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HI there....welcome To test visual acuity, the nurse should ask the patient to cover each eye separately and read the eye chart with glasses and without, as appropriate. Fundamental of Nursing Before teaching any procedure to the patient, the nurse must first assess the patient’s willingness to learn and his current knowledge. Fundamentals of Nursing A blood pressure cuff that is too narrow can cause a falsely elevated blood pressure reading. Fundamentals of Nursing When preparing a single injection for a patient who takes regular and NPH insulin, the nurse should draw the regular insulin into the syringe first because it is clear and can be measured more accurately than the NPH insulin, which is turbid. Fundamentals of Nursing Rhonchi refers to the rumbling sounds heard on lung auscultation; they are more pronounced during expiration than during inspiration. Fundamentals of Nursing Gavage refers to forced feeding, usually through a gastric tube (a tube passed into the stomach by way of the mouth). Fundamentals of Nursing According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority. Fundamentals of Nursing Checking the identification band on a patient’s wrist is the safest and surest way to verify a patient’s identity. Fundamentals of Nursing A patient’s safety is the priority concern in developing a therapeutic environment. Fundamentals of Nursing The nurse should place the patient with a Sengstaken-Blakemore tube in semi-Fowler’s position. Fundamentals of Nursing The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery; hand and finger spasms during occlusion indicate Trousseau’s sign and suggest hypocalcemia. Fundamentals of Nursing For blood transfusion in an adult, the appropriate needle size is 16 to 20G. Fundamentals of Nursing Pain that incapacities a patient and can’t be relieved by drugs is called intractable pain. Fundamentals of Nursing In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic transmission. Fundamentals of Nursing Decibel is the unit of measurement of sound. Fundamentals of Nursing Informed consent is required for any invasive procedure. Fundamentals of Nursing A patient who can’t write his or her name to give consent for treatment must have his or her X witnessed by two persons, such as a nurse, priest, or doctor. Fundamentals of Nursing The Z-track I.M. injection technique seals medication deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle that is 1’’ (2.5 cm) or longer. Fundamentals of Nursing A registered nurse (RN) should assign a licensed vocational nurse (LVN) or licensed practical nurse (LPN) to perform bedside care, such as suctioning and medication administration. Fundamentals of Nursing The therapeutic purposed of a mist tent is to increase hydration of secretions. Fundamentals of Nursing If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention. Fundamentals of Nursing The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity. Fundamentals of Nursing To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2” (5 cm) to that measurement. Fundamentals of Nursing Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies. Fundamentals of Nursing The appropriate needle size for an insulin injection is 25G and ⅝" (1.5 cm) long. Fundamentals of Nursing Residual urine refers to urine that remains in the bladder after voiding. The amount of residual urine normally ranges from 50 to 100 ml. Fundamentals of Nursing The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation. Fundamentals of Nursing Planning refers to the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan. Fundamentals of Nursing Implementation refers to the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions. Fundamentals of Nursing Evaluation refers to the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan, making the nursing process circular. Fundamentals of Nursing In the event of fire, the nurse should (1) remove the patient, (2) call the fire department, (3) attempt to contain the fire by closing the door, and (4) extinguish the fire, if it can be done safely. Fundamentals of Nursing Before administering any as need pain medication, the nurse should ask the patient to indicate the pain’s location. Fundamentals of Nursing Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people. Fundamentals of Nursing When providing oral care for an unconscious patient, the nurse should position the patient on the side to minimize the risk of aspiration. Fundamentals of Nursing During assessment of distance vision, the patient should stand 20’ (6.1 m) from the chart. Fundamentals of Nursing The ideal room temperature for a geriatric patient or one who is extremely ill ranges form 66º to 76º F (18.8º to 24.4º C). Fundamentals of Nursing Normal room humidity ranges from 30% to 60%. Fundamentals of Nursing Hand washing is the single best method of limiting the spread of microorganisms. Hands should be washed for 10 seconds after routine contact with a patient and after gloves are removed. Fundamentals of Nursing To catheterize a female patient, the nurse should place her in the dorsal recumbent position. Fundamentals of Nursing A positive Homan’s sign may indicate thrombophlebitis. Fundamentals of Nursing Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent equals the number of milligrams per 100 milliliters of a solution. Fundamentals of Nursing Metabolism takes a place in two phases: anabolism (the constructive phase) and catabolism (the destructive phase). Fundamentals of Nursing The basal metabolic rate represents the amount of energy needed to maintain essential body functions. It is measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment. Fundamentals of Nursing Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains adequate intestinal motility, and helps establish regular bowel habits. Fundamentals of Nursing Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs. Fundamentals of Nursing Petechiae refers to tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage. Fundamentals of Nursing Purpura refers to a purple skin discoloration caused by blood extravasation. Fundamentals of Nursing Glucose-6-phosphate dehydrogenase (C6PD) deficiency is an inherited metabolic disorder characterized by red blood cells that are deficient in G6PD, a critical enzyme in aerobic glycolysis. Fundamentals of Nursing According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse shouldn’t recap needles after use because most needle sticks result from missed needle recapping. Fundamentals of Nursing The nurse administers a drug by I.V. push by delivering the dose directly into a vein, I.V. tubing, or catheter with a needle and syringe. Fundamentals of Nursing When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied. Fundamentals of Nursing A nurse should have assistance when changing the ties on a tracheostomy tube. Fundamentals of Nursing A filter is always used for blood transfusions. Fundamentals of Nursing A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide. Fundamentals of Nursing The patient should carry a cane on the unaffected side to promote a reciprocal gait pattern and distribute weight away from the affected leg. Fundamentals of Nursing A good way to begin a patient interview is to ask “What made you seek medical help?” Fundamentals of Nursing The nurse should adhere to standard precautions for blood and body fluids when caring for all patients. Fundamentals of Nursing Potassium (K+) is the most abundant cation in intracellular fluid. Fundamentals of Nursing In the four-point gait (or alternating gait), the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot. Fundamentals of Nursing In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg. Fundamentals of Nursing In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch. Fundamentals of Nursing Vitamin B complex, the water-soluble vitamins essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12). Fundamentals of Nursing When being weighed, an adult patient should be lightly dressed and shoeless. Fundamentals of Nursing Before taking an adult’s oral temperature, the nurse should ensure that the patient hasn’t smoked or consumed hot or cold substances in the past 15 minutes. Fundamentals of Nursing The nurse shouldn’t take a rectal temperature on an adult patient if the patient has a cardiac disorder; anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery. Fundamentals of Nursing In a patient with cardiac problems, rectal temperature measurement may stimulate a vagal response, leading to vasodilation and decreased cardiac output. Fundamentals of Nursing When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3 indicates a bounding pulse (readily palpable and forceful); +2, a normal pulse (easily palpable); +1, a thready or weak pulse (difficult to detect); and 0, an absent pulse (not detectable). Fundamentals of Nursing The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia recovery unit. Fundamentals of Nursing On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water, has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have taken and recorded. Artificial limbs and other prostheses are usually removed. Fundamentals of Nursing Comfort measures, such as positioning the patient, performing backrubs, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness. Fundamentals of Nursing A drug has three names: its generic name, which is used in official publications; its trade name or brand name (such as Tylenol), which is selected by the drug company; and its chemical name, which describes the drug’s chemical composition. Fundamentals of Nursing The patient should take a liquid iron preparation through a straw to avoid staining the teeth. Fundamentals of Nursing The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon). Fundamentals of Nursing An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin. Fundamentals of Nursing In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma. Fundamentals of Nursing To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if indicated; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet. Fundamentals of Nursing The diaphragm of the stethoscope is used to hear high-pitched sounds such as breath sounds. Fundamentals of Nursing A slight blood pressure difference (5 to 10 mm Hg) between right and left arms is normal. Fundamentals of Nursing The nurse should place the blood pressure cuff 1'' (2.5 cm) above the antecubital fossa. Fundamentals of Nursing When instilling ophthalmic ointments, waste the first bed of ointment and then apply from the inner canthus to the outer canthus; twist the medication tube to detach the ointment. Fundamentals of Nursing The nurse should use a leg cuff to measure blood pressure in an obese patient. Fundamentals of Nursing If the blood pressure cuff is applied too loosely, the reading will be falsely elevated. Fundamentals of Nursing Ptosis refers to eyelid drooping. Fundamentals of Nursing A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position. Fundamentals of Nursing To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle. Fundamentals of Nursing To move the patient to the edge of the bed for transfer, follow these steps: (1) Move the patient’s head and shoulders toward the edge of the bed. (2) Move the patient’s feet and legs to the edge of the bed (crescent position). (3) Place both the arms well under the patient’s hips and straighten the back while moving the patient toward the edge of the bed. Fundamentals of Nursing When being measured for crutches, a patient should wear his or her shoes. Fundamentals of Nursing The nurse should attach a restraint to a part of the bed frame that moves with the head, not to the mattress or side rails. Fundamentals of Nursing The mist in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory pattern. Fundamentals of Nursing To administer heparin subcutaneously, the nurse should follow these steps: (1) Clean, but don’t rub, the site with alcohol. (2) Stretch the skin taut or pick up a well-defined skin fold. (3)Hold the shaft of the needle in a dart position. (4)Insert the needle into the skin at a right (90-degree) angle. (5)Firmly depress the plunger; but don’t aspirate. (6)Leave the needle in place for 10 seconds. (7)Withdraw the needle gently at the same angle it was inserted. (8)Apply pressure to the injection site with an alcohol pad. Fundamentals of Nursing For a sigmoidoscopy, the nurse should place the patient in a knee-chest or Sims’ position, depending on the doctor’s preference. Fundamentals of Nursing Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort) safety and security, love and belonging, self-esteem and recognition, and self-actualization. Fundamentals of Nursing When caring for patient with a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness. Fundamentals of Nursing During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube. Fundamentals of Nursing In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage, for example, “10 mm of brown mucoid drainage noted on dressing.” Fundamentals of Nursing To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as thumbnail. Fundamentals of Nursing In a positive Babinski’s reflex, the great toe dorsiflexes and the other toes fan out. Fundamentals of Nursing When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis. Fundamentals of Nursing The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours. Fundamentals of Nursing Antiembolism stockings decompress the superficial blood vessels, thereby reducing the risk of thrombus formation. Fundamentals of Nursing The most convenient veins for venipuncture in a adult patient are the basilic and median cubital veins in the antecubital space. Fundamentals of Nursing From 2 to 3 hours before beginning a tube feeding, the nurse should aspirate the patient’s stomach contents to verify adequate gastric emptying. Fundamentals of Nursing People with type O blood are considered to be universal donors. Fundamentals of Nursing People with type AB blood are considered to be universal recipients. Fundamentals of Nursing Herts (Hz) refers to the unit of measurement of sound frequency. Fundamentals of Nursing Hearing protection is required when the sound intensity exceeds 84 dB; double hearing protection is required if it exceeds 104 dB. Fundamentals of Nursing Prothrombin, a clotting factor, is produced in the liver. Fundamentals of Nursing If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory slip. Fundamentals of Nursing During lumbar puncture, the nurse must note the initial intracranial pressure and the cerebrospinal fluid color. Fundamentals of Nursing A patient who can’t cough to provide a sputum sample for culture may require a heated