Nurse's Notes - The Black Book The Nurse's Notes - Black Book is a compilation of must-know concepts in nursing n ursing education. This will help aspiring nurses to be fully equipped in their future exams (e.g. Nursing Licensure Exam, NCLEX, NC LEX, CGFNS). Do you want to pass this exams? Of course! Then we will start our journe y to uncover those topics as easy as 1,2,3. Psychiatric Nursing PSYCHIATRIC NURSING Beliefs— Beliefs—Feelings— Feelings—Behavior
Cry, suck – suck – mouth- survival Id dominant
Sigmund Freud – Freud – Father of Psychoanalysis
Maternal deprivation if not feed, not given
-structure of personality
milk/water, not kept warm.
Id- impulsive part, pleasure principle
Narcissistic – Narcissistic – seeks the Id – Id – I love myself
-eat, urinate, have sex
Regression – Regression – return to an earlier stage or earlier
-it’s all “I”
level Fixation – Fixation – stopped in a stage
Superego – Superego – small voice of God -conscience
ANAL- 18 mos-3yrs
-should not eat yet, should not eat yet
Toilet training Mom is superego.
Ego- arbiter, decision maker
Superego is being formed
-in touch with reality
Child is caught in ambivalence – ambivalence – pulled in 2 opposing factors
Id___________________Superego EGO
Too much toilet training with punishment will result to a child who is:
ID DOMINANT – DOMINANT – needs a superego-needs a conscience M- manic A- antisocial – antisocial – serial killer
Obedient, organized, clean Rebel, dirty, disobedient
N- narcissistic
= OC =Anti-social =anal retentive =anal expulsive
SUPEREGO DOMINANT – DOMINANT –needs needs an Id O- Obsessive Compulsive A- Anorexia nervosa
PHALLIC – PHALLIC – 3-6 yrs old -penis & vagina
EGO – EGO – impaired reality perception (RN will present
-love of parent of opposite sex
reality)
Oedipal-boy loves mom
S- schizophrenia- cant distinguish fact from reality
Electra-girl loves dad
Libido- sexual energy
Identification- boy imitates dad
FREUD - PSYCHOSEXUAL THEORY
Castration fears- fear that dad is angry at him and
ORAL – ORAL – 0-18 months
will cut off penis
Penis envy- girls envy little boys
Independence 6-12 yrs old (Latent) Industry vs I nferiority Industry
Dr. Karen Horney- detractor of Freud, didn’t believe
Induskul
in penis envy. Freud said that it is m aybe in her
12-20 (Genital) Identity vs Role confusion Peers
unconscious mind.
20-25 Intimacy vs Isolation Love
Or repressed.
25-45 Generativity vs Stagnation Parenting 45 up Ego Integrity vs Despair Reflection
Conscious- highest level of awareness Pre-conscious- at tip of tongue
Newly admitted pt- develop trust 1st
Unconscious – Unconscious – forgotten
-pts are dependent=self care deficit -develop/teach autonomy
Repression-kept in unconscious. Unconscious
-then pt will develop initiative
forgotten.
-etc
Suppression – Suppression – conscious forgetting LATENT- 6-12 years old Latent- Logtu = sexual energy asleep
Frontal lobe- personality, learning, judgment,
School age – age – School phobia- 1st time to go to school
language
– Separation anxiety
Occipital- vision
Child is busy with Reading, writing, arithmetic.
Temporal- hearing, smell
Sublimation – Sublimation –putting putting anger into something more
Parietal-taste, touch
productive putting all energies into schooling
Sensory Integration Motor
Ex. Angry at life, pour anger in singing. Somatic nervous system- voluntary movements GENITAL – GENITAL –12 12 years old Genital-Gising sexual energy
Acetylcholine- responsible for voluntary movements
Sexual intercourse most important in this stage!!
- on switch of movement
PHARMA MOMENTS
Autonomic nervous system- involuntary movements
Anti-anxiety Drugs (used also for alcohol
-Sympathetic(Anti cholinergic) and parasympathetic
withdrawal)
(cholinergic)
Valium Librium Ativan Serax Tranxene Miltown Equanil Vistaril Atarax Inderal Buspar
SYMPATHETIC (alert) PARASYMPATHETIC (relax) Heart tachycardia bradycardia
ERIK ERIKSON
Respiratory tachypnea bradypnea GI (opposite effect) Slow, constipation diarrhea
STAGE (+) (-) FACTOR
GU (opposite effect) Slow, oliguria, retention
0-18 months (Oral) Trust vs Mistrust Feeding
Polyuria, frequency
18 mos- 3yrs old (Anal) Autonomy vs
Dry mouth Moist mouth
Au-(anal)
Neurotransmitter Epinephrine, Norepinephrine
To-ilet training
Acetylcholine (AcH)
No-No! Favorite word.
Pupils Dilated (dilat when alert) (Midriasis)
My Shame/doubt Toilet training
Constricted (Myotic)
3-6 yrs old (Phallic) Initiative vs
Blood vessels vasoconstriction vasodilated
(Initiate 1st steps)
BP increased decreased
Phallic-oedipal,electra Guilt – Guilt –anger anger turned inward
Penis envy- girls envy little boys
Independence 6-12 yrs old (Latent) Industry vs I nferiority Industry
Dr. Karen Horney- detractor of Freud, didn’t believe
Induskul
in penis envy. Freud said that it is m aybe in her
12-20 (Genital) Identity vs Role confusion Peers
unconscious mind.
20-25 Intimacy vs Isolation Love
Or repressed.
25-45 Generativity vs Stagnation Parenting 45 up Ego Integrity vs Despair Reflection
Conscious- highest level of awareness Pre-conscious- at tip of tongue
Newly admitted pt- develop trust 1st
Unconscious – Unconscious – forgotten
-pts are dependent=self care deficit -develop/teach autonomy
Repression-kept in unconscious. Unconscious
-then pt will develop initiative
forgotten.
-etc
Suppression – Suppression – conscious forgetting LATENT- 6-12 years old Latent- Logtu = sexual energy asleep
Frontal lobe- personality, learning, judgment,
School age – age – School phobia- 1st time to go to school
language
– Separation anxiety
Occipital- vision
Child is busy with Reading, writing, arithmetic.
Temporal- hearing, smell
Sublimation – Sublimation –putting putting anger into something more
Parietal-taste, touch
productive putting all energies into schooling
Sensory Integration Motor
Ex. Angry at life, pour anger in singing. Somatic nervous system- voluntary movements GENITAL – GENITAL –12 12 years old Genital-Gising sexual energy
Acetylcholine- responsible for voluntary movements
Sexual intercourse most important in this stage!!
- on switch of movement
PHARMA MOMENTS
Autonomic nervous system- involuntary movements
Anti-anxiety Drugs (used also for alcohol
-Sympathetic(Anti cholinergic) and parasympathetic
withdrawal)
(cholinergic)
Valium Librium Ativan Serax Tranxene Miltown Equanil Vistaril Atarax Inderal Buspar
SYMPATHETIC (alert) PARASYMPATHETIC (relax) Heart tachycardia bradycardia
ERIK ERIKSON
Respiratory tachypnea bradypnea GI (opposite effect) Slow, constipation diarrhea
STAGE (+) (-) FACTOR
GU (opposite effect) Slow, oliguria, retention
0-18 months (Oral) Trust vs Mistrust Feeding
Polyuria, frequency
18 mos- 3yrs old (Anal) Autonomy vs
Dry mouth Moist mouth
Au-(anal)
Neurotransmitter Epinephrine, Norepinephrine
To-ilet training
Acetylcholine (AcH)
No-No! Favorite word.
Pupils Dilated (dilat when alert) (Midriasis)
My Shame/doubt Toilet training
Constricted (Myotic)
3-6 yrs old (Phallic) Initiative vs
Blood vessels vasoconstriction vasodilated
(Initiate 1st steps)
BP increased decreased
Phallic-oedipal,electra Guilt – Guilt –anger anger turned inward
Anti-cholinergic / anti-parasympathetic =effect is
but them.”
sympathetic!
INTROJECTION – INTROJECTION – --------------assume another persons trait as your own. “Not just you, me too.” “Ako din,
Sympathetic drug classifications:
gusto ko yan.”
A- anxiety
CONVERSION – CONVERSION – repression. Anger turned inward to
P- psychotic
herself. Converted to physical symptoms.
Anti C- cholinergic
Sensory-numbness. Motor-paralyzed, tremors.
D- depressants
COMPENSATION – COMPENSATION – -----------defects of the person, overachieve to cover a defective part.
MONO AMINE OXIDASE INHIBITORS:
SUBSTITUTION – SUBSTITUTION – -----------when you replace a difficult role with a more accessible one.
mARplan
Ex.Wants to go to Disneyland but can’t afford it.
nARdil
Went to Enchanted Kingdom instead.
pARnate DEFENSE MECHANISMS: coping mechanism from
Defense mechanism: Affects/interferes with ADL
stress:
Harm to self or others
DISPLACEMENT- -------------Your boss shouts at you,
Behavior Model – Model – Ivan Pavlov
you shout at your subordinate. SUBLIMATION - ---------------putting anger into
Classical Conditioning -behavior learned-repeated
something more productive or +
(+)
putting all energies into schooling Ex. Angry at life, pour anger in singing.
BF Skinner – Skinner – operant conditioning-reinforcement
DENIAL- ----------------------“I ---------------------- “I am not” an alcoholic!
Confront (-) behavior to make it extinct.
DISSOCIATION – DISSOCIATION – --------------psychological flight from self. Amnesia. Ex. Rape, trauma
MASLOW’S HEIRARCHY HEIRARCHY OF NEEDS:
REGRESSION – REGRESSION – ----------------RETURN to an earlier developmental stage
5. Self-actualization
FIXATION – FIXATION – ---------------------stuck in a stage of
4. Self-esteem
development
3. Love and belonging
REPRESSION – REPRESSION – -----------------unconscious forgetting
2. Safety and security
SUPPRESSION – SUPPRESSION – ---------------conscious forgetting.
1. Air, food, water, shelter, clothing, sex – sex –Basic Basic
Avoidance. “I don’t want to talk about it. I don’t
physiologic needs
want to remember it.” RATIONALIZATION – RATIONALIZATION – -------uses -------uses “because”. Has
LEVELS OF PREVENTION
illogical reasoning. “I drink because I don’t want to
PRIMARY SECONDARY TERTIARY
waste the beer in the ref.”
Healthy ill Relapse avoidance
REACTION FORMATION----plastic. Doing opposite of
Community teaching Crisis intervention Rehab
intention.
centers
UNDOING- ----------------------show true feeling/color
Community demographics Treatment and diagnosis
then feels guilty after.
Al anon
IDENTIFICATION – IDENTIFICATION – -----------models a certain behavior from a certain role model.
STAGES OF INTERACTION
PROJECTION – PROJECTION – -----------------blame other people,
ORIENTATION WORKING TERMINATION
pass load to others. Looks for a scapegoat. “Not me,
Assessment Problem solving Evaluation
Establishment of trust Discussion Summarize
11. Focusing-“Tell Focusing-“Tell me more abt this.”
Tell patient about termination Patient is most cooperative Say goodbye
ABG ANALYSIS
Set contract Grief-ANGER-focus of RN
Ph & PCO2-Respiratory-opposite signs
Patient is resistant Pt might become violent/suicidal
Ph & HC02-Metabolic – HC02-Metabolic – same signs
ANTI-PARKINSON DRUGS (Capables) – (Capables) –used used with
Compensation: Ph is normal=Fully compensated.
anti-psychotics
C02 & HC03 – HC03 –same same signs = Partially compensated
Anti-cholinergic Dopaminergic ABC PLSE
ANXIETY -vague sense of impending doom. Sympathetic
C- Cogentin
activation.
A- Artane P- Parlodel
Assessment: Level of anxiety
A- Akineton B- Benadryl
MILD-------------------sit restlessly, widened
L- Larodopa
perceptual field, enhanced learning experience.
E- Eldepryl
“You seem anxious.”
S- Symmetrel
MODERATE----------patient is pacing, selective inattention. Give PRN meds-Anti-anxiety drugs-
THERAPEUTIC COMMUNICATION NON-
valium…
THERAPEUTIC
SEVERE----------------patient SEVERE----------------patient can’t make decisions. “I
1. Offer self- “I’ll stay/sit with you.” “Don’t worry,
don’t know what to do or say.” RN directs patient.
be happy.”
“Sit down on the
2. Explores – Explores –use use what, when, where, how Why? – Why? –
chair.” – Directive.
Puts pt in defensive position.
PANIC- highest level of anxiety. Suicidal. Priority:
3. Silence Change the subject.
safety. Stay with patient. Don’t touch pt.
4. Active listening-nodding, eye contact, leaning
Sympathetic activation.
forward-show forward-show active participation. “Everything’s
“I think I’m having a heart attack!”
going to be alright.” – giving False reassurance.
Nrs Dx: -----------------Ineffective Individual Coping
5. Make observations. “You see/ I have observed/
P/I: Decrease anxiety, decrease stimuli
I have noticed…” noticed…” Ignore the patient.
HT: relaxation technique
6. Broad opening- “How are you?”
E: Effective Individual Coping
“You have combed your hair today.” Prejudicial. “Nice weather today.” –value –value based judgment.
GENERALIZED ANXIETY DISORDER – DISORDER – 6 months
7. Clarification-“What Clarification-“What do you mean by
excessive worrying. Patient knows what the
ploopplank?” Flattery – don’t use too much
problem is.
adjectives. “You have the most beautiful hair in the
Cant sleep, concentrate, seat
ward.”
Fatigue and palpitations
8. Restating-“I Restating-“I don’t want to eat.” (Word per word repetition!) “You don’t want to eat?” Arguing with
PANIC ATTACK – ATTACK – ------------------------------15-30
the patient
minutes, happens without warning. SNS activation.
Don’t impose your opinion.
