Pedia Notes Physiologic wt loss – 5 – 10% wt loss few days after birth Small GA < (less) 10 Large GA > (more) 90 Physical Exam and Deviations fr Normal 1. if client is new born, cover areas not being examined 2. if client is infant – the 1 st yr of life - get VS – take RR 1 st - begin fr least intrusive to the most intrusive area 3. if client is a toddler and preschool, let them handle an instrument like: - play syringe or stet, security blanket – favorite article. Let baby hold it. 4. Explain procedure and respect their modesty - school age and adolescent V/S: Temp: rectal- newborn – to rule out imperforate anus take it once only, 1 inch insertion Imperforate anus 1. atretic – no anal opening 2. agenetic – no anal opening 3. stenos – has opening 4. membranous – has opening Earliest sign: 1. no mecomium 2. abd destention
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Pedia Notes
Physiologic wt loss – 5 – 10% wt loss few days after birth
Small GA < (less) 10
Large GA > (more) 90
Physical Exam and Deviations fr Normal
1. if client is new born, cover areas not being examined
2. if client is infant – the 1st yr of life - get VS – take RR 1st
- begin fr least intrusive to the most intrusive area
3. if client is a toddler and preschool, let them handle an instrument like:
- play syringe or stet, security blanket – favorite article. Let baby hold it.
4. Explain procedure and respect their modesty - school age and adolescent
V/S:
Temp: rectal- newborn – to rule out imperforate anus
take it once only, 1 inch insertion
Imperforate anus
1. atretic – no anal opening 2. agenetic – no anal opening3. stenos – has opening4. membranous – has opening
Earliest sign:
1. no mecomium
2. abd destention
3. foul odor breath
4. vomitous of fecal matter
5. can aspirate – resp problem
Mgt:
Surgery with temporary colostomy
Cardiac rate: 120 – 160 bpm newborn
Apical pulse – left lower nipple
Radial pulse – normally absent. If present PDA
Femoral pulse – normal present. If absent- COA - coartation of aorta
Congenital Heart Dse
Common in girls – PDA, ASD atrial septal
Common in boys – TOGA ( transportation of great arteries)
TA – tronchus arteriosus
TOF – tetralogy of fallot
Causes:
1. familial2. exposure to rubella – 1st month 3. failure of strucute to progress
acyanotic L to R
cyanotic R – L
Acyanotic heart defects L to R
1. ventricular septal defect - opening between 2 ventricles
S&Sx 1. systolic murmurs at lower border of sternum and no other significant sign
2. cardiac catheterization reveals increased o2 saturation @ R side of heart3. ECG reveals hypertrophy of R side of heart
Nsg Care:
Cardiac catheterization: site – Rt femoral vein
1. NPO 6 hrs before procedure2. protect site of catheterization. Avoid flexion of joints proximal to site.3. assess for complication – infection, thrombus formation – check pedal pulses
( dorsalis pedis)
Mgt.
1. long term antibiotic – to prevent subacute bacterial endocarditis2. open heart surgery-
2.) ASD – failure of foramen ovale to close
S&SX
1. systolic murmur @ upper border of sternum 2. result of cardiac catheterization & ECG same with VSD
Mgt: open heart surgery
3.) endocardial cushion defects - atrium ventricular (AV) - affects both tricuspid and mitral valve
Dx – confirmed by cardiac catheterization
Mgt: - open heart surgery
Antibiotics to prevent subacute bacterial endocarditis
4.) PDA - failure of ductus arteriosus to close
- should close within 24 h -complete close – 1 month
S&Sx
1. continuous machinery like
murmurs 2. prominent radial pulse 3. ECG- hypertrophy Left ventricle
Drug:
1. endomethazine – prostaglandin inhibitor - facilitate closing of PDA2. ligation of PDA by 3-4 yo3. thoracotomy procedure- nakadapa child
5.)Pulmunary Stenosis- narrowing of valve of pulmo artery
S &Sx: 1.) typical systolic ejection murmur
2. S2 sound widely split
3. ECG- Lt ventricular hypertrophy
6.)Aortic Stenosis – narrowing of valve of aorta
