CHAPTER 28: PRINCIPLES OF GROWTH AND • 6-month-old to 12-month-old

DEVELOPMENT
FACTORS INFLUENCING GROWTH AND
TERMS DEVELOPMENT
GROWTH A. GENETIC INHERITANCE
➢ Increase in physical size or structure that is 1. GENDER
measurable.
• Girls are born lighter.
➢ Quantitative change in the body.
DEVELOPMENT • Girls begin puberty growth spurt 6 months to 1
yr. earlier than boys.
✓ Increase in skill and capacity to function
occurring in an orderly fashion. • Boys tend to be taller & heavier than girls by
end of puberty (14 – 16 y.o.).
✓ Child’s ability to perform specific tasks.
2. HEALTH
✓ Qualitative change.
MATURATION • Disorders included in the NB screening:
1. Congenital hypothyroidism
• Increase in competence or ability to function at 2. Congenital Adrenal Hyperplasia
a higher level. (CAH)
• The process by which the traits carried by the 3. Galactosemia (GAL)
child through his genes begin to unfold and are 4. Phenylketonuria (PKU)
realized. 5. Glucose-6-Phosphate
COGNITIVE DEVELOPMENT Dehydrogenase Deficiency (G6PD
➢ Acquiring concepts of time and space, abstract Def)
thought. • Hemophilia
➢ Ability to learn or understand from experience, • Type 1 Diabetes Mellitus
to acquire and retain knowledge, to respond to 3. INTELLIGENCE
new situations, to solve problems.
• Intellectual level affects vocabulary and ability
➢ Measured by: to encode & decode messages.
o Intelligence tests
o Observing child’s ability to function • Influences the number of languages a child
speaks, reading ability.
effectively in his/her environment.
• Depth of explanation that a child is capable of
PRINCIPLES OF GROWTH AND DEVELOPMENT understanding.
1. G & D are continuous processes from Examples:
conception until death. o Mental retardation
2. G & D proceed in an orderly sequence. o Autism
3. G & D are continuous processes from o ADHD (attention deficit
conception until death. hyperactivity disorder)
4. G & D proceed in an orderly sequence. 4. TEMPERAMENT
5. Different children pass through the • Usual reaction pattern of an individual, or an
predictable stages at different rates. individual’s characteristic manner of thinking,
6. All body systems do not develop at the behaving or reacting to stimuli in the
same rate. environment.
7. Development is cephalocaudal.
8. Development proceeds from proximal to
• Children are not alike:
distal body parts. o Others adapt quickly
9. Development proceeds from gross to o Some adapt slowly
refined skills. o Some react intensely
10. There is an optimum time for initiation of o Some react passively
experiences or learning.
11. Neonatal reflexes must be lost before REACTION PATTERNS
development can proceed. a) ACTIVITY LEVEL
12. A great deal of skill and behavior is learned • Some babies are constantly on the go.
by practice.
• Others stay where they are placed.
GROWTH PATTERN
b) RHYTHMICITY
HEAD CONTROL
• Some wake up at the same time each morning.
• Newborn to 6 months
SITTING UP • Hungry at regular intervals.
• 2 months to 8 months • Nap same time each day.
FINE MOTOR DEVELOPMENT • BM same time each day.
c) APPROACH 3. Parents must focus on preparing the child for
• Child’s response on initial contact with a new new activities.
stimulus. 4. Bring these characteristics to the parent’s
attention, because understanding the child is
• Some smile and “talk” to strangers.
the beginning of accepting & respecting the
• Others cry at the sight of strangers. child as an individual.
d) ADAPTABILITY B. ENVIRONMENT
• Ability to change one’s reaction to stimuli over 1. SOCIOECONOMIC LEVEL
time. ➢ Low socioeconomic status.
e) INTENSITY OF REACTION 2. PARENT-CHILD RELATIONSHIP
• Some children cry loudly. ✓ Children who are loved to thrive better
than those who are not.
• Some have mild or low-intensity reactions to
✓ Loss of love from a primary caregiver can
stress. interfere with a child’s desire to eat,
f) DISTRACTIBILITY improve, and advance.
• Children who are easily distracted or can easily 3. ORDINAL POSITION IN THE FAMILY
shift their attention to a new situation can be ➢ Only child or oldest child generally excels in
easily managed. language development.
• Others cannot be distracted. ➢ Youngest child may develop language more
• Parents may describe them as stubborn, willful, slowly.
or unwilling to compromise. 4. HEALTH
g) ATTENTION SPAN & PERSISTENCE • Children with physical disabilities may be
• Ability to remain interested in a project or limited in their ability to play.
activity. THEORIES OF DEVELOPMENT
A. SIGMUND FREUD
• Some play with their toy for 1 hr.
• Some play no more than 1 – 2 min. with each
• Austrian neurologist.
toy. • Founder of psychoanalysis.
h) THRESHOLD OF RESPONSE • Offered the first real theory of personality
• Intensity level of stimulation necessary to evoke development.
a reaction. • Describes child development as a series of
i) MOOD QUALITY psychosexual stages in which a child’s sexual
• The child who is always happy and laughing gratification becomes focused on a particular
can be said to have a (+) mood quality. body part.