-with or without agoraphobia -------------------- fear of
9. General leads- “And then/What else/Go on…”
open space
10. Refocusing-“We Refocusing-“We were talking abt the exam…”
-social phobia – phobia –------------------------------------------------------------------------ fear of
public Belief Feeling Behavior -provide safety
Object will hurt patient Scared Avoidant=interferes
-Alkalosis-brown bag
with ADL
-stay with patient -be directive
Gradual exposure to feared object- SYSTEMATIC DESENSYTHEZATION
POST TRAUMATIC STRESS DISORDER Individual Therapy Victims – rape, accident, war zone, disaster, trauma
1. Hypnosis – --------------relaxed state 2. Free association –------ ideas shared to
1. Survivor
psychoanalyst
2. Flashback > 1 month
3. Catharsis – --------------free to express feeling
3. Memory – nightmares
4. Transterence- -----------patient feels something for psychoanalyst
MALINGERING------------------------------------- no
5. Countertransterence –--RN feels something for
organic basis (no tissue change)
patient
-pretending to be sick, conscious -decrease anxiety – for primary gain -increase attention from RN – secondary gain
Green light-Go – Epi & Norepinephrine Red light – Stop – G-gamma
SOMATOFORM DISORDER –------------------
A-amino
unconscious, not pretending, no organic basis
B-butyric
- goes doctor hopping
A- acid Anxiety
Nervous system Minor discomfort BODY DYSMORPHIC DISORDER
Increase GABA Anti-cholinergic S/E
CONVERSION -Feels like illness -illusion of structural
GI-constipation
defect
GU-retention
-loss of sensory/motor fx -HYPOCHONDRIASIS -S/sx not real
Effect of GABA:
-s/sx real (biglang nabulag)
Drowsy, drink, don’t drive, orthostatic hypotension Anti-anxiety drug
PSYCHOSOMATIC DISORDER (Psychophysiologic) – real illness, real s/sx, real pain, with organic basis
Withdrawal from drug – abrupt – REBOUND
(with change in tissue)
PHENOMENA – leads to seizures. 1 week effect.
- stress ulcers, migraine, HPN
Gradual withdrawal – tapered dose Dependence- Can’t live without valium
PHOBIA---------------------------------------------------------irrational fear
ANTI-PSYCHOTIC AGENTS – Sympathetic effect.
Etiology – knowledge, experience
Effect – 2-4 weeks
Immediate nsg intervention: Remove object of fear
STELAZINE CLOZARIL
(Increase stimuli=increase level of anxiety)
SERENTIL MELLARIL
(Decrease stimuli=decrease anxiety)
THORAZINE HALDOL
TRILAFON PROLIXIN
disorganized manner/speech –flight of ideas (+) Hebephrenic- giggling (+)
SCHIZOPHRENIA-------------------------------impaired
Sx: both (+) and (-).
reality perception. Ego disintegration. Genetic vulnerability. Stress.
2. Catatonic ---------------------------------------------
-Chose fantasy over reality. Increase dopamine
ambivalence –anal stage (-)
theory. Cause: unknown.
No! Negativisim-rebel-anal (-)
Increase dopamine, increase schizophrenia.
Waxy flexibility--------------raise arm of patient.
4 A’s:
Patients arm remains up for a long time. (-)
1. Affect---------------------------------------------feelings &
(-) > (+)
emotions (smiles, laughs). External, readily observable.
3. Paranoid ----------------------------------------------uses
Mood, internal, does not match affect. (sad inside)
projection.
2. Ambivalence-------------------------------------pulled
Mistrust Scared/withdrawn/violent Based on
between 2 opposing forces
history
3. Autism --------------------------------------------self absorbed. Trapped in his own world.Attached to odd objects.Poor eye contact.
Develop trust: orientation -Leave door open
4. Associative looseness---------------------------talk
-1:1 interaction -Distance from pt: 1 arms length
about so many things but unrelated ideas.
-consistent approach -stay near door not window -short/frequent interaction -have visibility:stand
Disturbed thought process-------------------------Nsg dx
halfway in & out -food: sealed container to be able to c all for
Content of thought---------------
reinforcement.
Hallucinations/Illusions------------ADL---------------------
-meds: wrapped in tamper resistant foil -calm and
-------Harm
firm 4. Unclassified/ Undifferentiated-----------------------
Disturbed thought process
can’t be classified anymore.
Disturbed sensory Self care deficit Self Other Perception Directed Violence
5. Residual-------------------------------------------------no more (+), (-). Social withdrawal
P/I: Reality/Orient/Safety Eval: Improved thought process S & Sx of Schizophrenia:
THOUGHT PROCESS DISTURBANCE
(-)neg sx (+) positive sx
1. LOOSENESS OF ASSOCIATION----------------topics
hypoactive hyperactive flight of ideas
have connection but no thought. “I am going to the
withdrawn restless hallucinations
mall. The mall is in
quiet, flat affect talkative delusions many ideas
town. The town flies. Flies are her e.”
poverty of words queen of the world illusions
2. FLIGHT OF IDEAS ---------------------------------New unrelated topics. “I am going to t he mall. Where is
Types of schizophrenia:
the light? I treasure this chalk. Hurray!”
1. Disorganized schizo---------------------------------sad
3. AMBIVALENCE-------------------------------------Pulled
inside, happy outside – inappropriate affect (+)
by 2 opposing forces.
flat affect – no affect (-)
4. MAGICAL THINKING-----------------------------
believes he has magical powers. “I can turn you into
2. AKINISIA ---------------------------- rigidity
a frog.”
3. DYSTONIA--------------------------- affects neck
5. ECHOLALIA------------------------------------------repeat
TORTICOLLIS -------------wry neck
what is said. Parrots.
OCULOGYRIC CRISIS – fixed stare
6. ECHOPRAXIA----------------------------------------
OPISTHOTONUS ---------arched back, contracted
repeats what you do. Repeats what is seen.
4. TARDIVE DYSKINESIA------------lip smacking,
7. WORD SALAD----------------------------------------mixes
tongue is protruding, puffy cheeks. Irreversible!
words that don’t rhyme.
5. NEUROLEPTIC MALIGNANT SYNDROME-
8. CLANG ASSOCIATION----------------------------uses
hyperthermia, unstable BP, increase CPK,
words that rhyme. “Flank, blank, prank.”
diaphoresis, pallor
9. NEOLOGISM------------------------------------------
-discontinue meds, medical emergency.
invents new words not in the dictionary.
6. PHOTOSENSITIVITY------------------wear shades,
“Ploopplank, pisnok.”
sunscreen
10. DELUSIONS-----------------------------------------false
7. WBC- Agranulocytosis---------------sore throat,
belief
fever, malaise, leukopenia
Grandeur--------------I am a queen/ king/millionaire! Persecution------------NBI out to get me!
AUTISM- boys > girls. 1:100 kids gift-autistic savants
Ideas of reference-----They talk and write about me!
-echolalis, poor eye contact, can’t express verbally.
11. CONCRETE ASSOCIATION-----------------------
Assess:
pilosopo. “What will you wear tomorrow?”
A- appearance- neat, OC, wants constancy
“Clothes!”
B- behavior- ritualistic behavior, flat affect,
12. HALLUCINATIONS----------------------ILLUSIONS
repetitive
(with stimuli)
C- communication – difficulty communicating
Stimuli N Y Visual N Y
Nsg Dx: Impaired social interaction – cant form IPR
Auditory N Y
(Interpersonal relationship)
Tactile N Y
Impaired verbal communication Self mutilation – cant express anger. Express it
Present reality!!! H A R D-Directive. “Let’s go in the
inward.
garden.”
Risk for injury P/I: constancy, promote safety Expressive therapy – uses art, music, poetry,
Acknowledge: “I know the voices are real to you.
decreasing risk for injury, improved social
Present reality. “But I can’t hear them.”
interaction, be able to express feelings.
=Assess what voices are saying to know if patient
E: -Safety
will harm himself. ADHD- ATTENTION DEFICIT HYPERACTIVITY Increase Dopamine = increase schizo
DISORDER (can progress to conduct disorder to anti-
Decrease dopamine = decrease schizo
social behavior) Cant focus on anything.
Extra Pyramidal Side Effects (EPSE) (Happens when
Onset 7 yrs old and below
acetylcholine is up and dopamine is down)
Duration >6 months
1. AKATHISIA-------------------------- restless, inability
Setting: House & school
to sit still.
ID dominant: Mom or RN will act as superego
H- H20- 3L/d Assessment:
I- increase
A- appearance: dirty
T- uu
B- behavior: clumsy, impatient, easily distracted
M- mouth dry
C- talkative
N- Na- 135-145 mEq/L – to hold water
Nsg Dx: High risk for injury
Check kidney(blood level) before administration of Lithium – BUN, CREA, electrolyte
Safety
Lithium toxicity – n/v, diarrhea = Diamox
Structure- provide place to study, eat, play,bath,etc. Schedule – time for everything
BIPOLAR DISORDER – 2 poles, happy (more
Set limits
dominant) & sad -female, >20 yrs old, stress, obese
Residual ADHD grows up not anti-social
Self actualization Task to decrease self esteem
Meds: Ritalin, Dexedrine,Pemoline, Adderal
Family therapy
Best time to give meds: If once a day give AFTER
Risk for injury, risk for other directed violence
MEALS- to prevent loss of appetite.
Decrease eat, decreased sleep, hyperactive,
Don’t give at bedtime-it’s a stimulant-will cause
increase sex – masturbate in front of others
insomia. Can be given 6hours before bedtime (if q2d)
Nsg Dx: High risk for self or other directed violence Risk for injury
ANOREXIA NERVOSA – diet, underweight < 85% of expected fat, 3 months amenorrhea, failure to
Give task, no group games, any competition will
recognize problem.
increase anxiety, water the plants, activities using
BULIMIA NERVOSA – induce vomiting, takes
gross motor skills, escorted walk, punching bag-
laxative, normal weight, irregular menstruation,
displacement.
dental carries, diarrhea - knows problem but ashamed and embarrassed,
3 or more signs confirms disorder: G – grandiose, increase risk activities
Priority: Fluid volume balance
F – flt of ideas
Weight gain – monitor weight, eating pattern, stay 1
S - sleeplessness
hour after eating, accompany in toilet
P – pressured speech E – exaggerated SE
Problem: Body image Disturbance
E – extraneous stimuli (easily distracted)
NI: 1. Establish nutrition pattern
D – distractability
2. Teach stress management, journal keeping 3. Monitor eating pattern and weight.
PERSONALITY DISORDER
4. Anti-depressant MANIA – needs mood stabilizing agents- Lithium.
1. Schizoid – --------doesn’t care about people,
Group therapy
believes that he can stand on his ow n, never had a best friend
L- 0.5-1.5 mEq/L (If level is near 2.5-3 mEq/L –will
avoid groups & activities – no enjoyment
cause ataxia and mental confusion)
cares more about computers, pets
I- increase urination
2. Avoidant ----------avoid group – fear criticism,
T- tremors
have talent but no confidence.
3. Anti-social – ------as child steal, lie, always get reprimanded
A-LCOHOL ABUSE ----------------------happy –
Adult – grand robbery, illegal activities against the
socializing Narcotic oversode-give Narcan
law.
-escape from problem Narcotic detox- Met hadone
drug addiction, drives fast, unsafe sex, thrill seeker.
-peer pressure Aversion therapy-Antabuse
Good talker, charmer, witty, manipulator. Motto – “I will break the law”
B-blackout ---------------- awake but unaware C-confabulation ---------- invent stories to increase Self-Esteem
4. Borderline -------Favorite line – “ life is an empty
D-denial -------------------“ I am at not an alcoholic.”
glass.” Splitting, suicidal, superficial relationship,
D-dependence ------------“ I cant live without
labile-sudden change of
alcohol.”
Mood, self mutilation.
a. physical – tremors, tachycardia, restless
(+) (-)
b. psychological – craving
fill glass with friends suicide
E-enabling/codependency (significant others
have happy moments LABILE AFFECT sad moment
tolerate abusers)
labile- change from good to bad in a split moment DISULFIRAM 5. Dependent ---------Decrease self esteem,
voids alcohol beer
dependent
version therapy
Poor decision making skills
ntabuse (DISULFIRAM)
“I cant live if living is without you”
lcoholics anonymous n/v hypotension
6. Histrionics ----------excited, dramatic,
interval of alcohol & antabuse:
manipulative
12h interval after alcohol intake
- CENTER OR ATTENTION
B1 – Thiamine
-
Complications wernickes
7. Narcissistic----------“I love myself” – insensitive,
Encephalopathy
arrogant, self absorbed
Korsakoff psychosis
- exaggerated Self esteem, ambitious “I am the best”
Wernickes – VROOM – Motor sx effect
-
Korsakoff – memory- confabulation
8. OC ------------------ perfectionist, organized, constancy in environment. Provide time to do
24 – 72h after alcohol intake
rituals.
Delirium tremors – happens due SNS activation Tremors, hallucinations, illusions. Well lit room – to
9. Paranoid ----------- always jealous, suspicious,
avoid hallucinations
violent ANTI DEPRESSANTS – decrease serotonin problem Anti depressants – full stomach 10. Passive aggressive ------always say “yes”, but
All meds take on a full stomach, except anti anxiety.
resistance is hidden. ASENDIN TCA Nsg Intervention: Improve IPR, build trust
NORPRAMIN TCA TOFRANIL TCA
SINEQUAN TCA
antiparasympathetic
ANAPRANIL TCA - OC
Dry, constipation, retention, tachycardia
AVENTYL TCA
Male erectile dysfunction
VIVACTIL TCA ELAVIL TCA PROZAC SSRI
MAOI
PAXIL SSRI
mARplan
ZOLOFF SSRI
NARdil
LUVOX SSRI
PARnate
Serotonin ---------makes us happy Decrease serotonin – pt becomes sad – depression
DEPRESSION – decrease serotonin. If unresponsive
Increase serotonin – antidepressant
to drugs, ECT-electroconvulsive therapy
SSRI:
Assess: 1. Denial – this cant be happening. This cant be real.
Selective S
2. Anger – Why me, why now, why God?!
Serotonin S – (decrease S/E)
3. Bargaining – If returned, I will give reward.
Reuptake R –
4. Depression – 2 wks or more of sx = clinical
Inhibitors I – (1 – 4 weeks)
depression 5. Acceptance – client acts according to situation. Pt
If SSRI don’t work, give TCA
prepares living will.
Tri Cyclic Antidepressants –( TCA) ----------2 – 4 wks
Increase risk for self directed violence.
has increased S/E increased Serotonin & Norephinephrine
Maslows: 5 –
MAOI-------------------------- effect 2 – 6wks
4 – decrease Self-esteem – give TASK
Increase E, NE, serotonin kills serotonin - MAOI
3 – Pt is withdrawn
increase MAO = decrease serotonin
2 – Risk for self directed violence suicide
* decrease MAO = increase serotonin
1 – eat (wt gain) or not eat(wt loss), sleep or not
give MAOI
sleep, hypoactive, decrease sex
Most dangerous, most S/E Diet – avoid tyramine food – eat SARIWA, fresh
SUICIDE CUES:
foods
“I wont be a problem any longer”
HPN crisis – dangerous! Increase CR, diaphoresis
“Remember me when I’m gone” “This is my last day”
Tyramine rich food:
“This is my wedding ring. Give it to my so n”
Avocado Pickles
- Sudden change in mood.
