CONCEPT: HEALTH PROMOTION AND MAINTENANCE 1 Latest updated 2022,100% CORRECT

CONCEPT: HEALTH PROMOTION AND MAINTENANCE 1 Latest updated 2022 MENSTRUATION Ovulation: Purpose: prepare uterus for pregnancy Note: Ovum/egg is viable inside the uterus within hours Sperm is viable inside the uterus within days Menstruation INTERVAL (length of cycle) DURATION (days) AMOUNT (blood loss) NORMAL: NORMAL: NORMAL: Oligomenorrhea Hypermenorrhea Menorrhagia Polymenorrhea Hypomenorrhea Hypomenorrhea Metrorrhagia ACTIVITY!!! A woman enters the clinic because she missed her last menstrual period. The client asked the nurse what are the possible problems that a woman may encounter regarding menstruation. The nurse responds by identifying problems related this: Complete the table PROBLEM DESCRIPTION Long cycle and seldom menstruation Short cycle and frequent menstruation Bleeding more than 7 days Bleeding less than 3 days; blood loss less than 30 cc Heavy menstrual flow Bleeding in between menstruation FETAL GROWTH AND DEVELOPMENT 1. AOG – Age of gestation 2. Basis: a. LMP – Last Menstrual Period (First day) b. Date of quickening – First fetal movement c. Fundic height (Bartholomew’s rule) - distance from the pubic bone to the fundus Pre: bladder 12 weeks - 16 weeks - 20 weeks - 36 weeks - 3. Emphasis of development First trimester: Organogenesis - initiate the development of fetal organs Second trimester: Fetal length Third trimester: Rapid growth and development DEVELOPMENTAL EVENTS First month (4 weeks) 1. Germ layer formation a) Ectoderm – epidermis, skin, hair, nails, cornea, enamel b) Mesoderm: Musculoskeletal, Circulatory, Reproductive, Ureter, Kidney c) Endoderm: Bladder, Urethra, Neck, GI 2. Brain or nervous system development 3. Fetal heart beat but not audible 4. Development of trachea and esophagus Second month (8 weeks) 1. Organogenesis is complete 2. Development of placenta 3. Development of sex organs Third month (12 weeks) 1. Complete placenta and barrier 2. Production of amniotic fluid Volume: ml If low: high: pH:slightly alkaline (Nitrazine test: ) Color: 3. Audible FHT by _ 4. Bone formation Fourth month (16 weeks) 1. Audible FHT by _ 2. Visualization of skeletal outline 3. Human face appearance 4. Development of external genitalia 5. Lanugo (fine hair) Fifth month (20 weeks) 1. – first fetal movement felt by 2. Vernix (cheesy like substance acts as a lubricant to allow easy passage of the baby to the birth canal) 3. Audible FHT by Sixth month (24 weeks) 1. Term size 2. Scalp hair 3. Pinkish, wrinkled skin (lack of brown fats) Seventh month (28 weeks) 1. Development of alveoli (air sacs) 2. Production of surfactant- makes the lungs able to expand Eight month (32 weeks) 1. Decreased lanugo and vernix 2. Rapid fat deposition 3. Viable Ninth month (36 weeks) 1. Lanugo and vernix caseosa disappearance 2. Amniotic fluid decreases 3. Birth position assumed 4. Lightening(baby settles in the pelvis, ready to be delivered) PRENATAL CARE – is a preventive healthcare that benefit both mother and child 1. Assessment a. Prenatal History: Gravida (G) – no. of pregnancies Para (P) – no. of pregnancies that reached the age of viability Term (T) - wks Preterm (P) - wks Abortion(A) - wks Living (L) ACTIVITY!!! b. AOG c. EDC/EDD – Expected date of confinement (EDC) / Expected due date (EDD) Naegele’s Rule standard way of calculating the due date of pregnancy January - March April – December ACTIVITY!!! 