S & Sx: 1. inactive, sx sme with angina
2. typical murmur
3. rough systolic sound and thrill
4. ECG- Left ventricular hypertrophy
cardiac catheterization-
Mgt Pulmo Stenosis & Aortic Stenosis
1. balloon stenostomy2. surgery
Duplication of Aortic Arch- doubling of arch of aorta causing compression to trachea and esophagus
S&Sx : 1. dysphagia 2. dyspnea
3. left ventricular hypertrophy
Mgt: - close heart surgery
8.) Coartation of Aorta – narrowing of arch of aorta
outstanding Sx : absent femoral pulse
BP increased on upper extremities and decreased on lower extremities
ECG – hypertrophy Lft ventricle
Mgt: close heart surgery
CYANOTIC HEART DEFECTS R to L
1. Transportation of Great Arteries (TOGA) - aorta arising from Rt ventricle
pulmo artery arisin
g form Lt ventricle
Outstanding Sx:
1. cyanosis after 1st cry (due no exygenation) 2. polycythemia
– increased RBC =compensatory due to O2 supply=viscous blood
=thrombus = embolus = stroke
3. ECG – cardiomegaly
Cardiac cath – decreased O2 saturation
Palliative repair – rashkind procedure
Complete repair – mustard repair
2.) Total Anomalous Pulmonary
venous return – pulmo vein instead of entering Lt atrium, enters Rt atrium or SVC
Increased pressure on Rt so blood goes to Lft
Outstanding Sx: Open foramen ovale
Mild to moderate cyanosis
Polycythemia = thrombus = embolus = stroke
asplenia- absent spleen
Mgt: restructuring of heart
3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 1 single vessel or common trunk with VSD
S & Sx 1. cyanosis
2. polycythemia – thrombus = embolus = stroke
Mgt: Heart transplant
4.) Hypoplastic Left heart syndrome – non fx Left ventricle
1. cynosis
2. polycythemia – throm, emb, stroke
Mgt: heart transplant
5.) Tricuspid atresia – failure of tricuspid valve to open
S&SX: open foramen ovale
(R to L shunting – goes to Lt atrium)
cynosis, polycythemia
Mgt: fontan procedure – open tricuspid valve
6.) Tetralogy of Fallot
P – pulmonary stenosis
V – ventricular SD
O – overriding or dextroposition of aorta
R – Rt ventricular hypertrophy
S &Sx:
1. Rt ventricular hypertrophy 2. high degree of cyanosis3. polycythemia4. severe dyspnea – squatting position – relief , inhibit venous return facilitate lung expansion. 5. growth retardation – due no O26. tet spell or blue spells- short episodes of hypoxia7. syncope8. clubbing of fingernails – due to chronic tissue hypoxia9. mental retardation – due decreased O2 in brain
st. vetaus dance-purposeless involuntary hand and shoulder with grimace
2. low grade fever
3. carditis – tachycardia 3. all lab results
erythema marginatum - macular rashes
SQ nodules
increase antibody
" C reactive protein
" erythrocyte sedimentation rate
" anti streptolysin
o titer (ASO)
Criteria:Presence of 2 major, or 1 major and 2 minor + history of sore throat will confirm the dx.
Nsg Care:
1. CBR 2. throat swab – culture and sensitivity 3. antibiotic mgt – to prevent recurrence 4. aspirin – anti-inflammatory. Low grade fever – don’t give aspirin.
S/E of aspirin:
Reyes syndrome – encephalopathy- fatty infiltration of organs such as liver and brain
Respiration
Newborn resp – 30-60 cpm, irregular abd or diaphramatic with short period of apnea without cyanosis.
< 15 secs – normal apnea –newborn
Resp Check
Newborn – 40 – 90
1 yr - 20 – 40
2-3yr 20 – 30
5 yrs 20 – 25
10 yrs 17 – 22
15 & above 12- 20
BREATH SOUNDS HEARD DURING ASCULTATION:
1.) VESICULAR – soft, low pitched, heard over periphery of lungs, inspiration longer then expiration -Normal
2.) BRONCHOVESICULAR- soft, medium pitched, heard over major bronchi, inspiration equals exp. Normal
3.) BRONCHIAL SOUNDS- loud high pitched, heard over trachea, expiration longer than inspiration. Normal
4.) RHONCHI – snoring sound made by air moving through mucus in bronchi. Normal
5.) RALES-or crackles – like cellophane – made by air moving through fluid in alveoli.
Abnormal- asthma, foreign body obstruction.