3 CATEGORIES Freud’s Psychosexual Stages of Development

1. EASY CHILD
1. Infant (Birth – 1 Y.O.)
o Predictable rhythmicity.
Oral Stage
o Readily approach & adapt to new
situations. • Infants derive pleasure from sucking (e.g.,
o Mild to moderate intensity of reaction. breastfeeding, pacifiers).
o Overall (+) mood quality. • Sucking helps relieve tension and provides
2. DIFFICULT CHILD comfort.
o Irregular in habits. 2. Toddler (1 – 3 Y.O.)
o (-) mood quality. Anal Stage
o Withdraw rather than approach new • Focus shifts to the anal region.
situations. • Toilet training begins, introducing control over
3. SLOW-TO-WARM-UP CHILD bodily functions.
o Fairly inactive. • Child experiences pleasure in holding and
o Respond only mildly. releasing feces.
o Adapt slowly to new situations. • Developing independence and self-discovery.
o Have general (-) mood. 3. Preschooler (3 – 6 Y.O.)
NURSING IMPLICATIONS Phallic Stage
1. Require more planning & creative distraction
measures.
• Interest in genital area increases.
2. Talk to parents about their child’s reactivity • Masturbation and exhibitionist behaviors may
patterns. occur.
 • Awareness of anatomical differences between - Abstract thinking, scientific
sexes. reasoning.
• Oedipus complex (boys) – Unconscious Kohlberg’s Moral Development
attraction to the mother. 1. Preconventional (Infant – 6 Y.O.)
• Electra complex (girls) – Unconscious attraction o Morality based on rewards &
to the father. punishments.
• Concepts of penis envy (girls) and castration o “Good” behavior follows parental
anxiety (boys). approval.
4. School-Aged Child (6 – 12 Y.O.) 2. Conventional (7 – 12 Y.O.)
Latent Stage o Seeks social approval; obeys laws.
• Sexual impulses are dormant as energy is o Morality tied to external rules.
focused on school, friendships, and hobbies. 3. Post-Conventional (12+ Y.O.)
• Increased intellectual pursuits and skill o Internalized moral principles.
development. o Does what is right, even when not
observed.
• Formation of social relationships outside the
family.
5. Adolescent (12 Y.O. and Over) CHAPTER 29: NURSING CARE OF A FAMILY WITH AN
Genital Stage INFANT
Weight
• Puberty leads to sexual maturity.
• Birth weight
• Reproductive system matures, and sex o Doubles by 4 to 6 months.
hormones increase. o Triples by 1 year.
• Genital organs become the primary source of • First 6 months
pleasure. o Average weight gain: 2 lb per month.
• Formation of intimate relationships and • Second 6 months
friendships. o Average weight gain: 1 lb per month.
• Preparing for adult roles, including marriage • Average weight at 1 year
and career. o Males: 10 kg (22 lb).
o Females: 9.5 kg (21 lb).
Erikson’s Psychosocial Development
Length
Trust vs. Mistrust (Birth – 1 Y.O.) • First year growth
- Trust develops with consistent care. o Length increases by 50% (e.g., from
Autonomy vs. Shame & Doubt (1 – 3 Y.O.) 20 in to about 30 in / 50.8 to 76.2
- Independence builds confidence. cm).
Initiative vs. Guilt (3 – 6 Y.O.) • Growth trends:
- Child initiates activities & explores. o Early months: Most growth occurs in
Industry vs. Inferiority (6 – 12 Y.O.) the trunk.
• Develops competence & skills. o Later months: Growth shifts to the
Identity vs. Role Confusion (13 – 20 Y.O.) lengthening of the legs.
• Forms a personal identity.
• End of first year
Intimacy vs. Isolation (20 – 40 Y.O.)
o Legs may appear short or bowed.
• Forms relationships & friendships. • Measurement
Generativity vs. Stagnation (40 – 65 Y.O.) o Infants should be measured lying
• Contributes to society. supine for accuracy.
Integrity vs. Despair (65+ Y.O.)
Head Circumference
• Reflects on life with satisfaction or regret.
• End of first year
Piaget’s Cognitive Development o Brain reaches two-thirds of adult
• Sensorimotor (Birth – 2 Y.O.) size.
- Learns through senses & reflexes. • Growth
• Preoperational (2 – 7 Y.O.) o Rapid increase in head
- Egocentric, symbolic thinking, circumference reflects rapid brain
centering. growth.
• Concrete Operational (7 – 12 Y.O.) o Asymmetry may appear due to back-
- Logical thinking, cause & effect. sleeping; it will correct with time and
• Formal Operational (12+ Y.O.) more upright positioning.
Body Proportion • Functional at 2 months, with active production
• End of infant period of IgG and IgM by 1 year.
o Lower jaw becomes more prominent. • Other immunoglobulins (IgA, IgE, IgD) increase
• Chest circumference by preschool age.
o Typically, 2 cm smaller than head at
birth. Ability to Adjust to Cold
o May equal head size by 6 months or • Matures by 6 months:
12 months. o Infants can shiver in response to
• Abdomen cold, which generates warmth.
o Remains protuberant until walking o Additional adipose tissue develops
age. for insulation.
• Vertebral curves o Brown fat, which protects from cold,
o Cervical, thoracic, and lumbar curves decreases as subcutaneous fat
develop as the infant holds up their increases.
head, sits, and walks. Fluid Distribution
• Lower extremities • Extracellular fluid: 35% of an infant's body
o Lengthen during the last 6 months in weight (compared to 20% in adults).
preparation for walking. • Intracellular fluid: 40% by the end of the first
year (same as in adults).
Body Systems • This difference increases an infant’s
Cardiovascular System susceptibility to dehydration, especially in
• Heart rate slows from 110-160 bpm to 100-120 illnesses like diarrhea.
bpm by the end of the first year.
• Pulse rate may slow with inhalation (sinus Teething
arrhythmia). • First tooth eruption: Typically, around 6
• Blood pressure increases slightly (80/40 to months (usually a central incisor).
100/60 mm Hg). • Teething progress: One tooth erupts monthly
• Anemia may develop at 2-3 months. until all 20 deciduous (baby) teeth have
emerged by age 2 to 3 years.
• Hemoglobin converts from fetal to adult type by
5-6 months. • Natal/Neonatal teeth: Rarely, infants may
have teeth at birth or within the first 4 weeks.
• Iron levels decrease between 6-9 months. o Most often, lower central incisors are
Respiratory System
involved.
• Respiratory rate slows from 30-60 breaths per o Loose teeth: If attached loosely,
minute to 20-30 breaths per minute by the end they may need to be removed to
of the first year. prevent aspiration.
• Upper respiratory infections are more frequent o Teeth removal: Natal teeth should
and severe. not be removed unless loose, as they
Gastrointestinal System are important for the dental arch's
• Gastrointestinal tract is immature at birth but proper development.
gradually matures.
• Amylase: Limited until the third month (helps Motor Development
digest complex carbohydrates). • Infants progress through cephalocaudal (head
• Lipase: Low throughout the first year (helps to toe) and gross-to-fine motor development.
digest fats). • Control develops from head to trunk to lower
• Liver: Immature, extrusion reflex prevents solid extremities in a predictable pattern.
food intake before 3-4 months. • Motor development evaluation includes
• Feeding: Infants can drink from a cup with assessing both gross motor (large body
movements) and fine motor (hand coordination)
assistance and independently by 8-10 months.
skills.
Kidneys
Gross Motor Development
• Immature and less efficient in eliminating waste Ventral Suspension Position
than an adult.
Endocrine System
• Newborn: Head hangs with little effort at
control.
• Immature response to hormones, including
those from the pituitary gland and pancreas
• 1 month: Lifts head briefly but drops it again.
(affects stress response). • 2 months: Holds head in the same plane as
Immune System body.
• 3 months: Head raised well above the body;
Landau reflex develops.
 o Landau reflex: Infant extends head, • 1 month: Able to focus on objects about 18
spine, and legs when held in ventral inches away and follow briefly, but not across
suspension. the midline. Studies human faces.
• 6-9 months: Parachute reaction appears. • 2 months: Can follow moving objects and have
o Arms extend as if to protect from achieved binocular vision (fusion of two
falling. images).
• 3 months: Follows objects across the midline,
studies hands and fingers.
Prone Position
• 4 months: Recognizes familiar objects and
• Newborn: Can turn head but can’t keep it follows caregivers with eyes.
raised for long.
• 6 months: Can judge depth perception and
• 1 month: Lifts head and turns it to the side, accurately reach for objects.
knees tucked under.
• 7 months: Can pat their reflection in a mirror.
• 2 months: Can hold head raised but can't lift
chest high enough to look around. • 10 months: Begins to develop object
permanence, looking for objects hidden out of
• 3 months: Lifts head and shoulders off the sight.
table, begins looking around.
• 4 months: Lifts chest and turns head from side Hearing
to side. • 1 month: Newborn quiets at distinct sounds.
o First roll from front to back, typically
with neck-righting reflex. • 2 months: Stops activities at spoken words.
• 5 months: Rests weight on forearms when • 3 months: Turns head toward sounds.
prone, turns over front to back and back to • 4 months: Locates sounds by turning and
front. looking.
• 6 months: Raises chest and upper abdomen • 5 months: Can localize sounds downward and
off the table. to the side.
• 9 months: Creeps (abdomen off the floor, • 6 months: Can locate sounds made above.
using hands and knees to move). • 10 months: Recognizes their name and listens
Sitting Position intently when spoken to.
• Newborn: Extreme head lag when pulled to a • 12 months: Can locate sounds in any
sitting position. direction.
• 2 months: Holds head steady in a sitting Touch
position but may still have head bobbing and • Infants need skin-to-skin contact. Comfort with
lag. soft clothes and dry diapers is essential.
• 4 months: No more head lag. Taste
• 5 months: Straightens back when propped into • Infants turn away or spit out tastes they dislike
a sitting position. and show preference for foods introduced at 6
• 6 months: Sit momentarily without support, months.
Smell
anticipate being picked up, and may slide
backward. • Well-developed sense of smell at birth,
• 7 months: Transfer small toys and show more responds to pleasant or unpleasant odors, and
interest in colorful, rolling toys. recognizes the smell of breast milk.
• 8 months: Enjoy toys with different textures Emotional Development
and tactile feedback.
• 1 month: Can differentiate between faces and
• 9 months: Enjoy toys that fit into each other, other objects, remains calm with primary
like stacking rings or blocks. caregivers.
• 10 months: Enjoy peek-a-boo, can clap, and • 3 months: Smiles and laughs in response to
play patty-cake. caregivers’ faces and playful expressions.
• 11 months: Begin cruising, walking while • 4 months: Cries when play interactions stop.
holding on to furniture.
• 5 months: May show displeasure when an
• 12 months: Enjoy activities involving putting object is taken away.
objects in and out of containers and listening to
nursery rhymes or music.
• 6 months: Begins to distinguish familiar
caregivers from strangers.
Development of Senses • 7 months: Shows fear of strangers, may cry or
Vision cling to parents.
• 8 months: Stranger anxiety peaks; reluctance
to go to others.
 Standing and Fine Motor Development • 4 months: Needs a space to roll and move,
Standing such as a playpen or mat.
• 1 month: Stepping reflex, flexes knees and • 5 months: Ready to explore various objects
hips when standing. like rings, blocks, and toys.
• 3 months: Supports some weight on legs. • 6 months: Can play with bathtub toys and
• 4 months: Fully supports weight on legs. teething rings.
• 5 months: Reflexes (e.g., tonic neck) fading. • 7 months: Can transfer small toys and is
• 6 months: Nearly supports full weight. interested in brightly colored balls.
• 7 months: Bounces in standing position. • 8 months: Sensitive to texture differences in
toys.
• 9 months: Stands holding onto furniture.
• 9 months: Enjoys toys that fit together
• 10 months: Pulls up to stand with support. (blocks/rings). Begins creeping.
• 11 months: Cruises while holding onto • 10 months: Ready for games like peek-a-boo
furniture.
and patty-cake. Can clap hands.
• 12 months: Stands alone briefly. • 11 months: Begins cruising (walking while
Fine Motor
holding onto furniture).
• 1 month: Strong grasp reflex, hands in fists. • 12 months: Enjoys putting things in and out of
• 2 months: Holds objects briefly before containers. Responds to nursery rhymes and
dropping them. music.
• 3 months: Reaches for objects, but grasp is
unpracticed. Cognitive Development (Piaget)
• 4 months: Hands come together, beginning • 0-1 month: Reflex-based actions, interaction
thumb opposition. with the environment.
• 5 months: Grasps objects handed to them. • 3 months: Primary circular reaction (explores
• 6 months: Holds objects in both hands, may objects by grasping or mouthing).
drop one when offered another. • 6 months: Secondary circular reaction
• 7 months: Transfers objects from one hand to (realizes actions cause reactions).
the other. • 10 months: Object permanence achieved.
• 8 months: Advanced hand-eye coordination, • 12 months: Reproduces actions and explores
more controlled reaching. the environment more actively.
• 10 months: Uses a pincer grasp (thumb and
forefinger) to pick up small objects. Nursing Role in Health Promotion
Promoting Trust (Erikson):
• 12 months: Holds crayon and may draw a line,
enjoys putting objects in and out of containers, • Infants develop trust by having their needs
and feeds themselves with a spoon. consistently met.
• Caregivers should provide a predictable routine
Language Development for the infant.
• 1 month: Coos and makes small sounds. Infant Safety:
• 2 months: Differentiates cries. • Prevent aspiration (e.g., avoid small, round
objects).
• 3 months: Responds with squeals or laughter
to friendly faces or voices. • Prevent falls (never leave infant unattended on
elevated surfaces).
• 4 months: Coos, babbles, and laughs aloud.
• 5 months: Makes vowel sounds like "goo-goo" Car safety: Use rear-facing car seats until age 2 or
or "gah-gah." weight/height limit.
• 6 months: Imitates sounds. • Childproofing: Remove harmful objects, install
• 7 months: Imitates vowel sounds and safety gates, and avoid baby walkers.
increases vocalizations.
Nutrition:
• 9 months: First words, typically "da-da" or "ba-
ba." • Birth-6 months: Exclusive breastfeeding or
formula feeding.
• 10 months: Masters additional words like "bye-
bye." • 6-12 months: Continue breastfeeding/formula,
introduce complementary foods like iron-
• 12 months: Uses two words with meaning.
fortified cereals, and provide fluoride and iron
Play
supplements.
• 1 month: Fixes eyes on objects like a mobile.
• 2 months: Holds and drops small rattles. Developmental Readiness for Solid Foods:
• 3 months: Handles blocks or small rattles.
 • Signs of readiness include controlling • Clothing:
head/neck, sitting with support, bringing objects o Choose simple, easy-to-launder
to the mouth, and swallowing food. clothing to avoid struggle.
o Infants who begin to creep should
Feeding: wear long pants for knee protection.
• Human milk is ideal; formula is a substitute. o Soft-soled shoes or socks/booties
• Avoid cow's milk before age 1. are sufficient before walking.
• After 6 months, introduce nutrient-dense foods
o After walking starts, shoes should be
firm but nonslip.
(e.g., purees, cereals).
• Gradually reduce calorie intake as growth Sleep Guidelines
slows
• Sleep Patterns:
Bathing: o Infants sleep an average of 14 hours
from birth to 3 months, and 13 hours
• Bathing every day is unnecessary, but from 3 to 12 months.
head/scalp care (e.g., for cradle cap) may need o Encourage tummy time starting at 4
daily attention. months, lowering the crib mattress as
the infant gains mobility.
Safety:
o By 6 months, establish a bedtime
• Never leave infants unattended in bathtubs, routine and aim for sleep stretches of
highchairs, or strollers. 6 to 8 hours.
• Be cautious of environmental hazards like lead o Avoid sleeping in a semi reclined
paint and small objects they can swallow. position (e.g., swings, car seats) to
Cradle Cap: prevent oxygen deprivation and
o Use a soft toothbrush or fine-toothed reflux.
comb to remove yellow, crusty • Swaddling:
patches. o Swaddle to reduce the startle reflex
Bathing: but stop by 2 months or when the
o Bath time should be enjoyable and baby can roll over to reduce
become a playtime for the infant, suffocation risks.
especially starting at 6 months.
Exercise and Outdoor Time
Diaper Care
• Outdoor Benefits:
• Diaper Hygiene: o Sunlight provides natural vitamin D
o Change diapers frequently, every 2 but protect the infant from excessive
to 4 hours when awake. sun exposure.
o Air-dry or sleep without a diaper if a o Avoid sunscreen until 6 months.
rash develops from wet diapers. o Walks and outdoor activities can
o Use clear water or alcohol-free enhance language development and
wipes; pat or air-dry the skin. provide quality bonding time.
o Avoid baby or talc powder due to o Avoid walkers to prevent falls and
aspiration risks. injuries.
o Perform hand hygiene after each Teething and Oral Habits
diaper change. • Teething:
Dental Care
o Most infants experience mild
discomfort during teething, especially
• Oral Hygiene: with molars.
o Fluoridated water (0.3 ppm) helps o Provide chilled teething rings for
prevent tooth decay. relief and check for safety.
o Clean gums with a soft washcloth o If needed, administer acetaminophen
before teeth erupt. after consulting a provider for the
o Once teeth appear, brush with a soft right dosage.
brush or washcloth once or twice • Thumb-Sucking and Pacifiers:
daily.
o Thumb-sucking is common and does
o Toothpaste is not necessary for not harm the jaw.
infants.
o Pacifiers can provide comfort but
o First dental check-up should occur at may affect breastfeeding if
age 1, followed by regular visits. introduced too early. Wean from
pacifiers by 6 to 9 months.
Dressing and Footwear • Head Banging:
 o Some infants bang their heads to fall o Miliaria occurs in hot weather or
asleep, which is often a normal when overdressed. It appears as red
behavior that can occur until papules, usually on the neck.
preschool years. o Keep the infant cool and avoid
overheating to prevent rash
Safe Sleep Practices formation.
• Back Sleeping:
o Put infants to sleep on their back until Baby-Bottle Tooth Decay
they can roll over independently. • Prevent Tooth Decay:
o Avoid swaddling once the baby can o Never put an infant to bed with a
roll over. bottle of milk, formula, or juice as it
o Keep the crib clear of blankets, can cause tooth decay (baby-bottle
pillows, or other hazards during the syndrome).
first year. o Only water in bottles at bedtime to
o Use a pacifier at naps and bedtime avoid decay.
once breastfeeding is established.
• Avoid Bed Sharing:
o Bed sharing, especially with smoking, CHAPTER 30: NURSING CARE OF A FAMILY WITH A
impaired adults, or soft bedding, TODDLER
increases the risk of SIDS. PHYSICAL GROWTH
o If bed sharing is necessary, ensure • Weight & Height: Toddlers gain about 5-6 lbs
safety measures such as firm (2.5 kg) and 5 in. (12 cm) each year. They
mattresses, no pillows, and safe become leaner as baby fat disappears.
positioning.
• Head Circumference: Increases by about 2
Common Health Concerns cm during the second year. By 1 year, head
• Constipation: and chest circumference are equal; by 2 years,
o Breastfed infants rarely experience chest circumference is greater.
constipation. Formula-fed infants • Body Mass Index (BMI): Screening at 24
may struggle due to digestion months to identify weight issues.
difficulty. BODY CONTOUR
o Watch for symptoms like hard stools • Physical Changes: Prominent abdomen, weak
or signs of anal issues and consult
abdominal muscles, lordosis (spinal curve), and
the healthcare provider if needed.
waddle-like walk.
o Hirschsprung disease may present
as chronic constipation. • Body Systems:
• Loose Stools: o Respirations are slow and
abdominal.
o Breastfed infants often have looser o Heart rate slows from 110 to 90 bpm.
stools than formula-fed infants.
o Celiac disease or malabsorption o Blood pressure rises to ~99/64 mm
Hg.
should be suspected if diarrhea,
distended abdomen, or fat o The brain reaches about 90% of its
malabsorption occurs. adult size.
o Stomach capacity increases, allowing
• Colic: for three meals a day.
o Colic manifests as intense crying and o Immunity matures by age 2, passive
abdominal pain, often in the first few immunity ceases.
months. TEETH
o Offer a pacifier, reduce stimuli, or use
soothing techniques like car rides or • Teething: Eight new teeth erupt during the
music to comfort the infant. second year. All 20 deciduous teeth usually
present by 2.5 to 3 years.
Skin Conditions
DEVELOPMENTAL MILESTONES
• Diaper Dermatitis (Rash): Language Development
o Frequent diaper changes and air • 2-year-olds should use simple two-word
exposure help reduce rash.
sentences.
o Use antifungal treatment (e.g.,
Nystatin) for red, oozing rashes. • "No" becomes a common word used to express
o Allergies or irritations from diapers or autonomy.
laundry detergents may require • Encouraging language: Engage in
product changes. conversation, read aloud, and label objects
• Miliaria (Prickly Heat): during play.
• Bilingual children may mix languages.
Emotional Development
• Autonomy vs. Shame: Toddlers strive for CHAPTER 31: NURSING CARE OF A FAMILY WITH A
independence. PRESCHOOL CHILD
• Socialization: At 15 months, toddlers engage Physical Growth & Body Contour
in parallel play (playing besides, not with other • Body Changes: Thinner & taller; exhibits genu
children). valgus (knock-knees).
• Imitation: At 2 years, they begin imitating adult • Height Growth: 2 – 3 1⁄2 inches (6 – 8 cm) per
actions (e.g., feeding a doll, driving a car). year.
Cognitive Development • Weight Growth: Gains 4 1⁄2 lbs (2 kg) per
• Sensorimotor to Preoperational: Begins year.
between 18-24 months with symbolic thought • Teeth: All 20 deciduous teeth by 3 years old.
and problem-solving.
• Lymphatic Tissue: Increased size, especially
• Object Permanence: Fully developed by the the tonsils; higher IgG and IgA antibody levels.
end of the toddler period.
• Pulse Rate & Blood Pressure:
PROMOTING TODDLER SAFETY o PR = 85 bpm
o BP = 100/60 mmHg
• Accidents: Major cause of injury; includes
poisoning, aspiration, and motor vehicle • Voiding: 9 – 10 times per day; night-time
accidents. bladder control achieved.
• Car Seats: Toddlers should be in rear-facing Developmental Milestones
seats until age 2 or outgrow the seat’s Language Development
height/weight limit.
• 3 years old:
• Home Safety: Childproofing is essential—store o Vocabulary of 900 words; constant
poisons and small objects out of reach.
"How?" and "Why?" questions.
PROMOTING TODDLER DEVELOPMENT
• Dressing: Toddlers may start dressing • 4 – 5 years old:
themselves (e.g., socks, underpants) but may o Continual questioning and enjoyment
need help with clothes. of mealtime conversations.
o Can describe their day in detail;
• Sleep: Toddlers sleep around 8 hours a night stuttering (disfluency) common.
and may begin resisting naps or nighttime Play
sleep due to awareness of activities happening
while they sleep. • Cooperative Play:
• Bathing: Always supervise during bath time to o Purpose: Learn to share and play in
small groups, understand simple
prevent drowning or scalding.
games and social rules.
TOILET TRAINING
o Types of play: Dramatic, imitative,
• Readiness: Key developmental signs include creative.
control over sphincters and understanding the o Child expresses self through play,
concept of holding urine/stools. imitates parental actions, may have
• Timing: Begin when the child is walking well, imaginary friends.
typically around 2-3 years.
RITUALISTIC BEHAVIOR & NEGATIVISM Emotional Development
• Rituals: Toddlers may develop preferences • Erikson's Initiative vs. Guilt:
(e.g., certain toys or routines). o Learns to do things and derives
• Negativism: Common "no" responses indicate satisfaction from activities.
a desire for independence. Reducing questions o Needs exposure to a variety of
and offering choices can help manage it. experiences and play materials.
DISCIPLINE o Imitates role models; has an active
• Discipline vs. Punishment: Set clear rules, imagination and struggles to
praise correct behavior, and use "timeouts" differentiate between reality and
effectively for misbehavior. fantasy.
SEPARATION ANXIETY & TEMPER TANTRUMS
• Separation Anxiety: Common at 6 months to Cognitive Development
preschool age, where children have difficulty • Piaget's Preconceptual & Intuitive Thought
being separated from parents. Stages:
• Temper Tantrums: Natural consequence of o Increased understanding of time and
limited language skills and frustration. Manage space.
by ignoring the tantrum and reinforcing positive o Egocentrism: They believe they're
behavior. always right.
o Not aware of the property of
conservation.
 o Perception dominates reasoning.
• Parental Concerns:
Moral and Spiritual Development o Health issues like ear infections,
• Kohlberg's Pre-Moral Stage: gastrointestinal disturbances.
o Determines right and wrong based o Immunizations: MMR (2nd dose),
on rewards and punishments. IPV, DTaP (4th booster).
o May not understand the reasoning o Fears: Dark, separation, mutilation.
behind right and wrong.
o Believes God has physical Behavior Variations
characteristics and participates in • Telling Tall Tales: Imaginary friends, sibling
religious rituals without full rivalry, regression (thumb sucking, loss of
understanding. bladder control).
Safety Concerns
• Sex Education:
• Accident Prevention: o 3 years old: Knows sex differences.
o Motor Vehicles: Car seat, safety with o 6 years old: Gender identity well-
tricycles, parking lot safety, helmet established; may display curiosity
use. about anatomical differences.
o Falls: Supervision on playgrounds
and safe climbing distances. Preparing a Child for School
o Drowning: Supervise near water and • Instilling Fun Learning: Encourage the belief
teach swimming. that learning is enjoyable.
o Animal Bites: Do not approach
strange dogs. BROKEN FLUENCY
o Poisoning: Teach children not to play • Stuttering: repetition and prolongation of
with medications and store sounds, syllables & words
substances safely.
o Burns: Use flame-retardant clothing,
store matches securely. CHAPTER 32: NURSING CARE OF A FAMILY WITH A
o Community Safety: Teach "stranger SCHOOL-AGED
danger" and encourage children to
PHYSICAL GROWTH & DEVELOPMENT
report uncomfortable situations.
o General Safety: Teach emergency A. General Parameters
numbers, how to seek help, and
report bullying. • Growth Patterns:
o Girls usually grow faster than boys.
Nutritional Health • Height:
• Dietary Recommendations: o Average schoolager grows 1-2
o Follow food pyramid guidelines. inches per year.
o Caloric need: 1,700 kcal/day. o Average 6-year-old height: 45 inches.
o Children on vegetarian diets may o Average 12-year-old height: 59
need Vitamin B12 supplements. inches.
Daily Activities • Weight:
• Dressing: o Average schoolager gains 3-5 lbs per
o 3-4 years old: Can dress themselves year.
except for difficult buttons. o Average 6-year-old weight: 46 lbs.
o 5 years old: Can lace shoes. o Average 12-year-old weight: 88 lbs.
• Sleep: • Pre-adolescence (10-13 years): Rapid growth.
o Needs 12 hours of sleep; common • Brain Growth: Complete by age 10, adult
fear of the dark. vision achieved.
o Nighttime routines: Use of night-light, • Immune System: More efficient; developed
bedtime stories, soothing music. immunity to many organisms.
• Exercise: Games like Ring Around the Rosie,
London Bridge. B. Nutrition
• Bathing: Supervision needed, avoid bubble • Nutritional Requirements:
bath. o Average of 2,400 calories/day.
• Teeth: Night grinding (bruxism) may occur. o Balanced diet necessary to store
Healthy Family Functioning & Discipline resources for adolescence growth.
• Discipline: • Food Preferences:
o Time-out technique: 1 minute per o Picky eaters, but more willing to try
year of age. new foods.
 o Dislike for vegetables, liver, and • Social Skills: Children learn rules, competition,
spicy foods. and cooperation.
o Family, friends, and media influence
food choices. B. Fears & Stressors
C. Sleep Patterns • Common Fears:
• Sleep Requirements: 8-9.5 hours nightly. 1. Failure at school.
• Bedtime: Should be firmly established on 2. Bullies.
school nights. 3. Intimidating teachers.
• Fatigue Awareness: Children may not 4. Concerns about parents.
recognize tiredness and can feel fatigued if • Common Stressors:
allowed to stay up late. o Young schoolagers: Teasing,
decision-making, need for approval,
D. Dental Health loneliness, independence, opposite
• Permanent Teeth Eruption: Starts at age 6. sex.
o Older schoolagers: Sexual
• Dental Care: maturation, shyness, competition,
o Brush teeth after meals with soft peer pressure, drug temptation.
nylon toothbrush.
o Parents should floss teeth until age 8 C. Socialization
or 9.
• Peer relationships and group activities become
• Common Dental Issues: Caries, more important.
malocclusion, periodontal disease.
• Activities like team sports and clubs become
central.
E. Elimination
• Bowel and Bladder Control: 85% of children D. Play & Toys
achieve control by age 6.
• More competitive and complex play.
• Common Issues: • Activities include:
o Nocturnal enuresis (bed-wetting).
o Team sports, secret clubs, scouting,
o Encopresis (persistent stool complex puzzles.
leakage).
o Board games, crafts, and hero
worship.
MOTOR DEVELOPMENT
• Toys for Development:
A. Gross Motor Skills o Board and card games, books,
• Bicycling, roller skating, skateboarding. athletic activities, and team activities.
E. Discipline
• Improved running and jumping skills.
• Schoolagers need guidance from adults for
• Swimming. decision-making.
B. Fine Motor Skills
• Regular chores help build responsibility.
• Greater dexterity for crafts, video games, and
computer competence. • Discipline should involve clear, reasonable
C. Safety Concerns limits and explanations.
• Responsibilities: School-age children learn PSYCHOSEXUAL DEVELOPMENT
more about personal health care and illness
prevention. A. Overview (Freud)
• Increased Motor Abilities: Children prone to • Latency Period (Age 6-12):
accidents due to growing independence.
o Period of sexual indifference before
• Safety Education: Parents should guide and puberty.
educate on health, safety, and drug use. o Self-esteem linked with developing a
sense of industry.
PSYCHOSOCIAL DEVELOPMENT
B. Sexual Development
A. Overview (Erikson)
• Pre-adolescence (End of School-Age
• Industry vs. Inferiority: Years):
o School-age children develop a sense o Sexual maturation differences
of industry through achievements. between boys and girls become
o Unrealistic expectations may lead to apparent.
a sense of inferiority. o Children ask questions about sex;
o Significant others expand to include honest answers based on their
peers and adults. understanding are crucial.
• Boys:
 o 9-11: Prepubertal weight gain. ILLNESS AND HOSPITALIZATION
o 11-12: Hair at the base of the penis,
sebaceous gland secretion A. Overview
increases. • Stressors: Immobilization, fear of mutilation,
o 12-13: Pubic hair, penis lengthens, death, and concerns over modesty.
growth spurt. • Difficulty with forced dependency and
• Girls: expressing themselves.
o 9-11: Breast bud elevation.
o 11-12: Hair along the labia, B. Reaction to Illness
sebaceous secretion increases, • Children view external forces as causes of
growth spurt. illness, such as cancer being more serious than
o 12-13: Pubic hair darkens, breast a cold.
enlargement, menarche occurs.
C. Reactions to Hospitalization
COGNITIVE DEVELOPMENT • Defense Mechanism: Reaction formation
(acting brave while scared).
A. Overview (Piaget)
• Separation Anxiety: Loneliness, isolation,
• Concrete Operational Thought: aggression, irritability.
o Objective thinking replaces
egocentric thinking. D. Nursing Management
o Concepts of conservation, 1. General Interventions:
classification, and categorization o Encourage verbalization and self-
emerge. care.
• Activities: o Provide diversions and allow
o Collecting and sorting objects. participation in care.
o Ordering items by size, weight, and 2. Physical Comfort:
other criteria. o Give control over body functions,
B. Language develop fine motor skills through
• By ages 7-9, children develop adult-like play.
articulation. 3. Cognitive Interventions:
• Significant skill development in reading and o Use scientific explanations, involve
the child in schoolwork.
language structure.
4. Psychosocial & Emotional:
MORAL DEVELOPMENT
o Encourage peer interaction, praise
cooperative play, and promote
• School-age children internalize standards and industry.
seek approval from significant others.

WELLNESS PROMOTION
A. General
CHAPTER 33: NURSING CARE OF A FAMILY WITH AN
• Encourage well-childcare, screenings, ADOLESCENT
immunizations, and safety.
B. Nutrition ADOLESCENCE
• Promote healthy eating, limit junk food. • Transition period between childhood and
• Educate on the food pyramid and differentiate adulthood, characterized by rapid physical,
nutritious vs. junk foods. cognitive, social, and emotional changes.
C. Sleep • A time when boys prepare for manhood and
• Establish a consistent bedtime; allow flexibility girls for womanhood.
on non-school nights.
D. Growth & Development Subphases of Adolescence
• Encourage skill development in various 1. Early adolescence (13 – 14 years)
activities, promote safety for latchkey children. 2. Middle adolescence (15 – 16 years)
E. Family 3. Late adolescence (17 – 20 years)
• Foster open communication, responsibility,
decision-making, and individuality. Puberty
F. Health • A maturational and hormonal process marking
• Promote self-care and hygiene. sexual maturity and the development of
G. Anticipatory Guidance secondary sex characteristics.
• Teach about puberty, substance abuse, and • Normal Parameters:
sex education. o PR = 70 bpm
o RR = 20 bpm
 o BP = 120/70 mmHg • Value system: Establishing personal values,
identity, and making career decisions.
Stages of Puberty
1. Prepubescence (2 years before puberty):
• Emancipation from parents: Becoming
independent, though it may be difficult for both
Preliminary physical changes.
adolescents and parents.
2. Puberty: Sexual maturity is reached, and the
first menstrual flow occurs in girls.
Socialization:
3. Postpubescence (1–2 years after puberty):
Skeletal growth completes, reproductive • Varies by age, from impulsive and emotional
functions are well established. behavior at 13 years to thoughtful interactions
at 17 years.
Physical Growth
Cognitive Development:
• Girls:
o Typically, 1–2 inches taller than boys • Formal operational thought: Ability to think
at the start of adolescence. abstractly, reason scientifically, and plan.
o Growth stops within 3 years of • Brain development: Pre-frontal cortex still
menarche (around 16–17 years). maturing, leading to impulsive behavior and
o Weight gain: 15–55 lbs. emotional swings.

Discipline:
• Boys:
o Grow 4–12 inches during • Important to set firm but reasonable limits and
adolescence. maintain a supportive, non-interfering family
o Weight gain: 15–65 lbs. environment.

Teeth Psychosexual Development:

• 2nd molars by 13 years, 3rd molars by 18-21 • Focus on sexual organs during the genital
years. stage, including masturbation and sexual
relationships.
Secondary Sex Characteristics • Adolescents navigate societal expectations and
their sexual desires.
Males (13 – 20 years):
• Pubic hair and body hair development. Moral & Spiritual Development:
• Testes, scrotum, and penis enlargement. • Post-conventional morality: Internalizing
standards of conduct and making decisions
• Voice changes and facial hair. based on personal ethical reasoning, rather
• Spermatogenesis becomes mature by 15–16 than external authority.
years.
Females (13 – 17 years): Health Promotion & Safety:
• Pubic hair development and breast changes. • MVA (Motor Vehicle Accidents): Leading
• Menstruation begins with ovulatory cycles, cause of death due to rebellious behavior.
though may be unovulatory initially. Emphasize safe driving, wearing seatbelts, and
avoiding alcohol while driving.
Developmental Milestones: • Drowning: Teach swimming and water safety.
• Firearms: Treat all guns as loaded.
Recreation:
• Sports: Promote safe practices, appropriate
• 13 years: Listening to music, chatting online, training, and proper equipment.
following sports teams.
• Nutrition: Encourage healthy food intake, as
• 15 years: Spending more time alone, possibly adolescents may skip meals or prefer
looking for part-time jobs. unhealthy snacks.
Emotional Development: Common Health Issues:
• Early & Mid-Adolescence (13–16 years): • Obesity: May lead to eating disorders;
Forming a sense of identity. encourage healthy diets and exercise.
• Late Adolescence (17–20 years): Forming a • Daily Activities: Adolescents are usually
sense of intimacy and close relationships. concerned about hygiene and appearance.
Identity Development: • Teeth care: Regular brushing and flossing,
avoiding cariogenic foods.
• Body image: Educating adolescents to accept
their changing bodies. • Sleep: Average 8 hours; needed for rapid cell
growth.
• Self-esteem: Challenged by changes in body,
feelings, relationships, and family expectations.
 • Exercise: Important for muscle tone and stress
relief.