aerosol treatment to facilitate removal of a sample. Fundamentals of Nursing If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first. Fundamentals of Nursing When leaving an isolation room, the nurse should remove the gloves before the mask because fewer pathogens are on the mask. Fundamentals of Nursing Skeletal traction is applied to a bone using wire pins or tons. It is the most effective means of traction. Fundamentals of Nursing The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use because delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction. Fundamentals of Nursing Medication isn’t routinely injected I.M. into edematous tissue because it may not be absorbed. Fundamentals of Nursing When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice. Fundamentals of Nursing When cleaning dentures, the sink should be lined with a washcloth. Fundamentals of Nursing A patient should void within 8 hours after surgery. Fundamentals of Nursing An EEG identifies normal and abnormal brain waves. Fundamentals of Nursing Stool samples for ova and parasite tests should be delivered to the laboratory without delay or refrigeration. Fundamentals of Nursing The autonomic nervous system regulates the cardiovascular and respiratory systems. Fundamentals of Nursing When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion. Fundamentals of Nursing A low-residue diet includes such as foods as roasted chicken, rice, and pasta. Fundamentals of Nursing A rectal tube should not be inserted for longer than 20 minutes; it can irritate the mucosa of the rectum and cause a loss of sphincter control. Fundamentals of Nursing A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum. Fundamentals of Nursing When lifting and moving a patient, the nurse should use the upper leg muscles most to prevent injury. Fundamentals of Nursing Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal. Fundamentals of Nursing During occupied bed changes, the patient should be covered with a black blanket to promote warmth and prevent exposure. Fundamentals of Nursing Anticipatory grief refers to mourning that occurs for an extended time when one realizes that death is inevitable. Fundamentals of Nursing The following foods can alter stool color: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown). Fundamentals of Nursing When preparing a patient for a skull X-ray, have the patient remove all jewelry and dentures. Fundamentals of Nursing The fight-or-flight response is a sympathetic nervous system response. Fundamentals of Nursing Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia. Fundamentals of Nursing Wheezing refers to an abnormal, high-pitched breath sound that is accentuated on expiration. Fundamentals of Nursing Wax or a foreign body in the ear should be gently flushed out by irrigation with warm saline solution. Fundamentals of Nursing If a patient complains that his hearing aid is “not working,” the nurse should check the switch first to see if it’s turned on and then check the batteries. Fundamentals of Nursing The nurse should grade hyperactive biceps and triceps reflexes +4. Fundamentals of Nursing If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart. Fundamentals of Nursing In a postoperative patient, forcing fluids helps prevent constipation. Fundamentals of Nursing The nurse must administer care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy. Fundamentals of Nursing The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1º C. Fundamentals of Nursing As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion. Fundamentals of Nursing The body metabolizes alcohol at a fixed rate regardless of serum concentration. Fundamentals of Nursing In an alcoholic beverage, its proof reflects its percentage of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol. Fundamentals of Nursing A living will is a witnessed document that states a patient’s desire for certain types of care and treatment, which depends on the patient’s wishes and views and quality of life. Fundamentals of Nursing The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as needed with normal saline solution to maintain patency. Fundamentals of Nursing Quality assurance is a method of determining whether nursing actions and practices meet established standards. Fundamentals of Nursing The five rights of medication administration are the right patient, right medication, right dose, right route of administration, and the right time. Fundamentals of Nursing Outside of the hospital setting, only the sublingual and transligual forms of nitroglycerin should be used to relieve acute anginal attacks. Fundamentals of Nursing The implementation phase of the nursing process involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities. Fundamentals of Nursing The Patient’s Bill of Rights offers guidance and protection to patients by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization. Fundamentals of Nursing To minimize the omissions and distortion of facts, the nurse should record information as soon as it is gathered. Fundamentals of Nursing When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present. Fundamentals of Nursing Drug administration is a dependent activity. The nurse can administer or withhold a drug only with the doctor’s permission. Fundamentals of Nursing The nurse shouldn’t give false assurance to a patient. Fundamentals of Nursing After receiving preoperative medication, a patient isn’t competent to sign an informed consent form. Fundamentals of Nursing When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms. Fundamentals of Nursing A nurse may clarify a doctor’s explanation to a patient about an operation or a procedure but must refer questions about informed consent to the doctor. Fundamentals of Nursing The nurse shouldn’t use her thumb to take a patient’s pulse rate because the thumb has a pulse of its own and may be confused with the patient’s pulse. Fundamentals of Nursing An inspiration and an expiration count as one respiration. Fundamentals of Nursing Normal respirations are known as eupnea. Fundamentals of Nursing During a blood pressure measurement, the patient should rest the arm against a surface because using muscle strength to hold up the arm may raise the blood pressure. Fundamentals of Nursing Major unalterable risk factors for coronary artery disease include heredity, sex, race, and age. Fundamentals of Nursing Inspection is the most frequently used assessment technique. Fundamentals of Nursing Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a homey atmosphere. Fundamentals of Nursing The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication. Fundamentals of Nursing Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidosmastoid muscle use during respiration. Fundamentals of Nursing When patients use axillary crutches, their palms should bear the brunt of the weight. Fundamentals of Nursing Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially. Fundamentals of Nursing Normal gait has two phases: the stance phase, in which the patient’s foot rests on the ground, and the swing phase, in which that patient’s foot moves forward. Fundamentals of Nursing The phases of mitosis are prophase, metaphase, anaphase, and telophase. Fundamentals of Nursing The nurse should follow standard precautions in the routine care of all patients. Fundamentals of Nursing The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs. Fundamentals of Nursing The nurse can assess a patient’s general knowledge by asking questions such as “Who is the president for the United States?” Fundamentals of Nursing Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury. Fundamentals of Nursing The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers). Fundamentals of Nursing The autonomic nervous system controls the smooth muscles. Fundamentals of Nursing A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. It is developed in collaboration with the patient. Fundamentals of Nursing The optic disk is yellowish pink and circular with a distinct border. Fundamentals of Nursing A primary disability results from a pathologic process; a secondary disability, from inactivity. Nurses usually are held liable for failing to keep an accurate count of sponges and other devices during surgery. Fundamentals of Nursing The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals. Fundamentals of Nursing Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, leafy vegetables, eggs, and whole gains, generally have low water content. Fundamentals of Nursing Collaboration refers to joint communication and decision making between nurses and doctors designed to meet patients’ needs by integrating the care regimens of both professions in one comprehensive approach. Fundamentals of Nursing Bradycardia refers to a heart rate of fewer than 60 beats/minute. Fundamentals of Nursing A nursing diagnosis is a statement of a patient’s actual or potential health problems that can be resolved, diminished, or otherwise changed by nursing interventions. Fundamentals of Nursing During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data. Fundamentals of Nursing The patient’s health history consists primarily of subjective data, information supplied by patient. Fundamentals of Nursing The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation. Fundamentals of Nursing When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign every entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines. Fundamentals of Nursing Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy. Fundamentals of Nursing The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery, which is compressed against the radius to take the pulse rate. Fundamentals of Nursing The normal pulse rate of a resting adult is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults. Fundamentals of Nursing Laboratory test results are an objective form of assessment data. Fundamentals of Nursing The measurement systems most often used in clinical practice are the metric system, apothecaries’ system, and household system. Fundamentals of Nursing Before signing an informed consent, a patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phase; the risk involved; and the possible complications. The patient also should have a general idea of the time required from surgery to recovery and should have an opportunity to ask questions. Fundamentals of Nursing A patient must sign a separate informed consent form for each procedure. Fundamentals of Nursing During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds (that helps determine the size, shape, position, and density of underlying organs and tissues), elicit tenderness, or assess reflexes. Fundamentals of Nursing Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound. Fundamentals of Nursing A foot cradle keeps bed linen off the patient’s feet, which prevent skin irritation and breakdown, especially in a patient with peripheral vascular disease or neuropathy. Fundamentals of Nursing If the patient is a married minor, permission to perform a procedure can be obtained form the patient’s spouse. Fundamentals of Nursing Gastric lavage is the flushing of the stomach and removal of ingested substances through a nasogastric tube. It can be used to treat poisoning or drug overdose. Fundamentals of Nursing During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy. Fundamentals of Nursing Bruits commonly indicate a life- or limb-threatening vascular disease. Fundamentals of Nursing O.U. means each eye; O.D., right eye; and O.S, left eye. Fundamentals of Nursing To remove a patient’s artificial eye, the nurse depresses the lower lid. Fundamentals of Nursing The nurse should use a warm saline solution to clean an artificial eye. Fundamentals of Nursing A thready pulse is very fine and scarcely perceptible. Fundamentals of Nursing Axillary temperature usually is 1º F lower than oral temperature. Fundamentals of Nursing After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions. Fundamentals of Nursing On a medication prescription, the abbreviation p.c. means that the medication should be administered after meals. Fundamentals of Nursing After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment. Fundamentals of Nursing Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which she works. Fundamentals of Nursing Gauge refers to the inside diameter of a needle. The smaller the gauge, the larger the diameter. Fundamentals of Nursing An adult normally has 32 permanent teeth. Fundamentals of Nursing After turning a patient, the nurse should document the position used, time turned, and skin assessment findings. Fundamentals of Nursing PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation. Fundamentals of Nursing When purcussing a patient’s chest for postural drainage, the nurse’s hands should be cupped. Fundamentals of Nursing When measuring a patient’s pulse, the nurse should assess the rate, rhythms, quality, and strength. Fundamentals of Nursing Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair’s footrests to the sides and lock its wheels. Fundamentals of Nursing When assessing respirations, the nurse should document the rate, rhythm, depth, and quality. Fundamentals of Nursing For a subcutaneous injection, the nurse should use a ⅝" 25G needle. Fundamentals of Nursing The notation “AA & O x 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time). Fundamentals of Nursing Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or stool, and perspiration. Fundamentals of Nursing After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results. Fundamentals of Nursing When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle) with the bevel up. Fundamentals of Nursing To obtain an accurate blood pressure, the nurse should inflate the manometer 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure. Fundamentals of Nursing The nurse should count an irregular pulse for 1 full minute. Fundamentals of Nursing A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus. Fundamentals of Nursing Prophylaxis is disease prevention. Fundamentals of Nursing Body alignment is achieved when the body parts are in proper relation to their natural position. Fundamentals of Nursing Trust is the foundation of a nurse-patient relationship. Fundamentals of Nursing Blood pressure in the force exerted by the circulating volume of blood on arterial walls. Fundamentals of Nursing Malpractice refers to the professional’s wrongful conduct, improper discharge of duties, or failure to meet standers of care, which causes harm to another. Fundamentals of Nursing As a general rule, nurses can’t refuse a patient care assignment; however, they may refuse to participate in