2. Signs and symptoms of pregnancy Onset Presumptive Probable Positive First trimester B A U N Positive Hegar’s – Goodell’s – Chadwicks – Fetal heart tone (FHT): 12 wks - 16 wks - 20 wks - Second trimester Quickening – first fetal movement Chloasma – darkening of the skin “mask of pregnancy” Ballotement – the use of a finger to push sharply against the uterus and detect the presence of a fetus by its return impact. Braxton hick’s- painless false contractions Fetal outline UTZ (ultrasound) ACTIVITY!!! 3. Weight monitoring: 1st tri: lbs or lb/mo. 2nd tri: lbs or lbs/mo. 3rd tri: lbs or lbs/mo. Entire duration: lbs 4. Diagnostic tests: a. Rubella Titer – antibody titer to determine if patient is already immune to rubella 1:8 – 1:8 – : Avoid exposure to large crowds and contact with children If not immune – give NOTE: Avoid getting pregnant for at least after the vaccination If already pregnant: never give vaccination, do it after delivery Assess: eggs and gelatin allergies b. Alpha-fetoprotein Screening (AFP) – protein produced by the liver of unborn baby Normal value: 2.5 MoM (Multiples of Mean) Results: High - Low - Health teaching (diet): QUESTION!!! c. Chorionic Villi Sampling – uses a catheter to get a sample Pre: consent; Bladder Intra: Monitor Maternal VS and FHR Post: WOF – d. Amniocentesis – a needle is inserted in the abdomen thru the uterus, guided by an ultrasound Pre: consent; Bladder Intra: Monitor Maternal VS and FHR Post: WOF - Complication: e. Lecithin/Sphingomyelin ratio – test for lung maturity Normal: f. Leopold’s Maneuver Pre: bladder hands Fundus Fetal Back & Spine Symphysis Pubis Pelvic DETERMINE: HEAD: BUTTOCKS: DETERMINE: DETERMINE: DETERMINE: FETAL BACK: ENGAGED: NOT ENGGAGED: 5. Activities of daily living a) Smoking Still birth, abortion, small for gestational age b) Alcoholism C R I M P c) Sexual activity – generally but there will be changes in desire Avoided if: Pre-term labor – labor contractions before the 37th week Incompetent cervix – due to weak cervix d) Traveling/employment Prolonged sitting/standing Management: 6. Frequency of pre-natal visits 0-7 months: 7-9 mos: 9 mos and up: 7. Nutritional requirements 2,500 kcal/day or add 300 kcal to usual diet PHYSIOLOGIC CHANGES IN PREGNANCY CARDIOVASCULAR 1. Supine hypotension 2. Ankle edema, varicosities, possible clot formation 3. Physiologic anemia 4. Uterine pressure ENDOCRINE Hormones increases in activity 1. Increased activity of adrenal cortex 2. Increased activity of thyroid gland 3. Increased activity of anterior pituitary gland 4. Placental hormones a) HCG (Human Chorionic Gonadotropin) N&V (1st tri) - N&V beyond 1st tri – b) HPL (Human Placental Lactogen) - facilitates protein synthesis and transport of amino acid to the fetus c) Estrogen d) Progesterone GIT 1. Nausea & vomiting Mgt: -mall frequent meals E -at dry toast or crackers A -void gastric irritants and gas forming foods S -it upright 2. Constipation Mgt: F -iber increase L -ots of fluid E -xercise A -mbulation 3. Heartburn Mgt: same with N&V 4. Hemorrhoids – severe dilation of rectal veins Mgt: Correct constipation warm sitz bath – to promote circulation for healing cold compress - to prevent swelling MUSCULO-SKELETAL 1. Leg cramps due to Phosphorus and Calcium imbalance 2. Muscle relaxation joints affected = waddling gait WOF: 3. Backache due to Lordosis – inward curvature of the spine Mgt: Pelvic rock exercise Low heeled shoes REPRODUCTIVE 1. Amenorrhea –absence of menstruation 2. Leukorrhea – milky white vaginal discharge 3. Chadwick’s – bluish discoloration of the cervix and vagina 4. Goodell’s – softening of the cervix 5. Hegar’s – softening of the uterus 6. Breast changes 7. Colostrum production – thin watery high protein fluid - contains antibodies ACTIVITY!!! (LIST