6.) WHEEZING- whistling on expiration made by air being pushed through narrowed bronchi .Abnormal – asthma, foreign body obstruction
7.) STRIDOR- crowing or ropster life sound – air being pulled through a constricted larynx. Abnormal – resp obstruction
Asthma- pathognomonic sign – expiratory wheezing
Pet – fish. Sport – swimming
Drugs – amynophylline – monitor bp, may lead to hypotension
Laryngo Tracheo Bronchitis LTB
- inspiratory stridor – pathognomonic sign
RDS respiratory dist synd or hyaline membrane dis
Cause- lack of surfactant – for lung expansion
Hypotonia, Post surgery, Common to preterm
Fibrine hyaline
Sx – definite with in 1st of life
Increase RR with retraction
Inspiratory grunting – pathognomonic
7 – 10 severe RDS (silvermenn Anderson index)
cyanosis due to atelectasis
Mgt:
1. surfactant replacement and rescue 2. pos- head elevated 3. proper suctioning
4. o2 with increase humidity- to prevent drying of mucosa 5. monitor V/S skin color , ABG6. CPAP- continuous + a/w pressure7. PEEP - + end expiratory pressure
Purpose of #6-7- to maintain alveoli partially open and alveoli collapse
LARYNGOTRACHEOBRONCHITIS
LTB – most common Creup -viral infection of larynx, trachea & bronchi
outstanding sx - croupy cough or barking
pathognomonic - stridor
labored resp resp acidosis end stage – death
Lab:
1. ABG 2. neck and throat culture3. dx- neck x-ray to rule out epiglotitis
Nsg Mgt:
1. bronchodilators
2.increase o2 with humidity
3. prepair tracheostomy set
BRONCHOLITIS- Inflammation of bronchioles – tenatious mucus
Causative agaent – RSV - Resp sincytial viruses
Sx: flu like sx
Increased RR
Drug: Antiviral – Ribavirin
End stage – epiglotitis
EPIGLOTITIS - infl of epiglottis
- emer. Condition of URTI
Sx: sudden onset
Tripod position – leaning forward with tongue protrusion
never use tongue depressor
prepare tracheotomy set
< 5 yo – unable to cough out, put on mist tent (humidifier o2) or croupe tie
Nsg Care: check edges tucked on mist tent
Provide washable plastic material
No toys with friction due O2 on
No hairy toys – due moist environment medium for bacterial growth
BP – 80/46 mmHg newborn
BP after 10 days- 100/50
BP taking begins by 3 yo
COA – take BP on 4 extremities
SKIN:
Acrocyanosis
BIRTHMARKS:
1. Mongolian spots – stale gray or bluish discoloration patches commonly seen across the sacrum or buttocks due to accumulation of melanocytes. Disappear by 1 yr old
2. MIlla – plugged or unopened sebaceous gland . white pin point patches on nose, chin or cheek.3. Lanugo – fine, downy hair – common preterm 4. Desquamation – peeling of newborn, extreme dryness that begin sole and palm. 5. Stork bites (Talengeictasi nevi) – pink patches nape of neck
hair will grow as child grows old
1. Erythema Toxicum – (flea bite rash)- 1st self limiting rash appear sporadically & unpredictably as to time & place.
2. Harlequin sign – dependent part is pink, independent part is blue
(side lying – bottom part is dependent pink)
3. Cutis Marmorato – transitory mottling of neonates skin when exposed to cold. 4. Hemangiomas – vascular tumors of the skin
3 types Hemangiomas
a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can be removed surgically
b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. Enlarges, disappears at 10 yo.
c.) Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear with age. - MOST DANGERIOUS – intestinal hemorrhage
Skin color blue – cyanosis or hypoxia
White – edema
Grey – inf
Yellow – jaundice , carotene
Vernix Caseosa – white cheese like for lubrication, insulator
BURN TRAUMA – injury to body tissue caused by excessive heat.