abortions in most states. Fundamentals of Nursing A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform. Fundamentals of Nursing States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from such assistance. These laws don’t apply to care provided in a health care facility. Fundamentals of Nursing A doctor should sign verbal and telephone orders within the time established by institutional policy, usually within 24 hours. Fundamentals of Nursing A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of this refusal. Fundamentals of Nursing Although a patient’s health record or chart is the health care facility’s physical property, its contents belong to the patient. Fundamentals of Nursing Before a patient’s record can be released to a third party, the patient or patient’s legal guardian must give written consent. Fundamentals of Nursing Under the Controlled Substances Act, every dose of a controlled drug dispensed by the pharmacy must be counted for, whether the dose was administered to a particular patient or discarded accidentally. Fundamentals of Nursing A nurse can’t perform duties that violate a rule or regulation established by a state licensing board even if it is authorized by a health care facility or doctor. Fundamentals of Nursing The nurse should select a private room, preferably with a door that can be closed, to minimize interruptions during a patient interview. Fundamentals of Nursing In categorizing nursing diagnosis, the nurse should address actual life-threatening problems first, followed by potentially life-threatening concerns. Fundamentals of Nursing The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions. Fundamentals of Nursing Standing orders, or protocols, establish guidelines for treating a particular disease or set of symptoms. Fundamentals of Nursing In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostals space near the apex. Fundamentals of Nursing The S1 sound heard on auscultation is caused by closure of the mitral and tricuspid valves. Fundamentals of Nursing To maintain package sterility, the nurse should open the wrapper’s top flap away from the body, open side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body. Fundamentals of Nursing The nurse shouldn’t use a cotton-tipped applicator to dry a patient’s ear canal or remove wax because it may force cerumen against the tympanic membrane. Fundamentals of Nursing A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises. Fundamentals of Nursing The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse liability. Fundamentals of Nursing Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States. Fundamentals of Nursing Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential but have currently accepted medical uses. Their use may lead to physical or psychological dependence. Fundamentals of Nursing Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both. Fundamentals of Nursing Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs. Fundamentals of Nursing Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances. Fundamentals of Nursing Activities of daily living are actions that the patient must perform every day to provide self-care and interact with society. Fundamentals of Nursing Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI. Fundamentals of Nursing The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with stethoscope slightly raised from the chest. Fundamentals of Nursing The most important goal to include in a care plan is the patient’s goal. Fundamentals of Nursing Fruits are high in fiber and low in protein and should be omitted from a low-residue diet. Fundamentals of Nursing The nurse should use an objective scale to assess and quantify pain because postoperative pain varies greatly among individuals. Fundamentals of Nursing Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings. Fundamentals of Nursing The nurse should provide honest answers to the patient’s questions. Fundamentals of Nursing Milk shouldn’t be included in a clear liquid diet. Fundamentals of Nursing Consistency in nursing personnel is paramount when caring for a child, and infant, or a confused patient. Fundamentals of Nursing The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland. Fundamentals of Nursing The three membranes that enclose that brain and spinal cord are the dura mater, pia mater, and arachnoid. Fundamentals of Nursing A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively. Fundamentals of Nursing Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for medication. Fundamentals of Nursing The area around a stoma should be cleaned with mild soap and water. Fundamentals of Nursing Vegetables have a high fiber content. Fundamentals of Nursing The nurse should use a tuberculin syringe to administer an S.C. injection of less than 1 ml. Fundamentals of Nursing For adults, S.C. injections require a 25G 1" needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G ½" needle. Fundamentals of Nursing Before administering medication, the nurse should identify the patient by checking the identification band and asking the patient to state his name. Fundamentals of Nursing To clean the skin before an injection, the nurse should use a sterile alcohol swab and wipe from the center of the site outward in a circular motion. Fundamentals of Nursing The nurse always should inject heparin deep into S.C. tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation. Fundamentals of Nursing If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure. Fundamentals of Nursing The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative. Fundamentals of Nursing If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops; if bruising occurs, the nurse should monitor the site for an enlarging hematoma. Fundamentals of Nursing When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head. Fundamentals of Nursing Frequency of patient hair care depends on the length and texture of the hair, duration of hospitalization, and patient’s condition. Fundamentals of Nursing Proper hearing aid function requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries. Fundamentals of Nursing The hearing aid marked with a blue dot is for the left ear; the one with the red dot is for the right ear. Fundamentals of Nursing A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water. Fundamentals of Nursing The nurse should instruct a patient not to use hair spray while wearing a hearing aid. Fundamentals of Nursing The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy. Fundamentals of Nursing The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown. Fundamentals of Nursing The purpose of heat application is to promote vasodilation, which reduces pain caused by inflammation. Fundamentals of Nursing A sutured surgical incision is an example of healing by first intention (healing directly, without granulation). Fundamentals of Nursing Healing by secondary intention (healing by granulation) is closure of the wound by the granulation tissue filling the defect and allowing reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered. Fundamentals of Nursing Keloid formation is an abnormality in healing characterized by overgrowth of scar tissue at the wound site. Fundamentals of Nursing The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site. Fundamentals of Nursing The ascending colostomy drains fluid feces; the descending colostomy drains solid fecal matter. Fundamentals of Nursing A folded towel (called a scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis. Fundamentals of Nursing When giving an injection to the patient with a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection. Fundamentals of Nursing Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation. Fundamentals of Nursing To insert a nasogastric tube, the nurse should first instruct the patient to tilt the head back slightly and then insert the tube. When the tube is felt curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.) Fundamentals of Nursing According to families whose loved ones are in intensive care units, their four most important needs are to have questions answered honestly, to be assured that the best possible car is being provided, to know the prognosis, and to feel there is hope. Fundamentals of Nursing A double-bind communication when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to. Fundamentals of Nursing A nonjudgmental attitude displayed by the nurse demonstrates that she neither approves nor disapproves of the patient. Fundamentals of Nursing Target symptoms are those that the patient and others find most distressing. Fundamentals of Nursing Advise the patient to take aspirin on an empty stomach with a full glass of water and to avoid foods with acid such as coffee, citrus fruits, and cola. Fundamentals of Nursing For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for that specific problem, and then selecting the intervention from the choices provided that will enable the patient to reach that goal. Fundamentals of Nursing Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient. Fundamentals of Nursing Giving an I.M. injection against the patient’s will and without legal authority is battery. Fundamentals of Nursing An example of a third-party payor is an insurance company. Fundamentals of Nursing On-call medication should be given within 5 minutes of receipt of the call. Fundamentals of Nursing Generally, the best method to determine the cultural or spiritual needs of the patient is to ask him. Fundamentals of Nursing An incident report shouldn’t be made part of the patient’s record but is an in-house document for the purpose of correcting the problem. Fundamentals of Nursing Critical pathways are a multidisciplinary guideline for patient care. Fundamentals of Nursing When prioritizing nursing diagnoses, use this hierarchy: (1) problems associated with airway, (2) those concerning breathing, and (3) those related to circulation. Fundamentals of Nursing The two nursing diagnoses with the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern. Fundamentals of Nursing A subjective sign that a sitz bath has been effective is that patient expresses a decrease in pain or discomfort. Fundamentals of Nursing For the nursing diagnosis Diversional activity deficit to be valid, the patient must make the statement that he’s “bored, there is nothing to do” or words to that effect. Fundamentals of Nursing The most appropriate nursing diagnosis for an individual who doesn’t speak English is Communication, impaired, related to inability to speak dominant language (English). Fundamentals of Nursing The family of the patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him. Fundamentals of Nursing Up to age 3, the pinna should be pulled down and back to straighten the eustachian tube before instilling medication. Fundamentals of Nursing When administering eyedrops, the nurse should waste the first drop and instill the medication in the lower conjunctival sac to prevent injury to the cornea. Fundamentals of Nursing When administering eye ointment, the nurse should waste the first bead of medication and then apply the medication from the inner to the outer canthus. Fundamentals of Nursing When removing gloves and mask, the gloves, which most likely contain pathogens and are soiled, should be removed first. Fundamentals of Nursing Crutches should placed 6" (15 cm) in front of the patient and 6" to the side to assume a tripod position. Fundamentals of Nursing Listening is the most effective communication technique. Fundamentals of Nursing Process recording is a method of evaluating one’s communication effectiveness. Fundamentals of Nursing When feeding the elderly, limit high-carbohydrate foods because of the risk of glucose intolerance. Fundamentals of Nursing Passive range of motion maintains joint mobility whereas resistive exercises increase muscle mass. Fundamentals of Nursing Isometric exercises are performed on an extremity in a cast. Fundamentals of Nursing A back rub is an example of the gate-control theory of pain. Fundamentals of Nursing Anything below the waist is considered unsterile, a sterile field becomes unsterile when it comes in contact with nay unsterile item, a sterile field must be continuously monitored, and the 1" (2.5 cm) border around a sterile field is considered unsterile. Fundamentals of Nursing A “shift to the left” is evident when there is an increase in immature cells (bands) in the blood to fight an infection. Fundamentals of Nursing A “shift to the right” is evident when there is an increase in mature cells in the blood as seen in advanced liver diseases and pernicious anemia. Fundamentals of Nursing Before administering preoperative medication, make sure that an informed consent form has been signed and attached to the patient’s record. Fundamentals of Nursing The nurse should spend no more than 30 minutes per 8-hour shift in providing care to the patient with a radiation implant. Fundamentals of Nursing The nurse should stand near the patient’s shoulders for cervical implants and at the foot of the bed for head and neck implants. Fundamentals of Nursing The nurse should never be assigned to care for more than one patient with radiation implants. Fundamentals of Nursing Long-handled forceps and a lead-lined container should be in the room of the patient who has a radiation implant. Fundamentals of Nursing Generally, patients who have the same infection and are in strict isolation can share the same room. Fundamentals of Nursing Diseases requiring strict isolation include chickenpox, diphtheria, and viral hemorrhagic fever such as Marburg virus disease. Fundamentals of Nursing For the patient abiding by Jewish custom, milk and meat shouldn’t be served in the same meal. Fundamentals of Nursing Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps of the procedure (cognitive domain of learning). Fundamentals of Nursing Developmental stages according to Erik Erikson are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to 3 years), initiative versus guilt (3 to 5 years), industry versus inferiority (5 to 12 years), identity versus identity diffusion (12 to 18 years), intimacy versus isolation (18 to 25 years), generativity versus stagnation (25 to 60 years), and ego integrity versus despair (older than 60 years). Fundamentals of Nursing Face the hearing impaired patient when communicating with him. Fundamentals of Nursing A proper nursing intervention for the spouse of the patient who has suffered a serious incapacitating disease is to assist him in mobilizing a support system. Fundamentals of Nursing Hyperpyrexia refers to extreme elevation in temperature above 106º F (41.1º C). Fundamentals of Nursing

