on one side/ b. Webbing of the neck / webbed neck i. Redundant extending skin fold. x. Chest 1. Wide spaced nipples and shield like appearance – Turner’s Syndrome 2. Redness and purulent discharges – mastitis 3. Witch’s milk – disappear in 1 week xi.Abdomen 1. Absent bowel sound can indicate ileus 2. Umbilical cord – check stump for bleeding or infection 3. Umbilical hernias – midline outpouching from the sternum to the umbilicus with weak abdominal musculature (diastasis recti)

Audray Kyle Saydoven

Page 14

4. 5.

Inspection, auscultation, percussion, palpation Abnormalities a. Hematoma b. Omphalocele – protrusion of abdominal organs c. Infection/bleeding

xii.Anus 1. Imperforated anus 2. Meconium pass within 24 hours xiii.Genitalia 1. Male genitalia a. Undescended testes b. Smegma – normal c. Hydrocele d. Cremasteric reflex – T8 – T10 i. Disappear by 10th day of life 2. Female Genitalia a. Ambiguous genitalia 3. Abnormalities a. Chordee b. Chryptorchidism c. Hypospadias d. Epispadias xiv.Extremities 1. Multiple fracture indicates osteogenesis imperfect 2. Reflexes Palmar Grasp Reflex • When a solid object is placed on the palm then the baby will grasp the object • To cling to the mother for safety • Disappears at 3 months Step – in/ Walk – in Place Reflex/ Dance Reflex • Neonate placed on a vertical position with their feet touching on hard surface will take a few quick alternating steps • Placing reflex  almost the same with the dance reflex except that is when you are touching the anterior surface of newborns leg Plantar Grasp Reflex • When an object touches the sole of the newborn’s foot at the base of his toes, the toes grasp in the same manner as the fingers do • Disappears @ 8 – 9 months in preparation for walking Tonic Neck Reflex/ Fencing/ Boxing reflex • When the newborn lies on its bact, their heads usually turns to one side, the arm and the leg on the side to which the head turns extend to the opposite arm and legs contract Moro Reflex/ Startle Reflex • With a loud voice or by a jarring the base of the crib, the baby will assume a c position • Test for neurologic integrity Magnet Reflex • When there is pressure at the sole of the foot, the baby pushes back against the pressure Crossed extension Reflex • While supine and the sole of the foot is stimulated by a sharp object, it causes the foot to raise and the other foot to extend • Test for spinal nerve integrity Trunk Incurvation Reflex/ Galant Reflex • While in prone position and the parabvertebral area is stimulated, it causes flexion of the trunk and swing his pelvis towards the touch Landau reflex • While the infant is placed on a vertical position with the hand underneath supporting the trunk the baby exhibit some muscle tone • Present at 3 months • Test for muscle tone Parachute Reflex • When the infant is placed on a vertical suspension with the change in equilibrium, it causes the extension of the hands and legs • Present at 6 – 9 months Babinski Reflex

Audray Kyle Saydoven

Page 15

• •

When the sole of the foot is stimulated by inverted j, it causes fanning of the toes Disappears by 2 months but may persist till 2 years old 1. Abnormalities: a. Amelia/ phocomelia b. Hypotonia c. Club foot d. Webbing/syndactyl e. Extra / polydactyl f. Absence of gasp reflex B. Growth and Development Growing  complex phenomenon of a structure or whole GROWTH • Increase in physical size of a structure or whole • Quantitative • 2 parameters ○ Weight  Most sensitive measurement for Weight gain: 2x = 5 – 6 mos. 3x = 1 year 4x = 2 – 2½ years Height

○

○ FINE MOTOR ADAPTIVE  ability to use hand movements

○ GROSS MOTOR SKILLS  ability to use large body movements

MATURATION • Synonymous with development • Readiness/ learning is effortless COGNITIVE DEVELOPMENT • Ability to learn and understand from experiences, to acquire and retain knowledge, to respond to a new situation and to solve problems

 ESTROGEN  responsible for

LEARNING  change of behavior

 TESTOSTERONE  responsible

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

increase in height in female



for the increase in height in male Stoppage of height coincide with the eruption of the wisdom teeth

