PEDIATRIC NURSING (NORMAL) - essential nutrient needed: CALCIUM

- vitamin required for better absorption: VITAMIN D "Calciferol"

Neonate/Newborn
- normal height for newborn: 20 inches
↓
- height multiplies at:
Infant (Below 1 y.o.)
o 4 years old - 2x
↓
o 12 years old - 3x
Toddler (1-3 y.o.)
DEVELOPMENT
↓
- qualitative changes; observable data
Preschooler (3-6 y.o.) Early Childhood
- developmental tasks: set of skills and competence that
↓ children must accomplish to deal effectively with their
environment.
School Age (6-12 y.o.) Middle Childhood
I. DDST (Denver Developmental Screening Test) – A tool used to
↓ determine delayed, normal, and advanced development

Adolescent (12-18 y.o.)

II. CATEGORIES OF DEVELOPMENT

1. Gross (Big) and Fine (Small) Motor Skills

DEFINITION OF TERMS
- NOTE: gross > fine * (gross skills develop first!)
Growth - increase in size; height and weight.
2. Language
Development - advancement from lower to more advance stage;
skills and abilities; standing and sitting. - universal language of children: crying

Maturation - increase in competence and adaptability; - absent crying: hearing loss.

capabilities, rationalizing.
3. Personal - personality development

- Psychosexual: Sigmund Freud

GROWTH AND DEVELOPMENT
- Psychosocial: Erik Erikson
- have a predictable pattern; continuous, orderly, and
progressive - Cognitive: Jean Piaget

- each human being accomplished these in a manner unique - Moral: Lawrence Kohlberg
to that individual
4. Social
- cephalocaudal (head to tail) *
- PLAY: major socializing event: provides stimulation
- proximodistal (near to far) - e.g. elbows should work first needed to learn.
before the wrist. *
- TYPES OF PLAY:

o Solitary - play alone (infant)

GROWTH
o Parallel - play independently but among other
- quantitative change, measurable data children (toddler)

- rapid during INFANCY * o Cooperative/Associative - children play

together (preschooler)
- slow during SCHOOL AGE
o Competitive - play that involves competition
- increased during the beginning of ADOLESCENCE (school age)

- off during early ADULTHOOD REFLEXES

1. Rooting - stroke the check = starts sucking

I. Weight 2. Sucking - stroke the lips = starts sucking

• one of the most important health indicators! 3. Tonic Neck Reflex - if the child's head faces right, the right arm
will extend and the left arm will flex.
• "at birth, weight is more variable than height."
4. Palmar Grasp - close the fingers around an object.
• normal weight for newborn: 7-7.5 lbs (3.2-3.4 kg)
5. Plantar Grasp - toes curl down when the sole of the foot is
• NOTE: neonatal weight loss is normal IF below 1 lb.
pressed.
• weight multiplies at:
6. Pincer Grasp - holds a small object using the thumb and the
o 6 months - 2x index finger.

o 12 months - 3x 7. Parachute Grasp - extend arms when about to fall.

o 24 months - 4x 8. Babinski Reflex - stroke the sole of the foot = fanning out of the
toes. NOTE: should disappear in toddler stage, if not, may indicate
(+) neurologic disorder (Brain Tumor: "Glioma")
II. Height
9. Moro – Startle Reflex – Moro: Causes by movement/Motion.
- increase due to skeletal growth; elongation of: DIAPHYSIS Startle: Causes by sounds. Most involuntary reflexes start to fade
(middle part of bone) at 6 months
DEVELOPMENTAL MILESTONES C. Signs of Teething

1 Month - drooling

- (+) strong head lag - gum rubbing

- hands predominantly closed - increase thumb sucking

- strong palmar grasp - biting on hard objects

- watched parent's face intently as they talk to the infant - inflammation due to pain (intervention: cold teething
ring)
2 Months
7 Months
- lifts head while in prone (45°)
- sits leaning forward on both hands; sits with support
- closure of posterior fontanelle (TRIANGULAR)
- transfers object from one hand to another
- fading of grasp reflex
8 Months
- demonstrates social smile
- sits steadily unsupported
3 Months
- crawling: stuck in bed/floor
- lifts head while in prone (90º)
- onset of: SEPARATION ANXIETY
- slight head lag
- combines syllables such as "dada" without meaning
- able to hold head more erect when sitting but still bobs
forward - parachute reflex