Alcohol Fermented foods Beer Eggplant
Pt is suicidal, RN should: D –d irect question – “Are
Chocolate preservatives – tocino, bologna,canned
you going to commit suicide?
meat etc.
I – irregular interval of visit to pt room
Cheese – mozerella, swiss cheese
E – early am & endorsement period - time pt’s
W – ine
commit suicide.
S – soysauce Who will commit suicide? Anticholinergic = antidepressants –
S – sex – male (more successful)/female (hesitant)
hyperactivity, tachypnea, seizure. During
A – age – 15 – 24yo or above 45
withdrawal, pt will manifest bradypnea or coma.
D – depression P – pt with previous attempts will try again E – ETOH – (Ethanol) alcoholics
Substance Abuse Moments
R – irrational
(downer)
S – lacks social support
A – alcohol
O – organized plan – greater risk
B – barbiturates
N – no family
O – opiates Antidote
S – sickness, terminal
N – narcotics - Narcan (narcotic antagonist) M – marijuana
Suicide Triad: - Loss of spouse
Morph
- Loss of job
CODE
- Aloneness
HERO
Best approach for suicide: Direct approach
(uppers)
Nursing Mgt: close surveillance C – cocaine Hospital area majority suicide happens at:
H – Hallucinogens
weekends 1 – 3 am Sunday
A – amphetamines
Weekend – less staff personnel Early am – every one is asleep Uppers Downers Give simple task. Don’t give complex task – no
Seizure decrease RR, decrease HR
jigsaw puzzle
Tachypnea Para constricted pupil
Water the plants
Moist mouth
Wash the dishes except sharp objects
Dilated Blood Vessels Coma Asleep Decreased GI constriction Decrease GU retention
SUBSTANCE ABUSE
Decrease BP
Type of Addict:
State of euphoria
1. Nervous -----tremors Give downers
Sx of withdrawal – reverse of effect 1. Know if upper or downer
Sx of overdose
2. Opposite of effect
1. Identify if drug is upper or downer 2. Check effect 3. Sx of withdrawal
Overdose Withdrawal (opposite of withdrawal is
If patient takes a downer, all vital signs are down! If
overdose)
he stops taking it (during withdrawal), patient will
Alcohol – coma seizure
experience the opposite effect of a downer. All his
Morphine – bradypnea tachypnea
vital signs will shoot up! Same with uppers. Ex: Pt had cocaine intoxication. Pt will manifest
Detox – withdrawal with MD supervision
Methadone
Can interpret proverbs.
2. Depressed - Sits down on chair CHILD ABUSE Uppers Codeine increased heart increase - BP increase,
B=burns, bruises, bone fractures, bungi
awake
Don’t bathe child. Don’t brush teeth. Body of
Hallucinogen sympathetic HR increase seizure
evidence will be lost.
Amphetamine pupils- dilate GI - diarrhea
Bantay Bata 163
Mouth – dry Decrease appetite - thin ALZHEIMER Stop uppers
Anomia- don’t know name of object
Tremors crash syndrome Depressed Suicide
Agnosia – problem with senses (smell, taste, hear,
Fatigue
touch) Aphasia – can’t say it Apraxia – can’t do it
LEVELS OF MENTAL RETARDATION
Dissociative Fugue- takes a new per sonality from a
Profound severe moderate mild borderline normal
tar away place. New place new identity. Dissociative Identity Disorder – multiple personality
IQ 20 35 50 70 90 110
Dissociative Amnesia – don’t know who/where I am.
Profound Mental retardation IQ <20 =thinks like an INFANT. Cant be trained. Stay with patient. Severe MR 20-35 Moderate 35-50 = Can be trained. Mental age is 27yo. Pre-operational stage.
DEPERSONALIZATION- believe that they are not
Mild 50-70 = (mild 7) Mental age is 7 -12. Educable.
persons anymore
Can go to school.
PERSEVERATION- kulit. “I want to talk about
Borderline- 70-90
something because this is something that I w ant to
Normal- 90-110
do. It is something that I need to talk about. This is something that I want to do.”
JOHN PIAGET COGNITIVE THEORY
ELECTROCONVULSIVE THERAPY- sign informed
0-2 yrs old – S-ensory motor. Baby can sense, see,
consent. For depressed pt. If meds don’t work, use
perceive and hear. Object permanence
ECT.
2-4 yo- P-reconceptual- language. 4-7 yo- I-ntuitive stage. Unidimentional
Pre-ECT
classification or unidimentional characteristic.
N-npo 6 hours
Child can fix toys according to size, color,
A-atropine sulfate – dry mouth
height=one at a time only.
B-barbiturate
7-12 yo- C-conservation/concrete association.
S- succinylcholine chloride – to relax muscles
Multidemensional 12yo- F-ormal operation – good in abstract thinking.
Post-ECT
Side-lying- lateral
Look for words like:
S/E headache, dizziness, temporary memory loss
Orient=orient pt post delirium, ECT, pt with
(distinct sx)=RN-orient pt.
dementia Accept “Seem, observed, noticed, comment, feelings…”
EXAMS:
Group therapy- facilitator is RN.
Nsg intervention:
Rape, battered pt
Look for words like:
ALTRUISM – Victim becomes a counselor, shares
S=safety, support, stay, set limits, assist
experience to new victim.
Provide safety. Mobilize support system. I will stay with you. Assist in activity.
Self-help group=facilitator is the pt themselves. AL
Set limit- don’t allow patient to misbehave.
ANON groups –Alcoholics Anonymous
Pediatric Nursing
Growth and Development
understand from experience to acquire and retain knowledge. To respond to a new situation and to
Growth- increase in physical size of a structure or
solve problems.
whole. -quantitative change.
IQ test- test to determine cognitive development Mental age x 100 = IQ
Two parameters of Growth
Chronological age
1. weight- most sensitive measure of growth,
Average IQ – 90-100
especially low birth rate.
Gifted child- > 130 IQ
Wt doubles 6 months 3x 1yr 4x 2-2 ½ yrs
Basic Divisions of Life I. Prenatal stage from conception- birth
2. Height- increase by 1”/mo during 1st 6 months - average increase in ht - 1st year = 50%
II. Period of infancy
stoppage of ht coincide with eruption of wisdom
1. Neonatal- 1st 28 days or 1st 4 weeks of life
tooth.
2. Formal infancy- 29 day – 1 year
Development- increase skills or capability to function
III. Early childhood
- qualitative
1. Toddler – 1-3 yrs 2. Pre school 4-6 years
How to measure development IV. Middle childhood 1. Observe child doing specific task.
1. School age- 7 – 12 yrs
2. Role description of child’s progress 3. DDST- Denver development screening test.
V. Late childhood
MMDST (Phil) Metro Manila Developmental
1. Pre adolescent 11 – 13 yrs
Screening Test.
2. Adolescent 12 - 18 – 21
DDST measures mental Principles of G & D 4 main rated categories of DDST
1. G&D is a continuous process
1. Language communication
-begins form conception- ends in death
2. personal social-interaction
- womb to tomb principles
3. fine motor adaptive- ability to use hand
2. not all parts of the body grow at the same time or
movement
at same rate.
4. gross motor skills- large body movement
- asynchronism
maturation- same with development “readiness”
Patterns of G&D 1. )renal
Cognitive development –ability to learn and
digestive grows rapidly during childhood
circulatory musculoskeletal
4.G&D occurs in a regular direction reflecting a definitive and predictable patterns or trends.
2. )Neuromuscular tissue (CNS, brain, S. cord) - grow rapidly 1-2 years of life
Directional trends- occur in a regular direction
- brain achieved its adult proportion by 5 years.
reflecting the development of neuromuscular function. These apply to physical, mental, social and
3. )Lymphatic system- lymph nodes, spleen grows
emotional development and includes.
rapidly- infancy and childhood to provide protection
a. cephalo-caudal “head to tail”
-infection
- occurs along bodies long axis in which co ntrol over
- tonsil adult proportion by 5 years
head, mouth and eye movements and precedes control over upper body torso and leg s.
4. )Repro organ- grows rapidly at puberty
b. proximo- distal “Centro distal” - progressing form center of body to extremities.
Rates of G&D
c. Symmetrical- at side of body develop on same
1. fetal and infancy – most rapid G&D
direction at same time at same rate.
2. adolescent- rapid G&D
d. Mass specific “differentiation”
3. toddler- slow G period
- child learns form simple operations before
4. Toddler and preschool- alternating rapid and slow
complex function of move from a broad general
5. school age- slower growth
pattern of behavior. To a bore refined pattern.
fetal and infancy- prone to develop anemia
B. Sequential- involves a predictable sequence of G&D to which the child no9rmally passes.
3. Each child is unique
a. locomotion- creep than crawls, sit then stand. b. socio and language skills- solitary games, parallel
2 primary factors affecting G&D
games
A. Heredity - R – race
C. Secular- worldwide trend of maturing earlier and
I – intelligence
growing larger as compared to succeeding
S – sex
generations.
N - nationality 5.Behavioral in the most compressive indicator of Females are born less in weight than males by 1 oz.
developmental status.
Females are born less in length than males by 1 inch
6. universal language of child- play 7. great deal of skill and behavior is learned by practice. Practice makes perfect. 9. neonatal reflexes us must be lost before one can proceed.
B. Environment
-plantar reflex should disappear before baby can
Q – quality of nutrition
walk
S – socio eco. status
-moro reflex should disappear before baby can roll
H – health
persistent primitive infantile reflexes- case of
O – ordinal pos in family
cerebral palsy
P – parent child relationship Theories of G&D Eldest- skillful in language and soc ial skills
Developmental tasks- different form chronological
Younger- toilet trained self
age
-skill or growth responsibility arising at a particular
-period of suppression- no obvious development.
time in the individuals life.
-Childs libido or energy is diverted to more concrete
The successful achievement of which will ------- a
type of thinking
foundation for the accomplishments of future tasks.
-helps child achieve (+) experience so ready to face conflict of adolescence
Theorists
e.) Genital- 12-18 years
1. Sigmund Freud 1856-1939 Austrian neurologists.
-site of gratification -genitals
Founder of psychoanalysis
-achieve sexual maturity
- offered personality development
-learns to establish relationships with opposite sex.
Psychosexual theory
-give an opportunity to relate to opposite sex.
a.) Oral Phase 0-18 months
ERIC ERICKSON- psychoanalysis theory
- mouths site of gratification
- stresses important of culture and soc iety to the
-activity of infant- biting, sucking crying.
development of ones personality
-why do babies suck?- enjoyment and release of
- environment
tension.
- culture
-provide oral stimulation even if baby was placed on NPO.
stages of psychosocial
-pacifier.
a.) trust vs mistrust – 0-18 months.
-never discourage thumb sucking.
-foundations of all psychosocial task -to give and receive is the psychosocial theme
b.) ANAL- 18 months-3 years
-know to develop trust baby
-site of gratification- anus
1. satisfy needs on time
-activity- elimination, retention or defecation of
- breastfeed
feces make take place
2. care must be consistent and adequate
- principle of holding on or letting go.
-both parents- 1st 1 year of life
-mother wins or child wins
3.) give an experience that will add to security-
-child wins- stubborn, hardheaded anti social. (anak
touch, eye to eye contact, soft music.
pupu na, child holds pupu, child wins) -mother wins- obedient, kind, perfectionist,
b.) Autonomy vs shame and doubt 18-3 years ---
meticulous
independence /self gov’t
OC-anal phase
develop autonomy on toddler
-help child achieve bowel and bladder control even
1. give an opportunity of decision making like offer
if child is hospitalized.
choices. 2. encourage to make decision rather then judge.
c.) Phallic- 3-6 years
3. set limits
site of gratification -genitals activity- may show exhibitionism
c. initiative vs guilt- 4-6 years
-increase knowledge of a sexes
-learns how to do basic things
-accept child fondling his/her own genitalia as
-let explore new places and events
normal exploration
-activity recommended- modeling clay, finger
-answer Childs question directly.
painting will enhance imagination and creativity and
Right age to introduce sexuality – preschool
facilitate fine motor dev’t
d.) Latent- 7-12 years
d. industry vs inferiority 7-12 yrs
-child learns how to do things well
-anticipate familiar events.
-give short assignments and projects
Coordination of secondary reaction 8-12 months exhibit goal directed behavior
e. Identity vs role confusion or diffusion 12-18 yrs
-increase of separateness (will search of lost toy,
- learns who he/she is or what kind of person he/
knows mom)
she will become by adjusting to new body image
Tertiary circular reaction 12-18 months -use trial
and seeking emancipation form parents
and error to discover places and events
-freedom form parents.
-“ invention of new means” -capable of space and time perception
f. Intimacy vs isolation 20-40 yrs -looking for a
(hits fork, spoon on table or drops fork)
lifetime partner and career focus
Invention of new means there me ntal combination 18-24 months -transitional phase to the pre
g. generatively vs stagnation 40- 60 45-65 yrs
operational thought period.
h. ego integrity vs, despair 60-65 Preoperational thought 2-7 years JEAN PIAGET- Swiss psychologists
Schema age Behavior
-develop reasoning power
Preconceptual 2-4 yrs -thinking basically complete literal and static
STAGES OF COGNITIVE DEVELOPMENT
-egocentric- unable to view others interrupt
A-Sensory motor 0-2 yrs
-concept of dying is only now
-“practical intelligence”- words and symbols not yet
-concept of distance is only as fat as they can see.
available baby communicates through senses and
-concept of amenism inanimate object is alive
reflexes.
-not aware of concept of r3eversibility- in every
(sub div.)
action theories an opposite reaction or cause and effect Initiative 4-7 yrs Beginning of causation Concrete Operational thought 7-12 years 1. able to find solution to everyday problems which systematic reasoning. 2. have concept of reversibility- cause and effect 3. have concept of longer uation – constancy despite of transformation. 4. 4. activity recommended- collecting and classifying
Schema Age Behavior
5. –stamps stationeries, dolls, rubber band markers.
1.) neonate reflex 1 month All reflexes 2.) primary circular 1-4 months -Activity related to body
Formal Operational thought 12 and up.