DOWN APPROIPRIATE NURSING INTERVENTION FOR EACH PROBLEM) PROBLEM NURSING INTERVANTION Supine Hypotension Ankle Edema Physiologic Anemia Nausea and Vomiting Constipation Hemorrhoids Leg Cramps Backache COMPLICATED PREGNANCY BLEEDING IN PREGNANCY **TO DETERMINE CAUSE: Trimester (AOG) 1st: 1-12 wks 2nd: 13-27 wks 3rd: 28 and up First Trimester Bleeding ABORTION BLEEDING, CONTRACTION, DILATION Products of conception: Placental and fetal tissue TYPES: 1. INDUCED – intentional termination of pregnancy 2. SPONTANEOUS – miscarriage (pregnancy loss) A. THREATENED – vaginal bleeding during the first 20 weeks of pregnancy B. INEVITABLE – cervical dilation and uterine contractions Missed - products of conception are expelled Incomplete - products of conception are expelled Complete - products of conception are expelled MANAGEMENT: ECTOPIC PREGNANCY - implantation outside of the uterus Risk factors: Pelvic inflammatory Disease (PID) -Infection -IUD (Intrauterine Device) -In vitro fertilization (IVF) S/Sx: Sharp, stabbing unilateral pain Shoulder pain Scanty vaginal spotting Rupture: Diagnosis: Mgt: Methotrexate (chemotherapy agent and Immunosuppressant) -to attack the fast growing cells Mifepristone (abortifacient) Salphingectomy – removal of the fallopian tube Second Trimester Bleeding HYDATIDIFORM MOLE - also known as Gestational trophoblastic disease - abnormal proliferation of trophoblastic villi S/Sx High HCG levels Hyperemesis gravidarum – excessive vomiting more than 3 months Hypertension Height of fundus greater than AOG Heart tone absent History of grapelike clusters upon ultrasound Associated with: Mgt: Avoid getting pregnant for at least Methotrexate D&C, hysterectomy (removal of the uterus) INCOMPETENT CERVIX - premature dilation of the cervix Cause: Unknown Damage due to previous surgery or trauma Assessment: Management: Third Trimester Bleeding 1. Placenta Previa 2. Abruptio Placenta Placenta Previa Abruptio Placenta Risk factors Maternal age African american Previous history of Smoking HTN Cocaine use DM Polyhydramnios Pain Bleeding Uterus Management Monitor VS and FHR Left side lying Oxygen Fluids Monitor VS and FHR Left side lying Oxygen Fluids ACTIVITY!!! BIOPHYSICAL PROFILE Non stress test Contraction stress test - Assesses fetal well being – blood flow&oxygen • EVERY TIME THERE IS PRESS THE BUTTON. • Done 1 hour post meal - Duration: Measures: FHR acceleration r/t fetal movement RESULTS NORMAL/ REACTIVE ABNORMAL / NON-REACTIVE - Evaluates fetal response to stress of labor EMPTY MAY PROVIDE Duration: Measures: FHR deceleration r/t to uterine contraction RESULTS (-) NORMAL (+)ABNORMAL Pregnancy Induced Hypertension (PIH) Risk factors: History of preeclampsia, heart disease, DM, renal problems, hydramnios Obesity Multiple gestation Extremes in age: Low socioeconomic background African American Nulligravid(never been pregnant)/ Primipara (giving birth for the first time) Distention(over) of the uterus BP Edema Proteinuria Others Gestational HTN Mild Preeclampsia Severe Preeclampsia Eclampsia Management: Diet: Seizure precaution DOC  Antidote: Anti-HTN drugs If eclampsia, delivery Rh incompatibility Exposure: birth, miscarriage, trauma, puncture WOF: ERYTHROBLASTOSIS FETALIS Diagnosis: Coomb’s test Treatment: How to prevent RH Incompatibility: Coomb’s test ( ) wk of pregnancy within hrs post exposure LABOR AND DELIVERY Causes of Labor Onset 1. Decreased placental function due to aging placenta 2. Decreased progesterone 3. Increased oxytocin 4. Increased uterine stretch 5. Increased prostaglandin 4P A. PASSAGE – the pelvis Factors Affecting Labor and