Pediatric Slide show


IMMEDIATE CARE OF NEWBORN: DELIVERY ROOM

ESTABLISH OF RESPIRATION
With head extension, clear the mouth and nose to prevent meconium aspiration.
After expulsion:
place on SLIGHT TRENDELENBURG position (10 – 15 degrees angle) to drain secretions.
SUCTION briefly, gentle from the mouth to the nose using bulb syringe for shallow suctioning.
Deep suctioning is contraindicated as this can cause stimulation of the vagus nerve, laryngospasm and bradycardia.
OXYGENATE in between suctioning using safe oxygen concentration (NOT MORE THAN 40% concentration)
Excessive oxygen concentration can result to oxygen toxicity leading to neonatal blindness:

RETROLENTAL FIBROPLASIA.

Check for patency of the nostrils by occluding one nostril at a time.

CHOANAL ATRESIA is a congenital anomaly of the nose where the posterior nares are not patent.
Danger signs: persistent cry and difficult breathing relieved by crying and intensified by feeding

2. KEEP WARM
DRY and WRAP newborn to prevent heat loss.
The newborn’s high temperature at birth – 37.5 C – drops quickly at birth because of heat loss
c. NO SHIVERING in the newborn
d. initial temperature of the newborn is checked per rectum to rule out an imperforate anus.

3. APGAR SCORING
Done twice – 1 and 5 minutes after birth
First APGAR SCORE is to detect the cardiorespiratory-nervous functioning of the newborn
Second APGAR SCORE: used for planning nursing care







APGAR SCORING

ADAPTATIONS 0 1 2

Heart Rate Absent Below 100 Above 100
Respiratory Absent Weak cry Lusty cry
Effort respiration
Muscle Tone Limp, flaccid Some flexion Acute flexion
Reflex irritability No response Grimace Sneezing, crying
Color Blue, pallor Acrocyanosis Pink


Interpretation:

0 – 3: POOR: severely depressed
- needs resuscitation
4 – 6:FAIR: moderately depressed; needs suctioning and oxygenation
7 – 10:GOOD; needs only admission care

Heart rate is the most important ARGAR SCORE while color is least important
A total score of 0 means no heart rate
A score of 9 means acrocyanosis
4. PROPER IDENTIFICATION
a. Bracelets and foot tags can be used with -
maternal name date time of delivery hospital number/room number sex of the bab
b. FOOTPRINTING – best way to identify
c. Identification is done BEFORE THE BABY IS SEPARATED FROM THE MOTHER
5. CHECK FOR -
Gestational age
Congenital defects
Birth injuries
Gross anomalies









IMMEDIATE CARE: NURSERY

1. Continue with measures to keep newborn warm.
Use droplights during admission care

2. CREDE’S PROPHYLAXIS or eye care
Done to prevent OPTHALMIA NEONATORUM or gonorrheal conjunctivitis
Mandatory – done to all newborns
Drugs used – 1% Silver Nitrate 1 – 2 gtts into each conjunctival sac and Terramycin opthalmic 1 cm from INNER TO OUTER CANTHUS
CREDE’S PROPHYLAXIS is delayed for 1 – 2 hours in order not to interfere with bonding process

EYE-TO-EYE CONTACT is prerequisite to bonding.

3. SKIN CARE – done to prevent skin infection
a. OIL BATH: given to premature and high-risk newborns and those with plenty of vernix caseosa
SOAP AND WATER bath: given to normal full term

4. CORD DRESSING
Strict asepsis prevents TETANUS NEONATORUM
CHECK for 1 umbilical vein and 2 umbilical arteries
Report incomplete vessels
c. Check for 1 OMPHALOCELE – protrusion of abdominal viscera into weakened portion of the umbilicus because of absence of normal abdominal wall in the region of the umbilicus
In the first 24 hours, check the cord for bleeding called OMPHALANGHIA

5. VITAMIN K INJECTION
Mandatory, given to all newborns to prevent bleeding.
Reasons for bleeding tendency: gastrointestinal tract for newborns INITIALLY STERILE no bacteria to synthesize vitamin K decrease clotting factor bleeding tendency
Site for intramuscular injections in newborns:
Thigh muscles – VASTUS LATERALIS (best site)
RECTUS FEMORIS (alternate site)









6. Weighing and taking of Other Anthropometric Measurements

Weight: 3000g – 3,400g (7 – 7.5 lbs.) – International standard
: 6 – 6.5 lbs. – average birth weight of a Filipino newborn
> lower limit normal : 2,500g
Height : 19 – 21 inches (ave. 50 cm)
HC : 33 – 35 cm/13 – 14 inches
CC : 31 – 33 cm/12 – 13 inches
AC : 31 – 33 cm/12 – 13 inches