-repetition of behavior
1. Cognition achieved its final form
ex. thumb sucking
2. can deal with past present and future
3.) secondary circular reaction 4-8 months -activity
3. have abstract and mature thoughts.
not related to body
4. can find solutions to hypothetical problems with
-discover obj and person’s permanence
scientific reasoning.
-memory traces present
5. activity ------- will sort out opinions and current
events. 2 months- holds head up when in prone, KOHLBERG- recognized the theory of moral dev’t as
social smile,
considered to closely approximate cognitive stages
baby coos “doing sound”
of dev’t
cry with tears
-sabay with cognitive dev;t
-closure of frontal fontanel 2-3 months head lag when pulled to sitting position.
Stages of Moral dev’t Infancy – premoral, prereligious, amoral stage
3 months- holds head and chest up when prone follows obj. past midline
AGE STAGE DESCRIPTION
grasp and tonic neck reflex fading
Pre-conventional Level 1
hand regard (looks at hand)
2-3 yrs 1 -Punishment/ obedience oriented
4 months – turns form front to back
(heteronymous morality) child does right cause a
head control complete
parent tells him or her to and to avoid punishment
needs space to turn
4-7 2 -Individualism. Instrumental purpose and
Laugh aloud, bubbling sounds
exch. Carries out action to satisfy own needs rather than society.
5 months- turn both ways “roll over”
-Will do something for another if that person does
-teething rings
something for the child.
-handles rattle well
Conventional Level
-moro reflex disappears ( 4-5 months)
7-10 3 -Orientation to interpersonal relations of mutuality. Child followers rules cause of a need to
6 months- reaches out in anticipatory of being
be a “good” person in own eye s and eyes of others.
picked up
10-12 4 -Maintenance of social order fixed rules and
-sits with support
authority. Child finds ff. rules satisfying. Follows
-uses palmar grasp
rules of authority figures.
-eruption of 1st temp teeth 6-8 months 2 lower
Post-conventional Level III
incisors
Above 12 yrs 5 -Social contract, utilitarian level
-say vowel sounds “ah”, “oh”
making perspectives. Followers standards of
-handles bottle well
society. 6 Universal ethical principle orientation. Follows
7 months- transfer obj. hand to hand
internalized standards of conduct.
-likes obj that are good size
E. DEV’T MILESTONES-major markers of growth and
8 months- sits without support
dev’t
-peak of stranger anxiety
1. Period of infancy- universal language of child-play
-planters reflex disappears 8-9 months in prep for
a.) Play- Infancy- solitary plays
walking
-solo, mom interactive -facilitate motor and sensory dev’t
9 months - creeps or crawls
-safety- important age appropriate
-neat finger grasp reflex
solitary play- mobile, teeter, music box, r attle
- combine 2 syllables “mama” and “papa”
b.) fear of infancy- stranger anxiety beg in 6-7
- needs space for creeping
months peak 8 months diminishes 9 months 10 months – pull self to stand 1 month- dance reflex disappears looks at mobile
-understands “no”
-responds to own name
-can run and jump in place
-peak a boo, pat a cake
walks up and down stairs holding railing or persons
-can clap
hand -1-20 words
11 months- cruisse
-name, body part
- stands with assistance
-puts both feet on 1 step before advancing.
12 months- stand alone take 1st step
24 months- terrible two
-walk with assistance
-can open doors by turning door knobs
-drink from cup, cooperate in dressing
-unscrew lids
-says 2 words mama and dada
-can walk upstairs alone –using both feet on same
-pots and pans, pull tay, nursery rhymes
step at same time -50-200 words ( 2 words sentences)
Toddler- parallel play- 2 toddlers playing separately
-daytime bladder control achieved ( daytime 1st-
-provide with similar toys
next nighttime bladder control)
-squeaky frog to squeeze waddling duck to pull
30 months or 2 ½ years – makes simple lines or
trucks to push-push pull toy
stroke for crosses with a pencil
building blocks, pounding peg
-can jump down from chairs
toys to ride on
-knows full name
fear- separation anxiety
- copy a circle
begin 9 months
- holds up finger to show age
peak 18 months
- temp teeth complete
3 phases of separation anxiety (in order)
post molar- last temp teeth to appear
1. P- protect
how many deciduous teeth -20
2. d despair
beginning of toothbrush – 2-2 ½ yrs
3. d- denial
tooth brushing with little assistance 3 yrs tooth brushing alone – 6 yrs
-don’t prolong goodbye
right time to bring to dentist- when temp teeth
-say goodbye firmly to develop trust- say when ul
complete
be back 36 months or 3 yrs- trusting 3 15 months – plateau stage
- unbutton buttons (unbutton before learn to
walks alone
button)
lateness in walking- mild mental retardation
-draw a +
-puts small pellets into small bowl
- learns how to share
-holds spoon well
-knows full name and sex (gender identity)
- seats self on chair
- speaks fluently
-creeps up stairs
-nighttime bladder control
- 4 - 6 words
-300-900 words -ride a tricycle
18 months- height of possessiveness favorite word- “mine”
Characteristic Traits of toddler
bowel control achieved (bowel 1st before bladder)
negativistic- “NO!” -way to search for independence
-no longer rotates spoon
–limit questions
–modify questions to a statement
Character Traits of Pre-schooler:
2.) rigid, ritualistic and stereotype
1.) curious, creative imaginative, imitative
ritualism- for mastering
2.) 2. favorite words- why and how
3.)Temper tantrums- head banging, screaming,
3.) complexes- word identification to parent of
stamping feet, holds breath
same sex and attachment to parent of opposite sex
–ignore behavior
ex. Oedipal complex- boy to mom
scaffoid abdominal-due to underdeveloped
Electra complex- girl to dad
abdominal muscles
Cause of incest marital discord
physiologic anorexia- due to preoccupation with environment- food jag that last for short period of
Death-sleep only
time loves rough and tumbling play
Behavior problems Preschool
loves toilet trainingfailure of toilet training- unreadiness
1. telling tall tales-over imagination 2. imaginary friend- to release tension and anxieties
Clues of toilet readiness:
3. sibling rivalry- jealousy to newly delivered baby.
1.) can stand, squat walk alone
4. regression- going back to early stage
2.) can communicate toilet needs
-thumb sucking (should be oral stage only)
3.) can maintain dry for 2 hours
-baby talk -bed wetting
Pre schoolers- associative or cooperative play
-fetal position
1.) bahay-bahayan – play house
5. masturbation- sign of boredom
2.) role playing
-divert attention- offer a toy
3.) fear-body mutilation or castration fear of dark places witches
School Age
fear of thunder and lightning
Play- competitive play
fear of ghosts
Ex. Tug of war, track and field, basket ball Fear. 1.) school phobia -orient to new environment 2.) displacement from school
Milestones
-teacher and peer of same sex
4years old- furious 4 , noisy, aggressive, stormy
3. loss of privacy
-can button buttons
-wants bra
-copy a square
4.) fear of death
-jumps and skips
-7-9yrs death is personified
-laces shoes
-death- permanent loss of life
-vocabulary 1,500 -knows four basic colors
Significant Development a. boys- prone to bone fracture
5 years old- frustrating 5
b. mature vision 20/20
-copy a triangle -draw a 6 part man
6 years- temp teeth begin to fall
-imaginary playmates
perm teeth appear- 1st molar
-2,100 words
1st temp teeth- 5 months 1st perm teeth- 6 yrs
-yr of constant motion
GIRLS:
clensy mou’t
I-inc size breast and genitalia (pelarche- 1 st sign
recognize all shapes
sexual mat.
-1st grade teacher becomes authority figure
W- widening of hips
-nail biting
A- appearance axillary, pubic ( adrenarch)
-begin interest in God.
M- menarche- last sign sexual mat. Girls
7 yrs- assimilation age -copy a diamond -enjoys teasing and playing alone
BOYS:
-quieting down period
A-appearance axillary, pubic hair ( 1st sign sexual mat)
8 yrs- expansive age
D-deepening voice
-smoother mouth
D- development of muscles
-loves to collect objects
I--inc in testes and penis size
-count backwards
P- prod of viable sperm ( last sign sexual mat urity)
9 yrs –coordination improves
Adolescent
-tells time correctly
Fear
-hero worship
1. obesity
-stealing and lying are common
2. acne
-takes care of body needs completely
3. homosexuality
-teacher finds this group difficult to handle
4. death 5. replacement from friends
10 yrs- age of special talent
6. significant person- opp sex.
-writes legibly -ready for competitive games
Significant dev’t
-more considerate and cooperative
1. experiences conflict bet his needs for sexual
-joins orgs.
satisfaction and societies expectation
-well mannered with adult
2. change of body image and acce ptance of opp/sex
-critical of adults
3. nocturnal emission – wet dreams 4. distinctive odor- due to stimulation apocrine
11-12 yrs – pre adolescents
glands
-full of energy and constantly active
5. sperm is viable by 17 yrs
-secret language are common
6. testes & scrotum increase until age 17
-share with friends secrets
7. breast and female genitalia increase until age 18
-sense of humor present -social and cooperative
Personality Traits Adolescents 1. idealistic
Character Traits School Age
2. rebellious
1. industrious-
3. reformers
2. modest
4. conscious with body image
3. can’t bear to lose- will cheat
5. adventuresome
4. love collections- stamps Problems: Signs of sexual maturity
1. vehicular accident
2. smoking
administered by an (+) pressure bag and mask with
3. alcoholism
100% oxygen at 40-60b/m.
4. drug addiction 5. pre marital sex
Nsg alert: 1. No smoking
IMMEDIATE CARE OF NEWBORN
2. Always humidify to prevent drying of mucosa
1st days of life
3. Over dosage of oxygen can lead to scarring of retina leading to blindness ( retro lentalfibrolasia or
1. initiation and maintenance of respiration
retinopathy of prematurity)
2. establishment of extra uterine c irculation
4. When mecomium stained (greenish) never
3. control of body temp
administer oxygen with pressure ( O2 pressure will
4. intake of adequate nourishment
push mecomium inside)
5. establishment of waste elimination 6. prevention of infection
2.) Establishing extra uterine circulation
7. establishment of an infant parent relationship
- circulation is initiated by lung expansion or pulmo
8. dev’t care that balances rest and stimulation or
ventilation and completed by cutting of cord.
mental dev’t FETO PLACENTAL CIRCULATION -Placenta(simple diffusion) –oxygenated blood is 1.) Initiation and maintenance of respiration
carried by the umbilical vein- passes liver-ductus
2nd stage of labor- initial airway
venousus- IVC- RT atrium 70% blood is shunted to
-initiation of a /w is a crucial adjustment
foramen ovale- LT atrium mitral valve – LT ventricle-
-most neonatal deaths with in 24 h c aused by
aorta-lower extremities.
inability to initiate a/w -lung function begins after birth only
-Remaining 30%- tricuspid valve- RT ventriclepulmonary arteries- lungs (for nutrition)
How to initiate a/w
(vasoconstriction of lungs pushes blood to ductus
a.) remove secretions bulb syringe
arteriousus to aorta to supply upper extrem ities.
B. Catheter Suctioning 1.) place head to side to facilitate drainage 2,) suction mouth 1st before nose
SHUNTS-shortcuts
-neonates are nasal breathers
Ductus venosus- -shunts from liver to IVF
3.) period of time
Foramen ovale- shunts bet 2 atrias
-5-10 sec suctioning, gentle and quick
Ductus arteriosus- from pulmonary artery to aorta
prolonged and deep suctioning can lead to hypoxia, laryngo spasm, brady cardia due to stimulation vagal nerve 4.) evaluate for patency -cover nostril and baby struggles there’s a need for additional suctioning C. If not effective, requires effective laryngoscopy to open a/w. After deep suctioning an endotracheal
What will sustain 1st breath- decreased artery
tube can be inserted and oxygen can be
pressure
What will initiate lung circulation-lung expansion
CS- supine or crib level position
What will complete circulation- cutting of cord Signs of increased ICP 4.) 2 way to facilitate closure o f foramen ovale
1.) abnormally large head
a.) Tangential Footstep- slap foot of baby
2.) bulging and tense fontanel
-never stimulate baby to cry if secretions not fully
3.) increase BP and widening pulse pressure #3 & #4
drained to prevent aspiration
are Cushings triad of
-check characteristic of cry
4.) Decreased RR, decreased PR ICP
normal cry- strong, vigorous and lusty cry
5.) projective vomiting- sure sign of cerebral
cri-du-chat syndrome-chromosomal obliteration cat
irritation
like cry
6.) high deviation – diplopia – sign of ICP older child
b.) proper position -right side lying pos.
4-6 months- normal eye deviation
-will increase pressure on left and foramen ovale
>6 months- lazy eyes
will close
7.) High pitch shrill cry-late sign of ICP
Foramen Ovale and Ductus arteriosus will begin to close within 24h
Temp Regulation - goal in temp regulation is to maintain it not less than 97.7% F (36.5 C) - maintenance of temp is crucial on preterm and SGA (small for gestational age) - babies prone to hypothermia or cold stress A. factors leading to dev’t of HYPOTHERMIA 1. preterms are born poi kilo thermic- cold blooded - babies easily adapt to temp of environment due to
Obliteration-complete closure
immaturity of thermo regulating system of body. Hypothalamus
Structure Appropriate time of obliteration Structure
2. inadequate SQ tissue
remaining Failure to close
3. baby is not capable of shivering
F. Ovale 1yr Fossa Ovalis Atrial Septal Defect
4. babies are born wet
Ductus Arteriosus 1 month Ligamentum Arteriosum Patent ductus arteriosus Ductus Venosus 2 months Ligamentum venosum
PROCESS OF HEAT LOSS
Umbilical artery 2-3 months 1.) lateral umb.