Common Health Problems:

• Hypertension: Early detection and lifestyle
change important.
• Poor posture: Due to rapid growth, leading to
issues like scoliosis.
• Body Piercing & Tattoos: Monitor for signs of
infection.
• Fatigue: Investigate causes like diet, sleep
patterns, or potential disease.
• Acne: Common due to hormonal changes;
managed with topical or oral medications.

Health Concerns Regarding Sexuality:

• Sex education: Help adolescents make
informed decisions about sexual activity,
contraception, and sexual health.
• Peer pressure: Teach refusal skills and safe
sex practices.

Substance Abuse:
• Adolescents may use substances like tobacco,
alcohol, marijuana, or illicit drugs to cope with
stress or fit in with peers.
• Signs of abuse: Mood swings, declining
physical appearance, academic problems, and
changes in peer groups.

Depression & Suicide:

• Suicide risk: Often related to family problems,
peer issues, or loss of self-esteem.
• Signs of depression: Changes in behavior,
weight loss, irritability, and substance use.
• Crisis intervention: Provide emotional support
and help identify important aspects of the
adolescent’s life to offer hope.

Runaways:
• Adolescents may run away due to family
conflict, loneliness, or other personal struggles.
• Interventions: Support from family and
community resources to resolve underlying
issues.
CHAPTER 08: NURSING CARE OF A FAMILY HAVING 1. Female Infertility Tests
DIFFICULTY CONCEIVING A CHILD • Ovulation Testing: Blood test for hormone
levels
• Hysterosalpingography (HSG): X-ray to
STRUCTURE OF AN OVUM check for fallopian tube blockage
A. Nucleus
• Pelvic Ultrasound: Detects ovarian and
• The heart of the egg cell. uterine abnormalities
• It contains most of the genetic material in the 2. Male Infertility Tests
form of chromosomes. • Semen Analysis: Examines sperm count,
• This is where the genes are situated. movement, and shape
• An egg, like a sperm, contains half the number • Testicular Biopsy: If sperm production is in
of chromosomes as a normal cell, i.e., 23 question
chromosomes each. • Hormone Testing: Assesses testosterone and
B. Cytoplasm other hormones
• A gel-like substance that holds all the cell’s
other internal structures, called organelles. TREATMENT OPTIONS FOR INFERTILITY
• It is in the cytoplasm that all the cell’s activities 1. Medications
take place to keep it alive and functioning • Clomiphene Citrate: Stimulates ovulation
properly. • Metformin: Used for PCOS
• Among the more important organelles are • Gonadotropins: Stimulates the ovaries to
structures called mitochondria, which supply produce eggs
most of the energy for the cell. 2. Surgical Procedures
C. Zona Pellucida
• Laparoscopy: Removes blockages, fibroids,
• The zona pellucida (or egg wall) is an outer or endometriosis
membrane of the egg.
• Varicocele Repair: Surgery for enlarged veins
• This structure helps the sperm to enter the egg in the testicles affecting sperm production
through its hard outer layers. 3. Assisted Reproductive Technologies (ART)
D. Corona Radiata
• Intrauterine Insemination (IUI): Sperm is
• It surrounds an egg and consists of follicle placed directly into the uterus
cells that provide necessary proteins for the
egg’s growth. • In Vitro Fertilization (IVF): Eggs are fertilized
outside the body and implanted in the uterus
FACTORS AFFECTING FERTILITY • Intracytoplasmic Sperm Injection (ICSI): A
1. Female Factors single sperm is injected into an egg
a. Ovulation Disorders
• Hormonal imbalances ROLE OF THE NURSE IN INFERTILITY CARE
• Polycystic ovarian syndrome (PCOS) • Provide emotional support and counseling
• Premature ovarian failure • Educate couples about fertility awareness and
b. Tubal Factors lifestyle changes
• Blockage or damage to the fallopian tubes due • Assist in fertility treatments and procedures
to: • Advocate for patient mental well-being
o Pelvic Inflammatory Disease (PID)
o Endometriosis
o Previous surgeries CHAPTER 18: NURSING CARE OF A FAMILY WITH A
NEWBORN

c. Uterine or Cervical Factors 1. Neonatal Period & Transition

• Fibroids (noncancerous growths in the uterus) • Neonate: A baby within the first 28 days of life.
• Abnormal cervical mucus, which prevents • Neonatal Transition: The first few hours post-
sperm movement birth where the newborn stabilizes respiration &
circulation.
2. Male Factors
• Low sperm count 2. Healthy People 2030 Goals for Newborn Care
• Poor sperm motility (movement) • Increase exclusive breastfeeding from 25% to
• Abnormal sperm morphology (shape and 42.4%.
structure) • Increase back sleeping in infants from 78% to
• Ejaculation disorders 88.9%.
• Decrease tooth decay due to nighttime feeding
DIAGNOSTIC TESTS FOR INFERTILITY from 48% to 42.9%.
 • Reduce infant deaths to ≤5 per 1,000 live • Very Low Birth Weight (VLBW): <1.5 kg
births. • Extremely Low Birth Weight (ELBW): <1 kg
Nurse's Role in Achieving Goals
• Macrosomia: >9-10 lbs
Body Length
• Encourage breastfeeding for at least 6 months.
• Average: 48-52 cm (Females: 49 cm, Males:
• Educate parents on safe sleep practices. 50 cm)
• Warn against bottle feeding during sleep (risk • Short NB: <45 cm, Long NB: >55 cm.
of tooth decay). Head & Chest Circumference
• Teach signs of newborn illness to parents. • Head (HC): 32.5 - 36 cm (abnormal: <32 cm or
>37 cm).
3. Nursing Process
• Chest (CC): 30-34 cm (should be 2 cm less
than HC).
Assessment
• Pregnancy history & infant physical exam 5. Newborn Vital Signs
• Lab analysis (Hct, bilirubin, blood type,
bonding assessment) Temperature
Key Lab Values: • Axillary: 36.5-37.5°C (97.7-99.5°F)
• Hematocrit (Hct): Normal = 45%-61%, • Rectal: 36.6-38°C (97.9-100.4°F)
Polycythemia if >65%.
• Regulation Issues: Risk of hypothermia (low
• Bilirubin: Normal = 0.3-1.0 mg/dL in the first temp) or hyperthermia (high temp).
24 hours. High levels may lead to jaundice. Pulse (Heart Rate)
Nursing Diagnosis
• 180 bpm at birth, then 120-140 bpm after 1
hour.
• Ineffective airway clearance (mucus).
• Transient murmurs possible due to fetal
• Ineffective thermoregulation (heat loss). circulation adjustments.
• Malnutrition risk (poor sucking reflex).
• Health-seeking behaviors (parents’ Respiratory Rate
concerns). • 90 breaths per minute at birth.
• 30-60 breaths per minute once stable.
Outcome Identification & Planning
• Periodic breathing (brief apnea without
• Maintain stable vital signs. cyanosis is normal).
• Ensure successful respiratory & metabolic Blood Pressure
transition. • At birth: 80/46 mmHg, by 10 days: 100/50
• Educate parents for confidence in newborn mmHg.
care. • Not routinely measured due to small arm size.
Implementation Why Palpate Femoral Pulse?
Immediate Care
• If absent, could indicate aortic coarctation
• Drying, positioning, skin-to-skin contact. (heart defect).
• Breathing assessment & resuscitation if
necessary. 6. Thermoregulation & Heat Loss Prevention
• Identification (ID bands, footprints). Heat Loss Mechanisms:
Ongoing Care 1. Convection – Heat loss to cold air (e.g., AC,
fans).
• Feeding support, monitoring vital signs, 2. Radiation – Heat loss to nearby cold objects.
screenings.
3. Conduction – Heat loss via contact (e.g., cold
• Parental education on newborn care. table).
4. Evaporation – Heat loss via moisture (e.g.,
Outcome Evaluation amniotic fluid).
• Stability in vital signs, feeding, elimination. How Newborns Stay Warm
• Parents demonstrate confidence in newborn • Constricting blood vessels.
care. • Using brown fat for heat.
• Increasing metabolic activity (crying,
4. Newborn Profile (Anthropometric Measurements)
movement).
Nursing Interventions to Prevent Heat Loss
Body Weight
• Dry newborn immediately after birth.
• Normal: 2.5 – 4 kg (5.5 – 8.8 lbs)
• Skin-to-skin contact with mother.
• Low Birth Weight (LBW): <2.5 kg
• Warm blankets & radiant warmers.
 Physiologic Functions of a Newborn Gastrointestinal System
Respiratory System • Sterile at birth; bacteria colonize within 5-24
hours.
I. Initiation of Breathing
For newborn lungs to function properly after birth:
• Bacteria aid in digestion and Vitamin K
synthesis.
1. Pulmonary ventilation must be established.
2. Pulmonary circulation must increase • Deficient in lipase & amylase, limiting
significantly. digestion.
• Regurgitation is common due to an
What Happens After the First Inhalation? immature cardiac sphincter.
• Negative chest pressure allows passive Newborn Stomach Capacity
inspiration. • First 24 hrs: 30-60 mL.
• Crying creates positive intrathoracic • By Day 3: 60-90 mL.
pressure, helping air reach the alveoli. • Lower pH & slow digestion.
• Lung expansion moves residual lung fluid into
the bloodstream. Types of Stools
• Meconium (1st stool): Within 24-48 hours.
Note: First breath requires 40-70 cm H2O pressure.
• Transitional Stool: 2nd-3rd day.
Factors Opposing the First Breath • Breastfed Baby Stool:
1. Alveolar Surface Tension – Required for Yellow/golden/mustardy.
normal breathing. • Formula-fed Stool: Brown/greenish brown.
2. Lung Fluid Viscosity – Influenced by
surfactant levels.
• Bright Green Stool: Increased bilirubin
excretion.
3. Lung Compliance – Determines how easily
lungs fill with air. • Gray Stool: Bile duct obstruction.
• Blood-flecked Stool: Possible anal fissure.
Fetal to Neonatal Circulation • Loose, Watery Stool: Possible lactose
intolerance.
How Fetal Lung Fluid is Removed
• During labor, fluid is expelled with each Breastfeeding & Milk Digestion
exhalation. • Newborns digest breast milk well.
• Chest compression during birth increases • Breast milk contains digestive enzymes like
intrathoracic pressure. lipase.
• Chest recoil after birth creates an empty space • Contains growth factors for gut maturation.
in the chest, helping absorption.
Respiratory Stimuli at Birth Urinary System
1. Chemical – Temporary asphyxia (low oxygen)
stimulates respiration. • First void within 24 hours.
2. Thermal – Cold environment triggers • UO (Urinary Output): 30-60 mL/day.
breathing. • Specific Gravity: 1.008 - 1.010.
3. Sensory – Light, sounds, and gravity • First void can be pink/musky due to uric
encourage breathing. acid crystals.
Note: C-section babies retain more lung fluid than
vaginally delivered babies. Why no water for newborns?
Cardiovascular System • They cannot reabsorb sodium efficiently
before 6 months.
• First breath increases pulmonary blood flow.
• Risk of water intoxication.
• Fetal shunts close, shifting circulation to
newborn patterns. Immune System
• Peripheral circulation remains sluggish in • Newborns have limited immune protection.
the first 24 hours → May cause acrocyanosis
(blue hands & feet). • Cannot produce antibodies until 2 months.
Passive Immunity
Why is Vitamin K Given After Birth? • IgG – Passed from mother’s placenta (fights
• Prevents intracranial hemorrhage. infections).
• Vitamin K helps produce clotting factors II, VII, • IgM – First response to viruses & bacteria.
IX, and X. • IgA – Found in colostrum, protects GI &
• Dosage: 0.5-1 mg IM in the lateral anterior respiratory tracts.
thigh.
Neuromuscular System & Reflexes
Newborns demonstrate muscle function by: CHAPTER 19: NUTRITIONAL NEEDS OF A NEWBORN
1. Moving extremities.
2. Attempting to control head movement. 1. Indicators of Adequate Nutrition:
3. Strong cry. • Physical Signs:
4. Showing reflexes.
o Sleeps between feedings.
Common Newborn Reflexes o Demonstrates good skin turgor.
o Loses no more than 10% of birth
weight.
Disappear
Reflex Description Stimulus
s
o Voids six to eight times per day.
o Has two to three bowel movements
Bright daily.
Blink Closes eyes Never
light/touch
• Behavioral Signs:
Turns head o Appears content after feedings.
Rooting Cheek stroke 6 weeks
toward touch
o Shows alertness and responsiveness
Sucks when during awake periods.
Sucking lips are Touch lips 6 months
touched 2. Nutritional Requirements:
Swallowing
Swallows Tongue
Never • Calories:
when fed pressure o Require 110–120 calories per
Pushes kilogram of body weight per day.
Extrusion Press tongue 4 months o Human milk and standard infant
tongue out
Palmar Place object 6 weeks - 3 formulas provide approximately 20
Grabs object calories per ounce.
Grasp in palm months
Step/Walkin Mimics Feet on hard
• Protein:
g walking surface
3 months o Essential for growth and
development.
Touch lower o Recommended intake is 2.2 grams
Placing Lifts foot 4-6 months
leg per kilogram per day.
Plantar Toes grasp Touch sole of
8-9 months o Human milk contains whey and
Grasp object foot casein proteins in an optimal ratio for
One side digestion.
Tonic Neck extends,
Turn head 2-3 months • Fats:
(Fencing) opposite o Provide a significant portion of
flexes energy.
Extends arms, Loud o Linoleic acid is crucial for brain
Moro
then noise/sudden 4-5 months development and skin integrity.
(Startle)
embraces movement o Human milk contains essential fatty
Stroke sole in acids, including DHA and ARA.
Babinski Toes fan out 3 months
‘J’ shape
Pressure on • Carbohydrates:
Magnet Pushes back
sole
4-6 months o Lactose is the primary carbohydrate
in human milk, aiding in calcium
Raises leg in Touch leg
Crossed absorption and promoting healthy gut
response to while 6-8 months flora.
Extension
stimulus extended
• Fluids:
Trunk
Incurvation
Hips move
Stroke back
12-18 o Require approximately 150–200
toward touch months milliliters per kilogram per day.
(Galant)
o Adequate hydration is indicated by
Arches 18-24 regular urination and moist mucous
Landau Held prone
back/head lifts months membranes.
Patellar/bicep
Gentle strike • Minerals:
Deep to o Calcium: Supports bone growth;
s reflexes 4-6 years
Tendon biceps/tendo adequate amounts are present in
intact
n human milk.
o Iron: Sufficient stores are present at
birth to last for about three months;
human milk contains easily absorbed
iron.
 o Fluoride: Supplementation may be CHAPTER 20: NURSING CARE OF A WOMAN WITH A
considered after six months if the PREEXISTING ILLNESS OR NEWLY ACQUIRED ILLNESS
water supply is non-fluoridated.
• Vitamins: High-Risk Pregnancy
o Vitamin D: Supplementation of 400 • A high-risk pregnancy is one where a
IU per day is recommended to concurrent disorder, pregnancy-related
prevent rickets. complication, or external factor jeopardizes the
health of the mother, the fetus, or both.
3. Breastfeeding Considerations: • Both the mother and the fetus can be at risk for
• Contraindications: complications because either the pregnancy
o Maternal infections such as untreated can complicate the disease, or the disease can
tuberculosis or HIV. complicate the pregnancy.
o Maternal use of contraindicated
medications or substances. Initial Assessment:
• Maternal Benefits: • A thorough history and physical examination
o Promotes uterine involution. must be obtained at the first prenatal visit to
o Reduces postpartum bleeding. establish a baseline of information on the
o May lower the risk of certain cancers condition.
and osteoporosis. • Documentation of any medication being taken
4. Formula Feeding: for a secondary condition is necessary to
• Types of Formula: protect against adverse drug interactions and
the possibility of teratogenic action on the fetus.
o Ready-to-feed: No preparation
required. • Teaching is an important nursing intervention
o Concentrated liquid: Requires dilution because a woman with a preexisting illness
with water. must make modifications in her usual therapy
o Powdered: Needs to be mixed with to adjust to pregnancy.
water. • Pregnancy often stimulates women to learn
• Preparation Guidelines: more about their primary disease as well.
o Follow manufacturer's instructions Nursing Care Focus:
precisely.
o Use safe water sources for mixing. • Preventing such disorders from affecting the
o Ensure bottles and nipples are health of the fetus.
properly sterilized. • Helping a woman regain her health as quickly
as possible.
5. Feeding Techniques: • Helping a woman learn more about her chronic
• Breastfeeding: illness so she can continue to safeguard her
o Encourage feeding on demand, health during her childrearing years.
typically 8–12 times in 24 hours.
o Ensure proper latch and positioning. A. Assessment:
• Bottle Feeding: • Understanding of the course of a normal
o Feed every 3–4 hours, with amounts pregnancy.
increasing as the newborn grows. • Signs & symptoms of illnesses.
o Hold the infant semi-upright during • Assessment techniques include:
feeding to prevent ear infections. o Baseline vital signs.
o Extent of edema.
6. Monitoring Growth and Development: o Level of exhaustion.
• Regular Pediatric Visits: • Woman to assess her own health in relation to
o Track weight, length, and head objective parameters.
circumference. B. Nursing Diagnosis:
o Assess developmental milestones. • Examples of possible Nursing Diagnoses:
• Parental Education: o Ineffective tissue perfusion
o Recognize hunger and satiety cues. (cardiopulmonary) r/t poor heart
o Understand the importance of function 2° MVP during pregnancy.
responsive feeding. o Social isolation r/t prescribed bed
rest during pregnancy 2° to
concurrent illness.
o Ineffective role performance r/t
increasing level of daily restrictions
2° to chronic illness and pregnancy.
 o Knowledge deficit r/t normal changes • Cardiovascular disease complicates only 1% of
of pregnancy vs illness pregnancies but accounts for 5% of maternal
complications. deaths.
o Fear regarding pregnancy outcome • Blood volume and cardiac output increase up to
r/t chronic illness. 50% during pregnancy (peaks at 28 to 32
o Health-seeking behaviors r/t the weeks), placing stress on a compromised
effects of illness on pregnancy. heart.
o Situational low esteem r/t illness
during pregnancy. Cardiac Disease: Woman with L-Sided Heart Failure

C. Outcome Identification and Planning: Conditions:

• Expected outcomes established are realistic in • Mitral valve stenosis & mitral insufficiency.
light of a woman’s pregnancy and health
restrictions.
• Mitral valve thickening, which becomes rigid
and cannot fully open.
• Give the woman the available alternatives. • Aortic coarctation.
• Allow a woman to choose among the
alternatives. Complications:

