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HANDOUTS ON NCM 100 - PEDIATRIC NURSING PREPARED BY: MRS. VERAMAY G. CANDO, RN, MSN NURSING CARE OF A NEWBORN AND FAMILY Newborn or neonate – a baby in the neonatal period (the first 28 days of life) Nursing Diagnoses

Ineffective airway clearance related to mucus in airway Ineffective thermoregulation related to heat loss from exposure in birthing room Imbalanced nutrition, less than body requirements, related to poor sucking reflex Readiness for enhanced family coping related to birth of planned infant Health-seeking behaviors related to newborn needs

The Average Newborn

MLNG CELESTE, RN, MD

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Profile of a Newborn X “All newborns look alike.”  “ Every child is unique.” NEWBORN PRIORITIES IN THE FIRST DAYS OF LIFE 1. Initiation & maintenance of respirations 2. Establishment of extrauterine circulation 3. Control of body temperature 4. Adequate nourishment 5. Waste elimination 6. Prevention of infection 7. Infant-parent relationship 8. Developmental care IMMEDIATE CARE OF THE NEWBORN I. Care of the Newborn at the D.R. A. Establish and Maintain Respiration 1. Suctioning - Turn head to one side - Suction gently and quickly

- Suction the MOUTH first before the nose - Test patency of the airway - Proper position a. Ensure an open airway. b. Do not hyperextend head - place neonate supine - head slightly extended B. Maintain Appropriate Body Temperature *Blot dry/ Rub dry the infant. 1. 2. 3.

Wrap the newborn immediately Wrap him warmly Put him under a droplight

Warmth –At birth, the newborn must begin thermoregulation (maintenance of body temperature). 3 Factors : a. Heat production b. Heat retention c. Heat loss 1. HEAT PRODUCTION Thermogenesis – through o general metabolism o muscular activity o nonshivering thermogenesis (unique to the newborn) Newborns rarely shiver as adults do to increase heat production. Shivering in newborns indicates that the metabolic rate has already doubled. Infant in a cool environment  requires more heat  metabolic rate increases  producing more heat

- Newborn may cry and have muscular activity when cold, but there is no voluntary control of muscular activity. - If the newborn’s temperature is not adequately raised through increased metabolism, nonshivering thermogenesis : the metabolism of brown fat begins. Non Shivering Thermogenesis - the metabolism of brown fat BROWN FAT √ special tissue/ fat found only in newborns √ highly vascularized giving it a brown color √ oxidized to produce or conserve heat √ increasing metabolism √ located at the back of the neck, intrascapular region, thorax, around the kidneys and adrenals, in the axilla, around the heart and abdominal aorta and perineal area √ Once the brown fat has been metabolized, the infant no longer has this method of heat production available. 2. HEAT RETENTION Newborns retain heat by staying in a flexed position. - reduces the area of skin exposed to the environmental temperature, thus decreasing heat loss - peripheral vasoconstriction retains heat

Conservation of Heat 1. Brown fat 2. Kangaroo care – placing the newborn against the mother’s skin and then covering the newborn helps to transfer heat from the mother to the newborn, thus, conserving heat loss 3. HEAT LOSS Newborn - thin skin with blood vessels close to the surface and little subcutaneous fat to prevent heat loss Cold Stress - excessive heat loss increased metabolism  significant increase in need for oxygen  newborn may experience hypoxia ** There may not be enough oxygen for the metabolic rate to increase, and the newborn will not be able to maintain body temperature. Effects of Cold Stress (temp<36.5) 1. Metabolic Acidosis - increased BMR, anaerobic glycolysis, increased acid production, metabolic acidosis 2. Hypoglycemia - increased energy requirement to produce heat - glucose necessary for increased metabolism is made available when glycogen stores are converted to glucose - if the glycogen is depleted, hypoglycemia results 4 MECHANISMS OF HEAT LOSS 1. Convection - flow of heat from the newborn’s body surface to cooler surrounding air 2. Radiation - transfer of body heat to cooler solid object not in contact with the baby 3. Conduction - transfer of body heat to cooler solid object in contact with the baby 4. Evaporation -loss of heat through conversion of liquid to a vapor

OTHER CAUSES OF HEAT LOSS: 1. insulation in newborn is not effective (little subcutaneous fat ) 2. shivering is not present

IMMEDIATE ASSESSMENT OF THE NEWBORN A. ASSESSMENT FOR WELL-BEING APGAR SCORE A ppearance (color) – least important P ulse rate - most important G rimace (reflex activity); irritability A ctivity (muscle tone) R espiration SIGN Appearance/ Color Pulse / Heart rate

0

1

Blue/Pale Acrocyanosis

2 Pink all over; Ruddy

Absent

Slow (< 100)

> 100

Grimace/ Reflex irritability - Response to catheter in nostril - Slap to sole of food

No response

Grimace; weak cry

Cough or sneeze, good strong cry

Activity/ Muscle Tone

Flaccid Some flexion of Well flexed extremites extremities Absent Slow, Good; strong cry >60 irregular<30, weak cry

Respiration / Respiratory Effort

1st minute: general condition (NEURO/RESPI/CIRCULATORY CHECK) 5th minute: adjustment to extrauterine life Apgar Scoring System : Interpretation of Results Score: 9 – highest score; 10 – perfect score 0-3 ------ poor, serious, severely depressed, needs CPR 4-6: ----- fair, guarded, moderately depressed, needs suction 7-10: ---- good, healthy SILVERMANN ANDERSON SCORING (RESPIRATORY DISTRESS)

0 ------ - No respiratory distress 1 -3 ----- slight distress 4-6----- moderate distress 7-10---- seriously distressed !

CONGENITAL ANOMALIES : 1. Choanal Atresia - a complete blockage or severe narrowing of the nasal airway at the posterior nares 2. Tracheobronchial fistula - there is a fistula between the trachea and the distal portion of the esophagus 3. Cleft lip and cleft palate Substances 1. drugs 2. smoking 3. alcohol DUBOWITZ/ BALLARD (MATURITY TESTING TOOL) – 1st 24 hrs. Full Term Preterm Postterm AGA SGA LGA Low birthweight Very Low Birthweight

38-42 weeks AOG < 38 weeks > 42 weeks 10th – 90th percentile <10th percentile > 90th percentile <2500 gm <1500 gm

Extremely Low Birthweight

<1000 gm

IUGR

Rate of growth does not meet expected pattern - growth restriction

Gestational Assessment (Dubowitz) Finding Sole creases

Breast nodule diameter (mm) Scalp hair Ear lobe

Testes and scrotum

0-36

37-38

39 and over

Anterior transverse crease

Occasional creases in ant 2/3

Sole covered w/ creases

2

4

7

Fine and fuzzy

Fine and fuzzy

Coarse and silky

Pliable, no cartilage

Some cartilage

Scrotum empty, few rugae

Testes descended. rugae

Stiffened by thick cartilage pendulous, full scrotum, ext rugae

MLNG CELESTE, RN, MD

NEUROMUSCULAR MATURITY ASSESSMENT CRITERIA

1. POSTURE: With the infant supine and quiet, score as follows: 0 --- Arms and legs extended 1 --- Slight or moderate flexion of hips and knees 2 --- Moderate to strong flexion of hips and knees

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3 --- Legs flexed and abducted, arms slightly flexed 4 --- Full flexion of arms and legs 2. SQUARE WINDOW: Flex the hand at the wrist. Exert pressure sufficient to get as much flexion as possible. The angle between the hypothenar eminence and the anterior aspect of the forearm is measured and scored: -1 ---- >90 degrees 0 ----- 90 degrees 1 ----- 60 degrees 2 ----- 45 degrees 3 ----- 30 degrees 4 ----- 0 degrees 3. ARM RECOIL: With the infant supine, fully flex the forearm for 5 seconds, then fully extend by pulling the hands and release. Score the reaction: 0 --- Remains extended 180 degrees, or random movements 1 --- Minimal flexion, 140-180 degrees 2 --- Small amount of flexion, 110-140 degrees 3 --- Moderate flexion, 90-100 degrees 4--- Brisk return to full flexion, <90 degrees 4. POPLITEAL ANGLE: With the infant supine and the pelvis flat on the examining surface, the leg is flexed on the thigh and the thigh fully flexed with the use of one hand. With the other hand the leg is then extended and the angled scored: -1 --- 180 degrees 0 ---- 160 degrees 1 ---- 140 degrees 2 ---- 120 degrees 3 ---- 100 degrees 4 ---- 90 degrees 5 ----- <90 degrees 5. SCARF SIGN: With the infant supine, take the infant's hand and draw it across the neck and as far across the opposite shoulder as possible. Assistance to the elbow is permissible by lifting it across the body. Score according to the location of the elbow: -1 --- Elbow reaches or nears level of opposite shoulder 0 ---- Elbow crosses opposite anterior axillary line 1 ---- Elbow reaches opposite anterior axillary line 2 ---- Elbow at midline 3 ---- Elbow does not reach midline 4 ---- Elbow does not cross proximate axillary line 6. HEEL TO EAR: With the infant supine, hold the infant's foot with one hand and move it as near to the head as possible without forcing it. Keep the pelvis flat on the examining surface. Score as shown in the diagram above.