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

HEIGHT COMPARISON 9 y/o  male = female 12 y/o  Male < Female 13 y/o  Male > Female DEVELOPMENT • Increase in the skills or capacity to function • Qualitatively • How to measure development ○ By simply observing the child doing simple task ○ By noting parent’s description of the child’s progress ○ Measure by DENVER DEVELOPMENTAL SCREENING TEST (DDST) • MMDST ○ Metro Manila Developmental Screening Test ○ Philippine Based exam • Main Rated Categories ○ LANGUAGE  ability to communicate ○ PERSONAL/ SOCIAL  ability to interact

Audray Kyle Saydoven

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

Page 16

PRINCIPLES OF GROWTH AND DEVELOPMENT • Growth and development is a continuous process (WOMB TO TOMB PRINCIPLE)  begins from conception and ends with death • Not all parts of the body grows at the same time or at the same rate (ASSYCHRONOUS GROWTH) • Each child is unique • Growth and development occurs in a regular direction reflecting definite and predictable patterns or trends ○ Directional Terms  Cephalocaudal/ Head to Tail  It occurs along bodies long axis in which control over head, mouth and eye movemens and precedes control over upper body torso and legs  Proximo – Distal/ Centro – Distal  Progressing from center of the body to the extremities  Symmetrical/ Each side of the Body  Develop at the same direction at the same time and at the same rate  Mass – Specific  Differentiation – SIMPLE TO COMPLEX; BROAD TO REFINED ○ Sequential Trend  Involves a predictable sequence of growth and development to which the child normally passes  Locomotion  Creeps → Stands → Walks → Run  Language and Social Skills  Cry → coo ○ Secular Trend  Refers to the worldwide tend of maturing earlier and growing larger as compared to succeeding generation

• • • • •

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

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

Audray Kyle Saydoven

○ • • • •

Period of most rapid growth and development Prone to develop anemia

○ Toddler ○ Period of slow growth and development Toddler and preschool ○ Period of alternating rapid and slow growth and development School Aged ○ Slower growth and development ○ Least to develop anemia Adolescent ○ Period of rapid growth ○ Secondary prone to anemia

Two Primary Factors Affecting Growth and Development • Heredity ○ Race ○ Sex ○ Intelligence ○ Nationality

Page 17

•

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

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

*Universal Principle: F are born < wt. than M by 1 oz.; F are born < lt. than M by 1 in. THEORIES OF DEVELOPMENT Age Phase Oral Phase

Anal Phase (stage where OC are developed)

Site of Gratification

0 – 18 mos.

Mouth

19 mos. – 3 yrs.

Anus

SIGMUND FREUD’S PSYCHOSEXUAL THEORY • 1856 – 1939 • An Austrian Neurologist • Founder of Psychoanalysis • 1st to introduce Personality Development

Activities • • • • •

Biting Crying Sucking (enjoyment and release of tension) Elimination Retention/ Defecation of Feces

Task

• • • • • •

•

Phallic Phase

4 – 6 yrs.

Genital

• •

Latent Phase

7 – 12 yrs.

School aged

• • •

Genital Phase

12 – 18 yrs

Genitalia

•

May show exhibitionism Have or increase knowledge of 2 sexes Period of suppression No obvious development, slower growth Child’s energy or Libido is diverted into more concrete type of thinking Achieve sexual maturity and learn to establish satisfactory relationship with the opposite sex

• • • • •

•

Provide oral stimulation even if baby is place NPO (use pacifier)CBQ Never discourage thumb sucking Help the child achieve bowel and bladder control even if the child is hospitalized Principle of holding on and letting go Mother wins or child wins Child Wins ○ Holding on ○ Child turns to be hardheaded, antisocial, stubborn, unreliable, irresponsible Mother Wins ○ Letting go ○ Child turns to be kind, obedient, perfectionist ○ Meticulous, OCs, reliable, responsible Accept the child fondling his own genetalia as normal area of exploration Divert attention from masturbation Answer the child’s question directly Human sexuality Help the child achieve (+) experiences so that he’ll be ready to face the conflicts of adolescents