1. evaporation-body to air (TSB)
Ligament
2. conduction- body to cold solid object (cold
2.) interior iliac artery
compress)
Umbilical vein 2-3 months -ligamentum teres (
3. convection-body to cooler surrounding air
round ligament of liver)
(aircon) 4. radiation- body to cold object not in contact with body earliest sign of hypothermia- increase in RR
Position of infant immediately after birth:
Effects of Hypothermia ( Cold stress)
NSD-trendelenberg/ T position for drainage
1.) Hypoglycemia- 45-55 mg/dl normal
contraindication of trendelenberg position -
50- borderline
increase ICP
2.) met acidosis- catabolism of brown fats (best
insulator of newborns body)
Store milk- plastic storage container
will form ketones
Store milk – good for 6 months from freezer- put rm
3.) high risk for kernicterus- bilirubin in brain
temp. don’t heat
leading to cerebral palsy
Disadvantages:
4.) additional fatigue to allergy stressful heart
1. Possibility of transfer HEP B, HIV, c ytomegalo virus. 2. No iron 3. Father can’t feed & bond as well Stages of Breastmilk:
To Prevent Hypothermia
1. Colostrum- 2-4 days present
1. dry and wrap baby
content: decrease fats, increase IgA, dec CHO, dec
2. mechanical pressure – radiant warmer
CHON, inc minerals,
pre-heated first isolette (or square ac rylic sided
inc fat soluble minerals
incubator)
2. Transitional milk- 4 – 14 days
3. prevent an necessary exposure – cover baby
content: inc lactose, inc water soluble vit., inc
4. cover baby with tin foil or plastic
minerals
5. embrace the baby- kangaroo care
3. Mature milk- 14 & up content: inc fats (linoleic acid) – resp for devt of
A. Establish Adequate Nutritional Intake
brain & integrity of skin inc CHO- lactose – easily digested, baby not
CS- breastfeeding after 4 hours
constipated.
NSD- breastfeeding asap
- resp of sour milk smelling odor of stool.
Physiology breast milk production
Lactose intolerance- deficiency of enzyme LACTASE
As you deliver baby, decrease Estrogen, decrease
that digest LACTOSE
Progesterone- -Anterior Posterior Gland (APG)
Decrease CHON- lactalbumin
releases prolactin – acts on
Cows milk – inc fats-
acinar cells (or alveoli) – produce foremilk – stored
Dec CHO
in lactiferous tubules ( or collecting tubules)
Inc CHON – casing- has curd that’s hard to digest.
where breast milk is produced – alveoli post-
Inc minerals –traumatic effect on kidneys of babies.
pit.gland
Can trigger stone formation. Inc phosphorus
Sucking- PPG – oxytocin – contraction of lactiferous tubules - milk ejection reflex- let down reflex.
Health Teachings: 1. Proper hygiene- proper hand washing
Advantages of Breastfeeding
Care of breast - cotton balls with lukewarm water
1. Economical
Caked colostrum- dry milk on breast
2. Always available
2. Best position in breastfeeding – upright sitting -
3. Breastfed babies have higher IQ t han bottle fed
avoid tension!
babies.
3. Stimulate & evaluate feeding reflexes
4. It facilitates rapid involution
a.) Rooting reflex- by touching the side of
5. Decrease incidence of breast cancer.
lips/cheeks then baby will turn to stimulus.
6. Has antibodies- IgA
Disappear by 6 weeks- by 6 weeks baby can focus.
7. Has lactobacillius bifidus- interferes with attack of
Reflex will be gone
pathogenic bacteria in GIT
- Purpose rooting- to look for food.
8. Has macrophages
b.) Sucking – when you touch middle of lips then
baby will suck
- will create moisture, cotton only
- Disappears by 6 months
c.) Mastitis- inflammation of breast : staphylococcus
- When not stimulated sucking will stop.
aureus Factors:
c.) Swallowing- when food touches posterior of
1. Improper breast emptying
tongue then it will be automatically swallowed
2. Unhealthy sexual practices -contraindicated for breast feeding
d.) Extrusion/ Protrusion reflex
- manually express inflamed breast
-when food touches anterior portion of tongue then
feed on unaffected breast
food will be extruded.
- give antibiotics – can still feed on unaffected
Purpose: to prevent from poisoning
breast
Disappear by 4 months & baby can already spit out by 4 months.
Contra Indications in Breast Feeding: Maternal Conditions:
Criteria Effective Sucking
1. HIV CMV
a.) Baby’s mouth is hiked up to areola
Hepa B Coumadin
b.) Mom experiences after pain. c.) Other nipple is also flowing with milk.
Newborn Condition - Inborn errors of metabolism Erythrobastosis Fetalis – Rh incompatibility
To prevent from crack nipples & initiate pro per
Hydrops Fetalis
production of oxytocin.
Phenylketonuria
- begin 2-3 min at @ breast ( 5 – 7 min other
Galactosemia
authors)
Tay Sachs disease
to initiate production of oxytocin - increase 1 min/ day – until reaching 10 mins @
5. Establish of waste elimination
breast or 20 mins/ feeding.
A. Diff stools
For proper emptying & continuous milk production
1. Meconium - physiologic stool
/ feeding
- black green, sticky, tar like, odorless (Sterile
-feed baby on last breast that you feed her with,
intestine)
alternately ( if not emptied - mastitis)
will pass with in 24 – 36 hrs failure to pass mecomium after 24h- GIT
Problems experienced in Breastfeeding :
obstruction
3RD day changes in breast post partum
ex. Hirschsprungs disease
a.)Engorged- feeling of fullness & tension in breast.
imperforate anus
- sometimes accompanied by fever known as MILK
mecomium ileus – due to Cystic Fibrosis
FEVER. 2. Transitional stool Mgt: Warm compress- for breastfeeding mom
- green loose & shiny, like diarrhea to the untrained
Cold compress – for bottle feeding & wear
eye
supportive bra.
3. Breastfed stool - golden yellow, soft, mushy with
When is involution of breast- 4 weeks
sour milk smell, frequently passed - recur every feeding
b.) Sore nipple – cracked with painful nipple
4. Bottlefed stool –
Mgt: 1.) exposure to air – remove bra & wear dress,
- pale yellow, formed hard with typical offensive
if not, expose to 20 Watt bulb
odor, seldom passed, 2 –3 x/day
avoid wearing plastic liner bra
- with food added -brown & odorous
well flexed Jaundice baby – light stool
Reflex irritability
Under phototherapy – bright green
Catheter - no response - grimace - cough, sneeze
Mucus mixed with stool - milk allergy
Tangential Footslap - NR - grimace - cry
Clay colored stool – obstruction to bile duct
Color - blue/pale - acrocyanosis
Chalk clay stool – after barium enema
(body- pink
Black stool – GIT bleeding (melena)
extremities-blue) - pinkish
Blood flecked stool - anal fissure. Currant jelly stool – instussusection Ribbon like stool – hirschsprung disease Steatorrhea stool – fatty, bulky foul smelling odor stool
APGAR result
- malabasorption syndrome ( celiac disease or cystic
0 – 3 = severely depressed, need CPR, admission
fibrosis)
NICU
Cult blood – stool exam
4 – 6 = moderately depressed, needs add’l suctioning & O2
III Assessment for Well –being
7 - 10 =good/ healthy
APGAR SCORE – Dr. Virginia Apgar Special Considerations:
CPR – cardio pulmonary resuscitation or CPR
1st 1 min – determine general condition of baby
Cardio pulmonary cerebral resuscitation
Next 5 min- determine baby’s capabilities to adjust extra uterinely
5 min no O2 – irreversible brain damage
Next 15 min – dependent on the 5 min
1. shake, no resp, call for help 2. flat on head
A- appearance- color – slightly cyanotic after 1st cry
3. head tilt chin lift maneuver exce pt spinal cord
baby becomes pink.
injury over extension may occlude airway
P- pulse rate – apical pulse – left lower nipple G- grimace – reflex irritability- tangential foot slap,
Breathing ( ventilating the lungs)
catheter insertion
1. check for breathlessness
A – activity – degree of flexion or muscle tone
if breathless, give 2 breaths- ambu bag
R – respiration
> 1 yr old- mouth to mouth, pinch nose < 1 yr – mouth to nose
Baby cry – within 30 secs
force – different between baby & child
Failure to cry after 30 secs – asphyxia near the
infant – puff
neatorum Resp. depression – due mom given Demerol.
Circulation
Administer Naloxone
Check for pulslessness :carotid- adult Brachial – infants CPR – breathless/pulseless
APGAR Scoring Chart:
Compression – inf – 1 finger breath below nipple line or 2 finger breaths or thumb
012 HR -absent <100 >100
CPR inf 1:5
Resp effort -absent - slow, irreg, weak -good strong
Adults 2:15
cry Muscle tone - flaccid extremities - some flexion -
Assessment tool determines respiration of baby
Silvermann Anderson Index
- classic sign – old man’s face - desquamation – peeling of skin
Respiration Evaluation – lowest score – best
- long brittle finger nails
Criteria 0 1 2
- wide & alert eyes
Chest movement synchronized Lag on respiration See - saw
Neonates in Nursery
Intercostal retraction No retraction Just visible
Nsg responsibility upon receiving baby- proper
Marked
identification
Xiphoid retraction None Just visible Marked
- foot printing, affixing mother thumb print
Nares dilatation None Minimal Marked
- take anthropometic measurement
Expiratory grunt None Heard on stet only Heard on
normal length- 19.5 – 21 inch or 47.5 – 53.75cm,
naked ear
average 50 cm head circumference 33- 35 cm or 13 – 14 “
Interpretation result:
Hydrocephalus - >14”
0 -3 – normal, no RDS
Chest 31 – 33 cm or 12 – 13”
4 – 6 – moderate RDS
Abd 31 – 33 cm or 12 – 13”
7 – 10 – severe RDS Bathing - oil bath – initial - to cleanse baby & spread vernix caseosa Fx of vernix caseosa 1. insulator Assessment of Gestational Age
2. bacterio- static
-Ballards & Dobowitz
Babies of HIV + mom – immediately give full bath to
Findings Less 36 weeks (Preterm) 37 - 38 39 and up
lessen transmission of HIV
Sole creases Anterior transverse crease only
- 13 – 39% possibly of transmission of HIV
Occasional creases 2/3 in Covered with creases Breast nodules 2mm 4mm or 3.5 mm > 5 or 7mm
Full bath – safely given when cord fall
Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky Ear lobe Pliable Some cartilage Thick car tilage
Dressing the Umbilical Cord – strict asepsis to
Testes and Scrotum testes in lower canal
prevent tetanus
Scrotum – small few rugae Some intermediate Testes pendulus
3 cleans in community
Scrotum full extensive rugae
1. clean hand 2. clean cord
Signs of Preterm Babies
3. clean surface
Born after 20 weeks, after 37 weeks -frog leg or laxed positon
betadine or povidone iodine – to clean cord
-hypotonic muscle tone- prone resp problem
check AVA, then draw 3 vessel cord
-scarf sign – elbow passes midline pos. - square window wrist – 90 degree angle of wrist
If 2 vessel cord- suspect kidney malformation
- heal to ear sign-
- leave about 1” of cord
abundant lanugo-
- if BT or IV infusion – leave 8” of cord best access no nerve
Signs of Post term babies:
- check cord every 15 min for 1st 6 hrs – bleeding .>
> 42 weeks
30 cc of blood
bleeding of cord – Omphalagia – suspect hemophilia
Large GA > (more) 90
Cord turns black on 3rd day & fall 7 – 10 days
Physical Exam and Deviations fr Normal
Faiture to fall after 2 weeks- Umbilical granulation
1. if client is new born, cover areas not being
Mgt: silver nitrate or catheterization
examined
- clean with normal saline solution not alcohol
2. if client is infant – the 1st yr of life - get VS – take
- don’t use bigkis – air
RR 1st
- persistent moisture-urine, suspect patent uracus –
- begin fr least intrusive to the most intrusive area
fistula bet bladder and normal umbilicus
3. if client is a toddler and preschool, let them
dx: nitrazine paper test – yellow – urine
handle an instrument like:
mgt: surgery
- play syringe or stet, security blanket – favorite article. Let baby hold it.
Credes Prophylaxis – Dr. Crede
4. Explain procedure and respect their modesty -
-prevent opthalmia neonatorum or gonorrheal
school age and adolescent
conjunctivitis - how transmitted – mom with gonorrhea
V/S:
drug: erythromycin ophthalmic ointment- inner to
Temp: rectal- newborn – to rule out imperforate
outer
anus - take it once only, 1 inch insertion
silver nitrate (used before) – 2 drops lower conjunctiva (not used now)
Imperforate anus 1. atretic – no anal opening
Vit-K – to prevent hemorrhage R/T physiologic
2. agenetic – no anal opening
hypoprothrombinemia
3. stenos – has opening
- Aquamephyton, phytomenadione or konakion
4. membranous – has opening
- .5 – 1.5 ml IM, vastus lateral or lateral ant thigh - 5 ml preterm baby
Earliest sign: 1. no mecomium
Vit K – synthesized by normal flora of intestine
2. abd destention
Vit K – meds is synthetic due intestine is sterile
3. foul odor breath 4. vomitous of fecal matter
Weight: Normal wt 3.000 – 3400 gms/ 3 – 3.4 kg /
5. can aspirate – resp problem
6.5 - 7.5 lbs
Mgt: Surgery with temporary colostomy
Arbitrary lower limit 2500 gm Low birth wt baby delivered < 2500g
Cardiac rate: 120 – 160 bpm newborn
Small for gestational age (SGA) < 1 0th % rank or
Apical pulse – left lower nipple
born small
Radial pulse – normally absent. If present PDA
Large for gestational age > 90th % rank or
Femoral pulse – normal present. If absent- COA -
macrosomia >4000 g
coartation of aorta
Appropriate for GA – within 2 standard deviation of mean
Congenital Heart Dse
Physiologic wt loss – 5 – 10% wt loss few days after
Common in girls – PDA, ASD atrial septal
birth
Common in boys – TOGA ( transportation of great arteries)
Small GA < (less) 10
TA – tronchus arteriosus
TOF – tetralogy of fallot
endocarditis
Causes:
4.) PDA - failure of ductus arteriosus to close
1. familial
- should close within 24 h -complete close – 1
2. exposure to rubella – 1st month
month
3. failure of strucute to progress
S&Sx
acyanotic L to R
1. continuous machinery like murmurs
cyanotic R – L
2. prominent radial pulse 3. ECG- hypertrophy Left ventricle
Acyanotic heart defects L to R
Drug:
1. ventricular septal defect - opening between 2
1. endomethazine – prostaglandin inhibitor -
ventricles
facilitate closing of PDA 2. ligation of PDA by 3-4 yo
S&Sx
3. thoracotomy procedure- nakadapa child
1. systolic murmurs at lower border of sternum and no other significant sign
5.)Pulmunary Stenosis- narrowing of valve of pulmo
2. cardiac catheterization reveals increased o2
artery
saturation @ R side of heart
S &Sx: 1.) typical systolic ejection murmur
3. ECG reveals hypertrophy of R side of heart
2. S2 sound widely split 3. ECG- Lt ventricular hypertrophy
Nsg Care:
6.)Aortic Stenosis – narrowing of valve of aorta
Cardiac catheterization: site – Rt femoral vein
S & Sx: 1. inactive, sx sme with angina
1. NPO 6 hrs before procedure
2. typical murmur
2. protect site of catheterization. Avoid flexion of
3. rough systolic sound and thrill
joints proximal to site.