D. Implementation:
• The inability of the mitral valve (MV) to push
blood forward causes:
• For pregnant women with chronic illness: o Back pressure on the pulmonary
o Focus on teaching her new or circulation causing it to be distended.
additional measures to maintain o Systemic BP decreases.
health. o Pulmonary hypertension – pressure
• For women who developed a new illness: in pulmonary vein reaches 25 mmHg,
o Provide an opportunity to talk about fluid passes from pulmonary capillary
the event after her initial care is membranes into interstitial spaces
complete to identify concerns. and alveoli (pulmonary edema).
o Pulmonary edema.
E. Outcome Evaluation: o Pulmonary capillaries rupture.
• If the expected outcome is not met, High-Risk Outcomes:
reassessment, analysis, and planning need to • Women with pulmonary hypertension are at
be done. extremely high risk for:
• Make evaluation ongoing to ensure whether o Spontaneous miscarriage.
interventions are successful. o Preterm labor.
• Examples of outcomes: o Maternal death.
o Client states she rests for 2 hrs • If complications result in impaired blood flow to
morning and afternoon; dependent the uterus, the following events can occur:
edema remains at 1+ or less at next o Poor placental perfusion.
prenatal visit. o Intrauterine (IU) growth restriction.
o Family members state they are all o Fetal mortality.
participating in an exercise program
since mother developed gestational
• Serial Ultrasounds and Non-Stress Tests:
diabetes. o Woman needs serial ultrasounds and
non-stress tests done after 30-32
o Client reports no burning on urination
weeks to monitor fetal and maternal
or flank pain at next prenatal visit.
health.
o Client states she understands the
importance of taking daily thyroid
Signs and Symptoms of Left-Sided Heart Failure:
medicine for the total length of
1. Increased respiratory rate (RR).
pregnancy.
2. Increased fatigue, weakness, and dizziness.
3. Systemic decrease in blood pressure (BP).
Identifying a High-Risk Pregnancy
Cardiovascular Disorders:
Medical Management for Left-Sided Heart Failure:
• The cardiovascular disorders that most 1. If Mitral Valve (MV) Stenosis is Present:
commonly cause difficulty during o Thrombus formation can occur due to
pregnancy are: non-circulating blood.
o Valve damage concerns caused by o Anticoagulants:
rheumatic fever or Kawasaki disease. ▪ Heparin (does not cross
o Congenital anomalies such as atrial the placenta) for early
septal defect or uncorrected pregnancy.
coarctation of the aorta.
High-Risk Pregnancy: Cardiovascular System
 ▪ Warfarin (Coumadin) can • Cardiomegaly (heart enlargement).
be used after 12 weeks but Therapy:
return to heparin during the • Sharply reduce physical activity.
last month of pregnancy.
o Balloon Valve Angioplasty (for • Diuretic therapy.
treatment). • Arrhythmia agents, and digitalis therapy to
2. If Coarctation of the Aorta is Present: maintain heart function.
o Aortic dissection may occur. • Low-molecular-weight heparin may be
o Prescribed medications: administered.
▪ Antihypertensive • Immunosuppressive therapy (e.g.,
medications. corticosteroids).
▪ Diuretics to reduce blood • Postpartum Considerations:
volume. o If cardiomegaly persists, future
▪ Beta-blockers to improve pregnancies may be discouraged as
ventricular filling. the condition may recur or worsen.
o Oral contraceptives are
Right-Sided Heart Failure contraindicated due to the risk of
thromboembolism.
Common Causes:
• Pulmonary valve stenosis. Classification of Heart Disease in Pregnancy:
• Atrial & ventricular septal defects. • Heart disease in pregnancy is classified into
• Eisenmenger syndrome (R to L atrial or four categories based on criteria established by
ventricular septal defect with pulmonary the New York Heart Association (NYHA):
stenosis).
Pathophysiology: Class Description
• Occurs when output from the right ventricle Class
Uncompromised: Ordinary physical activity
(RV) is less than the blood volume received by causes no discomfort. No symptoms of cardiac
1
the right atrium (RA) from the vena cava. insufficiency or anginal pain.
• Back-pressure results in: Class
Slightly compromised: Ordinary physical activity
o Congestion of systemic venous 2
causes excessive fatigue, palpitation, dyspnea,
circulation. or anginal pain.
o Decreased cardiac output to the Markedly compromised: Less than ordinary
lungs. Class
activity causes excessive fatigue, palpitation,
3
o Decreased BP in the aorta. dyspnea, or anginal pain.
o High pressure in the vena cava. Severely compromised: Woman is unable to
o Jugular venous distention. Class carry out any physical activity without discomfort.
o Increased portal circulation (liver & 4 Symptoms of cardiac insufficiency or anginal
spleen distention). pain present even at rest.
o Ascites (fluid accumulation in the
peritoneal cavity). Assessments for Cardiac Disease in Pregnancy:
1. Thorough Health History:
Medical Management for Right-Sided Heart Failure: o Document pre-pregnancy cardiac
1. Eisenmenger Syndrome (uncorrected status.
anomaly): 2. Exercise Performance:
o Women with uncorrected anomalies o Assess the woman’s level of exercise
may be advised against pregnancy performance.
due to the high risks associated with 3. Symptoms Assessment:
this condition.
o Ask if the woman experiences a
cough or edema:
Peripartum Heart Disease:
▪ Coughing could be a sign
• Peripartum Cardiomyopathy can develop of pulmonary edema.
during pregnancy in women with no prior
history of heart disease. The cause is unknown Distinguishing Edema:
but may be related to pregnancy stress on the
circulatory system. • Innocent Edema vs. Heart Failure:
o Mortality rate = 50%. o The usual innocent edema of
Signs & Symptoms: pregnancy must be distinguished
from edema caused by heart failure,
• Shortness of breath. which is a more serious condition.
• Chest pain. Baseline Vital Signs:
• Non-dependent edema. • Assessment Considerations:
 o Irregular pulse, rapid or difficult • Deficient Knowledge:
respirations, and chest pain on o Women may have insufficient
exertion may be present in women knowledge on how to reduce the
with heart disease. effects of maternal cardiovascular
o Baseline Measurements: disease on pregnancy and fetal
▪ Record blood pressure, health.
pulse rate, and respiratory Outcome Evaluation:
rate in sitting or lying • Goals:
position at the first prenatal o Patient identifies danger signs, such
visit and continue as angina pain, and knows the
throughout pregnancy. appropriate actions to take.
▪ Always obtain these in the o Maternal blood pressure maintained
same position at future above 100/60 mmHg.
visits for accurate o Fetal heart rate maintained at 110-
comparison. 160 beats per minute.
o Additional Assessments:
• Realistic Expectations:
▪ Nail bed filling should be o Not all women with heart disease will
<5 seconds.
be able to complete pregnancy
▪ Assess for jugular venous successfully.
distention.
o Positive actions, like increased rest
periods, can help reduce
Liver Size:
complications.
• Right-Sided Heart Failure:
o If the heart disease involves right- Related Interventions:
sided heart failure, assess liver size Promote Rest:
at prenatal visits for signs of • Rest Periods:
congestion.
o Women with cardiac disease need
two rest periods a day and a full
ECG and Echocardiogram:
night’s sleep to avoid exertion.
• Cardiac Monitoring: o Women should stop exercising
o ECG (electrocardiogram) or before cardiac output becomes
echocardiogram may be done insufficient.
periodically. o Some women may need to
o Both procedures are safe for the discontinue employment early in
fetus: pregnancy to reduce strain on the
▪ ECG measures cardiac heart.
electrical discharge and o Activity restrictions may vary:
poses no harm to the fetus. "Normal housework" may involve
▪ Echocardiography uses light tasks like dusting for some, but
ultrasound, which is also more strenuous work for others.
safe for the fetus. Promote Healthy Nutrition:
• Weight Management:
Fetal Assessment: o Ensure that the woman doesn’t gain
• Maternal Blood Pressure and Fetal Health: excessive weight to prevent
o When maternal blood pressure overburdening the heart and
becomes insufficient, fetal health circulatory system.
may be compromised, leading to o Confirm the woman is taking prenatal
poor placental perfusion. vitamins and maintaining nutritional
o Potential Fetal Risks: balance.
▪ Preterm labor may occur. • Anemia Prevention:
▪ Late decelerations on fetal o Sodium-restricted diet may be
heart monitoring may recommended but should not be
indicate poor response to excessively restrictive.
labor.
▪ Cesarean birth may be Educate Regarding Medication:
necessary, increasing risks • Cardiac Medication Adjustments:
for both the mother and o Women taking cardiac medications
fetus. like digoxin may need to increase
their maintenance dose due to the
Nursing Diagnosis and Related Interventions: expanded blood volume during
Nursing Diagnosis: pregnancy.
 o Digoxin can also be used to slow Postpartum Care and Interventions
fetal heart rate if fetal tachycardia A. Assess for Heart Failure:
occurs. • The postpartum period is a critical time for
• Antihypertensive and Arrhythmia Agents: women with heart disease.
o Adenosine, beta-blockers, and • After birth, there is a rapid increase in
calcium channel blockers may be pressure within 5 minutes, which requires the
used to manage hypertension. heart to make a major adjustment quickly.
o Nitroglycerin, often prescribed for
angina, is considered safe during B. Decreased Activity:
pregnancy (Category C drug). • A program of decreased activity may be
• Penicillin Prophylaxis: necessary during the postpartum period to
o If the woman had rheumatic fever prevent additional strain on the heart.
and was on penicillin prophylaxis,
she should continue this during C. Medication Therapy:
pregnancy, as penicillin is not • Continue anticoagulant therapy and digoxin
teratogenic (Category B drug). until circulation stabilizes.
o Pre-birth Antibiotics: Providers may
prescribe ampicillin, amoxicillin D. Antiembolic Measures:
(Amoxil), or clindamycin (Cleocin) • Antiembolic stockings or intermittent
near birth to prevent infection at the pneumatic compression (IPC) boots may be
placental site. prescribed to increase venous return from the
legs and reduce the risk of clot formation.
Educate Regarding Infection Prevention:
• Infection Risks: E. Prophylactic Antibiotics:
o Systemic infections can increase • Prophylactic antibiotics should be
cardiac output and metabolism, administered immediately after birth to prevent
putting stress on the heart. subacute bacterial endocarditis due to
o Advise women with heart disease to potential microorganism introduction through
avoid exposure to infections and the placental site.
report any symptoms of upper
respiratory or urinary tract infections F. Stool Softener:
(UTIs).
• A stool softener may be prescribed to avoid
o Early Antibiotic Therapy can be straining during bowel movements, which
started to prevent complications. could increase cardiovascular stress.
o Monthly Screening for Bacteriuria
should be done with a clean-catch G. Use of Oxytocin (Pitocin):
urine test at prenatal visits to detect
UTIs early. • Oxytocin should be used with caution as it can
increase blood pressure, which places
Nursing Interventions During Labor and Birth: additional strain on the heart.
1. Frequent Monitoring:
H. Kegel Exercises:
o Assess the woman's blood pressure,
pulse, and respirations frequently. • Kegel exercises can be safely performed for
2. Fetal Monitoring: perineal strengthening immediately
o Continuously monitor fetal heart rate postpartum.
to assess fetal well-being.
3. Monitor Uterine Contractions:
o Monitor contractions to ensure proper I. Postpartum Exercises:
placental filling and to prevent • Postpartum exercises aimed at improving
circulatory system failure. abdominal tone can begin once approved by
4. Side-Lying Position: the woman's primary care provider.
o Advise a side-lying position to reduce
the risk of supine hypotension J. Assess Baby:
syndrome. • Acrocyanosis (peripheral cyanosis) in
5. Oxygen Administration: newborns is normal. The mother should not
o Oxygen may be administered during interpret this as cardiac inadequacy in her
labor due to increased oxygen baby.
demand.
6. Hemodynamic Monitoring: Hematologic Disorders: Anemia and Diabetes in
o Continuous monitoring may be Pregnancy
required using a Swan-Ganz catheter
to assess heart function during labor. TRUE ANEMIA
 • Hemoglobin Levels: • Type 1 Diabetes: An autoimmune disorder
o <11 g/dL (hematocrit <33%) in 1st or where the pancreas fails to produce adequate
3rd trimester insulin.
o <10.5 g/dL (hematocrit <32%) in 2nd • Type 2 Diabetes: Gradual loss of insulin
trimester production, but some ability to produce insulin
remains.
Iron-Deficiency Anemia Clinical Manifestations in Pregnancy:
Causes: • For women with Type 1 or Type 2 diabetes
1. Diet low in iron who had good glucose control before
2. Heavy menstrual periods pregnancy, pregnancy causes changes in
3. Unwise weight-reduction programs glucose metabolism, making control more
4. Pregnant within <2 years before current difficult.
pregnancy
5. Low socio-economic levels with poor iron-rich • Insulin resistance increases as pregnancy
diets progresses due to hormones like human
Associated Risks: placental lactogen, cortisol, estrogen,
progesterone, and catecholamines.
• Low birth weight & preterm birth
• Women with pre-existing kidney disease
• Extreme fatigue & poor exercise tolerance (proteinuria, decreased creatinine clearance,
Blood Characteristics: hypertension) have a higher risk of pregnancy-
• Microcytic (small red blood cells) related hypertension.
• Hypochromic (less hemoglobin than average
red blood cells) Complications Associated with Diabetes in
Medical Management: Pregnancy:
1. Prophylaxis: 27 mg/day iron supplement 1. Hydramnios:
during pregnancy o High glucose levels cause extra fluid
2. Diet: High in iron and vitamins (green leafy to shift, enlarging amniotic fluid.
vegetables, meat, legumes) 2. Macrosomia:
3. Treatment: 120-200 mg elemental iron (ferrous o Large infants (>10 lb), leading to
sulfate or ferrous gluconate) potential birth issues (CPD).
Reminders: 3. Congenital Anomalies:
• Iron is absorbed best in an acid medium, so o Increased risk of caudal regression
take with orange juice or vitamin C. syndrome, spontaneous
• Side effects include constipation or gastric miscarriage, or stillbirth if diabetes
is poorly controlled.
irritation, alleviated by increasing roughage or
Clinical Manifestations in Newborns:
taking with food.
• Ferrous sulfate can cause black stools. • Hypoglycemia
• If severe, intravenous iron may be prescribed. • Respiratory distress syndrome
• Hypocalcemia
Folic Acid-Deficiency Anemia • Hyperbilirubinemia
Importance of Folic Acid (B9):
• Normal RBC formation in the mother Monitoring a Woman with Diabetes During
• Prevention of neural tube defects in the fetus Pregnancy:
1. Pre-pregnancy:
Most Common in:
1. Multiple pregnancies o Meet with primary healthcare
2. Women with secondary hemolytic illness provider to ensure optimal glucose
3. Women taking hydantoin (anticonvulsant) control before conception.
4. Women with gastric bypass surgery or B12 o Early pregnancy glucose control is
deficiency vital to minimize congenital
Megaloblastic Anemia: anomalies.
2. Tests:
• Enlarged RBC that don't function properly. o Glycosylated Hemoglobin
Medical Management:
(HbA1c): Reflects average glucose
1. Pre-pregnancy: Supplement with 400 µg folic
over the past 4-6 weeks. A level of
acid daily
6% is considered normal.
2. During pregnancy: 600 µg folic acid daily
3. Eat folate-rich foods (e.g., leafy greens, citrus, o Urine culture: To detect
fortified cereals). asymptomatic UTIs due to increased
glucose in urine.
High-Risk Pregnancy: Endocrine System (Diabetes o Ophthalmic examination: Once
Mellitus) during pregnancy for gestational
Diabetes in Pregnancy: diabetes and each trimester for
known diabetics.
 3. Home Pregnancy Test: o A 100g glucose solution is ingested,
o Important for detecting pregnancy and blood samples are taken at 1, 2,
early, as glucose control is crucial and 3 hours after ingestion.
during the early weeks. o A diagnosis of diabetes is made if
two of the four blood samples are
Important Notes: abnormal, or if the fasting value is
• Women with diabetes often require increased >95 mg/dL.
insulin around week 24 of pregnancy to
prevent hyperglycemia. Nursing Diagnoses for Gestational Diabetes:
• Women with poorly controlled diabetes face • Risk for ineffective tissue perfusion due to
significant risks during pregnancy, including reduced vascular flow
larger babies and increased risk of • Imbalanced nutrition related to the inability to
complications such as stillbirth or miscarriage. use glucose effectively
• Risk for ineffective coping related to required
lifestyle changes
CLASSIFICATION OF DIABETES
• Risk for infection related to impaired healing
• Deficient fluid volume due to polyuria
• Deficient knowledge about managing diabetes
during pregnancy
• Health-seeking behaviors related to the need
for home glucose monitoring

Nursing Interventions and Health Teaching:

1. Health Teaching:
o Educating the patient is crucial.
Focus on topics such as:
▪ Nutrition: Managing
carbohydrate intake and
meal planning.
Diabetes Mellitus and Gestational Diabetes ▪ Exercise: Encouraging
regular, moderate
Risk Factors for Developing Gestational Diabetes: exercise.
1. Obesity ▪ Insulin Administration:
2. Age over 25 years Understanding when and
3. History of large babies (10 lbs or more) how to administer insulin.
4. History of unexplained fetal or perinatal loss
5. History of congenital anomalies in previous
▪ Blood Glucose Monitoring:
How to check blood
pregnancies
glucose levels at home.
6. History of polycystic ovary syndrome (PCOS)
7. Family history of diabetes (one close relative or ▪ Fetal Assessment:
two distant ones) Explaining fetal monitoring
8. Ethnic background: Native American, Hispanic, tests to assess the baby’s
Asian populations are at higher risk. health.
2. Education on Insulin and Carbohydrates:
Assessment for Gestational Diabetes: o Women with diabetes must
1. Fasting Plasma Glucose (FBS): manage their carbohydrate intake
o A fasting plasma glucose level ≥ 126 daily. They need to estimate the total
mg/dL or a non-fasting plasma carbohydrates in their meals and
glucose ≥ 200 mg/dL confirms adjust insulin doses based on a pre-
diabetes without the need for further determined insulin-to-carbohydrate
tests. (Fasting for 8 hours before ratio.
testing is required.) o Maintaining an adequate glucose
2. 50-g Glucose Challenge Test (24-28 weeks intake is essential, particularly in the
gestation): early stages of pregnancy when
o Screening test to identify those at risk nausea and vomiting may complicate
for gestational diabetes. A 50g diet management.
glucose drink is consumed, and
blood glucose levels are checked 1 Outcome Evaluation:
hour later. • Patient Knowledge and Actions:
o If blood glucose is elevated, further o The patient should express an
testing is needed. understanding of the importance of
3. Oral Glucose Tolerance Test (OGTT):
 monitoring nutrition, exercise, and snack before exercise to prevent
glucose levels. hypoglycemia.
o The patient should be able to o Risk of Hyperglycemia with Poor
describe a nutrition and exercise plan Control: In women with poor blood
and express commitment to glucose control, excessive exercise
maintaining these practices. can lead to hyperglycemia and
ketoacidosis.
Note: Gestational diabetes is a condition that requires
careful monitoring and lifestyle modifications to ensure Blood Glucose Monitoring:
both maternal and fetal well-being. Nurses play a pivotal • Frequency: Blood glucose should be
role in guiding and educating the pregnant woman on monitored four times a day using a glucometer
how to manage the condition through diet, exercise, (fasting and 1-hour postprandial values).
medication (if needed), and frequent glucose monitoring. o Fasting Blood Sugar (FBS): <90
mg/dL
Nutrition Guidelines: o 1-hour Postprandial Blood Sugar:
• Daily Caloric Intake: <140 mg/dL
o An 1,800- to 2,400-calorie diet (or 30 • Hypoglycemia Management: If blood sugar is
kcal/kg of ideal body weight) is low, consume carbohydrate-rich foods (like
common. crackers) along with a protein source (like milk).
o Example for a 60 kg woman: Simple sugars may cause rebound
▪ 60 kg × 30 kcal/kg = 1,800 hypoglycemia.
kcal/day
▪ Divided into three meals Insulin Pump Therapy:
and three snacks: • Insulin Pump: A small device that delivers
▪ Breakfast: 200 insulin continuously via thin tubing inserted
kcal under the skin (typically on the abdomen).
▪ Lunch: 200 kcal
Tests for Placental Function and Fetal Well-being:
▪ Dinner: 200 kcal
1. Serum α-Fetoprotein (AFP):
• Macronutrient Distribution: o Assessed at 15-17 weeks to screen
o Protein: 20% of total calories for neural tube defects.
o Carbohydrates: 40% to 50% of total 2. Ultrasound (18-20 Weeks):
calories o Used to detect major fetal
o Fat: Up to 30% of total calories abnormalities.
• Fiber: An increased amount of fiber is 3. Creatinine Clearance Test:
recommended to help slow glucose absorption. o Done each trimester to assess
• Hypoglycemia at Night: Pregnant women are kidney and vascular function.
prone to nighttime hypoglycemia due to o Normal creatinine clearance
continuous fetal glucose use. indicates good kidney function and
o Evening Snack: Recommend a adequate uterine perfusion.
snack with protein and complex o Normal serum creatinine for pregnant
carbohydrates (e.g., egg and whole women: 0.4–0.8 mg/dL.
grain toast) to allow for slow 4. Nonstress Test (NST) or Biophysical Profile
digestion overnight. (BPP):
• Nausea/Vomiting/Heartburn: If the woman o Performed during the last trimester to
experiences nausea, vomiting, or heartburn monitor fetal health.
that prevents eating, she should notify her o If blood glucose control is poor, NST
healthcare provider immediately for potential may be done daily.
intravenous fluids and glucose 5. Fetal Movement Count:
supplementation. o The woman may be asked to record
fetal movements, aiming for around
• Weight Gain: Aim for an appropriate weight 10 movements per hour.
gain of approximately 25-30 lbs to reduce the
6. Ultrasound at Weeks 28 and 36-38:
risk of large babies and enable the possibility of
vaginal birth. Avoid reducing caloric intake o Used to assess fetal growth, amniotic
below 1,800 calories to prevent fat breakdown fluid volume, placental location, and
and acidosis. biparietal diameter.
o Oligohydramnios (low amniotic
• Exercise: Exercise can help lower blood fluid) may indicate fetal growth
glucose levels due to increased muscle glucose restriction or renal abnormality.
utilization.
o Polyhydramnios (excessive
o Pre-Exercise Snack: Suggest a amniotic fluid) could suggest
protein or complex carbohydrate
 gastrointestinal issues or poor • Postpartum Testing:
diabetes control. o An oral glucose tolerance test
7. Amniocentesis (Lecithin/Sphingomyelin (OGTT) is recommended at the 6- to
Ratio): 12-week postpartum visit to assess
o Typically performed around 36 weeks glucose metabolism and screen for
to assess fetal lung maturity. potential type 2 diabetes.
o Presence of phosphatidylglycerol (a • Follow-Up Screening:
compound that stabilizes surfactant)
indicates lung maturity.
o If the postpartum OGTT is normal,
the woman should be screened every
8. Corticosteroid Use:
1-3 years using any glycemic test,
o Corticosteroids may accelerate fetal including:
lung maturity but could impair fetal
insulin release and pancreatic ▪ A1C test
development, so their use is typically ▪ Fasting plasma glucose
not recommended in diabetic test
pregnancies. ▪ OGTT
Timing for Birth: Note: By carefully monitoring blood glucose, managing
• Most Hazardous Period for Fetal Health: diet and exercise, and regularly assessing fetal well-
o Weeks 36–40 of pregnancy are being, pregnancy outcomes can be optimized for women
critical due to the increased risk of with diabetes.
fetal macrosomia (large baby).
o Historically, many infants were
delivered early by cesarean section
to prevent complications from
placental insufficiency and large size.
• Cesarean Birth:
o Typically recommended for very
large babies to avoid birth injuries.
o If possible, vaginal birth is preferred.
• Labor Induction:
o Labor can be induced through
rupture of membranes or oxytocin
infusion, following cervical ripening.
• Monitoring During Labor:
o Continuous monitoring of both
maternal labor contractions and fetal
heart rate is essential, especially for
women with diabetes.