7. Vital signs
Checking when infants is asleep/quiet
Gentle, minimal handling and watchful eyes


PHYSIOLOGIC CHANGES IN THE NEWBORN

1. Weight Loss : 7 – 10 days
5% to 10% of BW (6 – 10 oz)
After day 10, weight gain of 1 lb per month from 1 – 6 months
BW is doubled at 6 months and tripled at 1 year
2. Jaundice : 2 – 7 days for full terms and 3 – 10 days for preterm
Because of liver immaturity and fetal increase in RBC’s (polycythemia)
Expose to morning sunlight
3. Fever : 2 – 4 days
Primarily because of dehydration
4. Anemia : 4 – 6 months

NEWBORN SKIN MARKS

1. LANUGO - fine, downy hair, more in preterms
2. VERNIX CASEOSA - whitist, cheesy, odorless usually on folds of the skin; more in full term
protects skin and prevents heat loss
3. MILIA - white, pinpoint papules on the nose/chin/cheecks
disappears as early as 2 weeks or 3 – 4 weeks
4. MONGOLIAN SPOT - grayish blue patch at the lower back from accumulation of the pigment cells melanocytes
disappears by school age
5. NEVI(STORK BITES) - red spots found at the back of the neck and above eyelids
disappears spontaneously before 1 year
6. ERYTHEMIA TOXICUM NEONATORUM - newborn rash
pink papular rash appearing on the body within 24 – 48 hours after birth; harmless
disappears within a few days

SIGNIFICANT NEWBORN REFLEXES

A. FEEDING REFLEXES
Rooting – if the cheeck or the corner of the mouth is touched, hr turns to that side; for food location
Diasappears at 3 – 4 months when he can follow moving objects
Last period of disappearance : 7 months
2. Sucking – anything that touches the lips is sucked; present even before birth
disappears at 6 months
3. Extrusion or spitting up – anything that touches the anterior tongue is extruded, protects infant from swallowing inedible substances
- disappears at 4 – 6 months
Swallowing – swallows anything that touches the posterior tongue

B. PROTECTIVE REFLEXES
Sneezing and coughing – protect and clear the air passages
Yawning – protects cells from depleted oxygen
Blinking – protects eyes from objects coming near it

C. MORO or STARTLE – embracing motion of the arms in response to loud noise, jarring of the crib and falling sensation
Best index of CNS integrity; absence indicates BRAIN DAMAGE
Disappears by the end of 4th or 5th month

D. TONIC NECK REFLEX/FENCING – when head is turned to one side, the arm and leg on that side extend and opposite arm and leg flex
disappears at 3 – 4 months

E. BABINSKI – fanning or hyperextension of the toes when the sole is stroked from the heel upwards

F. DARWIN – dancing reflex; few quick alternating steps when the newborn is held upright and his feet touch a hard surface
Disappears at 4 weeks

G. MAGNET – If pressure is applied on the soles of the feet while infant lies supine, he pushes back against the pressure
A test of spinal cord integrity
H. CROSSED EXTENSION – if one leg of a newborn lying supine is extended and the sole is irritated by rubbing it with a sharp object, he will raise the other leg and extend it as if trying to push away the hand irritating the first leg.
A test of spinal cord integrity

SKIN DISORDERS IN INFANT
1. DIAPER DERMATITIS
1. Diaper rash/contact dermatitis : inflammation of the skin caused by irritants moisture, heat and chemical substances
Erythemia in the genital signals the beginning of the rash
Progresses from macules and papules to eroded, moist or crushed lesions
2. Ammonia dermatitis: diffuse erythema in the perianal and gluteal areas caused by breakdown of urea in the urine to ammonia by bacteria in the feces.
Progresses to shiny, red and excoriated skin.
3. INTERTRIGO: maceration of any two skin surfaces in close opposition/chafing of the skin.
Common in obese infants in gluteal and neck folds due to poor ventilation, high humidity and poor hygiene.
4. Nursing responsibilities: provide health teachings
Meticulous skin/care hygiene particularly along skin creases
Keeping areas involved well ventilated and free of irritating substances, use loose diaper/clothing
Quickly changing diapers after soiling after washing the area with water or bland soap and water if needed. Pat dry areas with soft cloth or towel; expose to air for few minutes before dipering
II. MILARIA/HEAT RASH/PRICKLY HEAT
A. Fine; erythematous papular rash over shoulders neck and skin folds due to warm weather or overdressing.
B. Intervention – frequent bathing with cool plain water avoiding soap; light dressing. Keeping environment cool, application of bland dusting powder and calamine lotion
III. SEBORRHREA DERMATITIS
A. Common recurrent skin disease called CRADLE CAP in neonates, dermatitis of the scalp in infants and dandruff in other children.
Cause – accumulation of sweat, sebum and dirt causing flat, adherent and greasy scales with pruritus, crushing usually indicates a secondary infection.
C. Prevention – Keeping involved areas clean, dry and cool and free of irritants.
Treatment – mineral oil, ointment or lotion to soften the scales before shampooing.
IV. IMPETIGO
Bacteria infection of the superficial layers of the skin invaded by streptococci, staphylococci, or pneumococci, commonly found on the face
Causes: poor skin care, overcrowding, malnutrition
Characteristics: macules, papules, pustules, crusts
Treatment: meticulous hygiene of skin, hexachlorophene scrubbing of lesions to prevent nephritis and rheumatic fever.
V. BOILS/FURUNCLES
Bacterial infection of hair follicles common face, neck, axila, buttocks
Progresses from papules to pustules than hard tender, hot nodless which form a pus “point”.
Treatment – personal hygiene, no squeezing, topical neomycin cream and diet high in protein, low in fats and carbohydrates.
VI. ORAL MONILIASIS
Also called oral thrush
Fungi infection of the mouth
Cause – Candida Albicans
Seen and white patches on the tongue
Prevented by oral hygiene, care of maternal nipples, proper sterilization of feeding bottles/nipples
Treatment – Mycostatin or Nystatin oral paint


SELECTED NEWBORN CONDITIONS

I. HYPOGLYCEMIA – low blood sugar
less than 30 mg % in the first 72 of the full term and less than 45 mg % after 72
less than 20 mg % in the preterm
A. Etiologic factors – prematurity, postmaturity, SGA, birth injuries, congenital defects, low APGAR, inadequate intake, stresses (cold stress, CS)

B. Danger Signs – jitteriness, apnea, tachypnea, irregular breathing plus signs of increased intracranial pressure:
tense, bulging fontanel
lethargy
high-pitch shrill cry
projectile vomiting
absent MORO reflex
tremors/convulsion




C. Nursing implementation
Give oral glucose
Administer ordered 10 % - 25 % IV glucose, monitor rate of flow strictly to prevent hyperglycemia
Keep warm
Prevent infection: handwashing – best measure
Prevent convulsion: decrease environmental stimuli
Monitor VS, behavior, serum glucose
Handle gently

II. HYPOTHERMIA – low body temperature less than 36.5 C

A. Etiologic Factor – prematurity, postmaturity, SGA, malnourished newborn
absence of adequate brown fat to burn

B. Danger Signs – low body temperature, mottling, cyanosis, crying, increased activity, tachypnea

C. Nursing Implementation
* Keep warm: maintain in incubator (best place for maintaining body warmth)
Prevent heat loss
Oxygenate PRN
Monitor temperature per axila

III. HYPERBILIRUBINEMIA – Increased serum bilirubin more than 12 – 13 mg %
- Normal serum bilirubin in newborn: 2 – 6 mg %
A. Etiologic factors – Rh and ABO incompatibility, infection, prematurity, drugs, breastfeeding (because of pregnanedial), polycythemia

B. Assessment/Findings -
pathologic jaundice (present in first 24)
dark, concentrated urine
lethargy, poor feeding
pallor
signs of increased urine
C. Treatment: phototherapy and exchange transfusion
D. Nursing responsibility: Detect and report early pathologic jaundice








HEMOLYTIC DISEASE OF THE NEWBORN
ERYTHROBLASTOSIS FETALIS

A. Blood incompatibility characterized by:
hemolytic anemia
hyperbilirubinemia

B. Types: Rh incompatibility and ABO incompatibility
Rh incompatibility is more severe: does not usually affect the first child.

C. Danger Signs – severe paleness at birth and pathologic jaundice (appears in the first 24)
Newborn is not jaundiced at birth because there is placental excretion of excess bilirubin.

D. Diagnosis: COOMBS TEST
- Direct Coombs test uses newborn blood mix with Coombs reagent whereas indirect Coombs test uses maternal blood mixed with Rh (+) blood.
Positive result: with RBC agglutination, mother has produced antibodies (+ isoimmunization)
Negative result: without RBC agglutination; mother has not produced antibodies yet (- isoimmunizatiion)

E. Prevention: RhoGAM
RhoGAM is given to an Rh (-) mother, with Rh (+) fetus, abortus or ectopic pregnancy, with (_) COOMBS test.
Action – destroys fetal antigens (fetal RBC’s) before mother produces antibodies.
Given intramuscularly in the first 72 after delivery of a fullterm, abortus or ectopic pregnancy.

F. Treatment: phototherapy and exchange transfusion
PHOTOTHERAPY – decreases serum bilirubin
Nursing responsibilities:
Undress infant leaving diapers
Cover eyes with eye shield
Have light 16 inches away from infant
Turn gently every 2 hours
Give sterile water in between regular milk feedings



Monitor temperature, I & O, serum bilirubin, jaundice and side effects: rise in temperature, dehydration, priapism (painful penile rection), bronze skin, dark and concentrated urine, loose and green stools.
Retinal damage if eyes are not shielded, sterility if genitalia is not covered .