4. ECG- Left ventricular hypertrophy
3. assess for complication – infection, thrombus formation – check pedal pulses
Mgt Pulmo Stenosis & Aortic Stenosis
( dorsalis pedis)
1.) balloon stenostomy 2.) surgery
Mgt. 1.) long term antibiotic – to prevent subacute
Duplication of Aortic Arch- doubling of arch of aorta
bacterial endocarditis
causing compression to trachea and esophagus
2.) open heart surgery-
S&Sx : 1. dysphagia 2. dyspnea 3. left ventricular hypertrophy
2.) ASD – failure of foramen ovale to close
Mgt: - close heart surgery
S&SX 1. systolic murmur @ upper border of ster num
8.) Coartation of Aorta – narrowing of arch of aorta
2. result of cardiac catheterization & ECG same with
outstanding Sx : absent femoral pulse
VSD
BP increased on upper extremities and decreased on lower extremities
Mgt: open heart surgery
ECG – hypertrophy Lft ventricle
3.) endocardial cushion defects - atrium ventricular
Mgt: close heart surgery
(AV) - affects both tricuspid and mitral valve Dx – confirmed by cardiac catheterization
CYANOTIC HEART DEFECTS R to L
Mgt: - open heart surgery Antibiotics to prevent subacute bacterial
1. Transportation of Great Arteries (TOGA) - aorta
arising from Rt ventricle pulmo artery arising form
O – overriding or dextroposition of aorta
Lt ventricle
R – Rt ventricular hypertrophy S &Sx:
Outstanding Sx:
1. Rt ventricular hypertrophy
1. cyanosis after 1st cry (due no exygenation)
2. high degree of cyanosis
2. polycythemia – increased RBC =compensatory
3. polycythemia
due to O2 supply=viscous blood
4. severe dyspnea – squatting position – relief ,
=thrombus = embolus = stroke
inhibit venous return facilitate lung expansion.
3. ECG – cardiomegaly
5. growth retardation – due no O2
Cardiac cath – decreased O2 saturation
6. tet spell or blue spells- short episodes of hypoxia
Palliative repair – rashkind procedure
7. syncope
Complete repair – mustard repair
8. clubbing of fingernails – due to chronic tissue
2.) Total Anomalous Pulmonary
hypoxia
venous return – pulmo vein instead of entering Lt
9. mental retardation – due decreased O2 in brain
atrium, enters Rt atrium or SVC
10. boot shaped heart – x-ray
Increased pressure on Rt so blood goes to Lft
Mgt: 1. O2
Outstanding Sx: Open foramen ovale
2. no valsalva maneuver , fiber diet laxative
Mild to moderate cyanosis
3. morphine – hypoxia
Polycythemia = thrombus = embolus = stroke
4. propranolol – decrease heart spasms
asplenia- absent spleen
5. palliative repair –
Mgt: restructuring of heart
BLT blalock taussig procedure Brock procedure – complete procedure
3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 1 single vessel or common trunk with VSD
ACQUIRED HEART DSE
S & Sx 1. cyanosis 2. polycythemia – thrombus = embolus = stroke
1. RHD Rheumatic Heart Disease
Mgt: Heart transplant
- inflammation disease ff an infection acquired by group A Beta hemolytic strepto coccus
4.) Hypoplastic Left heart syndrome – non fx Left ventricle
Affected body – cardiac muscles and valves ,
1. cynosis
musculoskeletal , CNS, Integumentary
2. polycythemia – throm, emb, stroke Mgt: heart transplant
Sorethroat before RHD Aschoff – rounded nodules with nucleated cells and
5.) Tricuspid atresia – failure of tricuspid valve to
fibroblasts – stays and occludes mitral valve.
open S&SX: open foramen ovale (R to L shunting – goes to Lt atrium)
Jones Criteria
cynosis, polycythemia Mgt: fontan procedure – open tricuspid valve
Major Minor 1. polyarthritis – multi joint pain 1. arthralgia – joint
6.) Tetralogy of Fallot
pain
P – pulmonary stenosis
2. chorea – sydenhamms chores or
V – ventricular SD
st. vetaus dance-purposeless involuntary hand and
shoulder with grimace 2. low grade fever
3.) BRONCHIAL SOUNDS- loud high pitched, heard
3. carditis – tachycardia
over trachea, expiration longer than inspiration.
erythema marginatum - macular rashes
Normal
SQ nodules 3. all lab results increase antibody
4.) RHONCHI – snoring sound made by air moving
“ C reactive protein
through mucus in bronchi. Normal
“ erythrocyte sedimentation rate
5.) RALES-or crackles – like cellophane – made by air
“ anti streptolysin
moving through fluid in alveoli.
o titer (ASO)
Abnormal- asthma, foreign body obstruction.
Criteria:Presence of 2 major, or 1 major and 2 minor
6.) WHEEZING- whistling on expiration made by air
+ history of sore throat will confirm the dx.
being pushed through narrowed bronchi .Abnormal – asthma, foreign body obstruction
Nsg Care:
7.) STRIDOR- crowing or ropster life sound – air
1. CBR
being pulled through a constricted larynx. Abnormal
2. throat swab – culture and sensitivity
– resp obstruction
3. antibiotic mgt – to prevent recurrence
Asthma- pathognomonic sign – expiratory wheezing
4. aspirin – anti-inflammatory. Low grade fever –
Pet – fish. Sport – swimming
don’t give aspirin.
Drugs – amynophylline – monitor bp, may lead to hypotension
S/E of aspirin: - Reyes syndrome – encephalopathy- fatty
Laryngo Tracheo Bronchitis LTB
infiltration of organs such as liver and brain
- inspiratory stridor – pathognomonic sign
Respiration
RDS respiratory dist synd or hyaline membrane dis
Newborn resp – 30-60 cpm, irregular abd or
Cause- lack of surfactant – for lung expansion
diaphramatic with short period of apnea without
Hypotonia, Post surgery, Common to preterm
cyanosis. < 15 secs – normal apnea –newborn
Fibrine hyaline Sx – definite with in 1st of life
Resp Check
Increase RR with retraction
Newborn – 40 – 90
Inspiratory grunting – pathognomonic
1 yr - 20 – 40
7 – 10 severe RDS (silvermenn Anderson index)
2-3yr 20 – 30
cyanosis due to atelectasis
5 yrs 20 – 25
Mgt:
10 yrs 17 – 22
1. surfactant replacement and rescue
15 & above 12- 20
2. pos- head elevated 3. proper suctioning
BREATH SOUNDS HEARD DURING ASCULTATION:
4. o2 with increase humidity- to prevent drying of
1.) VESICULAR – soft, low pitched, heard over
mucosa
periphery of lungs, inspiration longer then
5. monitor V/S skin color , ABG
expiration -Normal 6. CPAP- continuous + a/w pressure 2.) BRONCHOVESICULAR- soft, medium pitched,
7. PEEP - + end expiratory pressure
heard over major bronchi, inspiration equals exp.
Purpose of #6-7- to maintain alveoli partially open
Normal
and alveoli collapse
LARYNGOTRACHEOBRONCHITIS
Acrocyanosis
LTB – most common Creup -viral infection of larynx,
BIRTHMARKS:
trachea & bronchi
1. Mongolian spots – stale gray or bluish
outstanding sx - croupy cough or barking
discoloration patches commonly seen across the
pathognomonic - stridor
sacrum or buttocks due to accumulation of
- labored resp
melanocytes. Disappear by 1 yr old
- resp acidosis
2. MIlla – plugged or unopened sebaceous gland .
- end stage – death
white pin point patches on nose, chin or cheek.
Lab:
3. Lanugo – fine, downy hair – common preterm
1. ABG
4. Desquamation – peeling of newborn, extreme
2. neck and throat culture
dryness that begin sole and palm.
3. dx- neck x-ray to rule out epiglotitis
5. Stork bites (Talengeictasi nevi) – pink patches
Nsg Mgt:
nape of neck
1. bronchodilators
hair will grow as child grows old
2.increase o2 with humidity
6. Erythema Toxicum – (flea bite rash)- 1st self
3. prepair tracheostomy set
limiting rash appear sporadically & unpredictably as to time & place.
BRONCHOLITIS- Inflammation of bronchioles –
7. Harlequin sign – dependent part is pink,
tenatious mucus
independent part is blue
Causative agaent – RSV - Resp sincytial viruses
(side lying – bottom part is dependent pink)
Sx: flu like sx
8. Cutis Marmorato – transitory mottling of
Increased RR
neonates skin when exposed to cold.
Drug: Antiviral – Ribavirin
9. Hemangiomas – vascular tumors of the skin
End stage – epiglotitis 3 types Hemangiomas EPIGLOTITIS - infl of epiglottis
a.) Nevus Flammeus – port wine stain – macular
- emer. Condition of URTI
purple or dark red lesions seen on face or thigh.
Sx: sudden onset
NEVER disappear. Can be removed surgically
Tripod position – leaning forward with tongue
b.) Strawberry hemangiomas – nevus vasculosus –
protrusion
dilated capillaries in the entire dermal or subdermal
- never use tongue depressor
area. Enlarges, disappears at 10 yo.
prepare tracheotomy set
c.) Cavernous hemangiomas – communication
< 5 yo – unable to cough out, put on mist tent
network of venules in SQ tissue t hat never
(humidifier o2) or croupe tie
disappear with age. - MOST DANGERIOUS –
Nsg Care: check edges tucked on mist tent
intestinal hemorrhage
Provide washable plastic material
Skin color blue – cyanosis or hypoxia
No toys with friction due O2 on
White – edema
No hairy toys – due moist environment medium for
Grey – inf
bacterial growth
Yellow – jaundice , carotene Vernix Caseosa – white cheese like for lubrication,
BP – 80/46 mmHg newborn
insulator
BP after 10 days- 100/50 BP taking begins by 3 yo
BURN TRAUMA – injury to body tissue caused by
COA – take BP on 4 extremities
excessive heat.
SKIN:
INFANT 5-9 yo
ANTERIOR POSTERIOR Ant Post
needed for 2nd degree – very painful
Head 9.5 9.5 6.5 6.5
6.) 1st defense of body – intact skin
Neck 1 1 1 1
prevention of wound infection
Upper arm 2 2 2 2
a.) cleaning & debriding of wound
Lower arm 1.5 1.5 1.5 1.5
b.) open or close method of wound care
Hand 13 1.25 1.25 1.25
c.) whirlpool therapy – drum with solution
Trunk 13 13
7.) skin grafting – 3rd degree – thigh or buttocks
Back 13 13
(autograft), pigs/ animals – xenograft
Genital 1 1
frozen cadaver – hallow graft
@ buttocks 2.5@ 2.5 @
8,) diet – increase CHON, increase calories.
Thigh 2.75 2.75 4 4 Leg 2.5 2.5 3 3
ATOPIC DERMATITIS- infantile eczema (galis)
foot 1.75 1.75 1.75 1.75
Papulo vesicular erythematus lesions with weeping & crusting Cause – food allergies: milk, citrus juice, eggs,
DEPTH
tomatoes, wheat
1st degree – partial thickness – superficial
Sx: - extreme pruritus, linear excoriation, weeping
epidermis - erythema, dryness, PAIN
crusting; scaly shiny and white – lechenification
-sunburn, heals by regeneration from 1 – 10 days 2nd degree – epidermis & dermis- erythema,
Goal of care: decrease pruritus – avoid food
blisters, moist, extremely painful
allergens
scalds
Diet: Prosobi or Isomil
3rd degree – full thickness- epidermis, dermis,
Hydrate skin, borow solution 1% hydrocortisone
adipose tissue, fascia, muscle & bone
cream
lethargy, white or black, not painful – nerve
Prevent infection – proper handwahsing, trim nails
endings destroyed ex. lava burns
IMPETIGO- skin disease. Causative agent – grp A beta Hemolytic
Mgt:
streptococcus
1.) 1st aid a.) put out flames by rolling child on
- papulovesicular surrounded by localized erythema
blanket
–becomes purulent , oozes a honey colored crust
b.) immerse burned part on cold H2o
Pediculosiscapitis –“KUTO”
c.) remove burned clothing of with sterile material
- Mgt: proper hygiene – wash soap and H2o, oral
d.) cover burn with sterile dressing
penicillin – bactroban ointment Can lead to acute glomerulonephritis AGN
2.) a/w
ACNE- adolescent problem
a.) suction PRN, o2 with increased humidity
- self limiting infl dis – sebaceous gland comedones
b.) endotracheal intubation
– sebum causing white heads
c.) tracheostomy
- sebum- lipids causing acne bulgaris
3.) Preventiuon of shock & F&E imbalance
Mgt: - proper hygiene- mild soap or sulfur soap-
a. colloids to expand bld volume
antibacterial retin A or tretinoi
b. isotonic saline to replace electrolytes c. dextrose & H2o to provide calories 4.) Tetanus toxoid booster
ANEMIA-pallor
5.) Relief of pain – IV analgesic MORPHINE SO4 –
Causes:
1.)early cutting of cord – preterm – cut umb cord
MOST COMMON CANCER – (ALL) – Acute
ASAP
Lymphocytic Leukemia
fullterm – cut umb cord when pulsation stops
S&Sx:
2.) Bleeding disorders – blood dyscrasias
1. from invasion of bone marrow signs of infection
HEMOPHILIA – deficiency of clotting factor. X linked
a.) fever
recessive – inherited
b.) poor wound healing
If mom – carrier, son – affected
c.) bone weakness & causes fracture
If father carrier- transmitted to daughter
signs of bleeding a.) petecchiae-small, round, flat, dark red spot
Hemophilia A – deficiency of coagulation
b.) epistaxis
component factor 8
c.) blood in urine/ emesis
Hemophilia B –or christmas disease, deficiency of
signs of anemia
clotting factor 9
a.) pallor , body malaise , constipation
Hemophilia C – deficiency of clotting factor 11 2. from invasion of body organ- hepato Assessment:
spenomegaly – abd pain ,
- umphalagia – earliest sign
CNS affectation, increase ICP
- newborn receive maternal clotting factor
Dx Tests:
- newborn growing – sudden bruising on bump
1. PBS- peripheral blood smear – determine
area- marks earliest sign
immature RBC
- continuous bleeding – hematrosis – damage or
2. CBC – determine anemia, leukocytosis,
bleeding synovial membrane
thrombocytopenia neutropenia 3. lumbar puncture (LP) – determine CNS
Dx test :
involvement. Before LP, fetal pos.- avoid flexion of
PTT. Partial thromboplastin time – reveals
neck – will cause a/w obstruction.“C” position or
deficiency in clotting factor
shrimp position only.