Glucose Regulation During Labor:

• Glucose Monitoring:
o It's important to regulate a woman’s
glucose level during labor to prevent
hypoglycemia.
• Epidural Anesthesia:
o If a woman receives an epidural
anesthetic, intravenous glucose
solutions like D5NSS (Dextrose in
Normal Saline Solution) should be
avoided to prevent hyperglycemia.
Instead, Ringer’s lactate or 0.9%
saline should be used as an infusion
to maintain plasma volume.

Postpartum Adjustment for Women with Gestational

Diabetes (GDM):
• Risk for Type 2 Diabetes:
o Women who have had gestational
diabetes (GDM) are at an increased
risk for developing type 2 diabetes
later in life.
 CHAPTER 26: NURSING CARE OF A FAMILY WITH A LABORATORY TESTS
HIGH-RISK NEWBORN
1. HIGH HEMATOCRIT
PROBLEMS RELATED TO GESTATIONAL WEIGHT • If > 65% - 70% exchange, transfusion may be necessary.
• Due to lack of fluid in utero
SMALL FOR GESTATIONAL AGE (SGA) 2. INCREASED RBC (POLYCYTHEMIA)
➢ BW is below 10th percentile on an intrauterine • Due to anoxia
growth curve for that age. • More viscose and difficult to circulate blood
➢ Have experienced IUG restriction or failed to grow • May result to prolonged acrocyanosis
at the expected rate. • Vessels may be blocked & thrombus formation can result
Causes: 3. HYPOGLYCEMIA (< 40 mg/dl)
1. Lack of adequate nutrition during pregnancy. • Due to decreased glycogen stores
2. Placental anomaly • May need IV glucose solution to sustain blood sugar until
✓ Abruptio placenta able to suck vigorously
✓ Severe diabetes mellitus
NURSING DIAGNOSES
✓ PIH
3. Heavy smokers
• Ineffective breathing pattern r/t underdeveloped body
4. Use of narcotics
systems at birth
• Risk for ineffective thermoregulation r/t lack of
ASSESSMENT
subcutaneous fat
1. Fundal height becomes progressively less than
• Risk for impaired parenting r/t child’s high-risk status and
expected.
possible cognitive or neurologic impairment from lack of
2. Sonogram
nutrients in utero
3. Non-stress test
4. Placental grading
PLANNING AND IMPLEMENTATION
5. Amniotic fluid amount
1. MONITOR & MAINTAIN A PATENT AIRWAY
1) Suction mucus as needed to maintain an open airway
2) Position side-lying to facilitate drainage of mucus
3) Observe for signs of respiratory distress.
✓ Grunting
✓ Flaring of nostrils
✓ Sternal retractions
2. PROVIDE WARMTH
1) Keep in a heated crib until body temperature is stabilized
to prevent chilling.
2) Skin should be kept clean & dry
3) Monitor V/S.
4) Weigh daily.
APPEARANCE
LARGE FOR GESTATIONAL AGE (MACROSOMIA)
1. If nutritional deprivation early in pregnancy: ➢ BW is above 90th percentile on an intrauterine
✓ Below average in weight, length & head growth chart for that gestational age.
circumference. Causes:
2. If nutritional deprivation late in pregnancy: 1. Overproduction of growth hormone in utero.
✓ Reduction in weight 2. Infants of diabetic mothers
3. Small liver ✓ Fetus is exposed to high glucose level.
✓ Difficulty regulating glucose, protein & bilirubin 3. Obese women.
levels after birth (bilirubin is produced when the 4. Multiparous women
liver breaks 5. Beckwith syndrome
down old red blood cells) ✓ A congenital (present from birth) growth disorder
4. Poor skin turgor that causes large body size, large organs.
5. Large head 6. Congenital anomalies such as omphalocele
6. Skull sutures widely separated ✓ A birth defect in which an infant's intestine or
7. Dull hair & lusterless other abdominal organs are outside of the body
8. Sunken abdomen because of a hole in the belly button (umbilical
9. Cord appears dry, & may be stained yellow ring) area.
 ✓ The intestines are covered only by a thin layer o Infants with decreased blood perfusion of the lungs (i.e,
of tissue and can be easily seen. meconium aspiration)

ASSESSMENT PATHOPHYSIOLOGY
1. Uterus unusually large for the date of pregnancy.
2. Sonogram is used to confirm 1. Low or absence of surfactant
3. Non-stress test 2. The hyaline-like (fibrous) membrane
4. Amniocentesis formed from an exudate of an infant’s
✓ To determine lung maturity blood that begins to line the terminal
5. CPD or shoulder dystocia bronchioles, alveolar ducts & alveoli
3. This membrane prevents exchange of
✓ Baby cannot descend through the outlet of the pelvis.
O2 & CO2 at the alveolar capillary
membrane
APPEARANCE
4. Alveoli collapse with each expiration
1. Immature reflexes
(areas of hypoinflation occurs)
2. Extensive bruising or a birth injury such as broken clavicle
5. Pulmonary resistance increases
or Erb-Duchenne paralysis
6. Blood then shunts through the foramen
✓ Due to trauma to the cervical nerves if he/she
ovale and the ductus arteriosus
was born vaginally. 7. The lungs become poorly perfuse
3. Caput succedaneum, cephalhematoma 8. Tissue hypoxia
9. Carbohydrate breaks down for energy
OTHER PROBLEMS and
1. CARDIOVASCULAR DYSFUNCTION 10. Release of lactic acid
• Observe for signs of hyperbilirubinemia which 11. Severe acidosis
resulted from absorption of blood from bruising 12. Acidosis causes vasoconstriction and
and polycythemia. decreases pulmonary perfusion from
• Closely monitor HR vasoconstriction further limits surfactant
• If cyanosis is present, it may be a sign of production
transposition of the great vessels. 13. Alveoli are collapsing
2. HYPOGLYCEMIA 14. Oxygen–carbon dioxide exchange in the
• Infants use up nutritional stores readily to sustain alveoli is no longer adequate to sustain
his/her weight. life without ventilator support.
• Increase blood glucose in utero causes infant to
produce elevated levels of insulin. Cause: Low level or absence of surfactant.

NURSING DX ASSESSMENT
1. Ineffective breathing pattern r/t possible birth trauma
• Increased ICP from birth could lead to pressure • Initial Signs After Birth:
on the [Link]. o Difficulty initiating respiration →
• Diaphragmatic paralysis may occur due to Resuscitation.
cervical nerve trauma. o After resuscitation, subtle signs may
• If delivered by C/S, transient fluid could remain in appear:
the lungs. ▪ Decreased body temperature
2. Risk for imbalanced nutrition less than body ▪ Nasal flaring
requirement ▪ Sternal & subcostal
r/t additional nutrients needed to maintain weight retractions
• Infant needs to be breastfed immediately to ▪ Tachypnea (60 bpm)
prevent hypoglycemia.
• May need supplemental formula feedings after
▪ Cyanotic mucous membranes
breastfeeding to supply enough fluid and glucose • Expiratory Grunting:
for the first few days. o Caused by closure of the glottis.
• Additional Distress Indicators:
RESPIRATORY DISTRESS SYNDROME (HYALINE o Seesaw respirations (chest wall
MEMBRANE SYNDROME) retraction & abdominal protrusion with
inspiration, sternum rise on expiration).
Occurs in: o Heart failure (edema, low urine output).
o Preterm infants o Cyanosis, pale gray skin.
o Infants of diabetic mother
o Periods of apnea, bradycardia.
o Infants born by C/S
o Possible pneumothorax (air in pleural
cavity).
Diagnostic Criteria o The weight of the fluid helps open the
1. Clinical Signs: alveoli.
o Grunting o As the liquid enters the lungs, it carries
o Cyanosis (room air) oxygen along, allowing for oxygen
o Tachypnea exchange.
o Nasal flaring 8. Nitric Oxide
o Retractions • Action:
o Shock o Nitric oxide causes pulmonary
2. Diagnostic Tests: vasodilation, which increases blood
o Chest X-ray: Haziness. flow to the alveoli, improving
o Blood Gas Studies: Respiratory oxygenation.
acidosis.
o Culture of Blood, CSF, & Skin: Rule Prevention of RDS
out infections like Group B • Preventing Preterm Delivery:
Streptococcus. 1. Tocolytic Agents (e.g., Terbutaline):
Used to delay preterm labor.
Therapeutic Management 2. Glucocorticosteroids (e.g.,
1. Surfactant Replacement: Betamethasone):
o Administered via syringe or catheter ▪ Accelerate the production of
through an endotracheal tube at birth. lecithin, a surfactant
o Note: Avoid suctioning after surfactant component.
administration. ▪ Typically administered
o Monitor closely for excessive ventilator between 24-34 weeks of
pressure. pregnancy to improve lung
2. Oxygen Administration (O2): development in premature
o Continuous Positive Airway Pressure infants.
(CPAP) or Positive End-Expiratory
Pressure (PEEP) to keep alveoli open. Meconium Aspiration Syndrome (MAS)
o Complications: Retinopathy of • Meconium is present in the fetal bowel as early as
prematurity, bronchopulmonary 10 weeks of gestation.
dysplasia.
• Cause:
3. Ventilation Methods:
o Hypoxia can trigger a vagus reflex,
o Normal: Inspiration shorter than relaxing the rectal sphincter and
expiration (I/E ratio 1:2).
releasing meconium into the amniotic
o Non-compliant lungs: Reversed I/E fluid.
ratio (2:1) or high-frequency
o In breech deliveries, pressure on the
oscillatory/jet ventilation.
buttocks may also cause meconium to
4. Indomethacin/Ibuprofen:
be expelled into the amniotic fluid.
o Helps close patent ductus arteriosus o This leads to meconium-stained
(PDA) to improve ventilation efficiency.
amniotic fluid, which appears green to
5. Muscle Relaxants (e.g., Pancuronium):
greenish black at birth.
o Reduces the need for high ventilator
pressures.
• Occurrence:
o Important: Keep Atropine & Prostigmin o Meconium staining occurs in 10%-20%
of births.
available to reverse effects if needed.
6. Extracorporeal Membrane Oxygenation o 2%-4% of these infants will develop
(ECMO): Meconium Aspiration Syndrome
(MAS).
o Blood removed from the baby,
oxygenated in ECMO machine, and o Extremely Low Birth Weight (ELBW)
returned to body. infants are less likely to aspirate
meconium because the substance
o Used in severe cases when ventilation is
hasn’t reached the rectum in these early
insufficient.
stages.
7. Liquid Ventilation
• Mechanism: • Aspirated Meconium:
o Perfluorocarbons are introduced into the o In utero or at birth when the infant
takes their first breath.
lungs, helping to distend poorly inflated
lungs that lack surfactant. o Meconium causes severe respiratory
distress in affected infants.
 Signs & Symptoms 2. Cesarean Delivery:
• Immediate post-birth: o If deeply stained amniotic fluid is
1. Difficulty establishing respirations, noted during labor, consider scheduling
especially if not born breech. a cesarean section to reduce the risk of
2. Low Apgar score. meconium aspiration.
3. Tachypnea, retractions, and cyanosis 3. Post-Birth Management:
begin almost immediately. o Oxygen administration and assisted
▪ Resuscitation with positive ventilation may be required to manage
pressure ventilation may be respiratory distress.
required. 4. Antibiotic Therapy:
• After Resuscitation:
o Antibiotics may be prescribed to
prevent pneumonia, a common
1. Tachypnea persists.
secondary issue in MAS.
2. Coarse bronchial sounds are heard on
5. Surfactant Therapy:
auscultation.
3. Retractions continue: o If lung compliance is poor, surfactant
may be administered to help open the
▪ Inflammation in the bronchi
alveoli and improve oxygenation.
traps air in the alveoli,
6. High Inspiratory Pressure:
hindering oxygen entry.
o If lung noncompliance continues, higher
▪ This can lead to air trapping, inspiratory pressures may be needed.
increasing the
anteroposterior diameter of
o However, this can cause
pneumothorax (air in the pleural space)
the chest (resulting in a barrel
or pneumomediastinum (air in the
chest).
chest cavity).
• Respiratory Monitoring: 7. Air Trapping Monitoring:
o Pulse oximetry or blood gases reveal o Close observation is necessary to
poor gas exchange: monitor for air trapping in the alveoli,
▪ Decreased PO2 and which can cause rupture and result in
increased PCO2. pneumothorax.
▪ This indicates difficulty in o Increased pulmonary resistance can
oxygenating the blood keep the ductus arteriosus open,
properly. causing blood shunting from the
• Bilateral coarse infiltrates in the lungs. pulmonary artery to the aorta, which
increases hypoxia and compromises
• Hyper-aerated areas may be visible, creating a
cardiac efficiency.
honeycomb effect.
o Signs of heart failure (increased heart
• The diaphragm is often pushed downward due to rate, respiratory distress) should be
overexpanded lungs. monitored to detect a patent ductus
arteriosus.
Management Considerations 8. Temperature Maintenance:
• The infant should be placed under a warmer, and o Ensure a temperature-neutral
resuscitation should begin as needed (positive environment to reduce the infant’s
pressure ventilation). metabolic oxygen demand.
• Oxygen supplementation may be required to 9. Chest Physiotherapy:
maintain oxygen saturation in the mid to upper o Percussion and vibration may help
90s. remove meconium remnants from the
• Continued monitoring and respiratory support may lungs, aiding in better respiratory
be necessary as the infant recovers from the function.
distress caused by meconium aspiration. 10. Advanced Support:
o Some infants may require nitric oxide
Therapeutic Management of MAS therapy or may need to be placed on
1. Amnioinfusion: ECMO (Extracorporeal Membrane
o Isotonic fluid (Normal Saline) is Oxygenation) to ensure adequate
instilled into the uterine cavity using a oxygenation if conventional methods are
transcervical catheter. insufficient.
o Helps dilute meconium in the amniotic
fluid.
o May also improve oligohydramnios
(low amniotic fluid).
 Sepsis Neonatorum (Neonatal Sepsis) Treatment
• Sepsis is a severe infection that spreads through • Antibiotics:
the bloodstream and throughout the body. o Babies in the hospital and those
• Neonatal Sepsis (Sepsis Neonatorum) refers to younger than 4 weeks are often started
sepsis occurring in newborns, which can affect on antibiotics even before lab results
various organs, such as the lungs, brain, bones, come back (usually takes 24-72 hours
and joints. for results).
o Ampicillin administered IV during
Causes & Risk Factors pregnancy and labor helps reduce the
• Microorganisms causing sepsis: risk of neonatal exposure to Group B
Streptococcus.
o Bacteria: E. coli, Candida, Group B
Streptococcus (GBS).
Nursing Interventions
o Viruses: Rubella, RSV, CMV, Herpes 1. Monitor Respirations:
simplex virus, Hib, Listeria,
Enterovirus.
o Watch for periods of apnea or irregular
respirations.
o Fungi & Parasites.
o Administer oxygen as prescribed.
• Early-Onset Neonatal Sepsis (within 24 hours of 2. Vital Signs Monitoring:
birth): o Monitor temperature, heart rate, and
o Infection acquired before or during respiratory rate.
delivery. 3. Maintain Warmth:
o Risk factors for early-onset sepsis: o Ensure a temperature-neutral
1. Group B Streptococcus environment to prevent temperature
infection during pregnancy. instability.
2. Preterm delivery. 4. Isolation:
3. Rupture of membranes o Provide isolation as necessary,
lasting longer than 24 hours. especially if sepsis is suspected to be
4. Infection of placenta tissues contagious.
(chorioamnionitis). 5. Monitor Hydration:
• Late-Onset Neonatal Sepsis (after delivery): o Keep track of input & output to watch
o Risk factors for late-onset sepsis: for dehydration.
1. Catheters in blood vessels for o Weigh daily to monitor growth and fluid
extended periods. balance.
2. Extended hospital stays. 6. Assess Feeding:
o Observe feeding and sucking reflex.
Symptoms of Infection 7. Monitor for Jaundice:
1. Apnea (stopping breathing) or difficulty breathing. o Assess the baby for yellowing of the
2. Bradycardia (decreased heart rate). skin (jaundice).
3. Temperature instability or hypothermia. 8. Assess for CNS Involvement:
4. Weak suck.
o Look for signs of irritability, lethargy,
5. Jaundice.
or any abnormal neurological
symptoms.
Diagnostic Tests
9. Diarrhea Monitoring:
1. Blood Cultures: To identify infection-causing
microorganisms.
o Watch for diarrhea as it may indicate
gastrointestinal issues.
2. C-reactive protein (CRP): Checks for
10. Administer Antibiotics:
inflammation in the body.
3. Complete Blood Count (CBC): To assess • Give antibiotics as ordered to treat the infection.
infection markers.
4. Lumbar Puncture: To examine cerebrospinal Preventive Measures
fluid (CSF) for infection. • Ampicillin administration during pregnancy and
5. Chest X-ray: If the baby has respiratory issues labor to reduce the risk of neonatal Group B
(e.g., cough, trouble breathing). Streptococcus exposure.
6. Urine Culture: For babies older than a few days,
to check for urinary infections. Newborn Priorities in the First Days of Life
1. Initiation and Maintenance of Respirations:
Ensuring the newborn's ability to breathe
effectively after birth.
 2. Establishment of Extrauterine Circulation: 3. Lack of Prenatal Care: Limited or no medical
Transitioning from placental circulation to supervision during pregnancy.
independent circulation. 4. Multiple Pregnancy: Increased risk in twins,
3. Maintenance of Fluid and Electrolyte Balance: triplets, or more.
Monitoring hydration levels and electrolyte balance 5. Previous Early Birth: If the mother has had a
to prevent imbalances. previous preterm birth, the likelihood of it
4. Control of Body Temperature: Regulating the happening again increases.
newborn's body temperature to prevent 6. Race: Non-white populations (especially African
hypothermia or hyperthermia. American) have a higher incidence of prematurity.
5. Intake of Adequate Nourishment: Ensuring 7. Cigarette Smoking: Smoking during pregnancy
sufficient feeding, whether breast milk or formula, increases the risk of preterm birth.
for proper growth. 8. Age of the Mother: Teen mothers (under 20) are
6. Establishment of Waste Elimination: Monitoring at a higher risk for preterm birth.
for normal urine and stool output, indicating proper 9. Order of Birth: First pregnancies and pregnancies
organ function. beyond the fourth are at higher risk.
7. Prevention of Infection: Implementing measures 10. Closely Spaced Pregnancies: Short intervals
to protect the newborn from infections during the between pregnancies can increase the likelihood
first critical days. of preterm birth.
8. Establishment of Infant-Parent/Caregiver 11. Reproductive System Abnormalities: Issues
Relationship: Encouraging bonding and such as an intrauterine septum can contribute to
attachment for emotional and social development. preterm birth.
9. Developmental Care: Balancing physiological 12. Infections: Urinary tract infections and other
needs with appropriate stimulation for optimal infections are linked to preterm birth.
development.
• High-Risk Newborns: These same priorities Pregnancy Complications Increasing Risk of Preterm
apply to high-risk infants, though they may face Labor or Early Delivery:
challenges due to complications during pregnancy, 1. Premature Rupture of Membranes: Early
at birth, or adjusting to life outside the womb. breaking of the amniotic sac can lead to preterm
labor.
• Dysfunctional Transition: Some newborns may
2. Premature Separation of the Placenta
struggle with the transition to extrauterine life,
(Abruptio Placenta): Early detachment of the
possibly indicated by a low Apgar Score.
placenta can lead to preterm birth.
3. Incompetent Cervix: A weakened cervix that
Introduction
begins to open early, increasing the likelihood of
• Risk Factor Screening During Pregnancy: preterm labor.
Identifying maternal risk factors (e.g., age, 4. Birth Defects of the Uterus: Abnormalities in the
diabetes, HIV, placenta previa, drug use) helps uterus may contribute to preterm birth.
identify newborns who may need special care after 5. History of Preterm Delivery: A previous preterm
birth. delivery increases the risk for future preterm births.
• Dysmature Infants: Babies whose birth weight is 6. Infections: Infections, such as urinary tract
disproportionately low for their gestational age, infections or infections in the amniotic membrane,
whether preterm, term, or postterm, are at higher increase the risk of preterm labor.
risk for complications in the first days of life. 7. Poor Nutrition: Lack of proper nutrition right
before or during pregnancy can affect the baby's
Preterm Newborn development and increase the risk of preterm
• A premature infant is born before 37 weeks of birth.
gestation, which is more than 3 weeks before the 8. Preeclampsia: A condition characterized by high
due date. blood pressure and protein in the urine after the
20th week of pregnancy, increasing the risk of
Levels of Preterm Birth (WHO Classification): preterm delivery.
1. Extremely Preterm: Born before 28 weeks of 9. Premature Rupture of Membranes (PROM): A
gestational age (AOG). significant risk factor for preterm birth due to the
2. Very Preterm: Born between 28–32 weeks AOG. rupture of the amniotic sac before labor begins.
3. Late Preterm: Born between 32–37 weeks AOG.
Other Factors Increasing the Risk of Preterm Labor:
Common Factors Associated with Preterm Birth 1. Age of the mother:
1. Low Socioeconomic Status: Economic o Mothers younger than 16 or older than
difficulties that affect access to prenatal care. 35 years are at higher risk.
2. Poor Nutritional Status: Lack of proper nutrition
during pregnancy.
 2. Lack of Prenatal Care: Insufficient prenatal care Acute Bilirubin Encephalopathy (ABE)
increases the likelihood of complications, including • Definition: ABE is the destruction of brain cells
preterm labor. due to the invasion of indirect or unconjugated
3. Low Socioeconomic Status: Limited access to bilirubin into the brain tissue.
resources and healthcare can lead to higher
preterm birth rates.
• Cause: This occurs because of high
concentrations of indirect bilirubin in the
4. Substance Use: Tobacco, cocaine, or
bloodstream, which result from excessive
amphetamines use during pregnancy increases
breakdown of red blood cells at birth.
the risk of preterm labor and complications.
• Risk in Preterm Infants:
Physical Characteristics of a Premature Infant: o Preterm infants are more prone to ABE
1. Disproportionately Large Head: The head may than term infants due to acidosis
be ≥3 cm larger than the chest size. caused by poor respiratory exchange,
2. Ruddy Skin: The skin is typically red due to low which makes brain cells more
subcutaneous fat, which makes veins visible. susceptible to indirect bilirubin.
3. Acrocyanosis: The hands and feet may appear o Preterm infants also have less serum
blue due to poor circulation (common in premature albumin, which is responsible for
infants). binding and inactivating indirect bilirubin,
4. Vernix Caseosa: Newborns born after 28 weeks increasing the likelihood of bilirubin
will usually have a covering of vernix, though those toxicity.
born earlier may lack it. • Management:
5. Lanugo: A fine, downy hair; in late preterm o Phototherapy or exchange
infants, it may cover the back, forearms, forehead, transfusion can be used to lower
and sides of the face, but it’s sparse in very bilirubin levels and prevent brain
preterm infants. damage.
6. Fontanelles: The anterior and posterior o Preterm infants may require these
fontanelles (soft spots on the skull) are often small interventions at lower bilirubin levels
in premature infants. than term infants to prevent ABE.
7. No Creases on the Soles: Very preterm infants
may have smooth soles without the usual creases. Persistent Patent Ductus Arteriosus (PDA)