Give opportunity to relate to opposite sex

ERIK ERICKSON’S STAGES OF PSYCHOSOCIAL THEORY • • Former student of Freud

Audray Kyle Saydoven

Page 18

• •

Stresses the importance of culture and society to the development of one’s personality “environment” ○ words and symbols are not yet available 1. Trust vs. Mistrust ○ communication through senses • 0 – 18 months • TRUST is the foundation of all psychosocial 1. Schema 1: Neonatal Reflex tasks ○ 1 month • Theme: Give and Receive ○ Early reflexes • Trust is developed via 2. Schema 2: Primary Circular Reaction ○ Satisfying needs of infants on time ○ 1 – 4 months ○ Care must be consistent and adequate ○ Activities related to body; repetition of ○ Give experiences that will add security behavior  Hugs, kisses, touch, eye to eye ➢ Example: thumbsucking contact, soft music 1. Schema 3: Secondary Circular Behavior 1. Autonomy vs. Shame & Doubt ○ 4 – 8 months • 18 mos. to 3 years ○ Activities not related to the body • Theme: independence and self – government ○ Discover person and object’s permanence • Give opportunity for decision making, offer ○ Memory traces are present and anticipate choices familiar events • Encourage the child to make decision rather than 1. Schema 4: Coordination of Secondary Reaction judge ○ 8 – 12 months • Parents has a moral obligations to set limits ○ Exhibit goal directed behavior 1. Initiative vs. Guilt ○ ↑ sense of permanence and separateness • 4 – 6 years old ○ Play activities: Throw and retrieve • Learns how to do BASIC things 1. Schema 5: Tertiary Circular Reaction • Give opportunity exploring new places and ○ 12 – 18 months events ○ use trial and error to discover characteristic • Right time for amusement park and zoos of places and events • Activity recommended: modeling clay and finger ○ “Invention” of new means painting • Enhances creativity and imagination ○ capable of space and time perception and facilitates fine motor development 1. Schema 6: Invention of New Means thru Mental 1. Industry vs. Inferiority Coordination • 7 – 12 years old ○ 18 – 24 months • Learns how to do things well ○ Symbolic representation • Give appropriate short assignments and projects ○ Transitional phase to the pre-operational • Unfinished project will develop inferiority thought period 1. Identity vs. Role Confusion • 12 – 18 or 20 years old 1. Pre-operational Thought • Learns who he is or what kind of person he will 1. Pre – conceptual Thought become by adjusting to new body image and ○ 2 – 4 years old seeking EMANCIPATION/ freedom from ○ Concrete, literal, static thinking parents ○ CBQ EGOCENTRIC – unable to view 1. Intimacy vs. Isolation anothers viewpoint • 18 – 25 or 30 years old ○ CBQ (-) REVERSIBILITY – in every action • Career focus there is opposite reaction; cause and effect • Looking for a lifetime partner ○ Concept of time is only now and concept of 1. Generativity vs. Stagnation distance is only as far as they can see • 30 – 45 years old ○ CBQ ANIMISM – consider inanimate 1. Ego Integrity vs. Despair • 45 years old and above object as alive 1. Intuitive Thought JEAN PIAGET’S STAGES OF COGNITIVE ○ Beginning of causation DEVELOPMENT • Reasoning powers 1. Concrete Operational • Swiss Psychologist ○ 7 – 12 years old • Genetic Epistemologist ○ SYSTEMATIC REASONING as solution to problems 1. Sensorimotor ○ Concept of (+) reversibility • 0 – 2 years old ○ Concept of Conservation – constancy • Also called Practical Intelligence despite of transformation