Long Term Goal- prevention of injury
4. bone marrow aspiration – determine blast cells,
Nsg Dx- increase risk of injury
- common site- iliac crest
HT: avoid contact sport, swimming only, don’t stop
- post BMA s/effect – bleeding
immunization – just change gauge of needle
- apply pressure. Put pt on affecte d side to prevent
Falls – immobilized , elevate affected part, apply
hemorrhage
pressure-not more then 10 min
5. Bone scan – determine bone involvement
cold compress
6. CT scan – determine organ involvement
-determine case before doing invasive procedure Therapeutic Mgt: LEUKEMIA- grp of malignant disease
TRIAD:
- rapid proliferation of immature WBC
1. surgery
- WBC – protection from infection, soldiers of body
2. irradiation 3. chemotheraphy
Classification :
Focus Nsg Care: prevent infection
1. Lympho – affects lymphatic system 2. Myelo – affects bone marrow
4 LEVELS OF CHEMOTHERAPHY
3. acute / blastic- affects immature cells
1. induction – goal of tx; to achieve remission
4. chronic/ cystic- affects mature cells
meds: IV vincristine L- agpariginase
Oral predinisone
Mgt:
2. Sanctuary- treat leukemic cells that invaded
1. initiate breastfeeding to get colostrum
testes & CNS
2. Temp suspension of breastfeeding
give: methotrixate- adm intrathecally via CNS or
- content breast milk pregnanedioles – that delays
spine
action of glucoronil transferees
cytocine, Arabinoside, steroids with irradiation
liver enzymes converts in direct bilirubin to become direct bilirubin
3. maintenance- to continue remission
3. Needs phototherapy
give: oral methotrisate – check WBC
4. needs exchange therapy
-adm of methotrisate – do weekly WBC check Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin 4. Reinductin – treat leukemic cells after relapse
among full term
occurs. Meds – same as induction
Normal – 0-3 mg/dL - bilirubin encephalopathy
- give antigout agents: allopurinol or Zyloprim- treat
- Kemicterus - > 20 mg/dL among full term &
or prevent hyperurecemic nephropathy.
>12 mg /dl of indirect – preterm =can lead to cerebral palsy-
Nsg mgt: Outstanding nsg dx: alteration in nutrition less body requirement.
Physiologic jaundice – jaundice within 48 -72 h (2-3
Based on Maslow’s heirarchy
days) expose morning sunlight
S/Effect of Chemotherapy
Pathologic Jaundice – within 24h. Jaundice during
1. N/V – adm antiemetic drugs 30 mins before
delivery.
chemo until 1 day after chemo 2. Ulcerations / stomatitis / abscess o f oral mucosa-
Breastfeeding jaundice – caused by pregnanediole
(alteration nutrition less body req) - oral care – alcohol free mouthwash , betadine
Assessment of Jaudice :
mouthwash
1. Blanching neonates forehead, nose or sternum
- don’t brush – use cotton pledgets
- yellow skin & sclera
- topical xylocaine before meals
- color of stool – light stool
diet- soft, bland diet according to child’s preference
- color of urine – dark urine
Temporary S/E of chemo:
Mgt: Phototheraphy – photo oxygenation
Alopecia – altered body image Hirsutism – hair
Nsg Resp:
-give emotional support to parents
1. cover eyes – prevent retinal damage 2. cover genitals – prevent priapism – painful
ABO incompatibility –
continuous erection
Most common incompatibility – ( mom) O – ( fetus)
3. change position regularly – even exposed to light
A
4. increase fld intake – due prone to dehydration
Most severe incompatibility (Mom) O – (Fetus) B
5. monitor I&O – weigh baby
Can affect 1st pregnancy
6. monitor V/S – avoid use of oil or lotion due- heat at phototherapy
Hydrops (h20) Fetalis – edematous on lethal state
= bronze baby syndrome-transient S/E of
with pathologic jaundice
phototherapy
Within 24 h
weigh diaper 1gm = 1cc
Head – largest part of baby
- high pitched cry
¼ of its length
older child – diplopia – eye deviation, projectile vomiting
Craniostenosis or craniosinustosis – premature
- fontanel bossing – prominent forehead
closing of fontanel
- - prominent skull vein
Hydrocephalus – ant fontanel open after 18 mos
- sunset eyes
Microcephaly – small growing brain due- alcohol &
Mgt: position to lessen ICP – low semi-fowlers 30
HIV mom
degree angle
Anencepahly – absence of cerebral hemisphere
Administer- osmotic diuretic Mannitol/ Osmitrol ,
Craniotabes – localized softening cranial bone.
Diamex- Azetam
Common – 1st born child
Decrease CSF production
-due early lightening (2 weeks prior to EDD)
Shunting – AV shunt or Vp shunt
Rickets of Vit B deficiency – soft cranial bone in
(ventriculoperitoneal shunt)
older children
Shave hair – in OR – to prevent growth of micro org.
Caput Succedaneum – edema of scalp due prolonged pressure at birth
Nsg Care:
Char:
1.) post VP shunt – side lying on non operated site -
1. present at birth
to prevent increase ICP
2. crosses suture lines
-monitor for good drainage - sign – sunken fontanel
3. disappear after 2-3 days
-bulging fontanel – blocked shunt -change fontanel as child is growing
Cephalhematoma- collection of blood due to
SENSES
rapture of pericostal capillaries
EYES: Assessment
Char :
1. check for symmetry
1. present after 24 h
2. sclera – normal color – light blue then become
2. never cross suture line
dirty white
3. disappear after 4-6 weeks
pupil – round- adult size
4. monitor for developing jaundice
coloboma- part of iris is missing sign: key hole pupil
Seborrheic Dermatitis – ‘craddle cap”
-whiteness & opacity of lens congenital cataract
Scaling, greasy appearing salmon colored patches –
cornea – round & adult size
seen on scalp behind ears and umbilicus
large – congenital glaucoma
Cause: - improper hygiene Mgt:
Test for blindness common tests
1. proper hygiene
1. newborn – general appearance
2. put oil night before shampoo
- can only see 10 – 12 “
- baby oil
- visual acuity 20 /200 to 20/ 800 Doll’s eyes test- test for blindness
Hydrocephalus – excessive accumulation of CSF
- done 10th day
1. communicating – extra ventricular hydrocephalus
- pupil goes opposite to direction when head is
2. non-communicating- intraventricular
moved
hydrocephalus or obstructive hydrocephalus
Globellars test – test for blink reflex. Points near
due to tumor obstruction
nose – baby should blink
Sx – ICP – abnormally large head, bulging fontanel
2. Infant & children
- cushings triad
- appearance
- ability to follow object past midline
1st sense to develop & last to disappear – hearing
3. 3 yrs – school age
EARS:
- general appearance
1. Properly aligned with outer cantus of eyes
Allen cards – test for visual acuity. Show picture 20
low set ear – kidney malformation
ft away
ex. Renal aginesis – absence of kidney sign in uterus : oligohydramnios
Ishiharas plates – test for color blindness
sign in newborn: 2 vessel cord
Prechool E chart - test for stereopsi of depth
failure to void within 24 h
perception Cover testing test – cover 1 eye for 10 – 15 min.
Mgt: kidney transplant
Then remove. Test for strabismus 4. School age – adult
Chromosomal aberrations : -advance maternal age
- general appearance
1. non disjunction – uneven division
- snellens test Trisomy 21 - down syndrome - e xtra chromosome Retinobastoma – malignant tumor of retina
47xx + 21 - related to advance paternal age
Outstanding sign : oat’s eye reflex-whitish glow of
Sx:
pupil
Mongolian slant
- red painful eye
Broad flat nose
- blindness
Protruding neck
surgery – Enucliation – removal of eyeball put
Puppy’s neck
artificial aye
Hypotonic – prone to resp problem Simean crease – single transverse line on palm.
NOSE: 1. flaring alenase – case of RDS
Trisomy 18 – “edward syndrome”
2. cyanosis at rest – choanal atresia - post nares
Trisomy 13- patau syndrome
obstructed with bone or membrane
Turner – Monosomy of X synd.
Sx:
- 45x0
1. resistance during catheter insertion
- affected girls
2. emer. Surgery within 24 h
- signs evident during puberty
normal color nasal membrane – pinkish
- has poorly developed 2dary sexual char.
rhinitis – presence of creases & pale
- Sterile
check sense of smell – blindfold – smell Klinefelters Syndrome- has male genitalia - 47 XXY Hair in nose – cilia
- poorly devt secpndary sexual characteristics
Adolescent no hair with ulceration of nasal mucosa
- no deepening of voice
suspect cocaine user
-small testes, penis -sterile
Epistaxis – nosebleed
Klinefelter – Calvin Kline – male
- sit upright, head slightly forward to facilitate
Turner – Tina Turner – female
drainage - cold compress , apply gentle pressure, epinephrine
Otitis Media – inflammation of middle ear. Common children due to wider & shorter Eustachian tube
most developed sense of newborn – sense of touch
Causes
1.) bottle propping 2.) Cleft lip/ cleft palate –
Hypervitaminosis
Sx: Otitis
Natal tooth – tooth at birth. Move with gauze
1. bulging tympanic membrane, color – pearly gray
Neonatal tooth – tooth within 28days of life
2. absence light reflex 3. observe for passage of milky, purulent foul
Moniliasis – oral candidiasis
smelling odor discharge
- white cheese like, curd like patches that coats
4. observe for URTI
tongue
Nsg Care:
- oral thrush
1. position side lying on affected aside – to facilitate
- Nsg Care – don’t remove, wash with cold boiled
drainage
H2o
2. supportive care- bedrest, increase fld intake
Meds – nystatin / Mysnastatin – antifungal
Med Mgt: 1. Massive dosage antibiotic
Kawasaki Dse--strawberry tongue - originated in
Complication – bacterial meningitis
Korea
2. Apply ear ointment
- Dr. Kawasaki discovered it - common in Japan
School age – up and down
- “mucocutaneous Lymphnode Syndrome”
< 3 yo – down & back
Sx:
> 3 yo – up & back
-persistent fever – 5 days
Small child – down & back ( no age)
-strawberry tongue ,
surgery (to prevent permanent hearing loss) – otitis
-desquamation of palm & sole
media – myringotmy with tympanostomy tube
- lymph adenopathy > 1.5 cm
post surgery – position affected side for drainage
Drug: aspirin
both – put ear plug
Can lead to MI
if tympanous tube falls – healed na LIPS- symmetrical Bells Palsy- facial nerve #7 paralysis R/T forcep
Cleft lip – failure of median maxillary nasal process
delivery
to fuse by 5-8 wks of pregnancy
Sx.
- common to boys
1. Continuous drooling saliva
- unilateral
2. inability to open , eye & c lose either eye Mgt:
Cleft Palate- Failed palate to fuse by 9 – 12 wks of
Refer to PT
pregnancy - common to girls
TEF (Tracheoesophageal Fistula)-TEA- no connection
- unilateral or bilateral
bet esophagus and stomach Sx: Outstanding Sx – Coughing
1. evident at birth
Choking
2. milk escapes to nostril during feeding
Continuous drooling
3. frequent colic & otitis media or URTI
Cyanosis Mgt:: Emergency surgery
Mgt: 1. Surgery
Epstein pearl – white glistering cyst at palate &
cleft lip repair – Cheiloplasty =done 1-3 months to
gums related to hypercalcemia
save sucking reflex (lost in 6 months )
Cleft Palate- uranoplasty = done 4-6 months to save
delivery
speech Mgt: passive stretching exercise , Surgery Pre op care
Complication – scoliosis
1. emotional support especially to mom 2. proper nutrition
THYROID gland – for basal metabolism
3. prevent colic
Congenial cretinism – absence or non functioning
feed – upright seating or prone pos
thyroid glands
burp frequently 2x at middle and after feedinglower to upper tap
reasons for delaying dx:
4. orient parents to type of feeding
1. Thyroid glands covered by sternocleidomastoid
rubber tipped syringe – cheiloplasty
muscles in newborn
paper cup/ soup spoon/ plastic cup – urano plasty
2. baby received maternal thyroxine
5. apply restraints – elbow restraints
3. baby sleeps 16 – 20 h a day
so baby can adjust post op
earliest sign: 1. change in crying
Condition that warrants suspension of operation
2. change in sucking
- colds & pharyngitis = can lead to ge neralized
3. sleep excessively
infection – septicemia
4. constipation 5. edema – moon face
Post Op Nsg Care :
late sign
1. airway – positon post cheilopasty – side lying for
1. mental retardation
drainage
prognosis : mental retardation preventable when
post uranoplasty (tonsillectomy)- prone
Dx is early
2. assess for RDS sx bleeding
Dx:
3. assess for bleeding – freq swallowing. 6-7 days
1. PPI-protein
after surgery – bleeding
2. radioimmunoassay test
4. proper nutrition
3. radioactive iodine uptake
- clear liquids- ( gelatin except red or brown color due may mask bleeding)
Mgt: synthroid – sodium Levothyrosine -synthetic
- ( popsicle- not ice cream)
thyroid given lifetime
full liquid
- check pulse rate before giving synthroid
soft diet
- tachycardia – Sx of hyperthyroidism
regular diet 5. Maintain integrity of suture line such as:
CHEST
Logan bar – wash ½ strength Hydrogen Peroxide &
1. symmetry
saline solution- Bubbling effect
2. breast - transparent fluid coming out from
traps microorganism
newborn related to hormonal changes-
- prevent baby form crying
3. chest has retroactive – RDS
for pain- analgesic
4. sternum sunken – pectus excavation
NECK-
ABDOMEN (in order)
1.) check symmetry
1. inspection I
Congenital torticolis- “ wryneck”-burn injury of
2. Auscultation A
sternocleidomsstoid muscle during
3. percussion P
delivery – due to excessive traction at cephalic
4. Palpation P = Will change bowel sounds, so do
last
d.) soft table food – “modified family menu” given 1 yr
Normal contour of abd – slightly protruding
e.) dilute fruit juices – 6 mos
Sunken abd- diaphramatic hernia – protrusion of
f.) never give half cooked eggs – usually causes of
stomach content through a defective diaphragm
salmoneliosis
due to failure of puroperitoneal canal to c lose.
g.) don’t give honey – infant botulism
Sx:
h.) offered new food one at a time – interval of 4 –
1. sunken abd
7days or 1 week – determines food allergens
2. Sx of RDS 3. R to L shunting
Total Body Fluids- comprises 65 - 85% of body wt of
Mgt:
infants & children
Emergency surgery within 24h
Where fluids are greater in infants Extracellular fld – prone to develop dehydration
Omphalocele – protrusion of stomach contents in between junction of abd wall and umbilicus.