Potential Problems in Premature Infants • Cause: Preterm infants often lack surfactant,
Anemia of Prematurity: which makes their lungs noncompliant. This
makes it harder for blood to move from the
• Characteristics: pulmonary artery into the lungs, leading to
o Many premature infants develop pulmonary artery hypertension and interfering
normochromic, normocytic anemia with the closure of the ductus arteriosus.
(normal red blood cells but fewer in
number).
• Management:
o This can cause symptoms like o Intravenous therapy must be
administered cautiously because
paleness, lethargy, and poor feeding.
increasing blood pressure could worsen
• Causes: the condition.
o Immaturity of the hematopoietic o Indomethacin or ibuprofen can be
system, where the production of red used in term infants to help close a
blood cells doesn’t start effectively until patent ductus arteriosus (PDA),
after 32 weeks of gestation. improving lung ventilation. However,
o Destruction of red blood cells due to low these medications are given cautiously
levels of vitamin E, which normally in preterm infants due to potential
protects red blood cells from oxidation. adverse effects:
• Risk Factors: ▪ Decreased renal function
o Excessive blood draws for tests such ▪ Decreased platelet count
as complete blood counts or blood gas ▪ Gastric irritation
analysis after birth can exacerbate the o If indomethacin is used, urine output
anemia. should be carefully monitored, and the
o It is essential to limit blood draws in infant should be observed for bleeding
preterm infants and carefully track any at injection sites.
blood loss.
Periventricular/Intraventricular Hemorrhage (PVH/IVH) 1. Group B strep infection during
• Cause: Preterm infants are at higher risk of pregnancy
periventricular hemorrhage (PVH) or 2. Premature delivery
intraventricular hemorrhage (IVH) due to fragile 3. Prolonged rupture of
capillaries and immature cerebral vascular membranes
development. 4. Chorioamnionitis (infection of
o Sudden changes in cerebral blood the placental tissues)
pressure (due to hypoxia, intravenous o Late-onset neonatal sepsis: Occurs
infusion, ventilation, or pneumothorax) after birth and may be caused by
can lead to capillary rupture and brain hospital-acquired infections, prolonged
anoxia, resulting in bleeding. catheter use, or extended hospital stays.
• Classification of IVH:
Laboratory Tests for Sepsis:
o Grade 1: Bleeding in the periventricular 1. Blood culture: To identify the microorganism
germinal matrix or one ventricle. causing the infection.
o Grade 2: Bleeding within the lateral 2. C-reactive protein (CRP): Measures inflammation
ventricle without ventricle dilation. levels in the body.
o Grade 3: Bleeding causing enlargement 3. Complete blood count (CBC): To assess white
of the ventricles. blood cell counts and signs of infection.
o Grade 4: Bleeding in the ventricles and 4. Lumbar puncture: To examine cerebrospinal fluid
surrounding brain tissue. for bacteria if meningitis is suspected.
• Complications: Long-term complications of IVH 5. Chest x-ray: Used if there are respiratory
include hydrocephalus (fluid buildup in the brain), symptoms (e.g., cough or breathing problems).
especially if bleeding occurred into the narrow 6. Urine culture: Performed in babies older than a
aqueduct of Sylvius. few days to check for urinary tract infection.
• Monitoring and Prognosis:
Symptoms of Infection in Newborns:
o Preterm infants often have a cranial
1. Apnea (stopping breathing) or difficulty
ultrasound after birth and at regular
breathing
intervals to detect IVH.
2. Bradycardia (low heart rate)
o Infants with Grade 1 or 2 IVH usually 3. Temperature instability (either low body
have a good long-term prognosis.
temperature or fever)
o The prognosis for Grade 3 or 4 IVH is 4. Weak suck (difficulty feeding)
more guarded, and further complications 5. Jaundice (yellowing of the skin)
need to be ruled out.
Treatment:
Infection or Neonatal Sepsis (Sepsis Neonatorum)
• Immediate Antibiotics: Newborns younger than 4
• Definition: Sepsis neonatorum refers to a severe weeks, especially those in the hospital, are started
infection that enters the bloodstream and spreads on broad-spectrum antibiotics before laboratory
throughout the body, potentially affecting organs results are available.
such as the lungs, brain, bones, joints, or other
o Common antibiotics include ampicillin,
tissues.
often administered intravenously during
• Causes: Neonatal sepsis can be caused by labor to prevent infection.
microorganisms such as:
1. Bacteria: Escherichia coli (E. coli), Nursing Interventions:
Group B Streptococcus (GBS), Candida 1. Assess respiratory status: Monitor for apnea or
2. Viruses: Rubella, Respiratory Syncytial irregular breathing.
Virus (RSV), Cytomegalovirus (CMV), 2. Administer oxygen: As prescribed, to support
Varicella-zoster virus (chickenpox), oxygenation.
Herpes simplex virus, Haemophilus 3. Monitor vital signs (temperature, heart rate,
influenzae type b (Hib), Listeria respiratory rate, and blood pressure).
monocytogenes, Enterovirus 4. Maintain warmth: Keep the newborn warm to
3. Fungi and Parasites prevent hypothermia.
• Types: 5. Provide isolation: To prevent the spread of
o Early-onset neonatal sepsis: Appears infection if necessary.
within 24 hours of birth, typically 6. Monitor temperature: Watch for signs of
transmitted from the mother during hypothermia or hyperthermia.
pregnancy or delivery. Risk factors 7. Observe input and output: Monitor hydration
include: status and for signs of dehydration.
 8. Weigh the baby daily: Track growth and fluid substance that helps maintain the surface tension
retention. of the alveoli and prevents them from collapsing.
9. Monitor for diarrhea: As a sign of gastrointestinal • Hyaline Membranes: Without sufficient surfactant,
involvement. an exudate of the infant’s blood lines the terminal
10. Assess feeding and sucking reflex: To ensure bronchioles, alveolar ducts, and alveoli, forming a
adequate nourishment. hyaline-like (fibrous) membrane. This
11. Assess jaundice: For early detection of bilirubin- membrane prevents the exchange of oxygen (O2)
related complications. and carbon dioxide (CO2) at the alveolar-capillary
12. Monitor for irritability or lethargy: These may membrane.
indicate central nervous system involvement.
13. Administer antibiotics as prescribed and adjust
• Alveolar Collapse: As a result, the alveoli
collapse with each expiration, leading to
based on culture results.
hypoinflation and pulmonary resistance. This
worsens blood flow to the lungs, causing blood to
Low Blood Sugar (Hypoglycemia)
shunt through the foramen ovale and ductus
• Definition: Hypoglycemia in neonates refers to arteriosus.
low blood sugar levels. Preterm neonates,
particularly those with extremely low birth weight
• Tissue Hypoxia: Inadequate oxygenation and
high lactic acid production cause severe acidosis,
(ELBW), are especially vulnerable.
which can result in vasoconstriction and further
• Causes: Preterm neonates are at a higher risk for impair pulmonary perfusion. The lack of surfactant
hypoglycemia due to: continues to worsen lung function.
1. Limited glycogen and fat stores
2. Reduced ability to produce glucose Causes:
through gluconeogenesis
3. Higher metabolic demands,
• Primary Cause: Low level or absence of
surfactant in preterm infants.
particularly due to a larger brain relative
to body size • Risk Factors:
Categories of Hypoglycemia: o Preterm birth
1. Mild Hypoglycemia: 40 to 50 mg/dL (2.2 to 2.8 o Infants born to diabetic mothers
mmol/L) o Cesarean section delivery
2. Moderate Hypoglycemia: 20 to 40 mg/dL (1.1 to o Conditions like meconium aspiration,
2.2 mmol/L) which reduces blood flow to the lungs.
3. Severe Hypoglycemia: Below 20 mg/dL (1.1
mmol/L) Assessment and Clinical Signs:
1. At Birth: Difficulty initiating respiration may require
Factors Contributing to Hypoglycemia in Preterm immediate resuscitation.
Neonates: 2. After Resuscitation, the following signs may
• Extremely low birth weight (ELBW): These appear:
infants have low glycogen and fat reserves. o Decreased body temperature
• Enzyme deficiency: Enzymes involved in o Nasal flaring
gluconeogenesis (such as PEPCK, glucose-6- o Sternal and subcostal retractions
phosphatase, fructose-1,6-diphosphatase, and o Tachypnea (rapid breathing, typically
pyruvate carboxylase) are often at very low over 60 breaths per minute)
levels, making it difficult for the body to produce o Cyanotic mucous membranes (bluish
new glucose from non-carbohydrate sources. color of the lips and mouth)
o Expiratory grunting due to closure of
Neonatal Respiratory Distress Syndrome (Hyaline the glottis
Membrane Syndrome) o Rales (crackling sounds) and
Definition: diminished breath sounds due to poor
Neonatal Respiratory Distress Syndrome (RDS), also known air entry
as Hyaline Membrane Syndrome, is a condition 3. As Respiratory Distress Increases:
predominantly affecting preterm infants and those with o Seesaw respirations: The chest wall
certain risk factors such as infants of diabetic mothers or retracts during inspiration, and the
those born via cesarean section. It is caused by a lack of abdomen protrudes; during expiration,
surfactant in the lungs, which is essential for lung function the sternum rises.
after birth. o Heart failure: Reduced urine output and
extremity edema may develop.
Pathophysiology:
o Pale, gray skin indicating poor
• Surfactant Deficiency: The primary cause of oxygenation.
RDS is the low level or absence of surfactant, a
 o Periods of apnea (temporary cessation o Muscle relaxants like Pancuronium
of breathing). may be used to allow mechanical
o Bradycardia (slow heart rate). ventilation at lower pressure. This helps
o Pneumothorax (presence of air in the reduce the risk of pneumothorax while
pleural cavity, leading to lung collapse). improving oxygenation (pO2).
o Emergency Medications: Atropine
Diagnosis: and Prostigmin should be available to
1. Clinical Signs: reverse the effects of pancuronium if
o Grunting, cyanosis (on room air), necessary.
tachypnea, nasal flaring, retractions,
and shock. Extracorporeal Membrane Oxygenation (ECMO)
2. Chest X-ray: Shows haziness in the lungs.
3. Blood Gas Studies: Often reveal respiratory ECMO is a life-saving intervention for infants with severe
acidosis. respiratory or cardiac failure. It temporarily takes over the
4. Culture of Blood, CSF, and Skin: To rule out heart and lung functions to provide oxygenation and
infections such as Group B Streptococcus that circulation.
could mimic RDS.
How It Works:
Therapeutic Management: 1. Blood is drawn from the baby using a venous
1. Surfactant Replacement: catheter that is placed into the right atrium of the
o Surfactant is administered through an heart.
endotracheal tube at birth to help lower 2. The blood is then oxygenated and rewarmed by an
surface tension in the lungs and prevent ECMO machine.
alveolar collapse. 3. After being oxygenated, the blood is returned to
o Important: Avoid suctioning the infant's the aortic arch through a catheter inserted into
airway after surfactant administration. the carotid artery.
Indication:
o Monitoring: Infants on surfactant
ECMO is typically used in cases of severe respiratory
therapy may be placed on a ventilator,
distress syndrome (RDS) or other critical conditions that do
and close observation is necessary
not respond to conventional treatments.
because lung expansion can rapidly
improve, and ventilator pressure may
Liquid Ventilation
need adjustment.
2. Oxygen Administration:
Liquid ventilation is an advanced therapeutic technique that
o Oxygen is delivered to maintain introduces a fluid, typically perfluorocarbons, into the lungs
appropriate partial pressure of oxygen
of infants with surfactant deficiencies. This technique helps
(pO2) and pH levels.
improve lung function by expanding poorly inflated alveoli.
o Methods include Continuous Positive
Airway Pressure (CPAP) or Positive
How It Works:
End-Expiratory Pressure (PEEP) to
prevent alveolar collapse during • The perfluorocarbons help to distend the lungs
exhalation. by their weight, enabling better oxygenation.
o Complications: Retinopathy of • The liquid carries oxygen into the lungs, facilitating
prematurity and bronchopulmonary an exchange of oxygen and carbon dioxide, even
dysplasia are potential risks from in the absence of sufficient surfactant.
oxygen therapy.
3. Ventilation: Nitric Oxide Therapy
o Normal Breathing Pattern: Inspiration
is shorter than expiration (I/E ratio 1:2). Nitric oxide is used to vasodilate pulmonary blood vessels,
o In Non-Compliant Lungs: A reversed improving blood flow to the alveoli and enhancing
I/E ratio (2:1) may be necessary. High- oxygenation.
frequency oscillatory or jet ventilation Effect:
may also be used. • It helps reduce pulmonary hypertension and
4. Indomethacin or Ibuprofen: increases blood flow to areas of the lungs
o These medications can be used to help where oxygen exchange is most effective.
close the patent ductus arteriosus
(PDA), improving ventilation and Prevention of Preterm Delivery:
oxygenation. 1. Tocolytic Agent (Terbutaline):
5. Muscle Relaxants (Pancuronium): o Used to stop contractions and delay
preterm labor.
 2. Glucocorticosteroid (Betamethasone): 2. Body Hair (Lanugo):
o Given between 24–34 weeks of o Fine hair covering the body, common in
pregnancy to speed up the production preterm infants.
of surfactant and improve lung 3. Enlarged Clitoris (in female infants):
development in preterm infants. o Due to hormonal influences during fetal
development.
Extra Air in the Tissue of the Lungs (Pulmonary 4. Lower Muscle Tone:
Interstitial Emphysema) o Premature infants typically have lower
muscle tone and are less active.
Pulmonary interstitial emphysema occurs when air leaks 5. Feeding Difficulties:
from the alveoli into the tissues surrounding the lungs, o Difficulty coordinating sucking,
causing air pockets to form. This condition is most swallowing, and breathing, which makes
associated with ventilator use in premature infants. feeding challenging.
6. Undescended Testicles (in male infants):
Risk Factors: o A common occurrence in premature
• Mechanical ventilation male infants.
• High pressures in the lungs 7. Soft, Flexible Ear Cartilage:
o Preterm infants may have soft ear
Bleeding in the Lungs (Pulmonary Hemorrhage) cartilage that can be molded easily.
8. Thin, Shiny Skin:
Pulmonary hemorrhage refers to bleeding in the lungs, o Skin may appear transparent, and veins
which can occur in premature infants, especially those who are visible underneath due to insufficient
are on mechanical ventilation. fat stores.