Audray Kyle Saydoven

Page 19

○

Activity recommended: Collecting and Classifying

KOHLBERG’S THEORY OF MORAL DEVELOPMENT Formal Operational • Recognized the theory of moral development as ○ 12 years old and above considered to closely approximate cognitive stages of ○ Period when cognition achieve its final form development ○ Can solve hypothetical problem with • Stages of Moral Development SCIENTIFIC REASONING ○ Infancy ○ Can deal with past, present and future ○ Premoral ○ Capable of ABSTRACT, mature thought ○ Amoral and formal reasoning ○ Pre-religious ○ Activity recommended: talk time; focus on opinions and current events Age Descritption Stage PRECONVENTIONAL (Level I) 0 – 3 yrs 1 • PUNISHMENT/ OBEDIENCE/ ORIENTATION ○ Heteronomous morality ○ Child does right because PARENT tells him to and to avoid punishment 4 – 7 yrs. 2 • INDIVIDUALISM ○ Instrumental purpose and exchange ○ Carries out action to satisfy own needs rather than society ○ Will do something for another if that person does something for the child CONVENTIONAL (Level II) 4 – 10 yrs. 3 • ORIENTATION TO INTERPERSONAL RELATIONS OF MUTUALITY ○ Child follows rules because of need to be a “good person” in own eyes and eyes of others 10 – 12 yrs. 4 • MAINTAINANCE OF SOCIAL ORDER, FIXED RULES AND AUTHORITY ○ Child finds following rules satisfying ○ Following rules of authority figures as well as parents in an effort to keep the “system” working 1.

POST – CONVENTIONAL (Level III) Older than 5 • 12 ○ 6 • ○ ○ ○

SOCIAL CONTRACT, UTILITARIAN LAW – MAKING PERSPECTIVE Follows standards of society for the good of the people UNIVERSAL ETHICAL PRINCIPLE ORIENTATION Follows internalized standards of conduct Only few people achieved this level Only saints and holy

DEVELOPMENTAL MILESTONES • Major marker of growth and development • Determines developmental delays TEETH QUESTIONS 6 mos. 30 mos.

3 years 6 years

Eruption of first temporary teeth 2 LOWER CENTRAL INCISORS Temporary teeth complete 20 decidous teeth POSTERIOR MOLAR --> last to appear Time to go to Dentist Begins to brush teeth Tooth brushing with minimal supervision Tooth brushing alone Temporary teeth begins to fail 1st permanent teeth → 1st MOLAR

Audray Kyle Saydoven

Page 20

Last to appear → WISDOM TOOTH BOWEL/ BLADDER CONTROL Bowel Control → 18 months / 1 ½ years Day Time Bladder Control→ 2 years Night Time Bladder Control → 3 years MILESTONES Infancy • Solitary play ○ Consider when choosing a play ➢ Safety ➢ Age appropriateness ➢ Hygiene Neonate • Complete head lag • Largely reflex visual fixation for human face • Hands fisted with thumbs in • Cries without tears because lacrimal glands are not fully developed 1 month • Dance reflex disappears • Looks at mobile; follows midline • Alert to sound, regards face 2 months • Holds head up when in prone • Social smile, cries with tears, cooing sound • Closure of posterior fontanel (2-3 months) • Head lag when pulled to sitting position • No longer clinches fist tightly • Follows object past midline • Recognizes parents 3 months • Holds head and chest up when in prone • Holds hands open at rest • Hand regard, follows object past midline • Grasp and tonic neck reflexes are fading • Reaches for familiar people or object • Anticipates feeding 4 months • Head control complete • Turns front to back; needs space to turn • Laughs aloud; Babbling sound • Babinski Reflex disappears

•

Fear: Stranger Anxiety ○ Begins: 6 – 7 months ○ Peaks: 8 months ○ Diminishes: 9 months

•

Eruption of first temporary teeth ( Lower 2 central incisors) Vowel sounds “ah, eh” Uses palmar grasp; handless bottle well Recognizes strangers

• • •

7 months • Transfer objects from hand to hand (6 – 7 months) • Likes objects that are good sized for transferring 8 months • Sits without support • Peak of stranger anxiety • Plantar reflex disappear (6-8 months) 9 months • Creeps or crawls; need space for creeping • Neat pincer grasp reflex, probes with forefinger • Finger feeds, combine 2 syllables “mama & dada” 10 months • Pulls self to stand • Understand the word no • Respond to name • Peek – a – boo, pat a cake, since they can clap 11 months • Cruising, stand with assistance • Walking while holding to his crib’s handle • One word other than mama and dada

