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NCMA 219 (Lecture) Care for Mother and Child at RiskPRELIMSLESSON #1:Pediatric Nursing Pediatric Nursing or Child Health Nursing  Is the nursing specialty of caring for infants, children and adolescents.  A nurse who specializes in this area is usually referred to as a pediatric nurse Roles of Ped...

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NCMA 219 (Lecture) Care for Mother and Child at Risk PRELIMS LESSON #1: Pediatric Nursing Pediatric Nursing or Child Health Nursing  Is the nursing specialty of caring for infants, children and adolescents.  A nurse who specializes in this area is usually referred to as a pediatric nurse Roles of Pediatric  Primary Caregiver – provide promotive, preventive, curative and rehabilitative nursing care in all levels of health services.  Coordinator & Collaborator – maintains good interpersonal communication with the child, family and health team members.  Nurse Advocate – safeguard’s the child’s rights, to assist and provide the best care from the health care team.  Health Educator - provide information to children, parents and significant others, about the prevention of illness, health promotion or maintenance.  Nurse Consultant - Guides parents for maintenance and promotion of health.  Nurse Counselor – provides guidance to parents in hazards of children and health team for own decision making in different situations. Classification according to Gestational Age  Premature (preterm) infant – an infant born before the completion of 37 weeks of gestation, regardless of birth weight.  Full-term infant – an infant born between the beginning of 38 weeks and the completion of 42 weeks of gestation, regardless of birth weight  Postmature (postterm) infant – an infant born after 42 weeks of gestational age, regardless of birth weight Lesson 2:

Illness of the High-Risk Newborn 1. Respiratory Distress Syndrome

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A condition of surfactant deficiency

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Seen almost exclusively in PRETERM infant (multifetal

pregnancies, infants of diabtic mother, C/S delivery,etc)

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Suction only when necessary (gently but quickly) Encourage parents to verbalize feelings

2. Meconium Aspiration Syndrome ❑ Relaxation of the anal sphincter and passage of meconium into amnitic fluid due to intrauterine stress ❑ Occurs primarily in fullterm and postterm infants

Clinical Manifestations  Chest indrawing and retractions  Tachypnea  Labored breathing  Substernal retractions  Flaring of nares  Fine respiratory crackles  Central cyanosis (late and serious sign) Diagnostic Evaluation  Pulse oximetry (determines hypoxia)  Radiography  L/S ratio  TDx Fetal Lung Maturity assay (determines PG level in amniotic fluid or neonatal tracheal aspirate) Therapeutic Management  Administration of exogenous surfactant  Nitric oxide (pulmonary dilation)  Oxygen therapy (maintains correct PO2 and pH)  IV therapy (hydration and nutrition) Nursing Management  Close monitoring  Keep oxygen consumption as low as possible (handle infants as little as possible)

Clinical Manifestations  Stained from meconium stool  Tachypneic  Expiratory grunting, nasal flaring, retractions  Initially cyanotic  Classic Barrel chest  Respiratory distress with gasping Diagnostic Evaluation  Laryngoscopy  Chest radiographs  Pulse oximetry  Echocardiography Therapeutic Management  Tracheal suctioning (poor respiratory effort, low heart rate, poor tone)  Ventilatory support  Exogenous surfactant administration  IV fluids  Systemic antibiotics Nursing Management  Same with other high-risk neonate

3. Apnea of Prematurity (AOP)  Common phenomenon in preterm infant  Characterized by apneic spells Types  Central apnea -CNS does not transmit signals to the respiratory muscles  Obstructive apnea -airflow ceases due to upper airway obstruction  Mixed apnea -combination of central and obstructive apnea (*most common)

Therapeutic Management  Methylxantines (aminophylline, theophyline, caffeine)  CNS Stimulants to breathing  Observe for Sx of toxicity (tachycardia ar rest, vomiting, irritability, diuresis)  Cafcit (caffeine citrate)  Urine output should be closely monitored (mild diuretic effect) Nursing Management  Observation combined with monitoring is the most effective means of identifying neonatal apnea (if apnea begun)  Gentle tactile stimulation (rubbing the back or chest gently)  Flow-by oxygen and suctioning  Chin is raised gently to open airway  Infant is NEVER SHAKEN  Record episodes of apnea