EXCHANGE TRANSFUSION – decreases serum bilirubin and maternal antibodies, and elevates hemoglobin

Nursing responsibilities:
Have appropriate blood ready: Rh (-) and type (O), fresh, at room temperature with hematocrit 50 % + and pH 7.1 or as specified by the physician, heparinized
Check VS before and after 15 minutes during specially CR.
NPO 3 – 4 hours before or aspirate stomach to prevent vomiting and aspiration
Have resuscitation equipment ready
Place infant on his back with arms and legs restrained and under radiant warmer
Albumin (1 gm/kg) maybe given 1 – 2 hours before to allow more binding sites for bilirubin making exchange more effective.
Note and record the time of exchange more effective
Note and record time of exchange, monitor exchanges – 10 % calcium gluconate maybe given after each 100 ml of blood exchanged to prevent hypocalcemia.
Protamine sulfate maybe given after the exchange transfusion to prevent bleeding.
After transfusion, leave umbilical catheter with IV plug for a repeat exchange or remove catheter, small pressure dressing applied and site observed for bleeding.

V. RESPIRATORY DISTRESS SYNDROME/HYALINE MEMBRANE DISEASE

Pulmonary condition common in preterms and characterized by hyaline membrane formed in the alveoli causing atelectasis.
Etiologic Factors: prematurity, hypothermia, acidosis, hypoxia.
Main pathologic finding: inadequate surfactant
Major Assessment Findings:
*Expiratory grunting -Tachypnea (more than72 minutes)
* Flaring
*See-saw breathing - Chest retractions and Lower chest





THE PREMATURE AND POSTMATURE INFANTS






PREMATURE INFANT POSTMATURE INFANT

a. Born at 36 weeks or less a. Born at 43 weeks or over
b. Low birth-weight, poorly b. low birth-weight with placental
developed muscles and insufficiency from aging process
fatty tissues
c. Weak, lethargic, with poor c. wide awake, mentally alert
muscle tone and reflexes
d. Skin: red, wrinkled, transparent d. Skin: greenish (meconium
to translucent with visible stained, lethery desquamating
capillaries, less subcutaneous parchment-like, absent or slight
fats, MORE LANUGO, LESS lanugo and vernix caseosa
VERNIX CASEOSA









PREMATURE INFANT POSTMATURE INFANT

e. Associated Problems e. Associated Problems

1. Respiratory Distress Syndrome 1. Meconium aspiration
2. Hypothermia 2. Hypothermia
3. Hypoglycemia 3. Hypoglycemia
4. Hyperbilirubinemia 4. Polycythemia = Hyperbilirubinemia
5. Infection 5. Infection
6. Rickets and anemia
7. Mental retardation from kenicterus
8. Retrolental Fibroplasia




NURSING RESPONSIBILITIES FOR LOW BIRTH-WEIGHT INFANTS

A. Establish and maintain airway.
Resuscitation mostly necessary at birth because of poor APGAR.
Suction using a sterile catheter and brief suctioning LESS THAN 5 SECONDS per suctioning time as necessary.
Safe use of oxygen to prevent oxygen toxicity.

B. Keep warm inside ISOLETTE/INCUBATOR = the best place to keep him warm
Monitor temperature per axilla
Maintain heat and humidity

C. Prevent infection
Hand washing is the BEST way to prevent and its spread. Masking is the LEAST.
(NOSOCOMIAL NURSERY INFECTIONS are hospital acquired infection and the MOST COMMON CAUSE is staphylococcus aureus).

D. Monitor respiration, color, VS, I & O and weight
E. Maintain hydration and nutrition to promote rapid growth.
Usually led by NGT or GAVAGE because sucking and swallowing are poor; adhere to safety rules in gavage feeding

F. Gentle and minimal handling

G. Support parents; encourage verbalization, allow parenteral care as much as possible AFTER APPROPRIATE TEACHING.

H. PREVENT maturity or low birth-weight conditions
early and regular PRENATAL CARE is the best prevention to complications of pregnancy, labor and puerperium are also the best way to prevent high-risk newborn.











TERMINOLOGY

GROWTH - quantitative increased in size of the whole of any of its part, measurable
WEIGHT - the best measure of growth

DEVELOPMENT - quantitative increase in skills or capacity of functioning.

MATURATION - development of traits carried through genes

GENES - basic element in the transmission of hereditary traits

GENETICS - study of heredity

EUGENICS - study of ways to improve hereditary traits

EUTHENICS - study of ways to improve health

CRITICAL PERIOD - specific time period during which certain environmental stimuli has greatest effect on a child’s development


RATES OF DEVELOPMENT

INFANCY AND ADOLESCENCE – with fast growth periods
1.Infancy is the most rapid growth
Birth weight doubles at six months
Birth weight triples at twelve months


Toddler through school age period – slow growth period
- toddler stage is characterized by “PLATEAU” stage.

TODDLER AND PRESCHOOL PERIODS trunk grows faster than other tissues

SCHOOLER – limbs grow more rapidly

PUBERTY/ADOLESCENCE – characterized by “SPURTS” of growth both in height and in weight
trunk grows faster than other tissues
pre-adolescence girls grow faster than boys


FACTORS INFLUENCING GROWTH AND DEVELOPMENT

HEREDITY – sets the upper limits of growth
ENVIRONMENT – pre-natal, natal, postnatal
HEALTH
NUTRITION
RACE and CULTURE
SOCIOECONOMIC STATUS


PRINCIPLES OF GROWTH AND DEVELOPMENT

Each child is INDIVIDUALLY UNIQUE.
Each child is COMPETENT, equipped with capacity for growth and development.
Upper limits of growth and development that cannot be surpassed exist. Heredity sets the upper limits.
Growth is a regular process occurring in an ORDERLY, PREDICTABLE sequence and directions.

DIRECTION OF GROWTH

Cephalo-caudal: from head to toe
Proximo-distal: from the center to periphery
General to specific/grows to refined; simple to complex

5. Each individual grows AT HIS OWN RATE.
6. Different body parts grow at different rates.
7. There are critical period of growth and development.
8. Development continuous throughout life.
Although physical growth may cease development occurs throughout life with new skills and knowledge acquired if basic potential is present.
10. There is an inherent urge for an individual to grow and develop.
Growth and development are influence by many factors.














PSYCHOSOCIAL THEORY OF PERSONALITY DEVELOPMENT (ERIC ERIKSONIAN THEORY)

The most common used by health professionals

INFANCY trust vs. mistrust
TODDLER autonomy vs. shame and doubt
PRESCHOLER initiative vs. guilt
SCHOOLER industry vs. inferiority
ADOLESCENCE identity vs. role diffusion
YOUNG ADULT intimacy vs. isolation
LATER ADULT generativity vs. self-absorption
SENSCENCE adapts to triumphs and disappointments with a certain ego integrity.

PSYCHOSEXUAL THEORY OF PERSONALITY
DEVELOPMENT (SIGMUND FREUD’s THEORY)

INFANCY ORAL phase stage of the “ID”
TODDLER ANAL phase stage of the “Ego”
PRESCHOOLER PHALLIC stage
- ELECTRA COMPLEX – the daughter attached to father and is jealous of mother
OEDIPAL COMPLEX – the son is attached to mother and is jealous of father.
Stage of “SUPEREGO”

SCHOOLER LATENCY stage – stage of strict superego.
ADLOSCENCE genital stage

SIGNIFICANT DEVELOPMENT MILESTONE

1 mo. - heads sags; follows moving object to midline of vision
- smiles indiscriminately, crying is differentiated
- differentiates objects and face SWEATS

2 mo. - turns from side to back; holds rattles briefly; smiles socially, TEARS

3 MO. - follows moving objects up to 180 degrees
- lifts head and chest of bed discovers, plays with fingers
holds head erect, DROOLS (needs bibs)

4 mo. - turns from back to side, reaches for objects
- drools a lot, recognizes others with social interaction
- demands attention
laugh (3 – 4 mos.)