- (-) grasp reflex 9 Months

- can recognize familiar faces and objects, such as - creeping: not stuck anymore
feeding bottles.
- eruption of lateral incisors
4 Months
- pulls self to standing position and stands while holding on
- rolls from back to side a furniture

- balances head well in sitting position - NOTE: an infant who does not pull to a standing position
by 11 or 12 months of age should be evaluated for
- disappearance of Moro, Tonic, Neck and Rooting Reflex possibility of Developmental Hip Dysplasia

5 Months - Pincer grasp; PRIORITY: prevent aspiration

- can turn from abdomen to back (roll over) 10 Months

- PRIORITY: safety - stand with support

- do not let the infant sleep in prone: may cause SIDS - eruption of lower lateral incisors
(other causes: co-sleeping and soft beddings: can
cause respi. depression) - says "dada" with meaning

- holds head more erect when sitting - develops object permanence

- puts feet to mouth when in supine 11 months

- smiles at mirror image - Cruising: walks while holding on furniture

6 Months XII. 12 Months

- holds bottle - walks with one hand held

- extends arms out to be picked up - may attempt to stand alone and take first step

- begins to imitate sounds - can say 3-5 words with meaning

- onset of STRANGER ANXIETY (crying); (-) crying may 15 Months

indicate autism spectrum disorder
- walks alone

A. Eruption of the FIRST TEETH: 18 Months

1. Lower Central Incisors: first dental visit - can run and climb stairs

2. Upper Lateral Incisors - closure of anterior fontanelle (DIAMOND)

3. Lateral Incisors NEWBORN

B. Milk Teeth/Deciduous Teeth: TEMPORARY Anthropometric Measurements

- complete at 3 years old a) Head Circumference: 33-35 cm*

- total of 20 teeth b) Chest Circumference: 31-33 cm

- replaced at the age of 6 years old c) Abdominal Circumference: 31-33 cm

NOTE: Jaundice in newborn is normal if it appeared after 24-hours

after birth. It is caused by LIVER IMMATURITY = (-) conversion of
unconjugated bilirubin.
Hyperbilirubinemia Interventions (Phototherapy) 3. To be fed

- remove newborn clothes - to prevent hypoglycemia (Can cause brain damage)

- cover the eyes - NOTE: blood glucose should never be below 40 mg/dL;
ensure uninterrupted breastfeeding.
- cover the genitals
- RA 7600 "Rooming in and Breastfeeding Act of 1992"

RBC Breakdown: Spleen - exclusive breastfeeding: Executive Order 51: Philippine

Milk Code of 1986
Heme: bilirubin (unconjugated): water insoluble
- NOTE: Breastmilk is low in sodium
Globin: ammonia
- colostrum contains IGA (antibodies)
Liver
- introduction of solid foods: 6 MONTHS; intervals: 4-7 DAYS
↓
- NOTE: food should not be mixed in bottle and fed through
Conjugated bilirubin = water soluble a nipple with a large bottle.

Excretion STAGES OF DEVELOPMENT

I. Infant (below 1 year old)

BASIC NEEDS OF NEWBORN Psychosexual: Oral Stage - feeding, pacifier

1. To be warmed Psychosocial: Trust vs. Mistrust - consistent provision of basic needs;

avoid numerous individuals catering the infant's needs.
- to prevent hypothermia and heat loss
Cognitive: Sensorimotor
- NOTE: newborns have poor thermoregulation caused by
less brown fat immature HYPOTHALAMUS Play: Solitary - e.g. rattles, colorful toys

Fear: Stranger

A. Types of Heat Loss

a. Evaporation (evaPOration = punasan) II. Toddler (1-3 years old) - "The Great Imitators"
- when the body is wet, the water evaporates. Psychosexual: Anal Stage - toilet training