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

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

6 months • Reaches out in the anticipation of being picked- up • Sits with support • Puts feet in mouth in supine position

Toddlerhood • Parallel Play – 2 toddlers playing separately • Provide 2 similar toys for 2 toddlers • Toys

Audray Kyle Saydoven

Page 21

•

○ Squeaky frogs to squeeze ○ Waddling ducks to pull ○ Trucks to push ○ Building blocks ○ Pounding peg Fear: Separation Anxiety ○ Begins: 9 months ○ Peaks: 18 months ○ 3 stages  Protest  Despair  Denial ○ Prevent:  Do not prolong goodbye  Say goodbye firmly  Say when you’re back

Toddler Characteristic Traits • Negativistic: says no most of the time • Saying no – way of developing independence • Limit questions, offer choices • Rigid, ritualistic and stereotyped • Ritualistic – way to gain mastery • Temper Tantrums ○ Stomping of feet ○ Holding breath ○ Screaming ○ Head banging ○ NC: Ignore the behavior • Scaphoid abdomen – underveloped abdominal muscle • Physiologic Anorexia  food fad, food jag that last for a short period of time due to the preoccupation to environment 15 Months • Plateau stage • CBQ WALKS ALONE – lateness in walking is a sign of mild mental retardation • Puts small pellets into small bottle • Creep upstairs • 4 – 6 words • Scribbles voluntarily with pencil, holds spoon well, seat self in a chair 18 Months • Height of POSSESIVENESS – favorite word MINE • Bowel control achieved • No longer rotates a spoon • Can run and jump in place • Walks up and downstairs holding on to a person’s hand or railing, typically places both feet on one step before advancing • Names one body part 24 months • TERRIBLE TWOS • Turns pages one at a time, removes shoes, pants, etc • Can open doors by turning door knobs, unscrew lids

Audray Kyle Saydoven

• • •

•

50 – 200 words (2 word sentences), knows 5 body parts Walk upstairs alone, still using feet on the same step at same time Daytime Bladder Control CBQ best time to bring the child to dentist: 2 – 3 years or when temporary teeth is complete

30 months • Makes simple lines or stroke or crosses with pencil • Can jump down from chair • Knows full name, holds up finger to show age • Copy a circle • CBQ Temporary teeth complete (posterior molar: last to erupt) • CBQ 20 deciduous teeth • CBQ tooth brushing: 2 – 3 years 36 months • TRUSTING THREES • Tooth brushing with little supervision • Unbutton buttons • Draws a cross, learns how to share • Knows full name and sex • Speaks fluently, 200 – 900 words • NIGHTIME BLADDER CONTROL achieved • Rides tricycle Preschoolers • Cooperative play – playhouse • Role playing is usual • Fears: ○ Castration/ Body Mutilation ○ Dark places and witches ○ Thunder and lightning ○ Ghost • Curious, creative, imaginative and imitative Preschooler’s Characteristic Traits • Telling tall tales • Imaginary friend  way of relieving tension and anxiety • Sibling rivalry→ jealousy to a newly delivered baby • Regression ○ Signs: bedwetting ○ Thumbsucking ○ Baby talk ○ Fetal position • Masturbation ○ Sign of boredom ○ Divert attention ○ Offering toy 4 years old • FURIOUS FOUR • Noisy, aggressive and stormy • Buttons button • Copy square • Catches ball, jumps, skips • Alternates feet going downstairs

Page 22

• • •

CBQ LACES SHOES Vocabulary of 1500, knows the basic color Says song or poem from memory