5 – 6 mo. Rolls over completely
- sits with support and without support briefly
- transfer object from one hand to another
- begins to imitate sounds
- recognizes the parents
birth weight doubles

7-8 mos. Sits for longer period without support
- hitches
- discovers feet
- fears strangers

9-10 mos. creeps
- stands with support
- with develop pincer grasp
- with good hand-to-mouth coordination
- feeds self with bottle
- with patterned speech
- says first two words “ma” and “pa”

11-12 mos. Stands without support
- walks help (cruising)
- shows emotions
- begins to explore the environment
- birth weight triples
- start of closure of anterior fontanel
- knows name
- says 4 – 5 words
- with gesture language

18 mo. Walks alone – sideways and backward
- climbs stairs and furniture
- anterior fontanelle usually closed

- feeds self
- drinks from a cup
- physiologically ready for toilet training (with nerve tract myelinization at 15 – 18 months – earliest time for toilet training)

2 yr. - Runs fairly well
- walks up and down stairs one foot after another
- uses spoon without spilling
- jumps with both feet in place
- scribbles

2 ½ yr. Jumps from furniture or stairs
- balance on one foot
- feeds self well
- drinks from a straw
- walks backwards
- with complete primary teeth (20)
3 yr. - rides and pedals a tricycle
- goes upstairs with alternating feet
- climbs and jumps well
- draws a circle and a cross
- stands on one foot
- attempts to print letters
4 yr. - goes up and down the stairs like an adult
- hops two or more times
- dresses with minimal help
- can buttoned buttons and lace shoes
- catches ball
- copies a square
5 yr. - can jump rope, skip
- balance on one foot (10 sec.) with eyes closed
- dresses and washes self without assistance
- roller skates
- throws and catches ball well
- can draw a picture of a person
- ties shoelaces
- copies rectangle and triangle
- uses scissors well
- with improve balance
- prints, cuts, paste, hammers
7 yr. - rides a tricycle
- vision mature – hand to eye coordination developed completely (20/20 vision)
- with fine hand movements – can print sentences
- can swim
8 yr. - writes rather than prints
- with grace and balance even in sports
- with increase smoothness and speed
- since arms and legs begins to grow, may stumble on furniture and spill milk
9 yr. - “on the go” constantly
- uses both hands independently
- fully developed hand-to-eye coordination to enjoy baseball
- more mature writings


SIGNIFICANT PERSONS

INFANCY - Mother, mother substitute
- Primary caregiver
TODDLER - Parents
PRESCHOOLER Members of the basic family
SCHOOLER - teacher
- Peers of SAME SEX – neighbors and classmates
- Adults other than parents are “HERO” – “WORSHIPPED”
ADOLESCENCE Peers – greatest determined of his behavior
- models of leadership
- Adults other than parents are IDOLIZED
Partners of same and OPPOSITE SEX (establish close relationship with the opposite sex)


FEARS OF CHILDREN

INFANCY - Stranger anxiety
- Starts at six months, peaks at 7 – 8 months
TODDLER - Separation anxiety
- Phases: protest, despair, denial
PRESCHOOLER Castration fears: ghost, dark, and inanimate objects
SCHOOLER - Fear of Displacement or Replacement
fear of death, disease and body injury
ADOLESCENCE fear of loss of identity: acne, obesity, homosexuality, body odor
- Fear of the unknown
Fear of disease, death


LEADING ACCIDENTS/CAUSES OF INJURIES IN CHILDREN

INFANCY - aspiration (leading)
- falls
suffocation
burns
poisoning – lead paint
TODDLER - falls (leading)
burns
drowning
poisoning aspirin (most common drug that poisons children)
> The natural curiosity of a toddler leads him to accidents
PRESCHOOLER Motor accident (leading)
burns
drowning
SCHOOLER - Motor accident (leading)
- Sports accident
ADOLESCENCE Motor vehicular
Sports accidents
Burns
Drowning
Drugs
Alcohol
Suicide


PLAY – THE LANGUAGE OF A CHILD
TYPES OF PLAYGAMES

INFANCY - SOLITARY play
- He plays alone with his body or with his toys
TODDLER - PARALLEL play
- He plays alone in the presence of other children, no sharing
PRESCHOOLER COOPERATIVE play
He plays with others
Can be with large group of boys and girls
SCHOOLER - COMPETITIVE play
Plays with peers of same sex
Games have rules where winning is desired
ADOLESCENCE RECREATION/LEISURE activities
Can be with friends of same and opposite sex
Leisure activities are meant to get closer to friends of opposite sex

APPROPRIATE GAMES/TOYS FOR CHILDREN

INFANCY - rattles
cribmobiles (best) teethers
pacifiers
musical boxes
squeeze toys
large cuddly toys
“Peak-a-boo” game played at 10 months
TODDLER - Push and pull toys (best) building blocks
ball play
telephone (age of language training)
play hammer
drum
ball pots and pans (outlets of aggressive behavior)
dolls (security blanket)
“Throwing and Retrieving” game.
PRESCHOOLER tricycle (can ride if at 3 years)
play house
coloring books
clay cutting and pasting tools
superheroes costumes dress-up
dolls
ball
SCHOOLER - bicycle (can ride it at 7 years)
quiet games like reading
painting
radio, TV
Family computer sports game
table games like scrabbles
handicraft (late schooler)
ADOLESCENCE parties, outings, picnics, movies
fantasy and daydreaming (normal)
telephone conversations
reading romance novels
sports games
hobbies

THE TODDLER

I. Behavioral Traits:
A. Negativism: “no” – “no” age
an attempt to show autonomy

B. Temper Tantrums: crying and screaming when he does not get what he wants
an attempt to show autonomy and NOT a sign of poor discipline

C. Ritualism: doing things over and over again
- RESPECT HIS RITUALS: if hospitalized, adhere to his rituals to minimize separation anxiety

D. Dawdling: slowness in accomplishing tasks
- be patient: allow to dawdle: do not give him tasks he cannot accomplish.

E. Egocentricity: selfishness “normal”

II. Developmental Tasks:
Toilet training
Language training
Learning social behavior


LANGUAGE TRAINING

I. Language Training Principles
Teach one language at a time
Talk to child in simple, clear words
Do not baby talk
Talk to child at eye level
Provide a good model of speech
Provide of plenty sensory stimulation

II. Schedule
9 – 10 mos. - says two words “ma” and “pa”
11 – 12 mos. - has 4 – 5 words in gesture language
18 mos. - has 20 words
2 years - with short sentences (1 – 2 words/sentence)
- uses and says first name; with 300 words
3 years - 900 words; uses first and last name; names one color
5 years - with adult length sentences
- last year for normal stuttering
- (dysfluency): 2000 – 2100 words with increase of 600
per year. 1 counts to 10
School age - with passwords/secret language, with rapidly
Expanding vocabulary


TOILET TRAINING

I. Requisites:
Sphincter control – most important
Ability to stand and walk to the bathroom
Understands the act of elimination
Can express need to eliminate
Desire to please the mother

Positive maternal attitude and not “strictness” is important to success in toilet training

II. Schedule:

Start - as early as 15 – 18 months as late as 18 mos. – 2 years
Bowel control - 2 – 2 ½ years
Bladder daytime control - 2 ½ - 3 years
Night time bladder control - 3 – 4 years




III. PRINCIPLES OF TOILET TRAINING
Consistency
Firmness
Positive Maternal Attitude

DICIPLINE IN CHILDREN

I. FORMS OF DISCIPLINE
Ignoring
Diverting attention
Time-out
Corporal punishment
Explaining’ reasoning and reprimanding for older children
Withdrawal of privileges
II. PRINCIPLES OF GOOD DISCIPLINE
Consistency
Discipline a toddler RIGHT AWAY after a wrongdoing.
Explain the reason for discipline and allow child to explain first.
Disapprove of the behavior and NOT OF THE CHILD.
Withdraw privileges and NOT BASIC NEEDS. (You don’t send a child to bed without food for a wrongdoing).
Provide physical care after “ignoring” of temper tantrums.
Methods of discipline should be SAFE.


DENTITION

I. IMPORTANT SCHEDULE
6 – 7 MONTHS - eruption of FIRST milk teeth
- LOWER CENTRAL INCISORS
12 months - has 8 teeth
24 months - has 16 teeth
2 ½ years - with COMPLETE milk teeth - 20
Late preschool - eruption of the first permanent teeth
- the first MOLARS
6 years - brags about “dancing teeth”
12 years - has all permanent teeth
except FINAL MOLARS

II. CARE OF THE TEETH
Brush and floss (with parent’s help) twice daily.
Limit concentrated sweets.
If water is not fluorinated, supplements can be given
0.25 – 0.5 mg/day.
D. Do not allow child a bottle of milk or juice to bed; produces BOTTLE
MOUTH CARRIES.
E. Have the FIRST dental visit as soon as all deciduous teeth are out; 2 ½ years.

PERMANENT TEETH
6 – 7 years - 4 “six-year molars”
12 – 13 yr - 4 additional molars
7 – 21 yr - 4 molars “wisdom teeth”
6 yr - age of “dancing Teeth”

Note: Check the SCHOOL AGE child for any loose teeth before any surgery.



BREASTFEEDING

A. This is the best type of feeding that supplies the infant with all essential nutrients in the first six months.

B. ADVANTAGES OF BREASTFEEDING

MOTHER BABY
1. Promotes bonding 1. Contains antibodies (IgA) that
protects infant from GI infection
2. Promotes uterine involution 2. Always available in sterile form
and at correct temperature.
3. Delays fertility (But not safe to use as a 3. Less incidence of colic,
sole means of family planning constipation, diarrhea and
allergies
4. Economical in time, effort and money 4. Its protein, lacalbumin, is easy
to digest.
5. Less incidence of breast cancer 5. Contains taurine that enhances
brain development.

BREASTFEEDING REFLEXES

A. Milk secretion reflex – Prolactin reflex
> The best way to stimulate milk secretion reflex is to TOTALLY EMPTY the breast with each feeding always start with the breast that was last used.

B. Milk ejection reflex – Letdown reflex
> Licking and sucking of the nipples plus POSITIVE/RELAXED MATERNAL ATTITUDE stimulate the letdown reflex.
> Most important to success of breastfeeding.




PROLACTIN REFLEX LETDOWN REFLEX

Brought about by hormone prolactin Brought about by hormone oxytocin
Secreted by anterior pituitary gland secreted by posterior pituitary gland (APG). (PPG).

Prolactin stimulates ACINI to secrete Oxytocin stimulates BREAST TUBULES
Milk. to eject milk.

Total emptying of the breasts is the Relaxed and secured maternal feelings
BEST STIMULUS to more milk BEST stimulates letdown reflex.
secretion.