- immediate and thorough drying Psychosocial: Autonomy vs. Shame and Doubt

b. Convection (convection = electric fan) - Negativism

- temper tantrum: offer choices, promote safety, ignore
- heat loss due to surrounding air
the behavior
- do not place the newborn in contact with electric fan
Cognitive: Preoperational
c. Conduction (conDuction = dikit)
- egocentrism - inability to see the point of view of others.
- transfer of heat from higher temperature to water temperature
Moral: Preconventional/Premoral
- do not place the newborn in contact with cold surface
Play: Parallel - push and pull toys

Fear: Separation
2. To be protected

- from infection and injury

III. Preschooler (3-6 years old) "Magical Thinkers"
- vaccinations: if temperature reaches 38.5° HOLD
- highest level of curiosity
A. Types of Vaccination
- risk of poisoning: PRIORITY: safety
1. BCG - Tuberculosis
Psychosexual: Phallic Stage - loves the opposite sex, hates the
Site: Right Deltoid same sex.

Psychosocial: Initiative vs. Guild - allows the child to participate.

2. Hepa B - Hepatitis Cognitive: Preoperational - inability to convene.

Site: Vastus Lateralis Moral: Preconventional

Play: Cooperative/Associative - e.g. role playing

3. Vitamin K - Hemorrhage Fear: Body Mutilation

Site: Vastus Lateralis

IV. School Age (6-12 years old)

NOTE: newborns are at risk of bleeding caused by STERILE COLON Psychosexual: Latent - suppressed sex desires

Psychosocial: Industry vs. Inferiority

- support child's activities

- recognize efforts and give compliments
Cognitive: Concrete Operational DEOXYGENTED BLOOD FLOW

- perceptual thinking: making judgments based on what Right Atrium

they see.
- conceptual thinking: making judgments based on ↓
reason.
Right Ventricle
Moral: Conventional
↓
Play: Competitive
Pulmonary Artery → Lungs
Fear: Death, School, Displacement
↓

Ductus Arteriosus
V. Adolescent (12-18 years old) "Puberty Stage"
↓
a. menarche (first menses)
Aorta
b. thelarche (breast development)

c. adrenarche (sexual maturation)

PEDIATRIC NURSING (ABNORMAL)
Psychosexual: Genital
ACYANOTIC HEART DEFECTS
Psychosocial: Identity vs. Role Confusion
- (-) Cyanosis
Cognitive: Formal Operational - hypothetical/abstract - Non – life threatening congenital disorders

Moral: Post-Conventional – morality PATENT DUCTUS ARTERIOSUS

Focus: Body Image - Failure of the Ductus Arteriosus to close at birth

Fear: Peer Rejection - hates parents Manifestations:

- Machinery-like murmur (Note! Can be asymptomatic)

FETAL CIRCULATION
Medical Management:
Fetal Lungs
- Indomethacin
- non-functional (during pregnancy)
- Ibuprofen
- fluid-filled
Surgical Management:
What serves as the fetal lungs during pregnancy?
- Surgical Ligation
- Placenta
COARCTATION OF THE AORTA
Umbilical Cord (AVA)

- has 2 arteries, and 1 vein.

- Narrowing of the Aorta
- Narrowed aorta = Less oxygenated blood in systemic
circulation (compensatory mechanism).

OXYGENATED BLOOD FLOW Manifestations:

Upper Extremities Lower Extremities

Placenta - Bounding pulse - Diminished pulse

- High BP - Low BP
↓
- Cool to touch
Umbilical Vein
- Pallor
↓ - Numbness and tingling

Ductus Venosus

↓ Management:

Inferior Vena Cava

- Balloon Angioplasty
↓
ASTRIAL SEPTAL DEFECT (ASD)
Right Atrium
- Patent foramen ovale, hole in between the Right and
↓ Left atrium