5 years old • FRUSTRATING FIVES • Jumps over low obstacles • Spreads with a knife • Draws 6 part man, copy triangle • Imaginary playmates • 2100 words • Identification with same sex • Attachment to opposite sex School – Aged • Competitive Play: Tug of war • Fears ○ School Phobia  orienting child to his new environment ○ Displacement from school ○ Death • Significant Person ○ Teacher ○ Peer of same sex • Stoppage of height coincide with the eruption of wisdom tooth • Prone to fracture: Common Green stick • Mature vision ○ 20/200 legal blindness • They’ll Cheat → can’t afford to lose 6 years old • Temporary teeth begins to fall, permanent teeth begins to appear (1st: First Molar) • Tooth brushing alone • A year of continuous motion, clumsy moving • 1st grade teacher becomes authority figure ○ nail biting → sign of strict teacher • Beginning interest with God 7 years old • Age of assimilation • Copies a diamond • Enjoys teasing and playing alone • Quieting down phase 8 years old • Expansive age • Smoother movements • Normal homosexual • Loves to collexct objects • Counts backwards 9 years old • Coordination improves • Tells time correctly • Hero worship • Stealing and lying are common • Takes care of body needs completely • Teachers find their group difficult to handle

Audray Kyle Saydoven

10 years old • Age of special talents • Write legibly • Ready for competitive games • More considerate and cooperative • Joins organizations • Well mannered with adults and critical with adults 11 – 12 years old • Pre adolescent • Full of energy and constantly active • Secret languages are common • Share secrets with friends • Sense of humor is present • Social and coopoerative School – Aged Characteristic Traits • Industrious • Modest Signs of Sexual Maturity in Female I ncrease in size of breast and genitalia – telarche – 1st sign W idening of hips A ppearance of pubic axilliary and pubic hair adrenarche M enarche – last sign Signs of Sexual Maturity in Male A ppearance of axilliary and pubic hair D eepening of voice D evelopment of muscle I ncrease in size of penis and scrotum – 1st sign P roduction of viable sperm – last sign Adolescence • Fear

• • • •

• • • • • •

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

Page 23

•

○ Peer pressure Problems ○ Vehicular accident ○ Smoking ○ Alcoholism ○ Drug Addiction ○ Pre Marital Sex

Concept of Death 6 years old  death is reversible CBQ 7 – 9 years old  personification of death, permanent loss of the corporal life A. B. Congenital Heart Diseases/ Defects

CONGENITAL HEART DISEASE • Common in Boys ○ Transposition of the great artery (TOGA) ○ Truncus Arteriosus ○ Tetralogy of Fallot •

•

Common in Girls ○ Patent Ductus Arteriosus ○ Atrio Septal Defect

•

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

Two Major Types • Acyanotic Heart Defects  shunting from left to right • Cyanotic Heart Defects  from right to left

1.

Acyanotic Heart Defects with Increase Pulmonary Blood Flow 1.

1.

Vetricular Septal Defect • Opening Between 2 ventricles • Signs and symptoms ○ Systolic murmur at lower border of the sternum and no other significant sign ○ Cardiac catheterization reveals increase oxygen saturation at the right side of the heart ○ ECG reveals hypertrophy of the right side of the heart ○ Only 50% of the oxygenated blood will go to the aorta • Management ○ Open heart surgery ○ Placing the client on a long tern antibiotic therapy to prevent the development of sub-acute bacterial endocarditis ○ Protect site of catheterization (right femoral vein) ○ Avoid flexion of joints Atrial Septal Defect • Failure of the foramen ovale to close • Signs and symptoms

Audray Kyle Saydoven

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

1.

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

Acyanotic Heart Defects with Decrease Pulmonary Blood Flow 1.

Pulmonary Stenosis • Narrowing of valve of pulmonary artery • Signs and symptoms ○ Typical systolic ejection murmur ○ S2 sound is widely split ○ ECG reveals right ventricular hypertrophy ○ Only 50% of the blood goes to the lungs

Page 24

• 1.

1.

1.

Management ○ Balloon Stenotomy

Aortic Stenosis • Narrowing of valve of aorta • Signs and symptoms ○ Typical systolic ejection murmur ○ Murmur ○ ECG reveals right ventricular hypertrophy ○ Only 50% of the blood goes to the body ○ Angina like symptoms may be present when active • Management ○ Balloon stenotomy Duplication of Aortic Arch • Doubling of arch of the aorta causing compression to the trachea and esophagus • Signs and symptoms ○ Dysphagia – due to esophageal compression ○ Dyspnea – due to tracheal compression ○ Left ventricular hypertrophy ○ Only 50% of the blood goes to the body • Management ○ Close heart surgery

1.