Delivery B. PASSENGER – the baby will first contact the cervix A. Cephalic – head first B. Breech – buttocks and legs first C. Shoulder 2. Position – relationship of the fetal presenting part to the mother’s pelvis 3. Station – relationship of presenting part to ischial spine Above the ischial spine Below the ischial spine C. POWER – the ability to push Stages of Labor and delivery I. – Onset of true labor  full cervical dilation II. – Full cervical dilation  birth of baby III. – Birth of baby placental delivery IV. – Puerperium - period within 6 weeks after childbirth (post partum) D. PSYCHE – the emotional state during birth of the baby FIRST STAGE: True Labor False Labor Interval Contraction Pain Cervical changes PHASES OF LABOR Latent Active Transitional Dilation Frequency Duration Intensity Mild Moderate Strong FHR VARIABILITIES FHR Pattern Description Nursing Interventions EARLY Deceleration FHR at the of uterine contractions (UC) then returns to baseline at the of UC LATE Deceleration FHR the onset of UC and continues beyond the end of UC VARIABLE Deceleration FHR is in relation to UC SECOND STAGE: Intrapartal Care: 1. Assessment – Mother - VS Fetus -FHR 2. Nutrition: if presenting part is known: yogurt Unknown presenting part: NPO 3. Comfort measures a. Position: Squatting, On all fours, Semi-sitting b. Sacral pressure – relieves back pain c. Effleurage – light massage d. Breathing technique Latent- Chest Active - Abdominal Transitional – Pant pant blow (Hee-Hee-Ho) e. Encourage voiding – to allow more space for contraction f. Analgesics: Nalbuphine Hcl (Nubaine) Meperidine (Demerol) WOF: Contraindicated: Antidote: g. Anesthesia • Pudendal block – anesthesia injected in the pudendal canal where pudendal nerve is located • Epidural – (side lying position) WOF: • Spinal – (sitting with back arched) WOF: THIRD STAGE Signs of placental separation: Lengthening of the cord Change in shape of the uterus – Calkin’s sign Sudden gush of blood Firm contraction Appearance of placenta at vaginal opening Presentation: 1. Shiny Schultz – side: , separation: center 2. Dirty Duncan – side: , separation: edges FOURTH STAGE: Involution – return of reproductive parts to their non-pregnant state 1. Uterus: Firm and Contracted Placement: Immediately post placental delivery – After 1 upto 24 hours - Then it will decrease 2. After pains – intermittent cramping DOC: NSAIDS V. Lochia – vaginal discharge not clotted and not foul smelling Pattern Duration (days) Color 1-3 Dark red 4-9 Pink to brown 10 and up White 4. Abstinence – 3-4 weeks to prevent vaginal and cervical infection 5. Temperature – 1st 24 hours: (normal) increased in temperature due to dehydration After 24 hours: 100.4F – (abnormal) INFECTION POINTS TO REMEMBER: POST-PARTAL BLEEDING BOGGY BLEEDING SHOCK OTHER MGT UTERINE ATONY (Abnormal relaxation of the uterus) 1st 24 hours Ask patient to void Fundal massage Oxytocin RETAINED PLACENTA After 24 hours CLOT FORMATION DILATATION AND CURETTAGE (D&C) Gestational Diabetes Mellitus Risk factors: Native american, Hispanic, Asian Obesity Age History: DM, Polycystic ovarian syndrome (PCOS), large babies, unexplained fetal loss, congenital anomalies (previous pregnancy) Diagnostic test: Oral Glucose Tolerance Test (OGTT) Management: Increase fiber , Low fat, Adequate glucose, Exercise WOF: Hypoglycemia in baby after birth WHY? Because babies are exposed to high blood sugar levels from the mother PRIORITY: Assess glucose and feed the baby CONCEPT: HEALTH PROMOTION AND MAINTENANCE 2 INFANT 0-18 months DEVELOPMENTAL LEVELS Freud: Oral Erickson: Trust vs. Mistrust PLAY: Solitary HOSPITALIZATION: Satisfy oral needs CONCEPT OF DEATH: None SIGNIFICANT PERSON: mother Fear: Stranger Anxiety ACCIDENTAL INJURY: aspiration/ fall/SIDS • They play with their body and senses • Toys: mobiles, rattles, teething rings, music boxes and squeeze toys TODDLER 18months – 3 y.o. DEVELOPMENTAL LEVELS Freud: Anal – toilet training Erickson: Autonomy vs. shame & Doubt (Independence) Play: Parallel HOSPITALIZATION: Security objects CONCEPT OF DEATH: Reversible / Temporary SIGNIFICANT PERSON: Parents FEAR: separation Anxiety ACCIDENT/ INJURY: poisoning/ Fall / Thermal Burns MVA, drowning, child abuse Criteria for toys: Safe Goal Purpose – Talk and walk Toys: push and pull toys, talking toy telephone, blocks Behaviours to observe: Negativisim – Intervention: Set limits and offer choices Temper tantrums- Intervention: ignore and time outs Ritualistic Behavior – Security objects, routines and rituals PRESCHOOL 3 y.o. – 6 y.o. Oedipal – Mama’s boy DEVELOPMENTAL LEVELS Electra – Daddy’s girl PRESCHOOL:  Freud: Phallic  Erickson: Initiative vs. Guilt  PLAY: associative / cooperative HOSPITALIZATION:Explain using paper dolls and puppets CONCEPT OF DEATH: Reversible / Temporary SIGNIFICANT PERSON: Immediate family FEAR: Body mutilation/fear of castration ACCIDENT/ INJURY: motor accident • Loves to share and imitate adults into play • Toys role playing games – play school, play house, doctor-nurse kit Behaviors to observe:  Why stage  Imaginative fear of dark, telling tall tales makes the story exaggerated SCHOOL-AGE 6 – 12 y. o DEVELOPMENTAL LEVELS SCHOOL-AGE: ( normal homosexual )  Freud: Latency  Erickson: Industry v. Inferiority PLAY: Competitive  HOSPITALIZATION:Explain using simple diagrams / Illustrations  CONCEPT OF DEATH: Irreversible / Permanent  SINIFICANT PERSON: teacher FEAR: Doing wrong ACCIDENT/ INJURY: Motor accident, head injury Greenstick fracture • Toys Card games, scrabble, skipping rope Behaviors to observe: Achievement-ORIENTED years ADOLESCENT 12 – 20 y.o. DEVELOPMENTAL LEVELS ADOLESCENT: Freud: Genital Erickson: Identity vs. Role confusion SIGNIFICANT PERSON: Peers Fear: Body Image Disturbance ACCIDENT/ INJURY: sports accident, Drugs, Alcohol, Suicide, MVA, STI’s , Infectious Mononucleosis • Bodily changes which corresponds to puberty • Moody and unpredictable FINE MOTOR SKILLS GROSS MOTOR SKILLS 0 – Reflex grasp 3 – Hands held open 6 – Palmar grasp 9 – Pincer grasp 10 – Points at object 11 – Puts object in container 12 –Throws objects (2 tower blocks) 12-13 – Drinks from a cup, feeds self with spoon 2 yrs – 5 Tower blocks 2 ½ - 7-8 Tower blocks 3 – Unbutton – starts to copy circle, cross &square 4 – Button 6 – Tying shoe laces 0 – Head lag 2 – Lifts head 4 – Full head control 5 – Roll over 6 – Sits with support 7 – Foot in mouth 8 – Sits without support 9 – Crawl 10 – Stands with support 11 – Cruising 12 – Stands alone 14-15 – Walks alone 3y.o – Tricycle 4 y.o. - Bicycle SPEECH GROWTH PRINCIPLES 1 – 2 MONTHS COOS 2 – 4 MONTHS LAUGHS , MAKES CONSONANT SOUNDS 6 MONTHS IMITATIVE SOUNDS 8 – 9 MONTHS PRONOUNCES SYLLABLES (DA-DA) 12 MONTHS SAYS 4 – 5 WORDS 2 YEARS FIRST PHRASE, 300 WORDS 2 ½ YEARS KNOWS FIRST NAME 3 YEARS 3 – 4 WORD SENTENCES, 900 WORDS Physiologic loss of weight a couple of weeks after birth will be observed: 5 – 10% Rapid Stages: Infancy, Adolescence Slow Periods: Toddler, Pre-schooler , School age Reminder: 2x the weight: 6 months 3x the weight:12 months 4x the weight: Toddler Length: 50 % increase at 12 months CHILDHOOD IMMUNIZATION General Contraindication and Precaution General Side Effects Anaphylactic