PHYSICAL MATURITY ASSESSMENT CRITERIA

PREMATURITY- < 37 weeks AOG Risk Factors: 1. Fetal 2. Placental 3. Maternal 4. Infection Problems: a. Respiratory adaptation b. Susceptibility to infection c. Hyperbilirubinemia d. Cold stress e. Hypoglycemia HYPOGLYCEMIA - Blood sugar <40 mg/100 ml, dependent on maternal supply, Birth, continue to produce insulin Assessment : limpness, jitteriness, apnea, twitching and high pitched cry Complication: mental retardation Tx: early feeding, D10W Nsg: monitor blood glucose level Physical Examination: √ Skin and subcutaneous tissue -thin, transparent √ Increased lanugo √ Decreased plantar creases √ Breast bud scarcely felt

√ √ √ √

Pinna flat and shapeless Scrotum not pigmented Testes not descended Labia majora widely separated

Management √ Maintain patent airway √ Incubator care √ VS monitoring √ Oxygen therapy √ Feeding √ Infection precautions Nursing Intervention √ Meet physiologic needs √ Meet psychological needs √ Foster healthy family relationships √ Provide education POST-TERM (>42 WEEKS) •SIGN: - dry,cracked almost leather like skin, absence of vernix caseosa, fingernails grown well beyond the end of fingertips Complication: 1. may develop polycythemia (oxygenation) 2. hypoglycemia PROPER IDENTIFICATION – done in D.R. before being brought to the Nursery a. Footprints – most reliable  b. ID bands – ankle, wrist c. Birthmarks

IMMEDIATE CARE OF THE NEWBORN IN THE NURSERY * Note that ID bands of mother and baby are matched. Special Care 1. Initial Bath – temp stabilizes 36.5ºC 6-8 hrs after birth √ vernix caseosa - use oil √ warm water during the 1st week √ Don’t use soap 2. First bath –For the next 10 days to 2 weeks – sponge bath. –NB are not generally given tub bath until the cord has fallen off and healing is complete –Nurse giving the first bath to NB must wear gloves to comply with standard precautions regarding contact with blood or body fluids 3. Taking the Temperature √ Maintain temperature to prevent cold stress √ Use Rectal route √ Meconium - 24-48 hrs

Initial Cord Dressing √ Inspect for A .V. A. √ aseptic technique √ Povidone (Betadine); 70% Isoprophyl alcohol - prevent Tetanus Neonatorum and Omphalitis (streptococcal and staphylococcal)

Signs of Omphalitis: 1. Reddening of the area 2. Fever 3. Discharge or foul smell * Application of sterile cord clamp - prevent bleeding within 1st 24 hours (Omphalangia) 4. Crede’s Prophylaxis * Legal requirement for all NB (US) * Infection - acquired during delivery from a mother with untreated gonorrhea Medications: a. Ophthalmic drops – Silver Nitrate or AgNO3 1% 1-2 drops - lower conjunctival sac - wash with sterile NSS after 1 minute to prevent chemical conjunctivitis b. Ointment 1. Terramycin 2. Gentamycin 3. Chloramphenicol 4. Erythromycin Erythromycin √ pull eyelids downward √ 0.5-1 cm √ Inner to outer canthus √ Wipe excess away 5. Vitamin K Injection - sterile GIT - facilitates production of clotting factor - 1 mg. Aquamephyton - IM - lateral anterior thigh (Vastus lateralis)

6. Take Anthropometric Measurements (Vital Statistics) BW: 2.5 – 3.4 kgs (5.5 – 7.5 lbs)

* 1 K = 2.2 lbs BL: 47.5 – 53.75 cm (19 – 21 ½ in) Average: 50.8 cm/20 in * 1 inch = 2.54 cm

ANTHROPOMETRIC MEASUREMENT 1. Length : mature female neonate-53 cm(20.9 in); mature male- 54cm(21.3in) 2. Head circumference: mature newborn-34-35 cm (13.5 to 14 in) - measure with the tape measure drawn across the center of the forehead and around the most prominent portion of the posterior head) 3. Chest circumference: term newborn – 2 cm less than head circumference, measured at the level of the nipple

PHYSIOLOGIC WEIGHT LOSS - 5-10 % in 10 days Causes 1. No longer under influence of maternal hormones 2. Voids and passes out stools 3. relatively low nutritional intake 4. beginning difficulty establishing sucking Initial Feeding o 1-6 hours after birth o 1 oz of sterile water o Subsequent feeding – by demand o Breastfed infant recaptures birth weight within 10 days o Formula fed infant recaptures weight gain with in 7 days o Then continues to gain weight of 2lb/month( 6-8oz/ wk) for the 1st 6 months of life Breastfeeding Advantages: 1. bonding 2. uterine contraction 3. colostrum 4. Contraceptive 5. Cheap 6. Right temperature 7. Antibacterial – Lactoferrin, Lactobacillus bifidus, lysozyme, macrophage, T lymphocytes, Lactoperoxidase

Differences Between Human and Cows Milk NUTRIENTS

HUMAN MILK

COW’S MILK

CHON Fats Carbohydrates

8% 50% 42%

20% 50% 30%

Na K Ca Phosphorus Cl

7 mEq/l 14 mEq/l 12 mEq/l 9 mEq/l 12 mEq/l

25 meq/l 36 mEq/l 61 mEq/l 53 mEq/l 34 mEq/l

MLNG CELESTE, RN, MD

Nutrients

Human milk Cows milk

Fe

0.5

87

0.5

Linoleic acid (+)

(-)

Vit D

22

14

Vit A

1898

1025

Vit C

43

11

Vit K

15

60

MLNG CELESTE, RN, MD

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Contraindications of breastfeeding: 1. An infant with galactosemia ( can’t digest lactose in milk) 2. Herpes lesion on a mother’s nipple 3. Maternal diet is nutrient restricted, preventing quality milk production 4. Maternal medication inappropriate for feeding 5. Maternal exposure to radioactive compounds

•Advantages of breastfeeding : to the baby 1. contains secretory immunoglobulins A 2. Contain lactoferrin ( iron-binding chon in breast milk that interferes with growth of pathogenic bacteria 3. Contains antibodies 4. Reduces incidence of diarrhrea: ( presence of L.Bifidus interferes with colonization of pathogenic bacteria in the GIT) 5. Contains high amount of mineral and electrolytes 6. Contains more linoleic acid ( essential fatty acid for skin integrity and less Na,K,Ca and phosporous) Advantages of breastfeeding : to mother 1. Serves as protective function in preventing breast cancer 2. Release of oxytocin from the post. Pit. Gland aids in uterine involution 3. Successful breastfeeding can have an empowering effect, skill only women can master 4. Breastfeeding reduces the cost and preparation time 5. Provides an excellent opportunity to enhance true symbolic bonding between mother and child

BREASTFEEDING –Position for feeding -The infant should be held with head slightly higher than the rest of the body -Cradle hold with infant’s head in the bend of the mother’s elbow and arm supporting the infant’s body OTHERS: o Football hold o Side lying position o Across lap Breastfeeding o Latching on o The mother should use the infant's rooting reflex to allow positioning of the nipple in the infant’s mouth o Brushing the nipple against the infant’s lower lip will cause the infant to open the mouth. o When the mouth is wide open and the tongue is down, the mother quickly brings the infant closer to the breast so the infant can latch on the nipple and areola. o Breastfeeding Length of feeding -Varies with each mother /infant unit BREASTFEEDING • • • • • • • • • • • • • •

Non-allergenic Meet infant ‘s specific nutritional needs Immunologic properties help prevent infection Easily digested Constipation unlikely Overfeeding less likely No formula or bottles to buy No formula and bottle to prepare Oxytocin release help involution Mother more likely to eat well balance diet May help with mother’s weight loss Enhances mother/infant attachment through skin to skin contact Frozen -20c (6 mos) Refrigerated 4c ( 24 H)

BOTTLEFEEDING • • •

Father or others may feed infant day or night Feed less frequently (3-4H) Amount of milk taken at each feeding known

D I S A D V A N T A G E S

BREASTFEEDING

BOTTLEFEEDING

•Feed more frequently (2-3 H) •More frequent diaper changes •Amount of milk taken at each feeding unknown •Medications taken by mother present in milk •Discomfort of som mothers to nurse in public •Expense of pumping and storing milk for periods when mother is unavailable ( such as work)

•Expense of formula, bottles •Washing bottles •Fixing and refrigerating formula •Carrying bottles on outings •May cause constipation

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BURPING ALL INFANTS REQUIRE BURPING TO EXPEL THE AIR SWALLOWED WHEN THE INFANT SUCKS SOME INFANT SWALLOW MORE AIR THAN OTHERS AND REQUIRE MORE FREQUENT BURPING. Physical Assessment 1. Vital Signs a. Pulse - 1 full minute; use apical pulse - irregular, rapid >160-180 at birth - NORMAL: 120–160 bpm - During sleep - 90-110 bpm - If crying, up to 180 bpm Pulse : heart rate in utero- 120 t0 160bpm after 1 hr newborn settles, heart rate stabilizes to an average of 120 to 140 bpm - remains irregular because of immaturity of cardiac regulatory center in the medulla - crying, rate might increase to 180 bpm, 90 to 110 bpm during sleep - femoral pulses are more appreciated than radial and temporal pulses ( always palpate for the femoral pulses; their absence suggests coarctation of aorta) b. Respirations - 1 full minute - irregular, shallow, rapid w/ brief apneic spells < 15s - 60-80 breaths/min at birth - NORMAL: 30–60/minute - Respiration : average is 30 to 60 breaths per minute - respiratory rate, rhythmn, depth are likely to beirregular and short periods of apnea (periodic respiration) are normal - coughing and sneezing are present at birth to clear the airway - newborns are obligate nose-breathers c. Blood Pressure - not usually measured *not routinely obtained except for suspicion of Coarctation of the Aorta. 80–60/45–40 mm Hg at birth 100/50 mm Hg at day 10 d. Temperature Normal range: 36.5C–37.5C (axilla) Axillary: 36.4C–37.2C