Foramen Ovale Blood from: Superior and Inferior Vena Cava → Right Atrium

↓ Blood from: Left atrium → Right Atrium → Right Ventricle →

Congestion
Left Atrium
Manifestations:
↓
Enlargement of the Right Ventricle → Right Ventricular
Left Ventricle
Hypertrophy
↓
Enlargement of the Pulmonary Artery
Aorta
VENTRICULAR SEPTAL DEFECT (VSD) 4. Overriding of the Aorta - causes mixing of oxygenated and
deoxygenated blood
- Hole in between the Right and Left Ventricle
Manifestations:
Blood from: Right Atrium → Right Ventricle - Cyanosis - NDx: Ineffective tissue Perfusion
- “TET SPELL”
Blood from: Left ventricle → Right Ventricle → Congestion
- Exertional Dyspnea
- Pallor
Manifestations: - Clubbing of fingers
- SCHAMROTH WINDOW TEST
- Enlargement of the Right Ventricle → Right Ventricular
Hypertrophy
- Diminished blood flow to systemic circulation Management:
- Positioning:
• Squatting/Tripoding
Management:
• Knee Chest position
- Application of Dacron Patch - Oxygen therapy: 6-8L/min

PULMONIC STENOSIS HEMATOLOGIC DISORDERS

- Narrowing of the Pulmonic Valve

HEMOPHILIA

Blood from: Right Atrium → Right Ventricle → Pulmonary Artery → - X-linked disorder
Right Ventricular Congestion - FEMALE: Carrier
- MALE: Manifests the disease

Manifestations:
Cause:
- Enlargement of the Right Ventricle → Right Ventricular - Deficiency in clotting factor → Bleeding
Hypertrophy
- Murmur: 2nd ICS, Left
Types:
- Dyspnea
- Diminished blood flow to systemic circulation - HEMOPHILIA A - “Classic Hemophilia”: CF 8
- HEMOPHILIA B - “Christmas Disease”: CF 9
- HEMOPHILIA C - “Rosenthal Syndrome”: CF 11
Management:
- Balloon Angiopathy Manifestations:
- Easy bruising
CYANOTIC HEART DEFECTS - Prolonged bleeding time N:1-10 mins
- Trauma >>> Hemorrhage
- (+) Cyanosis
- HEMARTHROSIS: Bleeding joints - Hallmark sign!
- Life-threatening congenital anomaly
Rest
- Poor supply of oxygenated blood: Systemic Circulation Ice
Compression
Transposition of the Great Arteries or Transposition of the Great Elevate
Vessels (TOGA) - SPONTANEOUS HEMATURIA - Classic Sign

Management:
Right ventricle is connected to: Aorta
- Cryoprecipitate
Left ventricle is connected to: Pulmonary Artery
- Bleeding precautions:
• Avoid contact sports
Manifestations: • Soft bristled toothbrush
- Severe Cyanosis • Use electric razor
- Fatigue
VON WILLEBRAND DISEASE

What makes the patient alive? PDA (Patent Ductus Arteriosus) -

- Bleeding Disorder
allows blood mixing

Cause:
Management:
- Inability of the platelets to adhere → Excessive Bleeding
- Oxygen therapy: 6-8 L/min
- Limit physical activities
- PROSTAGLANDIN E: Alprostadil (keeps PDA open) Problem: Platelet adhesion

Surgical Management: Injury → Bleeding → Platelets will go to the site → Platelet adhesion
- Blalock- Hanlon Operation - surgical procedure to → Forms a Platelet Plug → Stops the bleeding
create PDA
- Jatene Operation / Arterial Switch - complete repair of SICKLE CELL ANEMIA
the vessels
Cause: Irregular-shaped
- RBC - CRESCENT (d/t: presence of HbS-gene )
TETRALOGY OF FALLOT - RBC - Carrier of oxygenated blood
4 PROBLEMS: - Normal: Biconcave
1. Pulmonary Stenosis - primary problem
2. Right Ventricular Hypertrophy - compensatory mechanism Manifestations:
3. Ventricular Septal Defect - keeps the patient alive; decreases - Underweight
pressure in RV - Chronic Anemia
 - Fatigue NEURAL TUBE DEFECTS
- Pain

Causes: Failure of the spine to fuse at the center

Management: Deficiency: FOLIC ACID:
- Priority: HYDRATION - Vit. B9
- Avoid: - Valproic acid
• High altitude places
• Cold temperature → Vaso-Occlusive Crisis o
Vigorous exercise ANENCEPHALY
- Oxygen Therapy Absence of skull
Management: Life support
DOWN SYNDROME
SPINA BIFIDA
- “Trisomy 21” Cause:
- Normal Chromosomes: 46 (23 pairs) - Failure of the spine to fuse