reaction from previous dose Live vaccines such as MMR, Varicella, Polio, Rotavirus are contraindicated for: Pregnant, patients with decreased immune system and with allergies to gelatin Moderate to severe acute illness with or without fever Swelling Tenderness Erythema Fever (low grade) VACCINE IMMUNOGLOBULIN ACTIVE IMMUNIZATION PASSIVE IMMUNIZATION MADE UP OF LIVE VIRUSES TO HELP THE CONTAINS ANTIBODIES BODY PRODUCE ANTIBODIES BEGIN TO WORK IN SEVERAL WEEKS WORKS IMMEDIATELY PROVIDES DECADES OF PROTECTION PROVIDES FEW MONTHS OF PROTECTION THE NEONATES (Birthmarks) REFLEXES DISAPPEARANCE Roof of the mouth is touched Sucking and Rooting 3 – 4 months Corner of the mouth is stroked “Fencing” Tonic Neck Pushes food out of the mouth Extrusion 4 months Hold tightly Palmar Grasp 6 months Due to a loud sound/noise Startle Reflex 4 months Sensation of falling Moro Reflex 6 months Stroke the sole of the foot Babinski Reflex 12 months THE RISK NEONATES CARDIOVASCULAR DISORDER ACYANOTIC Atrial Septal Defect (ASD) – Foramen ovale fails to close – Inc. blood flow in the Right atrium – causes an Increase in Heart rate A "hole" in the wall that separates the top two chambers of the heart. This defect allows oxygen-rich blood to leak into the oxygen-poor blood chambers in the heart. ASD is a defect in the septum between the heart's two upper chambers (atria). The septum is a wall that separates the heart's left and right sides. Patent Ductus Arteriosus (PDA) – Ductus Arteriosus fails to close –causes machine like murmur Coarctation of the Aorta (COA) – Narrowing of Aorta – causes Hypertension in upper extremities and hypotension in lower extremities Coarctation of the aorta — or aortic coarctation — is a narrowing of the aorta, the large blood vessel that branches off your heart and delivers oxygen-rich blood to your body. When this occurs, your heart must pump harder to force blood through the narrow part of your aorta. DIAGNOSTIC AND MANAGEMENT FOR ACYANOTIC HEART DEFECTS • Chest Radiography • Echocardiography • Cardiac Catheterization Corrective Surgery Open Heart • Induction of asystole • Induction of hypothermia • Use of bypass machine Close Heart: • Indomethacin (IV)  For Patent Ductus Arteriosus - IT CLOSES THE DUCTUS ARTERIOSUS MUSCLE Balloon angioplasty  Management for Coarctation of the Aorta Management: 1. Drugs: Digoxin – give before meals Note: Heart rate ( Bradycardia) WOF: Digoxin toxicity Hypokalemia – may cause toxicity Withhold Digoxin if: Infant – 100 bpm Adult – 60 bpm Antidote: Digoxin Immune Fab (Digibind) Diuretics ACE Inhibitors – decreases peripheral vascular resistance 2. Diet: Low Sodium 3. Decrease O2 demand: Cluster care – to do things all at once to provide longer rest periods Quiet play / activity Decrease anxiety and stress CYANOTIC A. Transposition of the great vessels B. Tetralogy of Fallot Pulmonary Artery Stenosis Right Ventricular Hypertrophy Overriding Aorta Ventricular Septal Defect Symptoms: • Exertional Dyspnea • “Tet spells” – “Blue spells” – Hypercyanotic - presence of cyanosis • Clubbing of fingers • Polycythemia • Stunted Physical Growth and delayed development Management: • Dec O2 Demand • Propranolol • Monitor Hgb and Hct count • Positioning during attacks: Squatting / Knee chest • Give Oxygen • Monitor Activity tolerance Surgery: Palliative: Blalock- Tausig - surgical procedure to temporarily direct the blood flow to the lungs and relieve cyanosis while waiting for the corrective surgery. Complete: Brock Procedure – surgical technique for correction of pulmonic stenosis, excision of the fibromuscular obstruction in the right