Skin: 36.0 C–36.5C Rectal: 36.6C–37.2C * Temperature 37.2 at birth Crying - increase body temperature slightly Radiant warmer - falsely increase axillary temperature √ √ √ √

General appearance Skin √ Ears Head √ Neck Eyes √ Chest

√ Abdomen √ Genitalia √ Back

√ Extremities

I. SKIN 1. 2. 3. 4. 5. 6. 7. 8.

Dark red – prematurity Acrocyanosis – up to 48 hours Central cyanosis – indicates decrease O2 Generalized mottling Gray color - infection Pale color - anemia Yellow color –jaundice Harlequin sign – pale and pink

Pallor * Excessive blood loss when cord is cut * Untimely cutting of the cord * Inadequate iron stores because of poor maternal nutrition * Blood incompatibility Jaundice ; Types: 1. Physiologic Jaundice / Icterus Neonatorum 2nd day – 7th day - TERM 2nd day – 10th day - PRE-TERM Causes: a. Hemolysis b. Decreased conversion of bilirubin to urobilirubin c. Decreased uptake of free bilirubin by hepatic cells 2. Pathologic Jaundice before the first 24 hours of life Most accurate method of assessing the presence of jaundice: Use natural light and blanch skin on the chest or tip of the nose. Normal total serum bilirubin = 15% Direct bilirubin = 1.7 Indirect bilirubin = 13.2 Causes:  a. Infection  b. Hemolytic disorders c.Inability of the newborn to conjugate bilirubin

Breastfed babies have longer physiologic jaundice because human milk has PREGNANEDIOL which depresses the action of glucoronyl transferase (enzyme responsible for converting indirect bilirubin to direct bilirubin) KERNICTERUS –Accumulation of bilirubin in the brain tissues –SEIZURES

–MENTAL RETARDATION –EXCHANGE TRANSFUSION Management Goal of treatment: to decrease the bilirubin levels 1. Early feeding 2. Phototherapy (Bililight) - Cover eyes with opaque mask to prevent blindness. - distance - 18-20 in from source of light. - Monitor V/S especially temp - Cover genitalia to prevent PRIAPISM (continuous erection). - Adequate hydration - Turn NB q 2º to expose all body surfaces Common Marks 1. Harlequin Sign

→BECAUSE OF IMMATURITY OF CIRCULATION, AN INFANT WHO HAS BEEN LYING ON HIS SIDE WILL APPEAR RED ON THE DEPENDENT SIDE & PALE ON THE UPPER SIDE.

2. Mongolian spots → bluish gray or dark nonelevated pigmentation area over the lower back and buttocks present at birth, primarily nonwhite, disappear at SCHOOL AGE 3. Milia →Unopened sebaceous glands; tip of nose and chin of the baby.

→Newborn sebaceous gland is immature. At least one pin-point white papule (a plugged or unopened sebaceous gland) can be found in the cheek or across the bridge of the nose of every newborn. →Disappears by 2-4 wks of age as the sebaceous glands mature and drain.

→Parents should be instructed to avoid scratching or squeezing the papules to prevent secondary infection. 4. Lanugo →Fine downy, hair that covers a newborn’s shoulder, back and upper arms

→Found also in the forehead and ears. →The newborn of 37-39 wks has more lanugo than the 40th wks old infant. →Post-mature infants have rarely have lanugo →By age of 2 wks, It disappears 5. Desquamation →peeling; at birth, postmaturity

→Within 24 hrs. of birth, the skin of most newborns has become extremely dry →The dryness is particularly evident on the palms of the hands and soles of the feet. → This is normal and needs no treatment. 6. Vernix Caseosa →White, cream-cheese-like substance that serves as a skin lubricant, usually noticeable on a newborn skin. Prominently seen in the skin folds, at birth in a term neonate. 7. Portwine Stain or Nevus Flammeus →birth; red to purple color, usually flat discoloration commonly on the face or neck; does not grow and does not fade; does not blanch on pressure nor disappear 8. Strawberry Mark or Nevus Vascularis

→2nd most common type of capillary hemangioma. elevated, sharply demarcated or bright or dark red, rough surface swelling. (+) school age or even longer. 9. Erythema Toxicum or Erythema Neonatorum →Newborn rash or fleabite rash/ dermatitis; transient; papules with vesicles at nape, back and buttocks. →It usually appears in the 1st to 4th day (2nd day) of life, but may appear up to 2 wks of age

→One of the chief characteristic of the rash is the lack of pattern; disappears without treatment. 10. Nevi →Stork bites or Telangiectasia Nevi; pink or red flat areas of capillary dilatation at upper eyelids, nose, upper lip, lower occiput bone, nape and neck. Can be blanched by the pressure of the finger; usually fade during infancy- 1st and 2nd year. 11. Cutis Marmorata →transitory mottling when exposed to cold 12. FORCEPS MARK →There may be a circular or linear contusion matching the rim of the blade of the forcep on the infant’s cheek. →The mark disappears in 1-2 days along with the edema that accompanies it. II. HEAD →Largest part of the human body (1/4 of his total body length);

→-forehead is large and prominent; →-chin is receding when startled or crying. Fontanelles 1. Anterior – diamond shape; o closes 12-18 months; 3-4 cm long/2-3 cm wide o junction of 2 parietal bones and 2 fused frontal bones o not indented depressed o suture lines - never appear widely separated 2. Posterior o triangular in shape o junction of the parietal bones and the occipital bones. o 1 cm o closes by end of 8th-12th week of life Sutures 1. Lambdoid (2) 2. Coronal (2) 3. Frontal (1) 4. Sagittal (1)

CRANIOSYNOSTOSIS - suture lines separated or fontanels prematurely closed; leads to mental retardation Molding –overlapping of sagittal and coronal suture line Craniotabes – localized softening of cranial bones; indented by pressure of a finger. Corrects w/o t treatment in weeks or months. Common to first borns because of early lightening

MLNG CELESTE, RN, MD

134

Comparison between Caput Succedaneum and Cephalhematoma Indicators

C. Succedaneum

Cephalhematoma

Edema of scalp

blood b/w

Presenting part of the head Both hem; (+) cross suture lines Pressure (as in prolonged labor)

periosteum of skull bone & bone individual bone; (-) cross suture line Pressure (rupture of capillaries)

Period of absorption

On or about the 3rd day or 4th days

Takes several weeks - months

Treatment

MLNG CELESTE, RN, MD

None

Support

Definition Location Extent of Involvement Cause

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III. EYES - Eyelids of equal size - temporarily gray or blue in color (d/t thinness) - Cry tearlessly 1st 3 months - Cornea round and adult sized - Pupils round, not keyholed (Coloboma) - cross-eyed (Strabismus) - see object at 8 inches; V.A. of 20/200 to 20/500 IV. EARS -Top of ear should align with inner and outer canthus of the eye - sense of Hearing – highly developed in NB Preauricular skin tag

- these represents remnant of the first branchial arch. Although they are often of little significance, they may be seen in serious malformations of branchial arch development involving multiple structures of the head and neck. Surgical removal may be indicated for cosmetic purposes

V. NOSE - Nasal obligates - Note for marked flaring of alae nasi, indicative of airway obstruction Causes of obstruction: 1. Secretions 2. Septal deviation - Sense of smell – least developed VI. MOUTH - open evenly when crying. If not, suspect CN VII Paralysis (Bell’s Palsy). - Palate intact; no breaks on the lip - cleft palate; cleft lip - Eptein’s Pearls – small round glistening cysts; palate and gums, d/t extra load of maternal Ca – If with tooth (NATAL TOOTH= not covered with gum membrane) should be extracted to prevent aspiration

Oral thrush – white gray patches on the tongue and sides of cheeks due to Candida albicans acquired during the passage of the baby through the birth canal of his mother who has untreated MONILIASIS; ORAL MONILIASIS. VII. NECK - Thyroid gland not palpable - soft, palpable and creased with skin folds - Head - rotate freely on the neck and flex forward and back. (+) rigidity of the neckCONGENITAL TORTICOLLIS (injury to SCM- sternocleidomastoid) -NB whose membranes ruptured 24 hours before birth, nuchal rigidity suggests meningitis. VIII. CHEST - As large as or smaller than the head - Symmetrically expands (retraction indicates respiratory distress) - Breasts may be engorged (due to maternal hormones) There could be passage of thin, transparent watery fluid known as WITCH’S MILK. IX. ABDOMEN - Dome shaped; - If scaphoid - DIAPHRAGMATIC HERNIA - Bowel sounds should be present within 1 hour after birth - Liver, spleen and kidneys are palpable at birth. X. EXTREMITIES - symmetric and of equal length - Fingers and toes equal count Supernumerary = polydactyly; fused or webbed = syndactyly Simean line

- Asymmetrical movement of upper and lower extremities - ERB – DUCHENE PARALYSIS - congenital hip dislocation: Ortolani’s Maneuver - Observe for clubfoot deformities SIMEAN CREASE

CONGENITAL HIP DYSPLASIA/DISLOCATION

→0.1% of infants →with a predilection for females to males of 5:1 →infants with a family history (first-degree relative affected) of CHD, the incidence is 10 times higher →also higher in infants born in the breech position and infants with certain other congenital abnormalities, including torticollis, clubfoot, metatarsus adductus, and hyperextension of the knee A. Ortolani test →In this maneuver, the infant is examined in the supine position.

→The examiner holds the infant's pelvis with one hand to stabilize it during manipulation. →The examiner then slowly and gently abducts the infant's opposite hip with the other hand, pulling the femur forward and using the greater trochanter as a fulcrum. →In the infant with an unstable hip, the examiner will feel a sudden shifting sensation and may hear or feel a "clunk" simultaneously as the hip reduces anteriorly.