Cause: Spina Bifida Occulta

- Extra chromosome at the 21st chromosome - (+) dimpling and tufts of hair
- (-) Paralysis
- (-) Alterations in bowel and bladder function
Manifestations:
- Large protruding tongue → difficulty of feeding →
malnutrition - most common cause of death Spina Bifida Cystica
- Flattened profile - (+) sac
- Simian Crease - (+) paralysis
- Sandal Sign - Alteration in bowel and bladder function
- Short broad neck
- Low set ears
Myelomeningocele - without spinal cord
- Slanted eyes
- Congenital Cardiac Defects Meningocele - spinal cord
- Mental Retardation
Management:
Management: - Prevent damage of the sac:
- Ensure feeding efficacy ➢ Prone
- Watch out for signs of cardiac difficulties ➢ No diapers!
- Parental Support - Apply sterile, moist, non-occlusive dressing

MENINGITIS Complications:
- Inflammation of the meninges - Short term: MENINGITIS
- MENINGES - membrane that covers the brain and spinal cord; - Long term: HYDROCEPHALUS
supports and covers the brain
AMELIA
Causative agents: - Absence of extremities
- Neisseria Meningitidis – common cause! Cause
- Haemophilus Influenzae – bacteria. Prevention: Hib
vaccination - ANTIEMETIC DRUGS: Thalidomide
- Streptococcus Pneumoniae
CLEFT LIP (1st)
- Hereditary
Diagnostics:
Common: MALES
- Lumbar Puncture: Between L4 and L5
- Contraindication: Increased ICP → Brain Herniation Problem:
- Poor sucking ability → malnutrition and aspiration

Manifestations: Management:
- Surgery: Cheiloplasty (2 months) Post-op:
- Irritability
• prevent the infant from crying
- High Pitched Cry
• supine head turned in unaffected side
- Projectile vomiting
- Seizure
- Nuchal Rigidity: Stiff neck CLEFT PALATE (2nd)
- Kernig’s Sign: flexion of knees → hamstring pain - Hereditary
- Brudzinki’s sign: flexion of neck → flexion of the knee
Common: FEMALES
- Opisthotonus: exaggerated arching of the back
- Side-lying position Problem: Speech
Management:
Management - Surgery: Palatoplasty (12-18 months) post-op:
• prone position
- Droplet precaution: Surgical Mask
• avoid use of straw, utensils, popsicles
- Antibiotics
• feed with cups
- Seizure precaution
- Control ICP
• Elevate HOB: Semi-fowler’s HYPERTROPHIC PYLORIC STENOSIS (W/VOMITING)
• Osmotic Diuretic: MANNITOL - Narrowing of the pylorus, thickening of the pyloric
sphincter.
Diagnostic:
- Abdominal Ultrasound
CELIAC DISEASE
Manifestations: - Gluten sensitive enteropathy; gluten intolerance;
- upper abdominal distention irreversible
- projectile vomiting - severe abdominal distention
- non-bilous vomitus
- signs of dehydration Diagnostic:
- metabolic alkalosis - Bowel Biopsy
- malnutrition and weight loss Manifestations:
- visible peristaltic movement (left to right) - diarrhea
- olive-shaped mass (RVQ) - steatorrhea (increase fat content in feces

Management: NO GAS FORMING FOOD! Management

- increase oral fluid intake
- Avoid food with gluten: BROW (Barley, Rye, Oats, Wheat)
- assess the vomitus
- No processed food
- positioning: high fowler’s
CYSTIC FIBROSIS
Surgical Management:
- Inherited genetic disorder
- Pylorotomy (Ramstedt Operation)
PROBLEM: all secretions are viscous
INTUSSUSCEPTION (W/PAIN)
Organs Affected:
- Telescoping of the colon
- Intestines
SITE: - Lungs
- Skin
- Ileocecal Valve (boundary between the small and large - Pancreas
intestine)
Manifestations:
Diagnostic:
- meconium ileus
- Barium Enema - thick bronchial secretions
- Guaiac’s Test - DOB
- very salty sweat (increased na)
Manifestations: - acute pancreatitis
- sudden abdominal pain (colicky)
- abdominal distention Management:
- red-currant jelly stool - Chest physiotherapy (requires MD order)
- sausage-shaped mass (RVQ) - Pancreatic enzymes – after meals