ventricle. ACQUIRED HEART DISEASE RHEUMATIC HEART FEVER - An autoimmune disease that affects CONNECTIVE TISSUES. It manifests 2-6 weeks after untreated GABHS infection of URTI (upper respiratory tract) Diagnostic: JONES CRITERIA Positive if: 2 Major criteria or 1 Major and 2 Minor criteria Management: Control joint pain (large joints) and inflammation Bed rest Antibiotics Salicylates (Aspirin) WOF: Reye’s syndrome ***Antibiotic prophylaxis for dental work and invasive procedures to prevent INFECTIVE ENDOCARDITIS KAWASAKI DISEASE - An acute systemic inflammatory illness. Cause: Unknown Most serious complication: Cardiac complication (affects the coronary arteries) Common to Asians: Boys under 5 years old Japanese and Korean Assess: Heart sounds Examine eye for conjunctivitis Monitor I and O Diet: soft foods and liquids Passive ROM Med“icAaNtioegna:tiAvsepMiriinn,d Iwgil(lInVe)ver give you Positive Result.” 28 GASTROINTESTINAL PROBLEMS Pyloric Stenosis Narrowing of Pyloric Sphincter Diagnostic finding: String sign Manifestations: Radiographic finding – a patient is given a Abdominal distention radio opaque dye (barium) and x-rays are Projectile vomiting taken. Dye will take on the appearance of Weight loss thin string as it passes through the Hypokalemia narrowed pyloric sphincter. Olive shaped mass Surgery: Fredet-Ramstedt Procedure (Pylorotomy with Pyloroplasty) – to dilate narrowed pyloric sphincter Nursing Consideration: Pre: Intravenous Fluid (IVF), NPO Post: Monitor, I&O, Small frequent feeding (SFF), Feed infant slowly, burping frequently Intussusception Imperforated Anus -Telescoping of the intestine Signs and Symptoms: • Spasmodic Abdominal pain • Blood with mucous (Currant jelly stool) • Sausage shaped mass • Bile stained vomitus Mgt: • Barium Hydrostatic reduction technique No opening in the anus Normal passage of meconium: 24-36 hours post birth Management: Colostomy and Anoplasty Small frequent feedings (SFF) Stay upright If with suspicion: Notify the MD No rectal temperatures HIRSCHPRUNG DISEASE -Absence of ganglion cells in the Large intestine – “AGANGLIONIC MEGACOLON” Signs and Symptoms: • Initial: Absence of stool • Constipation • Ribbon-like stool • Pellet-like stool • Abdominal Distention with possible fecaloid vomitus • Weight loss Dx: • Rectal Biopsy • Barium enema Surgery: Endorectal Pull –through procedure Esophageal Atresia and Tracheoesophageal Fistula Ends in a blind pouch Connection between the esophagus and trachea Cleft Lip Cleft Palate Cause: Gender: Multifactorial MALE Hypervitaminosis, drugs, smoking FEMALE Surgery Cheiloplasty – to save the sucking reflex at 3-6 mos. Palatoplasty / Uranoplasty – to prevent faulty speech habits at 6-24 mos. Position post surgery Feeding Supine Dropper, nipple with large holes Prone –for proper drainage to prevent aspiration No straws Use CUP (ex. sippy cups) Protection Logan bow device Elbow restraint Logan bow device – a wire piece attached to the patients cheeks and pushes the cheeks together NOTE: AVOID CRYING – it stresses the suture line NEUROLOGIC DISORDERS NEURAL TUBE DEFECTS Spina bifida occulta – Fissure in the spinal column Meningocele – Protrusion (sac) containing: Meninges and Spinal fluid Myelomeningocele – Protrusion (sac) containing: Meninges, Spinal fluid and nerves Over-all objective: Protect the sac from infection and pressure Intervention: 1. Position: prone 2. Feeding: hold the baby, avoid pressure on the sac 3. Cover: gauze + NSS 4. Bowel function: Increase in fiber 5. Monitor infection – check temperature 6. Provide adequate nutrition 7. Monitor: Increase ICP