→

→Ortolani’s Test B. Barlow test

In this maneuver, the infant is examined in the supine position. The examiner holds the infant's pelvis with one hand to stabilize it during manipulation. With the other hand, the examiner holds the infant's opposite hip in the adducted, flexed position while exerting gentle pressure over the lesser trochanter.

In the infant with an unstable hip, a similar "clunk" may be felt as the hip subluxes posteriorly.

* Assessment on the R and L hips may be done simultaneously

Clubfoot

A birth deformity in which the front portion of the foot is deformed and turned inward. It can be benefited greatly by surgery. XI. ANOGENITAL AREA 3 types of stools passed by NB: 1. Meconium – Greenish-blackish viscous; - amniotic fluid, intestinal secretions and cells shed from mucosa, take note of time when meconium first passed 2. Transitional – passed from 3rd to 10th day 3. Milk stool a. Breast fed infant stool – loose golden yellow in color with sweet odor; 2-3 times a day b. Bottle fed infant stool – formed, pale yellow w/ a typical odor; usually passed 1-2 times a day Lack of passage of stool on first few days indicates an inborn error of metabolism. Ex., Cystic fibrosis, Hirschsprung’s or Aganglionic Megacolon XII. FEMALE GENITALIA – Swollen labia and pass a slightly bloody vaginal discharge -“PSEUDOMENSTRUATION” Male Genitalia – Scrotum may be edematous due to maternal hormones. - Testes should be present; if undescended - CRYPTORCHIDISM Conditions for Cryptorchidism: 1. Agenesis – absence of an organ 2. Ectopic testes – Testes cannot enter the scrotum because opening of the scrotal sac is closed.

3. Vas deferens or artery is too short to allow the testes to descend. CIRCUMCISION – prior to discharge from nursery, preferably end of 1st week Procedure: 1. Vitamin K injected IM 2. Infant is restrained; penis is cleansed with soap and water 3. clamp is used 4. Petroleum gauze dressing is applied to prevent adherence of circumcised site to the diaper while applying pressure to prevent bleeding Nursing Care: - Check hourly for bleeding - Do not attempt to remove exudates which persist for 2-3 days; just wash with warm water. - Diaper must be pinned loosely during the 1st 2-3 days when the base of the penis is tender. XIII. BACK - On prone appears flat - Note for mass, hairy nodule and dimple along axis - Spina Bifida.

III. DISCHARGE INSTRUCTIONS a. Bathing b. Cord Care c. Nutrition Calories 120 kcal/kg body weight/day CHON 2.2 gms/KBW/day Fluids 160-120 cc/KBW/day Vitamins A,C, D for formula and breastfed babies Common Health Problems 1. Constipation 2. Loose stools 3. Colic Causes: Overfeeding Gas distention Too much carbohydrates

Management Feed by demand Burp infant Feed in upright position May need to change formula

Diaper Rash Miliaria Seborrheic Dermatitis Occasional “Crossed Eyes” Clothing Sleep Pattern SYSTEMIC EVALUATION (PHYSIOLOGIC FUNCTION) I. CARDIOVASCULAR SYSTEM

Fetal Circulation –Oxygen exchange occurs in placenta –pressure on the left side of the heart < right side –(+) accessory structures Accessory Structures a. Foramen ovale b. Ductus arteriosus c. Ductus venosus d. Umbilical vein e. Umbilical arteries 1.Cardiovascular system →changes in the cardiovascular system are necessary because the lungs must oxygenate the blood that was formerly oxygenated by the placenta. →As the lung inflates for the 1st time, pressure decreases in the chest, decreased pressure in the pulmonary artery leads to closure of ductus arteriosus, as pressure increases in the left side of the heart from increased blood volume, closure of foramen ovale ensues.

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Several circulatory changes are necessary for successful changes from FETAL circulation to NEONATAL circulation A. Pulmonary Blood vessel dilation - begins at first breath. - results : lower pulmonary resistance this allows the blood to freely circulate through the lungs to be oxygenated. B. Ductus Arteriosus - reversal blood flow increased pressure in aorta and increased O2 in the blood more blood flowing through the pulmonary arteries for oxygenation. - closure complete w/in 24H - permanent : 3-4 weeks

C. Foramen Ovale →closes within minutes after birth  because of the higher pressure in the LA than in the RA  increase blood flow in the lungs  decreases pressure in the RA the return of blood from the lungs increases the pressure in the LA

→Closure : permanent approximately 3 months D. Ductus Venosus Cord clamped blood ceases flowing from umbilical vein to ductus venosus and into IVC  blood now flows through the LIVER and is filtered as in adult circulation Increased pressure on the left side of the newborn’s heart results in: √ Closure of the foramen ovale (fossa ovale) √ Change of the ductus arteriosus into a mere ligament (ligamentum arteriosum) √ Ductus venosus becomes ligamentum venosum √ Since no more blood goes through the umbilical vein and arteries, these blood vessels atrophy and degenerate

√ Umbilical vein, umbilical artery, and ductus venosus – no longer receive blood,these atrophy over the next few weeks

√ (+) acrocyanosis ( cyanosis of infant feet and hands) for the 1st 24hrs due to sluggish peripheral circulation NEONATAL/ ADULT CIRCULATION With 1st breath, oxygenation takes place in lungs Lung expansion occurs Increase pressure on left side of heart > right side results in: Closure of accessory structures and obliteration of umbilical vessels

Blood Values: o blood volume- 80 to 110 ml per kg of body weight or about 300 ml total o (+) leukocytosis - about 15,000 to 30,000 cells/mm3

This is response to trauma in birth and is non- pathogenic( predominantly of neutrophils). Increased WBC count should not be taken as evidence of infection

Blood Coagulation –(+) prolonged coagulation or prothrombin time due to lower vit. K Most newborn are born with a prolonged coagulation or Prothrombin time, because their blood levels of Vitamin K are lower than normal. It takes 24 hrs. for flora to accumulate and vitamin K to be synthesized Vit. K is needed to synthesize: 1. Factor II- prothrombin 2. Factor VII- proconvertin 3. Factor IX- plasma thromboplastin 4. Factor X- Stuart –power factor II. RESPIRATORY SYSTEM First breath is initiated by:  combination of cold receptors  lowered partial pressure of oxygen(PO2)  increased partial carbon dioxide pressure (PCO2)

After the 1st breath ,breathing becomes much easier for a baby requiring only 6 to 8cm h20 pressure BREATHING In utero – fetus relied on PLACENTA and Mother’s respirations for gas exchange

11th wks AOG – chest wall muscle and diaphragm developed 35th wks AOG – surfactant produced by alveoli is sufficient in amount (L/S ratio: 2:1) to allow the alveoli to remain partially expanded when the newborn begins to breathe at birth . For Lungs to function 2 changes must happen: a. Pulmonary ventilation must be established with lung expansion at the first breath b. Pulmonary circulation must be greatly increased. THE INITIATION OF BREATHING is influenced by 4 factors 1. Physical 2. Chemical 3. Thermal 4. Sensory 1. Physical factor aka… Mechanical Factors include: Compression of the chest as it moves through the birth canal- squeezes fluid from the lungs  increase intrathoracic pressure chest wall recoil (w/c occur as the newborn trunk emerges) thus creating negative pressure ( w/c causes a small amount of air to replace the fluid that was squeezed out of the lungs and some lung fluid to move across the alveolar membranes into the interstitial tissue of the lungs.

ALL OF THE ALVEOLAR FLUID IS ABSORBED WITHIN THE FIRST DAY AFTER BIRTH

Chemical factor Cord is clamped

Placental gas exchange ceases Cause : increase PaCo2 decrease Pa02 & pH

Transitory asphyxia

Stimulate : carotid & aortic chemoreceptor Send impulses to the respiratory center in the medulla

Stimulate respiration Initiation of breathing MLNG CELESTE, RN, MD

193

3. Thermal factor The change in temperature from the intrauterine environment to extrauterine environment

A decrease of more than 20F is stimulus to breathing. Colder temperature stimulates nerve endings and the newborn breaths as a response. Cold stress and respiratory depression result from excessive cooling of the newborn Sensory factor –The auditory –Visual –Tactile

STIMULATION ASSIST IN THE INITIATION OF RESPIRATION

III. NEUROMUSCULAR SYSTEM 1. Blink reflex - to protect the eyes from any object coming near it by rapid eyelid closure 2. Rooting reflex- cheek is brushed or stroked near the corner of the mouth, a newborn infant turns the head on that direction, disappears in about six weeks of life

3. Sucking reflex - when newborn’s lips are touched, the baby makes sucking motion, diminishes within 6 months of life 4. Swallowing reflex - food that reaches the posterior portion of the tongue is automatically swallowed 5. Extrusion reflex - substance that is placed on the anterior portion of the tongue is extruded, prevents the swallowing of inedible substance, disappears with in 4 months of age 6. Palmar grasp reflex - newborn grasp an object placed in their palm, disappears about 6 wks to 3 months 7. Step-in-place reflex - newborn who is held in a vertical position with their feet touching a hard surface will take few alternating step -disappears by 3 months of age 8. Placing reflex - same as step in place reflex except that it is elicited by touching the anterior surface of newborn legs against hard surface, newborn makes a quick lifting motion 9. plantar grasp reflex - when an object touches the sole of a newborn’s foot at the base of the toes, the toes grasp in the same manner as the finger do; disappears about 8 to 9 months 10. tonic neck reflex - when the newborn lies on his back, the head usually turns to one side , arm and leg on that side extend and the opposite arm and leg contract, disappears 2nd or 3rd month of life . aka Fencing reflex 11. Moro reflex - can be stimulated by startling the newborn with loud noise or by jarring the bassinet, fades on 4th or 5th month of life . Aka Startle Reflex – elicited by sudden disturbance in the infant’s immediate environment, body will stiffen, arms in tense extension followed by embrace gesture with thumb and index finger a “c” formation (disappears by 6 mo) 12. Babinski reflex – when the side of the sole of the foot is stroked, fanning of the toes (+) will result. Stroking the sole of the foot from heel upward like an inverter “J” across ball of foot will cause all toes to fan (reverts to usual adult response by 12 mo)