1. Continuous drooling saliva 2. inability to open , eye & close either eye
Mgt:
Refer to PT
TEF (Tracheoesophageal Fistula)-TEA- no connection bet esophagus and stomach
Outstanding Sx – Coughing
Choking
Continuous drooling
Cyanosis
Mgt:
Emergency surgery
Epstein pearl – white glistering cyst at palate & gums related to hypercalcemia
Hypervitaminosis
Natal tooth – tooth at birth. Move with gauze
Neonatal tooth – tooth within 28days of life
Moniliasis – oral candidiasis
white cheese like, curd like patches that coats tongue oral thrush Nsg Care – don’t remove, wash with cold boiled H2o
Meds – nystatin / Mysnastatin – antifungal
Kawasaki Dse--strawberry tongue - originated in Korea
- Dr. Kawasaki discovered it
- common in Japan
- "mucocutaneous Lymphnode Syndrome"
Sx:
-persistent fever – 5 days
-strawberry tongue ,
-desquamation of palm & sole
- lymph adenopathy > 1.5 cm
Drug: aspirin
Can lead to MI
LIPS- symmetrical
Cleft lip – failure of median maxillary nasal process to fuse by 5-8 wks of pregnancy
common to boys unilateral
Cleft Palate- Failed palate to fuse by 9 – 12 wks of pregnancy
common to girls unilateral or bilateral
Sx:
1. evident at birth 2. milk escapes to nostril during feeding 3. frequent colic & otitis media or URTI
Mgt:
1. Surgery
cleft lip repair – Cheiloplasty =done 1-3 months to save sucking reflex (lost in 6 months )
Cleft Palate- uranoplasty = done 4-6 months to save speech
Pre op care
1. emotional support especially to mom2. proper nutrition 3. prevent colic
feed – upright seating or prone pos
burp frequently 2x at middle and after feeding-lower to upper tap
4. orient parents to type of feeding
rubber tipped syringe – cheiloplasty
paper cup/ soup spoon/ plastic cup – urano plasty
5. apply restraints – elbow restraints
so baby can adjust post op
Condition that warrants suspension of operation
colds & pharyngitis = can lead to generalized infection – septicemia
Post Op Nsg Care :
1. airway – positon post cheilopasty – side lying for drainage
post uranoplasty (tonsillectomy)- prone
2. assess for RDS sx bleeding
3. assess for bleeding – freq swallowing. 6-7 days after surgery – bleeding
4. proper nutrition
clear liquids- ( gelatin except red or brown color due may mask bleeding) ( popsicle- not ice cream)
full liquid
soft diet
regular diet
5. Maintain integrity of suture line such as:
Logan bar – wash ½ strength Hydrogen Peroxide & saline solution- Bubbling effect
traps microorganism
- prevent baby form crying
for pain- analgesic
NECK-
1. check symmetry
Congenital torticolis- " wryneck"-burn injury of sternocleidomsstoid muscle during
delivery – due to excessive traction at cephalic delivery
Mgt: passive stretching exercise , Surgery
Complication – scoliosis
THYROID gland – for basal metabolism
Congenial cretinism – absence or non functioning thyroid glands
reasons for delaying dx:
1. Thyroid glands covered by sternocleidomastoid muscles in newborn 2. baby received maternal thyroxine 3. baby sleeps 16 – 20 h a day
earliest sign:
1. change in crying 2. change in sucking 3. sleep excessively 4. constipation 5. edema – moon face
late sign
1. mental retardation
prognosis : mental retardation preventable when Dx is early
Dx:
1. PPI-protein 2. radioimmunoassay test 3. radioactive iodine uptake
Mgt: synthroid – sodium Levothyrosine -synthetic thyroid given lifetime
check pulse rate before giving synthroid tachycardia – Sx of hyperthyroidism
CHEST
1. symmetry 2. breast - transparent fluid coming out from newborn related to hormonal changes-
3. chest has retroactive – RDS
4. sternum sunken – pectus excavation
ABDOMEN (in order)
1. inspection I2. Auscultation A3. percussion P4. Palpation P = Will change bowel sounds, so do last
Normal contour of abd – slightly protruding
Sunken abd- diaphramatic hernia – protrusion of stomach content through a defective diaphragm due to failure of puroperitoneal canal to close.
Sx:
1. sunken abd2. Sx of RDS3. R to L shunting
Mgt:
Emergency surgery within 24h
Omphalocele – protrusion of stomach contents in between junction of abd wall and
umbilicus.
Mgt- very small surgery
If large – suspension surgery
Nsg Mgt: protect sac- sterile wet dressing
Gastrochisis – absence of abd wall
Nsg Mgt: sterile wet dressing
Fx of GIT
1. assists in maintaining F&E & acid base balance 2. Processes & absorbs nutrients to maintain metabolism & support G & D 3. excrete waste products from digestive process
Recommended Daily Allowance
Calories : 120 cal / Kbw/day (kilo body wt)
360 – 380 cal/ day
CHON_ 2.2g /Kbw/day
Principles in Supplementary Feeding
Supplementary Feeding usually – 6 mos
Supplementary feeding given – 4 mos.
a.) solid food offered to ff sequence!
1. cereals – rich in iron
2. fruits
3. veg
4. meat
b.) begin with small quantities
c,) finger foods – offered 6 months
d.) soft table food – "modified family menu" given 1 yr
e.) dilute fruit juices – 6 mos
f.) never give half cooked eggs – usually causes of salmoneliosis
g.) don’t give honey – infant botulism
h.) offered new food one at a time – interval of 4 – 7days or 1 week – determines food allergens
Total Body Fluids- comprises 65 - 85% of body wt of infants & children
Where fluids are greater in infants
Extracellular fld – prone to develop dehydration
Acid Base Balance dependent on the ff:
a. chemical buffersb. renal & resp system involvement c. dilution of strong acids and bases in bld