HYDROCEPHALUS Causes: Tumor, hemorrhage, infection or trauma Signs and symptoms: • S/sx of Increase in ICP Infant – irritability, restlessness, shrill cry (high pitched) Toddler – irritability, lethargy, lack of appetite, headache, nausea and vomiting Older children – altered LOC • Sun set eyes – eyes are driven downward • Frontal bossing – protruding forehead • Dilated scalp veins • Increase head circumference • Macewen’s sign - tapping over the frontal and temporal lobe (+) sign is known as having a “CRACKED POT SOUND” – sound of a broken vessel or container Nursing Care: • Side lying position • Measure Head circumference • Prevent increase in ICP: Quiet and non-stimulating environment Surgery: Ventriculoperitoneal shunt (VP SHUNT) - SHUNTING FLUIDS FROM THE VENTRICLES TO PERITONEUM Pre-op: Side lying position Monitor I&O Small Frequent Feedings Reposition head frequently Post-op: Flat on bed for the 1st 24 hours then semi fowler’s after 24 hours 31 CEREBRAL PALSY Impaired movement and posture Assessment: Feeding difficulties Abnormal motor performance Stiff, rigid, arms and legs Developmental milestones Persistent infantile reflexes Abnormal posturing Seizures NURSING INTERVENTIONS: Goal: Early detection and Intervention -Assess child’s developmental level -Maximize the child’s asset and minimize the limitations -Mobilizing device: WHEELCHAIR -Encourage communication and Interaction -Provide SAFETY! Candidate for tonsillectomy: 5 episodes in a year 1 episode in 3 consecutive years Pre-op: Check dental and bleeding status check for loose teeth – to prevent aspiration Post-op: Position: side lying (semi-prone) Observe for bleeding : FREQUENT SWALLOWING Prevent bleeding – ICE COLLAR DIET: clear and non-irritating fluids AVOID: red, purple and brown fluids crunchy foods, hot and spicy foods, citrus fruits/juices Allowed to give: water, apple juice, popsicle EPIGLOTITIS CAUSE: Haemophilus influenza COMMON: 2-5 y/o Signs and symptoms: Drooling , Dyspnea, Dysphagia Stridor The child is in tripod position -leaning forward- Management: Tracheostomy, Antibiotics , Corticosteroids (PRN) , O2 ***Do not put anything in the clients mouth! HYPOSPADIAS & EPISPADIAS A congenital condition in males in which the opening of the urethra is on the underside of the penis. Cause: Genetics Abnormal Embryonic Development Abnormal position of Urethra Mgt: - done before circumcision, at 6-18 mos Cantwell technique (Epispadias) Mathieu technique (Hypospadias) Principles: 1. Create a hole on tip 2. Cover the excessive hole 3. Fix the bend Post-op: VS, antibiotics, IFC REFER: (-) URINE OUTPUT within 1 hour Newborn Care – Dressing the umbilical cord CORD CARE: 1. DO NOT MOIST REGULARLY – Air Dry and Alcohol NOTE: FALLING OFF UMBILICAL CORD ON THE 7th DAY WOF: ALWAYS WET UMBILICAL CORD Patent Urachus – opening between the navel (belly button) and the urinary bladder INFECTED UMBILICAL CORD IS KNOWN AS Omphalitis CHILD ABDUCTION – forcibly taking someone away against their will Common: PRESCHOOLER Nursing interventions Instruct parents to teach child the basic guidelines on personal safety:  Don’t go anywhere alone  Always tell an adult where you’re going and when you’ll return  Say NO if you feel uncomfortable with a situation.  Don’t talk with strangers or get into their cars.  Don’t help anyone to look for a lost dog or cat and don’t accept candies from strangers.  If lost in a store, don’t wander around looking for the parent, go at once to a clerk/guard. • Children need to learn their full name, address, and parents’ name. • Watch out for PTSD in any child who experienced abduction.