13. Magnet reflex - if pressure is applied to the sole of the foot while the newborn is lying in supine position, he pushes back against the pressure; test for spinal cord integrity 14. Crossed extension reflex - if one leg of the newborn lying supine is extended and the sole of that foot is irritated by being rubbed, infant raises the other leg and extends it as if trying to push away the hand irritating the first leg 15. Trunk incurvation reflex - newborn lies on prone position and is touched along the paravertebral area by probing finger, newborn flexes his trunk and swings the pelvis toward the touch. aka Gallant Reflex 16. Landau reflex- a newborn who is held in a prone position with a hand underneath supporting the trunk should demonstrate some muscle tone (+) 3-6 months * Aka Parachute Reflex (+) 6-9 months 17. Deep tendon reflexes - patellar reflex can be elicited in newborn by tapping the patellar tendon with the tip of the finger, test for spinal nerve L2-L4 - bicep reflex - place the thumb of your left hand on the tendon of bicep muscles, test for C5 and C6 III. Gastrointestinal System Newborns stomach holds about 60-90 ml in 1 week of life. GIT of newborn is sterile at birth Has limited ability to digest fat and starch because the pancreatic enzymes, lipase and amylase, are deficient for the 1st few months of life. Meconium – mucus, vernix, lanugo, hormones - if not pass stool within 24 to 48 hrs there is possibility of meconium ileus, imperforate anus or bowel obstruction. Transitional stools – 2-10 days of life Breastfed babies stools Formula fed babies stools a. Breast fed infant stool – loose golden yellow in color with sweet odor; 2-3 times a day b. Bottle fed infant stool – formed, pale yellow with a typical odor; usually passed 1-2x a day

newborn under phototherapy- has bright green stool due to increase excretion of bilirubin newborn with bile duct obstruction- has clay-colored stool blood flecked stool- newborn with anal fissure IV. URINARY SYSTEM The average newborn voids within 24 hrs after birth Newborns who do not void within this time should be examined for the possibility of ureteral stenosis or absent kidneys or ureter A single voiding in a newborn is only about 15 ml The daily urinary output for the 1st 1-2 days is about 30-60 ml total. The 1st voiding may be pink or dusky because of uric acid crystals that were formed in the bladder in utero first voiding maybe pink or dusky ,small amount of protein maybe present( immature glomeruli)

Females – strong urine stream

Males – projected arc

newborn should void within 24hrs, amounting 15 ml specific gravity from 1.008 to 1.010 daily urine output for the 1st to 2nd day is about 30 to 60 ml, by week 1,total volume rises to 300ml CONGENITAL MALFORMATIONS OF THE URINARY TRACT A. EPISPADIAS - urethral opening on the dorsal surface of the penis

B.HYPOSPADIA Male urethral opening on the ventral surface of penis, or female urethral opening in vagina

V. IMMUNE SYSTEM The newborn is prone to infection Due to difficulty forming antibodies against invading antigen until they are about 2 mos. of age. This inability to form antibodies early also is the reason that most immunization against childhood diseases are not given to infants younger than 2 mos. Passive antibodies from the mother that have crossed the placenta are protective to a certain extent.

Passive natural immunity – mother to child (+) Ab from the mother against Polio, DPT, Rubella and Measles * immunization starts usually at 2 mos

Expanded Program on Immunization Vaccine

Age at 1st dose

Dose

Number of Doses

Min Interval

Possible Reaction

BCG

At birth

0.05 ml ID

1

 

DPT

6 wks

0.5 ml IM

3

4 wks

OPV

6 wks

2 drops

3

4 wks

Keloid, suppurative adenitis Fever, restlessness, irritability Paralytic polio rare

Hepa B

6 wks

0.5 ml IM

3

4 wks

Measles

9 mos

0.5 ml SC

1

 

MMR

12-15 mos

0.5 ml SC

1

 

Arthralgia Neuro reactions rare Fever and rash 5-10 days after dose Fever, rash,arthralgia, lymphadenopathy, rare – febrile seizures, nerve deafness, encephalitis

VII. SENSES

1. Sight – at birth (9 inches) 2. Hearing-at birth 3. Taste – at birth 4. Smell-at birth 5. Touch-at birth (well developed)

SENSES Sight – all newborns can see at birth although they cannot see objects past the visual midline (not until 6-8 weeks). The visual field is 20-22 cm or 9 inches. Hearing – as soon as amniotic fluid has been absorbed, the newborn can already hear Taste – as soon as secretions have been suctioned, newborns can already taste Smell – as soon as the nose has been cleared of mucus and fluid, newborns can smell Touch – the most developed of all the senses 1. hearing- becomes acute after birth, recognizes mothers voice immediately functional @ birth as soon as the external ear canal is cleaned 2. vision- focus best on black and white at distance of 9 to 12 inches. Not well developed at birth 4 months of age – clear vision. 7 y/o = 20/20 vision 3. Tactile (touch) starts in early prenatal life on face, then spreads to limbs and finally to the trunks in cephalocaudal succession.

Pain sensation – not well developed in NB last a week Response to pain – generalized movement & crying 7-9 months – can localize the site of pain and withdraw from it. 12-16 months – shoves painful away and bring hand to irritated area 4. Taste – can taste but unable to distinguish flavor 3 months – acute taste discrimination is achieved

5. Olfactory – observed at birth more acute at later age Newborn Screening Act of 2004 REPUBLIC ACT NO. 9288 “…ensure that every baby born in the Philippines is offered the opportunity to undergo newborn screening and thus be spared from heritable conditions that can lead to mental retardation and death if undetected and untreated.” NB screen Should be done after 24-48 hours of life After the infant is fed  done through extraction of blood in the heel of the foot

1. CONGENITAL HYPOTHYROIDISM √ Thyroid hypofunction or enzyme defect √ reduced T3, T4 √ Females S/sx a. excessive sleeping, b. enlarged tongue, c. noisy respiration, d. poor suck, e. cold extremities, f. slow pulse and respiratory rate, g. lethargy and fatigue,

h. short and thick neck, i. dull expression, j. open mouthed, k. slow DTR, l. obesity, m.brittle hair, n. delayed dentition, o. dry, scaly skin

Dx: low T3 T4, inc TSH Mx: synthetic thyroid hormone Nsg Care: Assist parents administer drugs 2. CONGENITAL ADRENAL HYPERPLASIA -inability to synthesize cortisol  inc. ACTH stimulate adrenal glands to enlarge  inc androgen. S/sx: masculinization, sexual precocity Mx: Steroids to decrease stimulation of ACTH

3. G6PD DEFICIENCY Glucose 6 phosphate dehydrogenase Deficiency Reduction in the levels of the enzyme G6PD in RBC leads to hemolysis of the cell upon exposure to oxidative stress Dx: blood smear – heinz bodies rapid enzyme screening test, electrophoresis Mx: avoid drugs ie ASA, sulfonamides, antimalarials, fava beans

4. GALACTOSEMIA (-) enzyme that converts galactose to glucose Galactose 1 phosphate uridyltransefrase S/sx: wt loss, vomiting, hepatosplenomegaly, jaundice and cataract Dx: Beutler test Tx: dec lactose – soy based formula regulate diet

5. PHENYLKETONURIA (PKU) - dec phenylalanine hydroxylase w/c converts phenylalanine to tyrosine

S/sx: mental retardation, musty odor, blond hair, blue eyes Dx: Guthrie bld test Tx: dec phenylalanine (Lofenalac), regulate diet

COMMON ILLNESSES OF THE NEWBORN A. Respiratory distress syndrome - HMD ( hyaline membrane disease) Common: 1. preterm infant 2. infant of diabetic mother 3. meconium aspiration 4. infants born by cesarean birth 5. those with decreased blood perfusion of the lungs Pathologic feature: hyaline-like (fibrous) membrane formed lines the terminal bronchioles, alveolar duct,and alveoli prevents exchange of O2 and CO2 at alveolar-capillary membrane respiratory acidosis Cause of RDS: low level/ absence of surfactant (phospholipid that lines the alveoli and reduces surface tension on expiration to keep the alveoli from collapsing) S/Sx: Initial 1.low body temperature 2. Nasal flaring 3. sternal and subcostal retraction 4. tachypnea 5. Cyanotic mucous membrane

Late: 1. seesaw respiration 2. heart failure 3. pale gray skin 4. periods of apnea 5. bradycardia 6. pneumothorax

diagnosis:  clinical sign of grunting, cyanosis in room air, nasal flaring, retractions and shock  chest X-ray reveals diffuse pattern of radioopaque areas (ground glass/ haziness) management 1. Surfactant replacement (ET tube) 2. Oxygen administration- Cx in very immature infant is retinopathy of prematurity 3. ventilation- normally I/E ratio is 1:2,there is difficulty in supplying O2 to stiff noncompliant lung, so in infant ventilators, it is reverse - can give Indomethacin prevention: √ usually happens on preterm infant; (tocolytic agents; preterm labor; √ steroids-quicken the formation of lecithin) √ Betamethasone- 12 & 24 hrs before birth; between wks 24 - 34