4. Sudden Infant Death Syndrome (SIDS)   

Sudden death of an infant under 1 year of age “crib death” Etiology: UNKNOWN

Contributing Factors:  Prone sleep position  Soft bedding

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Use of pillow Brainstem abnormality

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Co-sleeping with parents Maternal smoking

Manifestations & Diagnosis Manifestations: May be seen: ✓ Frothy-blood tinged fluid in the mouth ✓ Lying face down in the secretions ✓ Hands clutching the sheets Diagnosis: ✓ Autopsy ✓ Investigation of the scene

Therapeutic Management ✓Strict oxygen management ✓Cryotherapy ablation ✓Laser therapy

Nursing Management ✓Allow the parents to say bye ✓Encourage to hold their infant ✓Encourage verbalization of feelings ✓Provide a quiet room with dim lighting ✓Explain that the death is due to SIDS and it is not preventable or predictable

Quiz: 1. Nurse Mika is about to discharge Nico, a 3-year-old patient admitted for dengue hemorrhagic fever. Before discharging the patient, Nurse Mika explained the discharge plan to the patient's mother emphasizing the different pharmacologic considerations for toddlers. Nurse Mika is exemplifying what pediatric nursing role?  Health Educator 2. Nurse Mika catches a baby in the delivery room at exactly 3pm of September 1, 2020. The mother's LMP was February 1, 2020 (leap year). Based on the scenario, you are to anticipate that Nurse Mika will document that the baby is:  Preterm 3. On the assessment of a neonate after delivery, the nurse noted the following findings: Inability to hold the nurse's finger, Heel easily brought to ears, ears does not recoil after folding, and the neonate's extremities are flaccid. The nurse will document that the newborn is probably:  Premature 4. A nurse is assessing a newborn with Respiratory Distress Syndrome (RDS). Which of the following manifestations will be consistent with the patient's condition? Select all that apply.  Flaring Nares, 5. In order to ascertain fetal lung maturity for a mother who is having preterm labor, the nurse can expect which laboratory parameters to be checked?  L/S Ratio

Recommendations in preventing AIDS ✓ Place infants on their back when sleeping (plagiocephaly: change head position periodically) ✓ Use firm mattress ✓ Avoid exposure to smoke ✓ Offer a pacifier for sleep 5. Retinopathy of Prematurity 

 

A disorder involving immature retinal vasculature Formerly know as: “Retrolental Fibroplasia” Etiology: hyperoxemia, hypoxia, hypercarbia, hypocarbia, prenatal complications, exposure to light

Nursing Management ✓Decreasing constant bright environmental light ✓Inform the parents that infant’s eyelid will be closed and edematous post operatively

6. The nurse in the Neonatal Intensive Care Unit (NICU)is checking the cardiac monitor of a patient with Meconium Aspiration Syndrome, which of the following  93% 7. In assessing a neonate with Meconium Aspiration Syndrome, a prudent nurse will correctly correlate fast breathing as triggered by which of the following?  Both Acidemia & Hypoxemia 8. The nurse will note which common thoracic configuration for a neonate with Meconium Aspiration Syndrome?  Barrel Chest 9. A neonate with Apnea of Prematurity: Central Type is under the care of Nurse Mika. This problem is due to the immaturity of what structure in the brain the orchestrates the body's respiration?  Medulla Oblongata 10. A neonate with Apnea of prematurity is receiving caffeine citrate as ordered by the neonatologist. Which parameter will the nurse be more vigilant to check and monitor relative to the mentioned drug?  Urine Output 11. Theophylline was prescribed to baby Niko with Apnea of Prematurity. You know that this medication acts by:  Stimulating the CNS to activate respiratory system 12. Sleeping on supine position increases the chances of developing Sudden Infant Death Syndrome.  False 13. The eye of the baby who will undergo phototherapy for pathologic jaundice should be covered to prevent Apnea of Prematurity.  False 14. In resuscitating a premature infant with Respiratory Distress Syndrome should be given the highest oxygen concentration.  False 15. A baby with Retrolental Fibroplasia who underwent Cryotherapy Ablation may

have swollen eyes post procedure.