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

1.

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

1.

Hypoplastic Left Heart Syndrome • Non functioning left ventricle • Signs and symptoms ○ Cyanosis after 1st cry ○ Polycythemia because of increase production of RBC, a compensatory mechanism to the ↓ oxygen supply to the body, the blood become viscous ○ Polycythemia will lead to:  Thrombuis  Embolus

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

Cyanotic Heart Defects with Increase Pulmonary Blood Flow 1.

•

Transposition of Great Arteries • Aorta is arising from the right ventricle while the pulmonary artery is arising from the left • Signs and symptoms ○ Cyanosis after 1st cry ○ Polycythemia because of increase production of RBC, a compensatory mechanism to the ↓ oxygen supply to the

Audray Kyle Saydoven

body, the blood become viscous ○ Polycythemia will lead to:  Thrombus  Embolus  Stroke (CVA)cererbrovascular accident ○ ECG reveals Cardiomegaly Management ○ Palliative repair – Rash Kind repair ○ Complete repair – Mustard repair

Page 25

•

 Stroke (CVA) Management ○ Heart transplant

Cyanotic Heart Defects with Decrease Pulmonary Blood Flow 1.

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

1.

Tetralogy of Fallot • 4 Anomalies Present (PVOR) ○ Pulmonary Stenosis ○ Ventricular Septal Defect ○ Overriding of Aorta ○ Right Ventricular Hypertrophy • Signs and symptoms ○ High degree of Cyanosis  outstanding Sign ○ Polycythemia because of increase production of RBC, a compensatory mechanism to

•

the ↓ oxygen supply to the body, the blood become viscous ○ Polycythemia will lead to:  Thrombuis  Embolus  Stroke (CVA) ○ Severe dyspnea  relieved by squatting position because it will prevent venous return and facilitate maximum lung expansion  Knee chest position in infants ○ There is growth retardation ○ TET Spells – blue spells or short episode of hypoxia ○ Syncope – faintaing ○ Mental retardation ○ Clubbing in fingernails because of tissue hypoxia – late and last sign ○ X – ray reveal a boot shape heart Management ○ Oxygen therapy ○ Morphine sulfate – for hypoxic episode ○ Propanolol (inderal) – decrease heart spasm ○ Palliative repair – BLT or Blalock Taussig Shunt Procedure ○ Complete repair – Brock Procedure

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

Audray Kyle Saydoven

Page 26

Carditis – signs of tachycardia Erythema Marginatum – macular rashes Subcutaneous nodules Presence of 2 major or 1 major and 2 minor plus a history of sore throat will confirm diagnosis •

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

RESPIRATION • Normal Values = 30 – 60 bpm irregular • Either abdominal or diaphragmatic breathing with short period of apnea without cyanosis • Normal apnea in newborn is 15 seconds or less Age Newborn 1 year old 2 – 3 years old 5 years old 10 years old 15 and above

Vesicular Normal Bronshovesicular Normal Bronchial Normal Ronchi Normal Rales Abnormal Wheezing Abnormal Stridor Resonace Hyper Resonance 1.

Rate 40 – 90 20 – 40 20 – 30 20 – 25 18 – 22 12 – 20

•

Breath Sounds Heard on Auscultation Soft, low pitched, heard over periphery of lungs, aspiration is longer than expiration

•

Soft, medium pitched heard over major bronchi, inspiration equals expiration

•

Loud, high pitched, heard over the trachea, expiration is longer than inspiration

•

Snoring sound made by air moving through mucus in bronchi

• • • •

Crackles (like Celophane) made by air moving through fluid in alveoli Denotes pneumonia, fluid in the lungs or pulmonary edema Whistling on expiration made by air being pushed through narrowed bronchi Denotes children with asthma or foreign body airway obstruction

• • • •

Crowing or roster like sound made by air being pulled through a constricted larynx Indicative of Respiratory Obstruction Loud, low tone, percussion sound over normal lung tissue Louder, lower sound than resonance, percussion sound over hyperinflated lung tissue