TRANSIENT TACHYPNEA OF NEWBORN  results from slow absorption of lungs fluid , reflects slight decrease in production of mature  surfactant  limits the amount of alveolar surface area available for oxygenation  infant tends to have increased RR and depth  peaks in intensity at approx. 36hrs of life, and by 72hrs of life spontaneously fades as lung  fluid is absorbed Common in:

1. Infant born via CS 2. Infants whose mother received extensive fluid administration during labor 3. Preterm infants Management: 1. close observation 2. O2 administration

MECONIUM ASPIRATION  infant may aspirate meconium either in utero or in first breath after birth.  cause severe respiratory distress in 3 ways: o causes inflammation of bronchioles because it’s a foreign substance o blocks small bronchioles by mechanical plugging o causes a decrease in surfactant production through lung cell trauma signs and symptoms: 1. tachypnea 2. retraction 3. barrel chest 4. blood gas shows decrease PO2 and increase PCO2 5. chest x-ray shows a peculiar honeycomb effect Management: 1. suctioning with bulb syringe or catheter while at 2. severe aspiration- infant might be intubated 3. don’t administer O2 under pressure 4. antibiotic therapy 5. chest physiotherapy and chest clapping

the perineum

APNEA : - Pause in respiration longer than 20 secs. with accompanying bradycardia - commonly seen in: √ preterm infant √ infection √ hyperbilirubinemia √ hypoglycemia MANAGEMENT:

1. gently shaking an infant or flicking the sole of the feet 2. close observation 3. resuscitation, if necessary 4. Theophylline or caffeine sodium benzoate to stimulate respiration Prevention 1. maintain neutral thermal environment 2. use gentle handling to avoid excessive fatigue 3. never take rectal temperature in infant prone to apnea* 4. always suction the secretion gently to minimize nasopharyngeal irritation* 5. use indwelling not intermittent nasogastric tube* *(may cause vagal stimulation which results to bradycardia)

SIDS (Sudden Infant Death Syndrome) - sudden unexplained death in infancy - cause is unknown who are at risk: 1. Infant of adolescent mother 2. Infant of closely spaced pregnancies 3. Underweight infant

4. Preterm infant

Contributory factors: 1. Viral respiratory infection 2. Botulism infection 3. Brain stem abnormalities 4. Neurotransmitter deficiency 5. Heart rate abnormality 6. Decrease arousal responses 7. Possible lack of surfactant in alveoli 8. Sleeping prone

HEMOLYTIC DISEASE OF THE NEWBORN • ISOIMMUNIZATION (RH INCOMPATIBILITY) – Rh: major blood group antigen of importance during pregnancy –Rh (-) negative mother is carrying a fetus with Rh (+) positive blood –Incompatibility between the mother’s Rh (-) and fetus’ Rh (+) can lead to Hemolytic disease of the newborn Rh- mother carries Rh+ fetus Rh+ fetal blood may mix with Rh- maternal blood Mother’s immune system produces Rh antibodies in response to Rh+ fetal blood cells Antibodies remain in maternal blood following pregnancy Maternal antibodies attack Rh+ fetus in the next pregnancy, resulting in hemolysis Mother receives Rhogam to prevent her immune system from producing Rh antibodies so in a subsequent pregnancy, Rh+ fetal blood cells are NOT destroyed

If a tear in the placenta occurs and there was no treatment, the next Rh+ positive fetus will have RBCs destroyed by the maternal Rh antibodies.

This causes hemolysis of fetal RBCs and then -anemia which in turn causes fetal edema – Hydrops fetalis or Erythroblastosis fetalis (a syndrome with a hyperdynamic state, heart failure, diffuse edema, ascites and pericardial effusion) RhoGAM –Rh immune globulin given to gravidas who are Rh(-) if there is suspicion of feto-maternal bleeding (amniocentesis, miscarriage, vaginal bleeding and delivery), during any trimester, after delivery and prophylactically at 28 weeks

MATERNAL ANTI BODY FORMATI ON AGAI NST THE RH ANTI GEN

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268

• ABO INCOMPATIBILITY       

The problem occurs when the maternal blood enters fetal circulation. Most common: mother is Type O and the fetus is either Type A, B, or AB The mother’s plasma naturally contains anti-A and anti B antibodies With weaker hemolytic effect than Rh antibodies and only affect mature RBC’s Number of antibodies is limited to the amount of maternal blood that entered circulation May affect fetus of the 1st pregnancy Affected newborn will become jaundiced in the first 3 days of life

Possible combinations for ABO INCOMPATIBILITY MOTHER FETUS A B B A O A, B, AB Hemorrhagic disease of newborn - due to deficiency of vitamin K - bleeding occurs on 2nd to 5th day of life Sign and symptom √ primarily jaundice √ petecchiae √ vomit fresh blood or pass black tarry stool Management: -IM administration of 1mg of vit K -if with severe bleeding, transfusion can be done RETINOPATHY OF PREMATURITY - acquired ocular disease that leads to partial or total blindness in children - due to vasoconstriction of immature retinal blood vessels - endothelial cells in the layer of nerve fibers in the periphery of the retina proliferate Who are at risk: 1. preterm infant 2. severely ill infant Cause: high O2 concentration (PO2 >100) Txt : cryosurgery /laser therapy

GROWTH AND DEVELOPMENT

•growth and development can be used interchangeably, but they are different Growth - Is generally used to denote an increase in physical size or quantitative change

•growth in weight is measured in kgs. or pounds •While growth in height is measured in inches or cm. Development

•development (synonymous with maturation) - used to indicate an increase in skills or the ability to function (qualitative change) •can be measured by the ff: 1. observing child’s ability to perform specific task 2. by recording the parent’s description of child’s progress 3. by using standardized test such as Denver II Denver II TEST- (Denver developmental screening test II) 125 easily administered developmental test items, with age norm, presented in a convenient one-page format.

Principles of growth and development     

growth and development are continuous process from conception until death growth and development proceed in an orderly sequence different children pass through the predictable stages at different rates all body systems do not develop at the same rate development is cephalocaudal

    

development proceeds from proximal to distal body parts development proceeds from gross to refined skills there is an optimum time for initiation of experiences or learning neonatal reflexes must be lost before development can proceed a great deal of skill and behavior is learned by practice

Types of development: 1. Psychosexual development - Specific type of development that refers to developing instinct or sensual pleasure 2. Psychosocial development - refers to stages of personality development (Erikson) 3. Moral development - is the ability to know right from wrong and to apply this to real life situation (Kohlberg) 4.Cognitive development - refers to the ability to learn or understand from experience, to acquire and retain knowledge, to respond to new situation, to solve problem. - measured by intelligence tests, and by observing a child’s ability to function effectively in his/her environment

STAGE Age

ERIKSON FREUD SULLIVAN Psychocial Psycho Significant sexual person/s

PIAGET Cognitive

KOHLBERG Moral

Infancy Birth-1 yr Toddler 1-3 years

Trust vs Oral Mother Sensorimotor Mistrust Autonomy Anal Parents Preoperational thought vs (preconceptual phase) Shame & Doubt Preschool Initiative vs Phallic Basic family Preoperational thought 3-6 years Guilt (intuitive phase) School Age Industry vs Latency Neighborhood Concrete Operational 6-12 years Inferiority School (inductive reasoning, beginning logical thinking) Adolescence Identity vs Genital Peer group Formal operation 13-20 years Role (deductive and abstract Confusion thinking)

Early Adult 20-45 years Middle Adult 45-65 years Late Adult >65 years

Preconventional (pre-moral)

Conventional (law and order orientation) Post-conventional (principles, social and ethical orientation)

Intimacy vs Isolation Generativity vs Stagnation Ego Integrity vs Despair

PHYSIOLOGIC AND STRUCTURAL CHANGES: Respiratory rate and pulse rate decrease sharply during the first 2 years and then more gradually throughout childhood, blood pressure rises steadily beginning at approximately 6 yrs of age

Development of the paranasal sinuses continues throughout childhood, the ethmoid, maxillary, and sphenoid sinuses are present from birth. the ethmoid reaches its maximum size relatively early in childhood (7-14 yrs of age), others reach their maximum size after puberty

Lymphoid tissues develop rapidly, reaching adult size by 6 years of age and continue to hypertrophy throughout childhood and early adolescence before receding to adult size The metabolism of medication and child’s response to them change rapidly in the first month of life and again under the hormonal influences in puberty

Nutritional needs as well as a wide variety of biochemical and hematologic values undergo marked developmental changes.