Management: Complications:
- Females: Decreased Fertility
- assess bowel sounds (borborygmus)
- Males – Sterility
- assess abdominal distention
- NGT insertion (for decompression)
WILM’S TUMOR
CANCER: Kidney “Nephroblastoma”
Surgical Management:
- Laparotomy “Surgical Resection of Colon”
Manifestations:
- abdominal mass
- fatigue
HIRSHSPRUNG’S DISEASE
- high BP
- A ganglionic megacolon - hematuria

CAUSE: Management:
- constant monitoring of BP 4-6qhr
- Absence of ganglion → peristalsis movement, nutrients - NEVER palpate the abdomen
absorption
URINARY TRACT INFECTION
Diagnostic:
CAUSE: Escherichia coli (E-coli)
- Rectal Biopsy COMMON: Females: Shorter length of urethra (2-3 inches); males:
6-9 inches
Manifestations:
Manifestation:
- (-) peristalsis - dysuria/burning sensation
- enlarged colon: SIGMOID - cloudy urine
- fecal-shaped mass (LLQ) - hyperthermia
- bile-stained foul-smelling emesis
- foul breath Complications:
- malnutrition - cystitis
- pyelonephritis
Management:
Management:
- high caloric diet
- Antibiotic
- assess the stoma (normal: pinkish) (necrosis: bluish/gray –
report)
Prevention:
- colostomy care:
- increase fluid intake
• size: 1/8 larger than the stoma
- avoid holding urine
• emptying: 1/3 - ½ full
- avoid acidic drinks
Surgical Management: - good perineal hygiene

- Swenson Pull-Through
 - AVOID allergens
GABH’s (Group A Beta Hemolytic Streptococcus) Infections
FEBRILE SEIZURES
TONSILLITIS
- inflammation of the tonsillitis. CAUSE: high fever: > 38.5
- too much glucose which attracts microbes
- throat swabs OTHER CAUSE: immaturity of hypothalamus
- dysphagia,
- hyperthermia Management:
- seizures precautions
ADENIODITIS - during seizure episode:
- inflammation of the adenoids • PROMOTE SAFETY:
- cold weather ➢ remove pillows o never restraint the child
- nasal swab ➢ maintain patent airway: side-lying position
- dysphagia, - anticonvulsant medications:
- hyperthermia • Phenytoin (Dilantin) o therapeutic level: 10-20
mg/dL newborn: 8-15 mg/dL o never stop abruptly,
Complications: taper
- bacteremia ➢ status epilepticus
- endocarditis
- GN (acute glomerulonephritis) Complications
- Gingival Hyperplasia
Management: • Use soft bristled toothbrush
- antibiotics • Oral care
- increased fluid intake
- gargling solutions

Surgical Management:
- Tosillectomy
- Adenoidectomy post-op:
• side-lying position
• WOF: signs of bleeding
➢ frequent swallowing
➢ drooling of blood
➢ hypotension
➢ tachycardia
➢ tachypnea
• avoid food that may induce coughing
• avoid blowing of nose

EPISTAXIS (Nose Bleeding)

- Trauma in the anterior part of the nose

Management:
- lean forward
- apply pressure on the soft tissue part of the nose (at least 5
mins)
- apply cold compress

BRONCHIAL ASTHMA
- Reversible

CAUSE: Allergens

Pathophysiology

Allergen → Activation of Immune Response

↓
Inflammation: Bronchus
Leukotriene ← → Histamine
↓ ↓
Bronchoconstriction Swelling: Goblet Cells
↓ ↓
Wheezing (expiration) Increased mucus production

Airway obstruction
↓
Reduced O2 supply in the body

Manifestations:
- hyperventilation → respiratory alkalosis (initially) →
respiratory acidosis
- DOB
- dyspnea
- use of accessory muscles

Management
- orthopneic position
- bronchodilators: albuterol (short term m/x)
- oxygen therapy (short term m/x)
- corticosteroids “sone” (beclomethasone)