RESPIRATORY DISTRESS SYNDROME • Lack of surfactant within 24 hours of life • Aka Hyalin Membrane Disease • Common in preterm babies • The alveoli cannot expand properly • Signs and symptoms ○ Present within 4 hours of life ○ Using the Silverman Anderson Scoring to determine RDS ○ ↑ RR with retraction (1st sign of RDS) ○ Expiratory Grunting (major sign) ○ Xiphoid retraction

Audray Kyle Saydoven

Page 27

○ ○ ○ • Management ○ ○

○ ○

○ ○

Flaring nasal flares Cyanosis Respiratory acidosis Head elevated Proper suctioning O2 administration with ↑ humidity Client placed on  CPAP Continuous Positive Airway Pressure  PEEP Positive End Expiratory Pressure  Purpose id to maintain the alveoli partially open and prevent alveolar collapse Monitor for acidosis Surfactant replacement

1.

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

1.

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

LTB and Bronchiolitis ends with Epiglotitis 1.

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

Blood Pressure • Newborn – 80 – 46 mmHg • After 10 days – 100/ 50 mmHg • BP taking begins by 3 years old A. Congenital Disorders a. Hydrocephalus i. Excess CSF

Audray Kyle Saydoven

Page 28

b.

c.

d.

e.

f.

1. Overproduction of CSF 2. Occlusion of canals ii.Types: 1. Communicating 2. Noncommunicating iii.Rapidly increasing head circumferences enlarged fontanels, sunsetting eyes, high pitched cry. iv.Ventriculoperitoneal shunt – shunt to drain CSF from the ventricle into the peritoneal cavity *Monro – Kellie hypothesis - CSF/blood/brain tissue = fixed - cranial compartment is incompressible Spina Bifida i. Spinal cords and the other membranes protrude through a gap in the laminae of the vertebrae ii.Paralysis and sensory loss iii.Monitor ICP, head circumference, prone/sidelying, saline, gauze, check for leaks. iv.Mother – didn’t take folic acid during her pregnancy. v. Types: 1. SB Occulta 2. SB with meningocele – CSF; meninges 3. SB with myelomeningocele – CSF; meninges, SC 4. SB with myeloschisis - open Cerebral palsy i. Resulting from neuromuscular disorder due to damage / altered brain structure that controls motor functions. ii.Therapy: PT/OT; speech therapy iii.Nx Considerations: assist with ADL, help child learn as many self – care activities; safe environment. Cognitive disorders i. Down Syndrome (trisomy 21) 1. Most common genetic disorder causing moderate to severe mental retardation 2. Surgery + supportive care management Skeletal Congenital Disorder i. Talipes Equinovarus (TEV) – Club foot 1. Congenital malformation of the lower extremities that causes abnormal, twisting of the ankles, heels, toes, and feet. 2. Plantar flexed foot with inverted heel and adducted forefoot, unilateral or bilateral defect, rigid limb that can’t be manipulated into neutral position 3. Tx: serial manipulation and casting (6 – 18 mos); surgery (12 – 16mos); use of Dennis brown shoes ii.Congenital Hip Dysplacia 1. Head of the femur is improperly notched in the acetabulum. 2. Hip dislocation, asymmetry of leg position, asymmetric fat folds, and diminished movement on the affected side. 3. Tx: Pavlik’s harness, von rosen splint, stiff shell cast, total hip surgery 4. Types: Dysplastic; dislocated Chromosomal Disorders i. Turner’s syndrome 1. Medical disorder which is the result of a problem with a girl’s chromosome. 2. Short stature(4’7”); lack of sexual development, webbed neck, ptosis, extra fluids in the extremities. 3. Growth hormone treatment; estrogen replacement. ii.Klinefelter’s Syndrome 1. Chromosomal condition that affects male sexual development. 2. Testosterone treatment 3. Clinical manifestation a. Tall stature b. Narrow shoulder c. Small testes d. Infertility e. Gynecomastia f. Wide hips g. Fewer chest hair h. Poor beard growth

Audray Kyle Saydoven

Page 29