THEORIES OF GROWTH AND DEVELOPMENT 1. PSYCHOSEXUAL THEORY

-Psychosexual theory- Freudian theory , the idea of body-centered drives a. Infancy (0-1yr)--------- oral ( sucking of the first year of life) b. Toddlerhood (2-3 yr)-- anal (holding on and letting go during the Toddler years) c. Preschool (3-6 yr)----- oedipal drives (possessiveness toward a parent In the preschool years) d. School age (6-12 yr)--- Latency e. Adolescence (12-20)--- adolescence Oral – infant oral stimulation for nutrition, enjoyment and release of tension NI: provide oral stimulation – pacifiers, breastfeeding, thumbsucking Anal - toddler elimination is a way of discovery and exerting independence NI: help achieve bowel and bladder control even if hospitalized Phallic – preschool increased knowledge of 2 sexes NI: accept sexual interest and answer questions about birth or sexual difference Latent - school age libido diverted to school NI: help achieve positive experiences to promote self esteem Genital - Adolescent establish sexual aims and finding new love objects - NI: provide opportunities to relate with opposite sex and allow verbalization feelings

about new

2. PSYCHOSOCIAL THEORY > recast Freud’s stages in term of the emerging personality Infancy (0-1) – basic trust vs. mistrust Toddler hood (2-3)- autonomy vs. shame and doubt Preschool (3-6) –initiative vs. guilt School age (6-12) – industry vs. inferiority Adolescence (12-20) – identity vs. identity diffusion/ Role Confusion

 Trust vs Mistrust – infant T: appreciate environment as safe and people as dependable M: suspicious, fearful, shun emotional involvement NI: provide primary caregiver and visual stimulation

 Autonomy vs Shame and Doubt – toddler A: build on new motor and mental abilities, take pride in accomplishments S: doubt and stop trying NI: provide opportunities for decision making and give raises

 Initiative vs Guilt – preschool I: how to do things G: limited brainstorming and problem-solving skills NI: provide opportunities for exploration, answer questions and do not inhibit fantasy

Industry vs Inferiority - school age

Ind: how to do things well Inf: always worried about poor or incorrect performance NI: provide opportunities for completing short projects, give praise and rewards

 Identity vs Role Confusion – adolescent I: integrate image into a whole R: unsure of who they are or who they can become, may rebel NI: provide opportunities to discuss feelings and support and praise for decision-making 3.COGNITIVE THEORY( PIAGET THEORY) - described how children actively construct knowledge for themselves through the linked processes of assimilation ( seeking experiences) and accommodation (adapting their implicit ideas about the world to take new information into account) Piaget’s Theory of Cognitive development a. Sensorimotor – 1 mo-24 mo b. Preoperational Thought – 2-7 y/o c. Concrete Operational Thought – 7-12 y/o d. Formal Operational Thought – 12 y/o

Sensorimotor (stages 1-VI) o practical intelligence, because word and symbols for thinking and problem solving are not yet available at this early age. o Babies relate to the world through their senses using reflex behavior o Neonatal reflex-1 mo. (stimuli are assimilated into beginning mental images o Primary circular reaction- 1-4 mo., hand-mouth and ear-eye coordination developbeginning o intention of behavior is present o Secondary circular reaction- 4-8 mos. o memory traces present; anticipates familiar events o Coordination of secondary reaction- 8-12 mo., infant can plan activities to attain specific goals-perceives that others can cause activities and that activities of own body are separate from activity of objects. o Tertiary circular reaction-12-18 mo. Capable of space perception as well as permanence. o Invention of new means through mental coordinations- 18-24 mo.-transitional phase, uses memory and imitation to act. good toy are blocks, Colored plastic ring

 Preoperational thought- 2-7 yr. ( pre-school) -Thought becomes more symbolic -Comprehends simple abstraction -Child is egocentric -Display static thinking( inability to remember what he or she started to talk about so that the end of the sentence the child is talking about another topic) -Concept of time is now and concept of distance is only as far as he or she can see -No awareness of reversibility is present -Unable to state cause-effect relationships, categories and abstraction, good toys are items that require imagination like modeling clay.

Concrete operation- 7-12 yr.( school age ) -Includes systemic reasoning -Can discover concrete solutions to everyday problems and recognize cause and effect relationships -Uses memory to learn broad concepts and subgroups of concept -Child is aware of reversibility, Understand conservation, sees constant despite transformation

-Collecting and classifying natural objects-good activity for this period Formal operational-12 yr. (adolescence) o o o o o o

Can solve hypothetical problems with scientific reasoning Understand causality Can deal with the past, present, and future Capable of thinking in terms of possibility- what could be (abstract thought) Adult or mature thought Talk-time- good activity for this period

Sensorimotor - relate through senses, separate from environment, practical intelligence Preoperational - toddler: symbolic thought, simple abstractions, literal thinking, poor concept of time and distance pre-schooler: centering, egocentric, no reversibility, no cause and effect, assimilation, role fantasy Concrete Operational - systematic reasoning - memory to learn broad concepts and subgroups - seriation and classification - reversibility - inductive reasoning (specific to general) - conservation (7 y/o – numbers; 7-8 y/o quantity; 9 y/o – weight; 11 y/o – volume)

Formal Operational Thought -solve hypothetical problems, causality, time - talk time to sort attitudes and opinions Kohlberg’s Theory of Moral Development 1. Preconventional (Level I) Stage 1 - 2-3 y/o “mother or father says so” punishment obedience orientation Stage 2 - 4-7 y/o “mother says it’s wrong” individualism/egocentrism 2. Conventional ( level II ) 7-10 yr- orientation to interpersonal relation of mutuality ( child follows rules because of a need to be a “good” in own eyes and in eyes of others) - 10-12 yr – maintenance of social order, fixed rules and authority( child finds following rules satisfying) Stage 3 – 7-10 y/o “nice girl, nice boy” Stage 4 – 10-12 y/o following rules is satisfying “Law and Order” 3. Postconventional ( level III) older > 12yrs - social contract, utilitarian , law making perspective (follows standards of society for the good of all people) - universal ethical principle orientation (follows internalized standards of conduct)

Postconventional (level III) Stage 5 & 6 - >12 y/o following standards for everyone’s good “Social Contract” “Principled conscience”

HARRY SULLIVAN 1. Prototaxic mode – infancy - undifferentiated thought (unable to separate the whole into parts or to use symbols) – need for bodily contact and love; anxiety due to unmet needs 2. Parataxic mode – 2-5 y/o

sees events as causally related because of temporal or serial parents viewed as source of praise and acceptance

connections

3. Syntaxic mode – 5-8 y/o - logical, rational and most mature type of cognitive functioning; need for peers and how to deal with them DEVELOPMENTAL STAGES IMPORTANCE OF KNOWLEDGE OF GROWTH AND DEVELOPMENT 1. health promotion and Illness prevention 2. health restoration and maintenance STAGES OF GROWTH and DEVELOPMENT A. 1st Prenatal – conception – birth B. 2nd Neonate - birth - 28 days Infant - 1 month - 1 y/o C. 3rd Toddler - 1 - 3 y/o Preschool - 3 - 6 y/o D. 4th School age - 6 - 12 y/o Adolescence - 13 - 18 y/o FACTORS THAT AFFECT GROWTH and DEVELOPMENT I. Genetics a. Gender – girls generally lighter in weight at birth; boys taller and heavier at puberty b. Health – inherited illnesses c. Intelligence – advance faster in skills d. Temperament - Reaction Patterns – response to situations Nursing implications: 1. talk to parents about reactivity patterns 2. Notice temperamental characteristics when hospitalized II. Environment a. Socioeconomic level – lack supervision, health care or nutrition b. Parent-Child Relationship – thrive better if loved c. Ordinal position in the family – size and position in family

d. Health – debilitating diseases

DEVELOPMENTAL AGE PERIODS INFANCY – 0-1 y/o 4-6 mos -2x birthweight 1ST 6 mos – 2 lb/mo; 2nd 6 mos – 1 lb/mo 1 y/o - 3x birthweight - HC=CC 6-12 mos - 50% inc in height; 1st 6 mos – trunk; 2nd 6 mos - legs o 2/3 brain growth o HR 100-120 bpm - RR 20-30 12-18 mos - Anterior fontanel 2 mos - Posterior fontanel o Immune system 4 mos - Liquids to solids 6 mos - Shivering o Tooth eruption · ECF 35%, ICF 40%

–Health visits – 2 weeks, 2 mos, 4 mos, 6 mos, 12 mos GROWTH AND DEVELOPMENTAL MILESTONES GROSS MOTOR 2 mos - 45 degree head control 3 mos - 90 degree head control 4 mos - lifts head & chest on prone, - rolls over 5 mos - 6 mos - good head control o sits with support 8 mos - sits without support 9 mos - pulls self to stand - creeps 10-11 mos – cruises 12 mos – stands alone FINE MOTOR 1 mo - eyes to midline 3 mos – eyes past midline 4 mos –bring hands together 5 mos – grasps/reaches object 6 mos – holds object in 2 hands 7 mos - hand to hand transfer 9-10 mos - pincer grasp - points at object

11 mos - bangs objects together 12 mos - throws toys o attempts 2 tower blocks

LANGUAGE 1 mo - throaty gurgling sound 2 mos - differentiate a cry 3 mos - squeals 4 mos - coos and gurgle, moves head to sound 5 mos - simple vowel sounds 7 mos - “ma” when crying 9 mos - mama, dada 10 mos - understands gestures , responds to name 12 mos - obeys commands, one word other than mama, dada PERSONAL SOCIAL 2 mos - social smile 4 mos - plays with rattle 7 mos - feeds self with crackers, recognizes familiar faces 8 mos - peek-a-boo, stranger anxiety 9 mos – waves bye bye 10 mos – nursery games 11 mos – holds arm or foot out in dressing 12 mos – attempts to use spoon PLAY – solitary play: self is the interest of activities; alone but enjoys presence of others Mirror play Balloon mobiles Peek-a-boo Being held Rocking Block play Singing games Feet & toes games Squeaky toys Fingers & hand games Pat-a-cake Listening to stories Making faces NUTRITION Lipase – dec until 1 yr Amylase – dec until 3 mos Immature liver – inefficient storage and formation of nutrients Extrusion reflex – until 4 mos Calories: 100-115 kcal/kg/day