Risk Factors: Common Tests Performed on Premature Infants:

• Severe RDS 1. Blood Gas Analysis:
• Use of high-pressure ventilators
o Measures oxygen levels and helps
assess respiratory function.
2. Blood Tests:
Problems with Breathing Due To:
1. Immature Lungs: Premature infants have o To check glucose, calcium, and
underdeveloped lungs, making them prone to bilirubin levels.
respiratory distress. 3. Chest X-ray:
2. Pneumonia: Infection can lead to difficulty o To evaluate lung development and
breathing and further complications. identify issues such as RDS.
3. Patent Ductus Arteriosus (PDA): The ductus 4. Continuous Cardiorespiratory Monitoring:
arteriosus, a blood vessel that is supposed to o To track breathing, heart rate, and
close after birth, remains open, causing increased oxygen levels continuously.
strain on the heart and lungs.
Treatment for Premature Infants:
Severe Intestinal Inflammation (Necrotizing 1. High-Risk Birth Preparation:
Enterocolitis) o The mother may be moved to a
neonatal intensive care unit (NICU) if
Necrotizing enterocolitis (NEC) is a serious a preterm delivery is anticipated.
gastrointestinal emergency where the intestines become 2. High-Risk Nursery:
inflamed, and in some cases, tissue in the intestines dies. o Infants are placed under a warmer or
Risk Factors: incubator to regulate temperature, and
• Premature birth machines monitor breathing, heart
rate, and oxygen levels.
• Use of formula feeding (in contrast to breast milk)
3. Feeding:
Symptoms:
o A small feeding tube is often inserted
• Abdominal distention to provide nutrition if the infant cannot
• Bloody stools feed orally.
• Feeding intolerance o In very premature or sick infants,
nutrition may be provided via
Common Signs of Prematurity: intravenous (IV) methods.
1. Abnormal Breathing Patterns: 4. Breathing Support:
o Shallow, irregular breathing with apnea o A ventilator may be used for infants
(pauses in breathing). with severe breathing issues.
 o Less severe cases may be treated with supplying nutrients and oxygen to the
CPAP or nasal oxygen. fetus.
2. Nutritional Deficits:
Possible Long-Term Complications: o The fetus receives inadequate
1. Bronchopulmonary Dysplasia (BPD): nutrients from the mother, leading to
o A form of chronic lung disease resulting soft tissue wasting and fetal growth
from mechanical ventilation and restriction. The baby may be smaller
prolonged oxygen use. than expected for gestational age due to
2. Delayed Growth and Development: the limited nutrient supply.
o Premature infants may experience 3. Decreased Amniotic Fluid Volume:
delays in reaching milestones. o The amount of amniotic fluid
3. Mental or Physical Disabilities: decreases, which can further increase
o Some infants may develop disabilities or the risk of fetal distress and asphyxia.
delays in mental or physical 4. Meconium Aspiration Syndrome:
development. o The meconium in the infant's intestines
4. Retinopathy of Prematurity (ROP): may be aspirated into the lungs due to
o Abnormal blood vessel growth in the hypoxia (low oxygen levels) or stress
retina, which can lead to vision loss or during delivery. In postmature infants,
blindness. the meconium is often less diluted,
making the condition more severe. This
Best Ways to Prevent Prematurity: leads to meconium aspiration
1. Pre-conception Health: syndrome (MAS), which can result in
o Being in good health before pregnancy respiratory failure.
is crucial for reducing the risk of preterm 5. Insufficient Glycogen Stores:
birth. o Postmature infants may be born with
2. Early and Consistent Prenatal Care: insufficient glycogen stores, leading
o Early prenatal care and ongoing to neonatal hypoglycemia. If the baby
monitoring throughout pregnancy can has experienced perinatal asphyxia,
help prevent preterm labor. hypoglycemia may be more
pronounced, as the anaerobic
Postmature Infant: metabolism of glycogen exacerbates
the condition.
A postmature infant is one born after 41 weeks of
gestation. These infants are at increased risk due to potential General Appearance of Postmature Infants:
placental insufficiency after 40 weeks, which can lead to 1. Thin, Long Newborn:
reduced nutrients reaching the fetus, resulting in post-term o The infant may appear longer and
syndrome. thinner than expected for their
gestational age due to the lack of
Risks: adequate growth in utero.
• Placental Insufficiency: After 40 weeks, the
2. Dry, Parchment-like Skin:
placenta may no longer provide adequate nutrients o Skin may appear dry and wrinkled,
to the fetus. resembling parchment, due to the
reduced amount of subcutaneous fat.
• Fetal Distress: The baby may experience growth 3. Decreased or Absent Vernix:
restriction or difficulty during delivery.
o Vernix is a protective, waxy coating on
Cause:
the skin that is typically found in preterm
• The cause of postmaturity is usually unknown. infants. In postmature infants, it may be
Rarely, it may be due to abnormalities in the fetal absent or minimal.
pituitary-adrenal axis (e.g., anencephaly or 4. Little Subcutaneous Tissue:
adrenal agenesis). o The infant may have loose skin due to
the lack of subcutaneous fat, making
Pathophysiology of Postmaturity them more prone to cold stress.
1. Placental Insufficiency: 5. Meconium Staining:
o After the 41st week of gestation, the o The amniotic fluid may be stained with
placenta undergoes involution (shrinking meconium, and the nails and skin of
and aging), which causes villous the infant may appear yellowish due to
degeneration and infarcts. This results meconium aspiration or stress.
in placental insufficiency, meaning the 6. Absent Lanugo:
placenta becomes less effective at
 o Lanugo, the fine body hair that covers o Diagnosis also relies on the estimated
the skin of preterm infants, is typically date of delivery (EDD) to determine if
absent in postmature infants. the infant is indeed postmature.
7. Alert and Wide-eyed:
o The infant may be alert, with wide-open Treatment of Postmature Infants:
eyes, which can be a sign of hypoxia • Management Depends on Complications:
(oxygen deprivation). o The treatment plan will depend on the
8. Long Nails: specific complications that arise in the
o Nails may be longer than expected for postmature infant. For example, if
the gestational age of the infant, another meconium aspiration is present,
indication of postmaturity. treatment may focus on respiratory
support and the use of surfactant
Associated Problems with Postmature Infants: replacement therapy.
1. Hypoxia:
• Meconium Aspiration:
o The primary cause of many o Infants with meconium aspiration
complications in postmature infants is
syndrome may require chronic
hypoxia, often due to placental
respiratory support and potentially
insufficiency. This can result in fetal
surfactant therapy. If left untreated,
distress and asphyxia.
MAS can lead to pulmonary
2. Hypoglycemia:
hypertension and other long-term
o Hypoglycemia is common in respiratory issues.
postmature infants due to insufficient
glycogen stores at birth, especially if CHAPTER 27: NURSING CARE OF A CHILD BORN WITH
the infant has had compromised nutrient A PHYSICAL OR DEVELOPMENTAL CHALLENGE
supply during gestation.
3. Postmaturity Syndrome with Intrauterine Assessment Focus:
Asphyxia:
o Postmature infants are at risk of • Immediate physiologic needs (to sustain life)
intrauterine asphyxia (lack of oxygen) • Parents’ emotional needs (to promote bonding)
due to placental insufficiency. Key Needs to Assess (9):
4. Polycythemia: 1. Respiration
o Due to chronic hypoxia, the body may 2. Circulation
produce more red blood cells 3. Temperature regulation
(polycythemia) in an attempt to increase 4. Blood glucose levels
oxygen delivery to tissues. 5. Infection prevention
5. Seizure Disorders: 6. Parent-infant bonding
o Seizures may occur as a result of 7. Sensory stimulation
chronic hypoxia and other metabolic 8. Nutritional intake
disturbances. 9. Waste elimination
6. Cold Stress:
Common Nursing Diagnoses
o Cold stress is common due to the
minimal subcutaneous fat that makes • Imbalanced nutrition – related to feeding
it difficult for the infant to regulate body difficulties
temperature. • Impaired physical mobility – due to congenital
7. Meconium Aspiration: anomaly
o The risk of meconium aspiration • Risk for impaired parenting – related to
syndrome (MAS) is higher in emotional distress
postmature infants, which can result in
• Anticipatory grieving – loss of the “perfect” child
respiratory complications.
image
Diagnosis of Post maturity:
Planning Considerations
• Clinical Appearance:
• Immediate stabilization (e.g., oxygen, temperature
o The new Ballard score can help assess support)
the gestational age of the infant based
on physical and neurological features. • Long-term needs of infant & family
• Estimated Date of Delivery: • Evaluate emotional/financial resources
• Involve supportive family members
 • Use interdisciplinary team: social worker,
therapist, nutritionist, etc. CLEFT PALATE
• More common in girls
Implementation • Palatal structures fail to close
• Life-sustaining care (oxygen, feeding support) • There is an opening at the palate, usually at the
• Promote skin-to-skin contact midline
• Encourage parent-newborn interaction • May involve the anterior hard palate, posterior soft
• Educate parents on procedures palate, or both
• Acknowledge and support grief stages: • Normally closes at 9–12 weeks of intrauterine life
o Denial
o Anger
o Bargaining
o Depression
o Adjustment
• Provide positive nursing role modeling

Outcome Evaluation CAUSES

➢ Helps parents adjust to caring for a child with • Heredity
physical or developmental challenges.
• Teratogenic Factors:
Focus Areas: o Viral infections (e.g., rubella)
1. Child’s Physical & Developmental Needs: o Exposure to radiation
o Set realistic, expected outcomes. o Smoking during pregnancy
o Monitor and support developmental
progress. NURSING DIAGNOSES & INTERVENTIONS
2. Family Coping Ability:
Risk for imbalanced nutrition less than body requirements r/t
o Assess how the family is coping now
feeding problem caused by cleft or palate
and prepare for future needs.
o Offer emotional and practical support. PREOPERATIVE PERIOD
Support Strategies:
1. Assess ability to suck & swallow
• Address family concerns. 2. Monitor weight daily
• Provide educational materials and community 3. Modify feeding techniques:
resources. ✓ Support the baby in an upright position
• Ensure a support plan is in place for after ✓ Direct the formula to the side and back of the
discharge. mouth to prevent aspiration
✓ Feed the infant gently using a commercial cleft
lip nipple
OROFACIAL CLEFTS ✓ Feed small amounts gradually and burp
frequently
CLEFT LIP
✓ Keep suction equipment and bulb syringe at
• More common in boys bedside
• The maxillary and median nasal processes fail to ✓ Teach parents the ESSR method of feeding:
fuse o E – Enlarge the nipple
• Normally fuse between 5–8 weeks of intrauterine o S – Stimulate the suck reflex
life (embryonic stage) o S – Swallow
• May be unilateral or bilateral o R – Rest to allow the child to finish
swallowing what has been placed in the
mouth

SPECIALTY FEEDING DEVICES FOR INFANTS WITH

CLEFT LIP AND/OR CLEFT PALATE

MEAD-JOHNSON CLEFT PALATE NURSER

• As the baby begins to suck, squeeze the bottle
with a firm steady pressure to the count of “squ-e-
 e-ze two three,” relaxing your squeeze on the two Impaired tissue integrity at incision line r/t cleft lip or
three count cleft palate surgery
• This provides the baby with an intermittent flow 1. After cleft lip surgery, the suture line is held close
of milk by a Logan Bar or an adhesive bandage
o Assess after each feeding to be certain
HABERMAN FEEDER that it is secure
2. If possible, prevent the infant from crying
• Also called Medela Special Needs Feeder
o Provide pain relief
• Works well for babies who are small or
o Anticipate the infant’s needs
premature, or who have cleft palate only
o Help parents use measures like
• It has a one-way valve that keeps milk in the rocking, carrying, or holding to make
nipple the infant feel secure and comfortable
• The baby can obtain milk by compressing the 3. Observe infant after palate repair not to place toys
nipple against the roof of the mouth, without with sharp edges into their mouth
need for suction 4. Do not use a straw to drink, nor brush their own
teeth
NURSING DIAGNOSES & INTERVENTIONS 5. Soft elbow or jacket restraints may be used
when no one is with them, to keep the child from
Closure of cleft lip touching the repair site
• Performed usually between 6 weeks to 9 months 6. Instruct parents to monitor for signs of infection
Cleft palate repair at the surgical site:
• Performed between 12 to 18 months of age to o Redness
allow for the palatal changes that take place with o Swelling
normal growth o Drainage
• A prosthetic device may be used to close the
Risk for infection r/t surgical incision
palate
1. Clean the suture line with sterile water, sterile
saline, or 50% hydrogen peroxide using sterile
POSTOPERATIVE PERIOD
cotton-tipped applicators every after feeding
1. Keep infant NPO for 4 hours
2. Avoid tension on a lip suture line o Use a smooth, gentle rolling motion
3. After palate surgery, liquids are generally to apply the solution
continued for 3 to 4 days, followed by soft diet o Dry the suture line with a sterile cotton-
until healing is complete tipped applicator
4. After a cleft palate repair, should not use spoon
because they will invariably push it against the roof Risk for impaired parenting r/t the birth of an infant who
of the mouth and possibly disrupt sutures is physically challenged
5. Do not include milk in the first fluids offered 1. Promote bonding
o Milk curds tend to adhere to the suture 2. Caution them the incision line will appear
line swollen in the immediate postoperative period
6. After feeding, offer the child clear water to rinse 3. Caution the parents that time will be needed for
the suture line the infant to learn how to suck

Risk for ineffective airway clearance r/t oral surgery

1. Observe for respiratory distress due to: TRACHEOESOPHAGEAL ATRESIA & FISTULA
o Local edema at the operative site • The esophagus terminates before it reaches the
o Before surgery, the infant breathes stomach and/or a fistula is present that forms an
through their mouth; after surgery, the unnatural connection with the trachea
infant now has to learn to breathe • The condition causes the oral intake to enter the
through their nose lungs or a large amount of air to enter the
2. Suction secretions stomach
o Be gentle • Choking, coughing, and severe abdominal
o Do not touch suture line distention can occur
3. After cleft lip surgery (cheiloplasty), place infant • Aspiration pneumonia and severe respiratory
on their side to drain secretion distress will develop, and death will occur
without surgical intervention