Acid Base Balance dependent on the ff: a. chemical buffers
Mgt- very small surgery
b. renal & resp system involvement
If large – suspension surgery
c. dilution of strong acids and bases in bld
Nsg Mgt: protect sac- sterile wet dressing
Resp Acidosis – carbonic acid excess - hypoventilation
Gastrochisis – absence of abd wall
- RDS
Nsg Mgt: sterile wet dressing
- COPD - Laryngotracheobronchitis (LTB)
Fx of GIT
Resp Alkalosis – carbonic acid deficit
1. assists in maintaining F&E & acid base balance
- hyperventilation
2. Processes & absorbs nutrients to maintain
- fever
metabolism & support G & D
- encephalopathy
3. excrete waste products from digestive process
Met. Acidosis – base HCO3 deficit - diarrhea
Recommended Daily Allowance
- severe dehydration
Calories : 120 cal / Kbw/day (kilo body wt)
- malnutrition
360 – 380 cal/ day
- ciliac crisis Met Alkalosis – base HCO3 excess
CHON_ 2.2g /Kbw/day
- uncontrolled vomiting - NGT aspiration
Principles in Supplementary Feeding
- Gastric lavage
Supplementary Feeding usually – 6 mos Supplementary feeding given – 4 mos.
PROBLEMS LEADIING TO F&E IMBALANCE 1. vomiting – forceful expulsion of stomach content
a.) solid food offered to ff sequence!
Sx:
1. cereals – rich in iron
1. nausea
2. fruits
2. dizziness
3. veg
3. facial flushing
4. meat
4. abd cramping
b.) begin with small quantities c,) finger foods – offered 6 months
assess: amt, freq, force
projectile vomiting= increase ICP or pyloric stenosis Mgt: BRAT diet - banana, rice – cereal, apple sauce, toast
Gastric Motility Disorder: HIRSCHPRUNGS DISEASE – congenital aganglionic
2. Diarrhea – exaggerated excretion of intestinal
megacolon
contents
Aganglionic – absence of ganglion cells needed for
Types:
peristalis
Acute diarrhea – related to gastroenteritis, salmoneliosis
Earliest sign
- dietary indiscretions
1. failure to pass mecomium after 24h
- antibiotic use
2. abd distension 3. vomitus of fecal material
Chronic non specific diarrhea
early childhood – ribbon like stool
Cause:
foul smelling stool
1. food intolerance
constipations
2. excessive fld intake
diarrhea
3. CHO, CHON malabsorption
Dx: 1. Barium enema – reveals narrowed portion of
Assess: freq, consistency, appearance of given
bowel
colored stool.
2. Rectal Biopsy – reveals absence of ganglionic cells
Best criteria to determine diarrhea : consistency
3. abd x-ray – reveals dilated loops on intestine 4. rectal manometry – revels failure of intestine
Complication = dehydration
sphincter to relax
Mild dehydration 5% wt loss Moderate dehydration 10% wt loss
Therapeutic Mgt/Nsg care
Severe dehydration 15 % wt loss
1. NGT feeding – measure tube fr nose to ear to midline of xyphoid & umbilicus
Earliest sx of dehydration
2. surgery
tachycardia increase temp weight loss
a.) temp colostomy
tachypnea sunken fontanel & eyeballs scanty urine
b.) anastomosis & pull through procedure
hypotension absence of tears
Diet: Increase CHON, increase calories , decrease residue
Severe dehydration:
– pasta
Oliguria , Prolonged capillary refill time GER- Gastroesophageal Reflux Mgt:
Chalasia – presence of stomach contents to
Acute – NPO ( rest the bowel )
esophagus
- with fluid replacement – IV
Will lead to esophagitis complication – aspiration
- prone to Hypokalemia – give K chloride
pneumonia
before adm of K chloride – check if baby can void, if cant void – hypokalemia
Esophageal cancer
Drug: Na HCO3 – adm slowly to prevent cardiac
Assessment :
overload
1. chronic vomiting 2. faiture to thrive syndrome 3. organic – organ affected
4. melena or hematemesis – esophageal bleeding
5.)serum electrolyte – increase Na & K, decrease
Dx procedure
chloride
1. barium esophogram – reveals reflux
6.) ultrasound
2. esophageal manometry – reveals lower
7.) x ray of upper abd with barium swallow reveal
esophageal sphincter pressure
“string sign”
3. intra esophageal pH content – reveals pH of distal esophagus.
Mgt:
Meds of GERD
1. Pyleromyotomy
Anti-cholinergic
2. Fredet Ramstedt procedure
a.) Betanicol ( urecholine) – increase esophageal tone & peristaltic activity
INSTUSSUSCEPTION- invagination or telescoping of
b.) Metachloporomide (Reglam) – decrease
position of bowel to another
esophageal pressure by relaxing pyloric & duodenal
Common site – ilio-secal junction
segments
Prone pt: person who eats fat
- increase peristalsis without stimulating secretions
Complication – peritonitis – emergency
c.) H2 Histamine Receptor Antagonist – decrease
Sx:
gastric acidity & pepsin secretion
1.) persistent paroxysmal abd pain
- Zimetidine, Ranitidine (Zantac) – take 30 min
2.) vomiting
before meals
3.) currant jelly stool- dye bleeding & inflammation
d.) antacid – neutralizes gastric acid between
- palpate sausage shaped mass
feedings - Maalox
Mgt: 1.) Hydrostatic reduction with barium enema
Surgery: Nissen funduplication :
2.) Anastomosis & pull thru procedura
Chronic vomiting – - thickened feeding with baby cereals - effective if
Inborn Errors of Metabolism- deficient liver
without vomiting
enzymes
- feed slowly, burp often every 1 ounce
PHENYLKETONURIA (PKU) – deficiency of liver
- positioning
enzymes (PHT)
< 9 months – infant sit with infant supine
Phenylalaninehydroxylase Transferase – liver
> 9 months – prone with head of mattress slightly
enzyme that converts CHON to amino acid
elevated 30 degree angle 9 amino acids: OBSTRUCTIVE DISORDERS
valine isolensine tryptophase
A. PYLORIC STENOSIS – hypertrophy of muscles of
lysine phenylalanine
pylorus causing narrowing & obstruction.
Thyronine – decrease malanine production
1.) outstanding Sx- projectile vomiting
1.) fair complexion
- vomiting is an initial sx of upper GI obstruction
2.) blond hair
- vomitus of upper GI can be blood tinged not bile
3.) blue eyes
streaked. (with blood)
Thyroxine – decrease basal metabolism
- vomitus of lower GI is bilous ( with pupu)
- accumulation of Phenyl Pyruvic acid
- projectile vomiting – increase ICP or GI obstruction
4.) Atopic dermatitis
- abd distension – major sx of lower GIT obst
5.) musty / mousy odor urine
2.) met alk
6.) seizure – mental retardation
3.) failure to gain wt 4.) olive shaped mass – on palpation
Test – GUTHRIE TEST – specimen – blood
- preparation increase CHON intake
Dx:
- test if CHON will convert to amino acid
1. lab studies – stool analysis
specimen and urine
2. serum antiglyadin – confirmatory of disease
mixed with pheric chloride, presence of green spots at diaper a sign of PKU
gluten free diet – lifetime
DIET:
all BROW – not allowed
Low phenylalanine diet- food contraindicated-
ok – rice & corn
meats, chicken, milk, legumes, cheese, peanuts Give Lofenalac- milk with synthetic protein
Mgt: 1. vitamin supplements
Galactosemia – deficiency of liver enzyme
2. mineral supplements
- GUPT – Galactose Urovil Phosphatetranferase
3. steroids
- Converts galactose to phosphate tranferace glucose Galactose – will destroy brain cells if untreated –
POISONING- common in toddlers. (falls- common to
death within 3 days
infant) 1. determine substance taken, assess LOC
Dx:
2. unless poison is corrosive, caustic (strong alkali
Beutler test – get blood -done after 1st feeding
such as lye) or a hydrocarbon, vomiting is the most
presence of glucose in blood – sign of galactosemia
effective way to remove poison.
galactose free diet lifetime
- Give syrup 1 pecac to induce vomiting
neutramigen – milk formula
3. 1 pecac – oral emetic - 15 ml – adolescent, school age & pre school
CELIAC DISEASE – gluten enteropathy
- 10 ml to infant
Common gluten food:
4. UNIVERSAL ANTIDOTE- charcoal, milk of
Intolerance to food with brow
magnesia & burned toast
B- barley
5. Never adm charcoal before 1 pecac
R- rye
6. antidote for acetaminophen poisoning –
O- oat
acetylsysterine ( mucomyst)
W- wheat
7. caustic poisoning ( muriatic acid ) neutralize acid by giving vinegar . Don’t vomit prepare tracheostomy set 8. Gas- mineral oil will coat intestine Lead poisoning
Early Sx:
Lead = Destroy RBC functioning = Hypochornic
1. diarrhea – failure to gain wt ff diarrheal episodes
Microcytic Anemia = Destroy kidney functioning
2. constipation
Accumulation of anemia = Encepalopathy
3. vomiting Late Sx:
Sx:
1. abd pain – protruberant abd even if with muscle
1. beginning sx of lethargy
wasting
2. impulsiveness, learning difficulties
2. steatorrhea
3. as lead increases, severe encepalopathy with seizure and permanent mental retardation
Celiac Crisis- exaggerated vomiting with bowel inflammation
Dx:
Tst of Dx:
1. Blood smear
Transillumination with use of flashlight - glowing
2. abd x ray
sign
3. long bones Mgt:
Varicocele – enlarged vein of epididimis ( girls-
1. remove child from source
vulvular varicosities)
2. if > 20 ug/dL – need chelation therapy = binds with led & excreted by kidney =nephrotoxic
BACK- check for flatness & symmetry
Amogenital
Open Neural Tube Defect- decreased Folic Acid
Female:
intake
Pseudomenstration slight bleeding on vagina related to hormonal changes
SPINA BIFIDA OCCULTA- failure of post laminae of vertebrae to fuse
Tearing of fourchette with blood – rape/ child abuse
Sx: dimpling of back , Abnormal tufts of hair
Rape- Report within 48 h Shape pubic hair in inverted triangle ( female)
SPINA BIFIDA CYSTICA- failure of post laminae of vertebrae to fuse with a sac
Male: Undescended testes – cyrptorchidism -common to
Types:
preterm
1. Meningocele – protrusion of CSF & Meninges
surgery – orchidopexy
2. Myelomeningocele – protrusion of CSF &
assess scrotum- warm room & hands
Meninges & spinal cord ( most dangerous) 3. Encephalocele ( CNS complication –
baby – pee within 24 h
hydrocephalus) – cranial meningocele or
-check for arch of urination
myelomeningocele
Epispadias- urinary meatus located dorsal or above
Most common problem
glans penis
- rupture of sac
Hypospadias- urinary meauts loc ventral or below
- prone pos
glans penis
- sterile wet dressing Most common complication - infection
Hypospadias with chordee- fibrous band c ausing
Myelomeningocele – genitourinary complication-
penis to curb downward
urinary & fecal incontinence Nsg care: always check diaper
Mgt:
Orthopedic complication – paralysis of lower
Surgery
extremities Surgery to prevent infection
Phimosis- tight foreskin
Post op – prone position
Balanitis-infection of glands penis – due smegma SCOLIOSIS- lateral curvature of the spine Mgt:
2 types:
Circumsicion
1. structural – rye neck 2. postural – improper posture
Hydrocele – fld filled scrotum Dx:
1. uneven hemline
2. carry baby astride
2. bend forward- 1 hip higher
3. Frejka splint
1 shoulder blade more prominent
4. Pavlik harness
Nsg care:
5. Hip Spica Cast
1. conservative – avoid obesity, exercise 2. preventive – Milwaukee brace - worn 23 h a day
TALIPES – “clubfoot”
3. corrective surgery – insert Harrington rod
a.) Equinos – plantar flexion – horsefoot
post op- how to move
b.) Calcaneous – dorsiflexion – heal lower that foot
log rolling- move client as 1 unit
anterior posterior of foot flexed towards anterior leg
EXTREMITIES:
c.) Varus- foot turns in
check # of digits = 20
d.) Valgus- foot turns out
1. syndactyly – webbing of digits
Equino varus- most common
2. polydactyly – extra digits 3. olidactyly – lack of digits
Assessment:
4. Amelia – total absence of digits
1. Straighten legs & flexing them at midline pos
5. pocoamelia- absence of distal part of extr emities
Mgt: 1. Corrective shoe- Dennis brown shoe, spica cast Fx: of cast – - to immobilize
ErQ duchennes – paralysis- brachial plexus injury or
- bone alignment
brachial palsy
- prevent muscle spasm
- birth injury caused by lateral & excessive traction
lead pencil – mark area to be amputated
during a breech injury
cold H20 – hasten setting process
Sx:
hot H20- slow setting process
1. unable to abduct arms from shoulders, rotate arm externally or supinate forearm
After cast application – how to move pt:
2. absence or asymetrical moro reflex
- use open palm not fingers- fingers will cause
Mgt:
indention
1. abduct arm from shoulders with elbow flex.
- dry cast – natural air not blower
CONGENITAL HIP DISLOCATION – head of femur is
- priority check : neurovascular check
outside acetabulum
C- circulation
Types;
M- motion S- sensation
1. subluxated – most common type 2. dislocated
Cast – with bleeding
Sx:
- mask with ball pen edge of blood to know if
1. shortening of affected leg
bleeding is on going
2. asymmetrical gluteal fold
sign cast is dry = resonant sound, cast cold to touch
3. limited movement – earliest sx 4. (+) ortolanis sign – abnormal clicking sound
do petaling – making rough surface of cast smooth
5. when able to walk – child limps – late sxtrendelenburg sign
CRUTCHES
Goal of Mgt:
Fx: To maintain balance
Facilitate abduction
- To support weakened leg
Mgt. 1. triple diaper
Principles in crutches