0-3 mos - breastmilk 4-6 mos - semi-solid food Introduce one at a time Start with small quantities Cereals, strained vegetables, meat 7-9 mos - Finger food, fluids 10-12 mos - 3meals w/ snacks DAILY CARE - bathing - diaper care - care of teeth - dressing - sleep – 10-12 hrs/day; 1 or more naps - exercise Concerns - Constipation - Teething – cleanliness - thumb sucking – until school age - pacifiers – wean after 3 mos - head banging – begin 2nd half of infancy to preschool, naptime, under 15 min - sleep problems – breastfed infants wake up sooner - spitting up - diaper dermatitis - miliaria/prickly heat – papular, erythematous on neck, ear, face, trunk - baby bottle syndrome - Loose stools – breastfed - Colic – paroxysmal abdominal pain, < 3 mos, inc in formula fed - Obesity – 32 oz formula daily, add fiber and water to diet - Stranger anxiety REACTION TO ILLNESS

Discomfort and pain Lack of stimulation Separation anxiety disruption of routine NURSING CARE

Soothing stimulation Toys from home Human contact Provide/Anticipate needs TODDLER – 1 –3 y/o

Slowed growth Wt gain 5-6 lbs (2.5 kg) 5 in (12 cm)

Baby fat disappears brain 90 % adult size Baby fat disappears CC > HC; inc by 2 cm HR 90 bpm BP 99/64 Protruberant abdomen Stomach capacity increases Control of urinary and anal sphincters IgG and IgM 20 deciduous teeth GROWTH AND DEVELOPMENTAL MILESTONES Gross

15 mos – walks alone well 18 mos – run and jump in place, walk up & down stairs holding on to railing, seat self in chair

24 mos – walks up & down stairs w/ both feet same step, same time 2 ½ yo – tiptoes 3 yo - throws balls, rides tricycles, stands on 1 foot momentarily LANGUAGE

15 mos - vocalizes wants, 3 words other than dada, mama 18 mos - uses phrases 2 y/o - short sentences; 2-3 words, points to one body part 3 y/o - speaks fluently using longer sentences - tells stories - plurals PERSONAL/SOCIAL

15 mos - pats pictures, imitates housework 18 mos - turns page 2-3 at a time, - uses spoon 2 yo - removes garments - toilet trained by day (2-3 yrs old)

3 yo - dry by night (3-4 yrs old) - washes and dries hands

NUTRITION

Decrease in appetite Picky eaters 1, 300 kcal/day Allow self feeding Allow choice between 2 types of food Offer finger food Risk of aspiration PLAY – parallel play: plays alongside, but not with another; has not learned sharing yet

Babbling and talking Ball games Clay Listening to music Listening to stories Making music and noise Push and Pull toys Puppet play Scribbling Stack-and-dump toys DAILY CARE - dressing – can put on socks, underpants, undershirt - sleep – 8 hours sleep w/ 1 nap - bathing - care of teeth CONCERNS

Toilet Training bowel control – 18 mos daytime bladder ctrl – 2-3 y/o nighttime bladder ctrl – 3-4 y/o CONDITIONS: 1. control of sphincters 2. cognitive understanding 3. delay immediate gratification 4. mature nervous system

Negativism Temper Tantrums

Accidents Rituals Egocentrism Sibling rivalry Discipline Separation anxiety REACTION TO ILLNESS and NURSING INTERVENTIONS

fear of separation - Assure of parents return Regressive behaviors - reassurance Nutrition – allow finger food Dressing changes – allow to pull off tape Medication – allow choices of “chaser” after oral medication Hygiene – allow choice of bathtime toy, allow to put toothpaste Pain – allow to express pain Stimulation Elimination – continue potty training Rest – allow choice of toy at bedtime PRE SCHOOL 3-5 y/o

Future body build apparent Increased skeletal growth Handedness 5 yo - may have permanent teeth Tonsils inc in size IgG and IgA increases PRE SCHOOL

HR 85 bpm BP 100/60 4.5 - 5 kg/yr 2 - 3.5 in/yr

Frequent voiding GROWTH AND DEVELOPMENTAL MILESTONES Gross

3 1/2 y/o - stands on 1 foot 5 sec - upstairs on 1 foot/step; down 2 feet /step

4 – 4 ½ - climbs stairs - hops on 1 foot

5 y/o – heel to toe walk - skips and runs FINE MOTOR

3 y/o – copies circle 4 –4 1/2 - imitates cross - draws man w/ 3 parts - copies square

5 y/o - copies triangle - writes alphabet LANGUAGE

3 ½ y/o - gives full name, sex - counts to 3 or more

4 y/o - exaggerates and boasts 5 y/o- talks constantly PERSONAL/SOCIAL

3 ½ y/o - dresses w/ supervision - separates more easily from mother

4 y/o – buttons up 4 ½ - dresses w/o supervision 5 y/o – uses a knife NUTRITION

Slow/Steady growth Decreased appetite Offer small servings Healthy snack food PLAY – associative play; plays in random without group goal; follows a leader

Dress up clothes Housekeeping toys

Dolls and other toys for pretending Bikes and climbing toys Paper and crayons DAILY CARE accidents – bicycle safety, seat belts dressing – choose own clothes sleep – resist taking naps exercise – very active bathing – can wash and dry hands; need supervision care of teeth – independent brushing; 1st dental visit CONCERNS - imitation - Oedipus and electra complex - gender roles – need exposure to parents of opposite sex - Socialization – capable of sharing - Discipline – “time out” - Common fears – dark, mutilation, separation - Telling tales - Imaginary friends - sharing – define limits and teach property rights - Regression –reaction to stress - Sibling rivalry - sex education - pre-school center - broken fluency - swearing - High energy level - Curiosity REACTIONS/CONCERNS IN ILLNESS AND NURSING INTERVENTIONS - nutrition – food in animal/alphabet shapes - dressing change – allow to measure, cut tape, see incision site - medication – allow to choose “chaser” - hygiene – allow choice of toys, wash hands and face - pain – allow pain expression, handle syringe, analgesic - stimulation

7 – 11 y/o SCHOOL AGE –3-5 lb/yr –1-2 in /yr –10 yo – brain growth complete –Adult vision –Abundant tonsillar and adenoid –“innocent” heart murmurs –HR 70 bpm –BP 112/60 –32 permanent teeth –Pubertal onset

tissue

SECONDARY SEX CHARACTERISTICS GROWTH AND DEVELOPMENTAL MILESTONES

6 y/o – skip, jump, tumble, hop, ride bicycle, walk a straight line; first molars 7 y/o – central incisors; sexual differences seen in play; quiet play 8 y/o – improved coordination; playing w/ gang important; eyes fully developed GROWTH AND DEVELOPMENTAL MILESTONES

9 y/o – all activities done w/ gang - hero worship

10 y/o – more improved coordination - well mannered w/ adults

11 y/o – aticve but awkward - mixed sex activities

12 y/o – coordination improves - joins organizations PERSONAL/SOCIAL/PLAY Competitive play and recreational activities Hobbies and personal interests

Arts and crafts Biking Board games Clubs Collecting items Chess Comic Books NUTRITION

Good appetite Food w/ high nutritional value - more calories and nutrients - hungry after school – give snacks and make mealtimes enjoyable DAILY CARE dressing – influenced by peers sleep – 8-12 hrs; no naps exercise – games, bike riding, walking hygiene – 8 y/o – capable of bathing alone care of teeth – 2x yearly visit to the dentist; brush daily safety – bicycle, school bus safety, prevention of falls and sports injuries CONCERNS problems w/ articulation – disappears 9 y/o School anxiety and phobia Sex education Stealing – 7 y/o – importance of money Violence/terrorism – education; reassurance

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Bullying Recreational drug and alcohol use Obesity

REACTION TO ILLNESS AND NURSING INTERVENTIONS Death and disability - Still need comfort Unknown events & procedures - Allow to help w/ care & treatment Loss of ctrl & independence - Give choices Loss of contact w/ peers - Allow visits Disruption of school - Talk about interest - nutrition – allow choices - dressing – ask opinions on bulk of dressing and where to apply tape - medicine – teach name and action, allow to choose form if possible - pain – allow expression of pain, explain source and cause - stimulation ADOLESCENT

Girls taller than boys 2-8 in, 15-55 lbs Growth stops 16-17 y/o Boys grow 4-12 in and gain 15-65 lbs Growth stops 18-20 y/o Heart and lung size increase more slowly HR 70 bpm RR 20 breaths/min BP 120/70 ADOLESCENT

Androgen inc sebaceous gland activity resulting in acne Apocrine glands inc activity 13 yo – 2 molars PUBERTY – capable of sexual reproduction Secondary sexual characteristics Competitive Play: with win-lose type of rules nd

GROWTH AND DEVELOPMENTAL MILESTONES

13 y/o – sports 15 y/o - enjoys privacy - stays in room

16 y/o - part time job , charitable causes NUTRITION faddish diet give responsibility for food planning increased calories

DAILY CARE dressing and hygiene care of teeth sleep – need more sleep exercise – daily CONCERNS Socialization – falling in love Obesity; Diseases – HPN Acne Body piercing Fatigue - emotional fatigue Menstrual irregularities Sexuality and sexual activity Poor posture Stalking – educate girls Substance abuse Suicide runaways REACTION TO ILLNESS AND NURSING INTERVENTION Main issue – body image – educate and Allow participation in tx decisions; compassionate understanding Fears loss of control and independence - Respect privacy and confidentiality Fears injury and pain - Provide opportunities for self expression Separation from peers and lack of emotional support - Approach w/ caring and understanding, age compatible roommate, Phone at bedside -

Nutrition – food preferences Dressing – final appearance of dressing, and time for changing Medicine – choice for injection site, teach name and action Rest – time and length of rest periods Hygiene – respect modesty, extent of self care Pain – allow pain expression, ask for analgesics stimulation

Thank You!