ASSESSMENT
1. Frothy saliva in the mouth and nose, and drooling
 2. Coughing and choking during feeding 13. Instruct parents to identify behaviors that indicate
3. Unexplained cyanosis the need for:
4. Regurgitation and vomiting • Suctioning
5. Abdominal distention
6. Inability to pass a small gauge (no. 5 French)
• Signs of respiratory distress
orogastric feeding tube • Signs of constricted esophagus such as:
o Poor feeding
TREATMENT o Dysphagia
1. Maintenance of a patent airway o Drooling
2. Prevention of pneumonia o Regurgitated undigested food
3. Gastric or blind pouch decompression
4. Supportive therapy
5. Surgical repair CARE OF AN INFANT WITH CHEST TUBE
STEP 1
IMPLEMENTATION • Examine the area around the tubing often to help
prevent potential infection.
PREOPERATIVE PERIOD
o Make sure the area surrounding the
1. Intubation and mechanical ventilation may be
chest tube is as clean and sterile as
necessary if respiratory distress occurs
possible
2. Maintain NPO status
3. Monitor and regulate IV fluids as prescribed
o The area surrounding the incision and
chest tube should be covered and
4. Suction secretions
protected from the surrounding
5. A double-lumen catheter is placed into the upper
environment
esophageal pouch and attached to intermittent or
continuous low suction to keep the pouch empty o Ensure that tubing is not kinked or
6. Maintain in an upright position to facilitate otherwise bent
drainage and to prevent aspiration of gastric STEP 2
secretions • Lift infant by placing one hand beneath her
7. A gastrostomy tube may be placed and is left head and shoulders, the other beneath her
open so that air entering the stomach through the buttocks
fistula can escape, minimizing the danger of o Don't lift an infant with a chest tube by
regurgitation clasping her under the arms and lifting,
8. Administer broad-spectrum antibiotics as as this may cause pain and dislodge
prescribed because of the high risk for aspiration the tube placement
pneumonia o You may hold the child on your lap or
encourage her to breast feed or bottle
POSTOPERATIVE PERIOD feed, always taking care to provide
1. Monitor respiratory status adequate back and neck support
2. Maintain IVFs, antibiotics, and parenteral o Don't place the infant on her stomach
nutrition as prescribed STEP 3
3. Monitor I & O and weigh daily • You can start giving the infant a tub bath or
4. Inspect surgical site shower after the stitches have been removed or
5. Assess for signs of pain after about one week post-surgery
6. Assess for dehydration and possible fluid
o Make sure the bathing area and water
overload
are clean
7. Provide care to the chest tube if in place
8. Monitor for anastomotic leaks as evidenced by:
HYPERTROPHIC PYLORIC STENOSIS
o Purulent chest drainage
o Increased temperature • Hypertrophy of the circular muscles of the
pylorus, causing narrowing of the pyloric canal
o Increased WBC count between the stomach and the duodenum
9. If a gastrostomy tube is present, it is attached to
gravity drainage until the infant can tolerate
o Baby fails to grow
feedings (usually 5–7th day postop) o Less fluid can pass through this defect
10. Before oral feedings and removal of the chest o Majority of absorption in the small
tube, a barium swallow is performed to verify the intestine
integrity of the esophageal anastomosis o Because of distention, baby will vomit
11. Feedings through the gastrostomy tube may be (characteristics: projectile vomiting);
prescribed until the anastomosis is healed fast intake, slow discharge
12. Oral feedings are begun with sterile water, o Tracheoesophageal – non-projectile;
followed by small frequent feedings of formula equal to the amount that is ingested
 • Usually develops in the first few weeks of life, PREOPERATIVE CARE
causing: 1. Monitor hydration by daily weights, I&O, urine
o Projectile vomiting specific gravity
o Dehydration o General anesthesia causes muscle
relaxation – danger of aspiration and
o Metabolic alkalosis
airway obstruction
o Failure to thrive 2. Correct fluid and electrolyte imbalances
• Vomiting is the first symptom in most children: o Administer IVF as prescribed
o May occur after every feeding or only 3. Maintain NPO status
after some feedings 4. Monitor number and character of stools
o Usually starts around 3 weeks of age, 5. Maintain NGT patency for stomach
but may occur between 1 week to 5 decompression
months o NGT is not for feeding – removes air
o Vomiting is forceful (projectile and fluids from stomach
vomiting) = stomach is overdistended
o Infant is hungry after vomiting and POSTOPERATIVE CARE
wants to feed again 1. Monitor I&O
2. Maintain IVF until infant takes and retains oral
Other Symptoms fluids
• Abdominal pain (overdistention) o Wait for doctor's signal (return of
• Belching (dug-ab) peristalsis)
o Auscultate for bowel sounds
• Constant hunger (less nutrients absorbed)
3. Begin small, frequent feedings of glucose water
• Dehydration (gets worse with severity of vomiting) or electrolyte solution 4–6 hrs. postop
o Less fluid enters small intestine = less 4. Advance to formula 24 hrs. postop as prescribed
fluid 5. Gradually increase amount and interval until full
• Failure to gain weight or weight loss feeding schedule resumed (48 hrs. postop)
• Wave-like motion of the abdomen shortly after 6. Feed slowly, burping frequently to prevent
feeding and just before vomiting tension on suture line
7. Monitor for abdominal distention
SIGNS AND TESTS 8. Monitor surgical wound for infection:
o Redness
• Diagnosed before baby is 6 months old
o Drainage
• Physical exam may reveal signs of dehydration o Pus formation
• Swollen abdomen 9. Instruct parents on wound care and feeding
• Doctor may detect abnormal pylorus = olive-
shaped mass DIAPHRAGMATIC HERNIA
• Ultrasound of abdomen is the first imaging test • Definition: A diaphragmatic hernia is a birth defect
• Other tests:
where there is an abnormal opening in the
diaphragm, allowing abdominal organs to move
o Barium x-ray → reveals swollen into the chest cavity. This condition occurs before
stomach & narrowed pylorus
birth during fetal development.
▪ Upper GI (barium swallow) – o Cyanosis and abnormal appearance
baby swallows liquid for
may be observed in the baby after birth.
tracing
o An issue that develops in-utero due to
o Blood chemistry panel → shows the abnormal formation of the
electrolyte imbalance
diaphragm.
SURGERY • Cause:
• Pyloromyotomy – pyloroplasty (ultimate
o Genetic and environmental factors, such
as exposure to teratogens.
intervention)
o Widen the opening in the pylorus so o Diaphragm formation occurs between
the 7th and 10th week of pregnancy;
contents can empty into small intestine
any disruption can lead to congenital
• Balloon dilation doesn’t work as well, but may be anomalies.
used if anesthesia is risky o In Bochdalek hernia, improper
• Fluids via IV are given before surgery (NPO baby) diaphragm formation or trapped
intestines during development.
 o In Morgagni hernia, improper o The abdominal organs are moved back
development of the diaphragm’s tendon. into the abdominal cavity, and the
diaphragm is repaired.
TWO TYPES OF DIAPHRAGMATIC HERNIA
1. BOCHDALEK HERNIA: LONG-TERM CARE:
o Most commonly (85%) occurs on the left • Babies with diaphragmatic hernias often face
side of the diaphragm. chronic lung disease and may need long-term
o Stomach, liver, spleen, and/or intestines oxygen support or medications.
may move into the chest cavity, leading • Regular follow-up care is essential after hospital
to more severe symptoms. discharge for continued support of respiratory
2. MORGAGNI HERNIA: health.
o Occurs on the right side of the
diaphragm.
o Liver and/or intestines move into the TREATMENT/NURSING CARE FOR DIAPHRAGMATIC
chest cavity. HERNIA (CDH)
• Physiologic Emergency: Diaphragmatic hernia is
SYMPTOMS:
a physiologic emergency rather than a surgical
• Bochdalek Hernia: one. The critical concern is preventing or
o Difficulty breathing improving Persistent Pulmonary Hypertension of
o Rapid breathing the Newborn (PPHN).
o Fast heart rate o Medical Management:
o Cyanosis ▪ Stabilize the infant’s condition.
o Abnormal chest development (one side ▪ Manage pulmonary
larger than the other) dysfunction before
o Concave abdomen considering surgery.
• Morgagni Hernia: ▪ Delay surgery if needed (from
o Symptoms may or may not appear after a few days up to two weeks),
birth. depending on the infant's
oxygenation and nutritional
DIAGNOSIS: status.
1. Physical examination ▪ The goal is to decrease
2. Chest x-ray: Used to assess lung, diaphragm, and pulmonary hypertension and
intestine abnormalities. stabilize pulmonary
3. Arterial blood gas: To evaluate the baby’s dysfunction.
breathing ability. o Respiratory Management:
4. Other tests: ▪ Provide adequate ventilation
o Chromosome blood test (to check for and oxygenation while
genetic problems). avoiding permanent lung
o Echocardiogram (ultrasound of the damage.
heart).
Treatment Options:
TREATMENT: • Gastric Decompression:
1. Neonatal Intensive Care (NICU): - Use of oro/nasogastric tubes with low
o Life-threatening condition, requiring care continuous suction to prevent air from
in NICU. entering the intestines, which could
o Mechanical ventilators may be needed obstruct the lungs and cause
to assist with breathing due to regurgitation.
underdeveloped lungs. • Inhaled Nitric Oxide:
2. ECMO (Extracorporeal Membrane - A vasodilator that decreases pulmonary
Oxygenation): hypertension (PPHN).
o A heart-lung bypass machine that helps - It dilates the pulmonary vascular bed,
temporarily support the heart and lungs. improving oxygenation.
o Used to stabilize the baby’s condition. • Pressors (Hypertensive Drugs):
3. Surgery: - Increase systemic blood pressure to
o Once the baby stabilizes, surgery is override pulmonary vascular resistance.
performed to repair the diaphragmatic - Reduce right-to-left shunting and
hernia. increase pulmonary blood flow.
- Common pressors include:
Dopamine: Increases peripheral vascular resistance. Diagnosis
Administer at 2 mcg/kg/min, up to 20 mcg/kg/min via • Sonography to determine type of imperforate
continuous infusion. anus.
Dobutamine: Increases cardiac contractility. Administer at 2 Treatment
mcg/kg/min, up to 20 mcg/kg/min via continuous infusion.
• Surgery: Open passage for feces or use fistula
o Parent Education: until corrective surgery.
Pre-operative Education:
Inform parents about surgery
o Perineal anoplasty or colostomy (higher
defect).
plans and post-operative
Postoperative Care
expectations.
1. Monitor for infection.
▪ Post-operative Education: 2. Position side-lying with legs flexed or prone to
Update parents on the infant's reduce edema.
status, and review any new 3. Keep incision clean and dry.
equipment, medications, or 4. Maintain NPO status and NGT if in place.
therapies. 5. Maintain IV fluids until GI motility returns.
6. Provide colostomy care, keeping the area dry.
INTESTINAL OBSTRUCTION: IMPERFORATE ANUS 7. Fresh colostomy stoma may be red and
edematous, will decrease over time.
Imperforate anus is a congenital defect where the anus is 8. Instruct parents on anal dilatation (if prescribed) to
either missing or blocked. maintain bowel patency:
• Forms of Imperforate Anus: o Use only prescribed dilators with water-
1. Low Lesion: soluble lubricant, inserting 1-2 cm to
▪ The colon is close to the skin, avoid mucosal damage.
possibly covered by a
membrane. Hirschsprung’s Disease
▪ The anus may be narrowed or • Absence of ganglionic innervation, usually in the
missing, and the rectum may sigmoid colon, leading to chronic constipation and
end in a blind pouch. ribbon-like stools.
2. High Lesion:
• Cause: Abnormal gene on chromosome 10.
▪ The colon is higher in the Assessment
pelvis, with a fistula 1. Failure to pass meconium by 24 hours.
connecting the rectum to the 2. Abdominal distention.
bladder, urethra, or vagina. 3. History of constipation, intermittent
▪ Symptoms may include constipation/diarrhea.
meconium mixed in urine 4. Empty rectum on examination.
(green color). 5. Barium enema to assess affected area.
3. Persistent Cloaca: 6. Biopsy for confirmation.
▪ A rare anomaly where the Therapeutic Management
rectum, vagina, and urinary • Surgery: Dissection and removal of affected bowel
tract form a single channel. section, followed by anastomosis. Temporary
colostomy, bowel repair at 12-18 months.
ASSOCIATED ANOMALIES: Diagnosis
These conditions develop from the same germ layer during 1. Constipation related to reduced bowel function.
fetal development. Some anomalies include: 2. Imbalanced nutrition due to bowel issues.
• V: Vertebral anomalies 3. Risk of compromised family coping due to chronic
• A: Anal atresia (absence or closure of the anus) illness.
Nursing Interventions
• C: Cardiovascular anomalies
Preoperative:
• T: Tracheoesophageal fistula 1. Empty bowel with enemas and colonic irrigations.
• R: Renal (kidney) and/or radial (bone) anomalies 2. If distention persists, consult doctor for NG tube.
• E: Esophageal atresia 3. Offer pacifier for infants on parenteral fluids.
4. Encourage parent-infant bonding.
• L: Limb defects
5. Position with head elevated to prevent discomfort.
6. Offer soothing stimulation (e.g., music, touch).
7. Provide small, frequent feedings (low residue diet).
8. Administer parenteral nutrition if needed.
9. Provide instructions for saline enema and stool
softeners for older children.
Postoperative: Therapeutic Management
1. Change dressings using sterile technique. 1. Non-surgical reduction: Water-soluble contrast
2. Prevent wound contamination from diapers. enema, barium or air contrast enema.
3. Prevent excoriation by cleaning and applying 2. Surgical reduction: Manual reduction or resection if
ointments. ischemia/necrosis present. Laparoscopic approach
4. Use strict handwashing. may be used.
5. Report any redness, swelling, drainage, evisceration,
or dehiscence immediately. Nursing Diagnosis & Interventions
6. Suction oral secretions frequently to prevent Risk for Deficient Fluid Volume due to Bowel Obstruction:
respiratory infections. 1. Keep infant NPO pre-surgery or non-surgical
7. Encourage older children to cough and deep breathe reduction (pacifier for comfort).
to maintain respiratory status. 2. Administer IVF to re-establish fluids and
8. Allow infants to cry briefly to prevent atelectasis. electrolytes.
9. Change infant's position frequently to improve 3. After non-surgical reduction: Keep NPO for a few
circulation and lung aeration. hours, gradually introduce regular feedings.
10. Maintain NG tube patency to prevent abdominal 4. After surgery:
distention. o Keep NG tube on low suction until
11. Keep NPO until bowel sounds return, as per healing and return of peristalsis.
physician's orders. o Keep IVF, start oral feedings gradually
12. Provide frequent oral hygiene while NPO. when bowel sounds are present.
13. Administer fluids to maintain hydration and
electrolytes and begin oral feedings when ordered. Developmental Disorders of the Nervous System
14. Support parents in colostomy care, reassuring that 1. Hydrocephalus (abnormal CSF accumulation)
it won't delay normal development. 2. Neural tube closure abnormalities (e.g.,
15. Involve the whole family in teaching colostomy care meningocele, meningomyelocele)
for better acceptance.
Hydrocephalus
Intussusception
• Excess CSF in ventricles/subarachnoid space
leading to brain swelling.
• The invagination of one bowel segment into
• Normal ICP: 5-15 mmHg, with 500 ml CSF
another, common in infants, typically after 6
produced/day.
months.
Causes
• Causes include Meckel’s diverticulum, polyp,
• Overproduction of CSF (rare, due to tumor).
hypertrophy of Peyer’s patches, or tumors in older
infants. • Obstruction in fluid passage (e.g., aqueduct of
Symptoms Sylvius, foramina of Magendie and Luschka,
Early: hemorrhage, infection).
• Nausea, vomiting (sometimes bile-stained), pulling • Interference with CSF absorption (e.g., post-
legs to chest. surgery or hemorrhage).
Additional Causes
• Intermittent, severe abdominal cramping.
Later: • Genetic defects, infections during pregnancy,
bleeding, trauma, tumors.
• "Red currant jelly" stool (blood and mucus).
Types of Hydrocephalus
• "Sausage-shaped" mass in the upper right 1. Communicating (Extraventricular): Fluid
abdomen. reaches spinal cord.
• Risk of ischemia, necrosis, perforation, and sepsis. 2. Obstructive (Intraventricular): Blocked fluid
circulation.
3. Congenital: Present at birth, often with
meningomyelocele.
4. Acquired: Occurs later in life, such as from
prematurity or intraventricular hemorrhage.
Signs and Symptoms
Early signs (infants):
1. Widened, tense fontanelles and separated
sutures.
2. Enlarged head, shiny scalp, prominent veins.
3. Brow bulging (bossing), “sunset eyes” (sclera
above iris).
4. Seizures, lethargy, vomiting.
 5. Increased ICP: Decreased pulse, increased BP, o Outcome: No signs of increased ICP or
hyperactive reflexes. altered vital signs.
6. Irritable or lethargic with shrill cry. o Interventions:
Symptoms in Older Children: ▪ Keep the bed flat or slightly
1. High-pitched cry, personality/memory changes. raised.
2. Facial changes crossed eyes.
▪ Avoid turning the child onto
3. Difficulty feeding, excessive sleepiness.
the side with the shunt.
4. Headaches, irritability, urinary incontinence.
5. Loss of coordination, muscle spasticity, slow ▪ Prevent exposure to magnets
growth. (affects shunt function).
Tests ▪ Monitor for signs of ICP (e.g.,
1. Head circumference measurements. tense fontanelles, vomiting).
2. CT scan, cranial ultrasound, arteriography. ▪ Check for infection signs (e.g.,
3. Brain scan, skull X-rays, lumbar puncture (rare). fever, irritability).
4. Transillumination to detect fluid-filled skull. ▪ Manage pain to prevent CSF
Treatment Goal pressure increase.
• To prevent brain damage by improving CSF flow, 2. Risk for Imbalanced Nutrition (related to
tailored to the cause and extent of hydrocephalus. increased ICP)
o Outcome: Child’s weight remains within
1. Overproduction of Fluid: the normal range; no vomiting.
o Acetazolamide (Diamox): Diuretic to o Interventions:
excrete excess CSF. ▪ NPO until bowel sounds
o Ventricular Endoscopy: Destroys part return; gradually introduce
of the choroid plexus. fluids.
o Tumor Removal: If a tumor is causing ▪ Ensure proper head support
fluid overproduction. while feeding.
2. Laser Surgery: ▪ Monitor for ineffective sucking
o Used to reopen fluid flow or bypass or vomiting as signs of
obstructions, especially in children increased ICP.
without neural tube involvement. 3. Risk for Impaired Skin Integrity (related to head
3. Ventriculoperitoneal Shunt: weight/immobility)
o A catheter from the ventricles to the o Outcome: Skin remains intact and free
peritoneum to drain and absorb CSF. of breakdown.
4. Endoscopic Third Ventriculostomy (ETV): o Interventions:
o Relieves pressure without the need for a ▪ Change the child’s head
shunt. position every 2 hours.
5. Cauterizing: ▪ Use a pressure-relieving
o Removing or burning away parts of the mattress or padding.
brain that produce excess CSF.
▪ Ensure surgical dressings
6. Regular Check-ups:
remain dry and secure.
o To monitor for developmental,
intellectual, neurological, and physical
▪ Prevent head flattening
(nonsynostotic plagiocephaly).
issues.
4. Deficient Knowledge (related to home care for
Other Treatments:
hydrocephalus)
• Antibiotics for infections. o Outcome: Parents feel confident in
• Shunt Removal: In severe infections like managing care.
meningitis. o Interventions:
Complications: ▪ Address parents’ anxieties
1. Surgical complications and provide support.
2. Infections (meningitis, encephalitis)
▪ Educate about the shunt, its
3. Intellectual impairment
care, and infection prevention.
4. Nerve damage (e.g., loss of movement, sensation)
5. Physical disabilities ▪ Teach signs of increased ICP
(e.g., irritability, vomiting).
Nursing Diagnoses and Interventions: ▪ Educate on the severity of
1. Risk for Ineffective Cerebral Tissue Perfusion shunt infections and
(related to increased ICP) necessary interventions
 🧬 Neural Tube Defects (NTDs) 5. Abnormal eye movements
Latex allergy (up to 68%) — avoid latex in gloves,
• Group of congenital malformations from improper
6.
catheters, dental tools.
neural tube closure.
• Often referred to collectively as Spina Bifida. Neurological Complications
• Occurs early in intrauterine life due to failure of
posterior fusion of the embryo. Arnold-Chiari II Malformation:
• Cerebellum and brainstem herniate into foramen
Types of Neural Tube Defects: magnum.
1. Anencephaly
• Causes hydrocephalus due to CSF flow
• Absence of cerebral hemispheres. obstruction.
• Usually results in neonatal death (medulla intact— Hydrocephalus:
may breathe briefly). • Common in spina bifida due to cerebellar
• Diagnosed by elevated AFP, amniocentesis, or displacement.
prenatal ultrasound. • Often requires shunting.
• Emotional support is critical; allow grieving rituals Brain Structural Changes:
(e.g., holding, naming the baby). • Smaller cerebellum

2. Microcephaly
• Frontal cortex may be thickened; parietal/posterior
areas thinner.
• Brain is underdeveloped (more than 3 SD below
normal). 4. Encephalocele
• Causes: • Cranial defect where brain/meninges herniate.
o Intrauterine infections (e.g., rubella,
• Most common in the occipital region.
CMV, toxoplasmosis)
o Zika virus (via mosquitoes) • Covered by skin or dura; imaging (MRI/CT)
o Malnutrition or birth anoxia confirms diagnosis.

• Cognitive impairment common, prognosis varies

• Surgical repair required.
based on severity.
🧪 Pregnancy Screening for NTDs:
3. Spina Bifida (Spinal Dysraphism) • AFP blood test (maternal serum alpha-
Types: fetoprotein)
• Spina Bifida Occulta: • Follow-up: Ultrasound and amniocentesis (AFP
o Mildest form; incomplete closure of + acetylcholinesterase)
vertebrae. • Consider genetic testing (some NTDs linked to
o May present with a dimple, hair tuft, or trisomy 18)
birthmark. Treatment:
• Meningocele: • No cure for nerve damage.
o Meninges protrude through vertebral • Surgery (usually shortly after birth) to close spinal
defect (no neural tissue). openings.
o Can also occur near skull base (e.g., • Ongoing management of complications
endonasal).
(orthopedic, urologic, neurological).
• Myelomeningocele:
• Return spinal cord and nerve roots into the spinal
o Most severe form; spinal cord protrudes canal.
with meninges.
o High risk of paralysis and neurogenic • Cover with meninges to protect neural tissue and
prevent infection.
bladder/bowel.
Causes: • Install a shunt (if hydrocephalus is present) to
divert CSF to the abdomen or chest wall.
• No single cause; folic acid deficiency is a known
risk factor.
Management by Condition:
• Prevention: Folic acid supplementation (leafy 1. Spina Bifida Occulta:
greens, beans, fortified cereals). o No surgery needed.
Physical Signs:
o Parents should be informed and
1. Leg weakness/paralysis
educated to monitor for signs like
2. Orthopedic issues (club foot, scoliosis)
numbness, weakness, or pain as the
3. Bowel/bladder dysfunction
child grows.
4. Skin breakdown (due to poor mobility)
2. Meningocele or Encephalocele:
 o Immediate surgery (within 24–48 hours o Encourage pumping and providing
after birth) to close the skin and protect expressed breast milk.
against infection. o Direct breastfeeding can usually begin
3. Myelomeningocele: by 3–4 days post-op.
o Surgery to return meninges and spinal
cord to the vertebral canal. 3. Risk for Ineffective Cerebral Tissue Perfusion
o Despite surgery, neurological deficits Related to: Increased intracranial pressure (ICP)
remain (e.g., lower limb paralysis, OUTCOMES:
bowel/bladder dysfunction). • Head circumference remains stable on growth
chart.
Nursing Diagnoses and Interventions
• No signs of increased ICP.
INTERVENTIONS:
1. Risk for Infection
Preoperative:
Related to: Open meningeal sac
Outcome: • Measure head circumference regularly.
• Neural sac remains intact • Use indelible pen marks at standard points for
consistent measurement.
• Axillary temp < 98.6°F (37°C)
Postoperative:
Interventions – Preoperative:
• Continue head measurements.
• Use sterile gloves, linens, warm sterile saline
dressings. • Observe for increased ICP signs:
• Positioning:
o Bulging fontanelles
o Prone or carefully side-lying using o Pupillary or neurological changes
rolled blankets above and below the o Vital sign variations
defect to avoid pressure. o Irritability or lethargy
o Place plastic barrier under defect to
prevent contact with feces. 4. Risk for Impaired Skin Integrity
Related to: Required prone positioning
o Use towel under abdomen to flex hips
OUTCOMES:
and reduce sac pressure.
o Do NOT use radiant heat — dries sac; • Skin on knees and other pressure areas remains
use incubator instead. intact.
o Report clear fluid leakage immediately INTERVENTIONS:
→ may be CSF. 1. Reposition head every 2 hours (especially with
hydrocephalus) to avoid pressure on temples.
▪ Confirm with glucose strip 2. Use paper tape, stockinette, or skin barriers
test (CSF is glucose-positive).
like Stomahesive to minimize irritation from
Postoperative Care:
dressings.
• Monitor with cardiorespiratory monitor. 3. Change diapers frequently to prevent skin
• Keep prone until incision heals (about 7 days). breakdown from urine contact.
• Continue protection from urine/feces.
Long-Term Nursing Diagnoses & Interventions
2. Risk for Imbalanced Nutrition: Less Than Body
Requirements 1. Impaired Physical Mobility
Related to: Inability to assume normal feeding position Related to: Neural tube defect (e.g., myelomeningocele)
Outcomes: OUTCOME:
• Good skin turgor • Child ambulates with minimal assistive devices.
INTERVENTIONS:
• Weight within 10% of birth weight
1. Begin age-appropriate stimulation early.
• Urine specific gravity: 1.003–1.015 2. Encourage social and family integration (visits,
Interventions: outings).
1. Feed infant side-lying in incubator if lifting is 3. Teach parents to perform passive ROM
risky. exercises to prevent:
2. Slightly elevate head with a folded diaper. o Atrophy
3. Support arm must not press on the lesion. o Contractures
4. Do not pat over the lesion when burping. 4. Provide or recommend braces or crutches for
5. Stroke the head, arms, or upper back for ambulation.
emotional comfort. 5. Consider tendon transplants or osteotomy later
6. Offer a pacifier for non-nutritive sucking. to correct deformities.
7. Support breastfeeding:
 6. Instruct parents in daily skin inspections of lower
limbs/buttocks (due to sensory loss).
7. Encourage wheelchair-bound children to lift
themselves hourly to prevent pressure ulcers.
8. Involve rehabilitation therapists to optimize
development and mobility.

2. Risk for Impaired Elimination

Related to: Neurogenic bladder/bowel dysfunction
OUTCOME:
• Child independently manages elimination by
school age.
INTERVENTIONS:
1. Teach intermittent clean catheterization (CIC) to
parents.
o Every 4 hours to prevent bladder
overdistension.
2. Early CIC = fewer bladder surgeries later in life.
3. Teach self-catheterization as child grows (early
school age).
4. Consider Ditropan (oxybutynin chloride) to
improve bladder capacity.
5. Surgical options for continence if needed:
o Artificial bladder sphincters
o Continent urinary reservoir
o Ureterosigmoidostomy