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True

Additional Lesson:

Principles of Growth and Development

Growth (Quantitative) vs. Development (Qualitative) - often used interchangeably but they are different. Growth  Increase in physical size or a quantitative change  Increase in the number and size of cells o Hyperplasia; Hypertrophy Parameters of Growth: Weight  Most sensitive indicator of growth  DOUBLES – 6 months  TRIPLES – 1 year  QUADRUPLES – 2 and 3 years most infants lose 5-10% of birth weight days after delivery Height  1 inch/ month – 1st 6 months  1 ½ inch/ month – remainder of the first year  3 inches/year – 1-7 years  2 inches/year – 8-15 years Height Comparison 9 y/o – MALE = FEMALE 12 y/o – MALE < FEMALE 13 y/o – MALE > MALE Head Circumference (Reflects brain growth)  At birth – 13-14 inches (33-35.5cm) Teeth FIRST TO ERRUPT: lower (mandibular) central incisor – 6-8 months Age of child in months – 6 = number of teeth 1 year no teeth = Delayed dentition Development  Increase in skill or the ability to function (qualitative change)  Synonymous with MATURATION

Measured by observing a child’s ability to perform tasks Psychosexual Development  Developing instincts or sensual pleasure (Freudian theory). Psychosocial Development  Refers to personality development (Erikson’s theory) Moral Development  Ability to know right from wrong and apply these to real-life situations (Kohlberg’s theory) Cognitive Development  Ability to learn and understand from experience, acquire and retain knowledge, and solve problems (Piaget’s theory) 

Factors influencing growth and development  Genetics  Health  Gender  Intelligence Role of Play in Development ❑ Sensorimotor development ❑ Self-awareness ❑ Cognitive ❑ Moral ❑ Creative ❑ Therapeutic ❑ Socialization Things to remember when choosing toys Toys should have no: ❑ Sharp edges that can cut and puncture ❑ Propelled objects that can injure the eyes ❑ Small parts that can be swallowed ❑ Excessive noise that damage hearing ❑ Weak points (brittle/broken easily) ❑ Elements that can burn ❑ Electric toys (for 8y/o above) ❑ Toxic material (lead → poisoning) INFANCY  Period of 1 month to 1 year of age Freud`s Psychoanalytic Theory “Oral Phase”

❑ Infants are interested in oral stimulation or pleasure during this time ❑ Infants suck for enjoyment or relief of tension Erikson`s Psychosocial Theory “Trust vs Mistrust” ❑ Learning confidence or learning to love ❑ Infants whose NEEDS are MET view the world as safe place ❑ Infants who receives INADEQUATE or INCONSISTENT care becomes fearful and suspicious INFANCY Fear: STRANGER ANXIETY  Begins at 6-7 months peak at 8 months and diminishes at 9 months. Play: Solitary Play Health Promotion of an Infant and Family ❑ DEVELOP TRUST -Arises when one can predict what is coming next -Caring should have a rhythm or consistency ❑ PROMOTE SAFETY Aspiration prevention -toilet paper roll test -inspect toys for loose parts -avoid clothes with buttons ❑ PROMOTE SAFETY Fall Prevention -lower the crib mattress -raise side rails (narrow enough to avoid the child to insert their head) Car Safety -place the infant in rear-facing seats in the back seats (inflating front-seat airbag could suffocate the infant) Suffocation -allow no plastic bags within infant’s reach -remove constricting clothing at bedtime (bib from neck) Promoting Nutritional Health of an Infant ❑ FEEDING DURING THE FIRST YEAR Birth to 6 months ✓Breastfeeding -most desirable complete diet for first half of life 6 to 12 months ✓Solid foods -due to depleting iron stores (4-6 months)

❑THINGS TO REMEMBER when

introducing solid foods:

✓Solid foods may be started by 5- 6 months

✓First foods are strained, pureed, or finely mashed ✓Finger foods (raw fruit/vegetables) can be introduced by 6-7 months ✓Avoid foods that have potential for choking (hotdogs, nuts, grapes, carrots, popcorn, and hard candies) ❑ METHODS of introduction ✓Introduce one food at a time ✓Intervals of 5-7 days to identify food allergies ✓Never introduce foods by mixing them with the formula in the bottle Suggested Schedule for introduction of Solid Foods

Bottle Syndrome ❑ Occurs when the carbohydrate in the solutions such as formula or glucose water ferments to organic acids that demineralize tooth enamel until it decays. ❑ Propped bottle continuously soaks upper teeth and lower back teeth that causes tooth decay. TODDLERHOOD - Period of 1 to 3 years old Freud`s Pyschoanalytic Theory “ANAL PHASE” ❑ At this age they begin toilet training ❑ Children find pleasure in both the retention of feces and defecation ❑This anal interest is part of toddler’s Self-discovery, a way of exerting INDEPENDECE Erikson`s Psychosocial Theory “AUTONOMY vs SHAME and DOUBT” ❑ Children takes pride in new accomplishments

❑ Parent’s recognition of this trait will help in the development of autonomy ❑ If children are never allowed to do things they want to do, they will eventually doubt their ability to do them TODDLERHOOD Fear: Separation Anxiety  Begin at 9 months and peaks at 18 months Play: Parallel Play PARALLEL PLAY ✓Provide duplicate toys (avoids arguments) ✓Offer toys that the that they can play by themselves and that requires action ✓Toys that children can manipulate gives a sense of power, an expression of AUTONOMY ✓Examples: trucks they can go, waddling duck they can pull, toy telephone they can talk into. SEPARATION ANXIETY Prevented by: ✓Not prolonging goodbye ✓Saying goodbye firmly to develop trust ✓Saying when you will be back Characteristic trait of a toddler ❑NEGATIVISTISM ✓Loves to say “NO!” ✓A way of achieving INDEPENDENCE Managed by: ✓Limiting questions and offering options ✓If the child’s answer is still a “No”, parents should make a choice for the child ❑ RITUALISM ✓A way of achieving MASTERY TEMPER TANTRUMS ✓A way of achieving INDEPENDENCE by violently objecting to discipline ✓May lie down of the floor, kick their feet, and scream as loud as possible, others hold their breath ✓Indication that of child’s inability to control emotions Managed by: ✓IGNORING the behavior (if not injurious to the child)

✓If can result to injury: substitute a toy or a favorite activity for the request ✓Continue to be present to provide feeling of control and security ✓Corporal punishment may further aggravate the situation ✓Offer options instead of “all or nothing” and praise positive behavior LOVES TOILET TRAINING FIVE MARKERS OF TOILET TRAINING READINESS: 1. Bladder readiness 2. Bowel readiness 3. Cognitive readiness 4. Motor readiness 5. Psychologic readiness *physiologic and psychologic readiness is not complete until ages 22-30 months, but preparation should start earlier than 30 months ✓Night time bladder control normally takes several months to years after daytime training (sleeps cycle needs to mature) ✓Bowel training is usually accomplished before bladder training (bowel training has greater regularity and predictability) ✓there is no universal right age to begin toilet training or absolute deadline to complete training PRESCHOOL AGE - Period of 4 to 6 years old Freud`s Psychoanalytic Theory “PHALLIC STAGE” ❑Children’s pleasure zone appears to shift from the anal to genital area ❑ Masturbation is common ❑Children may also shoe exhibitionism suggesting they hope this will lead to increased knowledge of the two sexes “PHALLIC STAGE” ❑ Also known as oedipal stage ❑Oedipus complex (son wants to marry his mother) ❑Electra complex (daughter wants to marry her father)

❑Penis envy (female) ❑Castration complex (male)

❑ Resolved by identification with same sex parent Erikson`s Psychosocial Theory

INITIATIVE vs GUILT ❑Freedom and opportunity to initiate motor play reinforces their sense of...