“ESSENTIALS” OF BREASTFEEDING
A. START
Right on the delivery table PRIMARILY to promote bonding
30 minutes after birth in normal spontaneous delivery.
4 hours after cesarean section.

B. DURATION OF FEEDING
5 minutes /breast, after establishment of feeding: the first 10 minutes is for nourishment, the 2nd 10 minutes is for sucking pleasure. Total breastfeeding time: 20 minutes.

C. CARE OF THE BEASTS
Daily bath: towel-dry nipples to strengthen them
Clean bra, non-plastic-lined, day and night.
Use nursing pads inside the bra cup to absorb milk leaking between feedings.
Washing of the nipples with plain water once daily.
If source of water and its mode of transport to home is reliably safe, NO NEED FOR STERILE WATER TO WASH/CLEANSE NIPPLES.
RATIONALE: The mouth of the infant is NOT STERILE. No soaping or use of alcohol on nipples.

ARTIFICIAL FEEDING
Not recommended if only breastfeeding is possible.
Some advantages
Provides an alternative to breastfeeding.
More accurate assssment of intake.
May meet the needs of working mothers.
Maybe indicated in cases of congenital deformities (cleft palate), inborn errors of metabolism, allergies.

C. Factors to Success
Pasteurization of milk.
Sanitation in milk handling
Adequate sterilization, refrigeration and storage
Tuberculin testing of cows
To equal mother’s milk in nutrients: add sugar to increase energy value (Mother’s milk has more carbohydrates, water and fats). Dilute with water to reduce mineral and protein concentration. (Cow’s milk is higher in protein casein and mineral content)

C. BOTTLE-FEEDING TECHNIQUES
A. Never prop bottle; always hold infant during feeding.
provides warm body contact.
Provides attachment (bonding)
Allows continued observation during feeding, thus, preventing he usual complication of propping bottles – ASPIRATION.
The closeness and eye-to-eye contact are the ones that promote bonding. The mother can be close to her bottle-fed baby provided she holds him during feeding.
B. Hold bottle so nipple is always filled with milk to prevent swallowing of gas and colic.
C. Burp or bubble during and after feeding.
D. Hold upright for 30 minutes more before putting down best on his right side to avoid digestion and prevent vomiting and aspiration.
Whether breasfeeding or bottle feeding, the best is DEMAND FEEDING which is feeding the infant according to his NEEDS.

SUPPLEMENTARY FEEDING

A. REQUISITES/CUES TO START SOLID FOODS
Extrusion and sucking reflexes fading.
Can sit support.
A nutritional need for iron to be met.
Develop salivary glands and presence of intestinal enzymes needed for digestion.
B. The usual age for introducing solid foods: 4 – 6 months.
C, SIMPLE RULES TO FOLLOW
Introduce one food at a time
Small amount (1 tsp.) each time
Have an interval of 4 – 7 between new foods to detect what food he is allergic to.
Do not mix new food with formula.
Feed when infant is hungry after few sucks of milk increases his patience for a new food.
Do not force, bribe, plead nor threaten.
D. SEQUENCE OF INTRODUCING SOLIDS
Cerelac – “Am” 5. Eggyolk
Fruits 6. Fish
Vegetables 7. Teething foods at 6 – 7 mo
Whole eggs 12 months 8. Meats
Eggwhite is hyperallergenic

COMMON FOOD STARTER
I. Cereals/”Am” - first solid food
iron-rich
easy to digest
hypoallergenic
can be continued – up to 18 months
II. Common Vegetables Starters
Squash, Sayote, Potato
III. Common Fruits Starters
banana, papaya, mango


CALORIE REQUIREMENTS OF CHILDEN
Newborn - 400 (45 – 55 Kcal/lb or 80 –120 Kcal/kg)
Infant - 800 - 1200
Toddler - 1300
Preschool - 1700
Schooler - 2400
Adolescence - 2200 - 2700
Note: Males have higher caloric requirements

FEEDING PROBLEMS IN CHILDREN
I. Infancy
Aspiration tendency
Colic – more common
Constipation – more common
Supplementary food introduction
Diarrhea
Food allergies
Burping
weaning
II. Toddlers
Physiologic anorexia
Iron-deficiency anemia
III. Preschool
Food likes and dislikes
IV. School
Junk foods
Zero-caloric foods (soft drink)
MARASMUS

I. Marasmus is caloric malnutrition.
II. Causes:
Insufficient diet, Improper feeding habits
Emotional cause – disturbed mother-child relationship
Metabolic disorders
Congenital malformations
IV. Signs
Underweight, emanciated
“Old man’s” face
all skin and bone look
pot belly (distended abdomen)
skin wrinkled and loose with no subcutaneous fat
muscle wasting
hypotonia, hunger
subnormal temperature, slow pulse
usually constipated or with starvation diarrhea – frequent, small stools with mucus
V. Treatment:
FOOD – increase calories in the diet

KWASHIORKOR

I. This is PROTEIN MALNUTRITION
II. Causes:
insufficient protein intake
impaired protein absorption – diarrhea
abnormal losses – proteinuria in nephrosis
infection
burns
III. Signs
lethargy, apathy, irritability
edema
loss of muscular tissue
with hair sign – flag sign: thinning, straight with alternate – dark bands
with flack dermatosis
liver enlargement
increase susceptibility to infection
anorexia
IV. Treatment:
Food is the only cure for malnutrition
High protein, high energy milk feed is the easiest way to give the severely malnourished child food.
Kwashiorkor is the MOST SERIOUS AND PREVALENT form of malnutrition in the world today.

HEALTH PROBLEMS OF THE SCHOOLER AGE GROUP

PRESCHOOLER SCHOOLER ADOLESCENT

Fear of the dark, uni- Stealing (7 years) Acne vulgaris – hallmark
versal fear of the age of the age

Imaginary friends Shoplifting
Tell tales/tattling lying speech dificulties – articu- poor posture, slouchy walk,
lation is most common fatigue, Suicide – causes
Sibling rivalry preparation of malnu- include: 1.Anger to another
Hurting others trition. 2. Desire to punish or ma-
Bad language nipulate someone. 3. To
Malnutrition signal distress.
Goal of therapy:
Sex education: started Sex education: health Improve self-image
At about 5 yrs; parents care personnel are usual Sex education:
Are sources of inform- resource person Menstrual hygiene
ations.

Stuttering Handedness: consistent Adolescent pregnancy
Right or left-handedness
Is stabilized by 9 yrs Alcoholism
(AMBIDEXTROUS -
Regression (thumb- uses hand interchangeably) Drug experimentation
sucking), bedwetting, a form of adolescent
negativism) Drug Experimentation - rebellion
because of preadolescent
Preparing for school rebellion and poor
Judgment.


THE ILL AND HOSPITALIZED CHILD

I. Factors Affecting Responses To Illness And Hospitalization
Developmental stage in which the child is in
Nature of illness or injury; seriousness of illness or injury
Level of anxiety of both child and parents
Type of relationship that exist between parents and the child
Past experiences with hospitalization, medical treatment and surgical procedures.
Support systems
Sociocultural status, race, culture and education



II. Major Sources of Fears of Hospitalization.
Separation D. Immobility
Pain E. Body Injury
Loss of Control F. Punishment and rejection


PREPARATION OF CHILD FOR ADMISSION

Under 2 years – explanations are ineffective
allow to take security blanket – the favorite toy or objects
2. 2 – 7 years – tell child ahead in days equal to years of age
example: 2 years old – tell the child two days ahead.
3. Over 7 years – tell the child when parents know
4. Adolescent – provide him with full explanations; answer questions completely and honesty.

CHOLASIA

Abnormal relaxation of the cardiac sphincter of the stomach resulting to self-limiting vomiting.
Etiology: unknown; common in babies of tense mothers.
Signs and symptoms:
Self-limiting, non-projectile, non-bile vomiting
Regurgitation after feeding
Dehydration
Increased hunger
Weight loss
D. Effect of frequent vomiting: METABOLIC ALKALOSIS (due to loss of HCL acid).
E. Nursing Care:
1. Correct feeding techniques
Feed slowly in upright position
Burp/bubble frequently
Do not overfeed (overfeeding is the most common cause of vomiting)
Maintain upright for 30 minutes more after feeding
Put on right side after
Re-feed with thicker formula (more difficult to vomit)
Allow play before feeding time to relax mother.
2. Provide psychological support.
Encourage verbalization of concerns and feelings about feeding/breastfeeding.
Observe for signs of dehydration.







PYLORIC STENOSIS

Congenital hyperthropy/hyperplasia of the muscles of the pylorus causing obstruction of the pyloric sphincter.
Etiology: unknown
Signs and symptoms
Non-bile, non-projectile vomiting
Increasing hunger, dehydration in children.
Signs of dehydration in children
sunken fontanelles (first sign of dehydration in infants)
sunken eyeballs
oliguria
dry mucus, tears
fever, rapid thready pulse
poor skin turgor/non-elastic skin
3. Visible gastric peristalsis
4. Olive-shape mass at the right upper quadrant
5. Abdominal distention
6. Constipation, or decreased number of schools
7. Failure to thrive/decreased weight
D. Treatment
1. Medical
Monitor IV and IO
Measures to prevent vomiting
2. Surgical: Pyloroplasty/Pyloromyotomy/Fredet – Ramstedt Surgery: creation of a longitudinal incision into the muscles of the pylorus to create a gaping wound.
E. PREOPERATIVE CARE
NPO with IV and NGT
Observe, monitor I & O, vomiting, NGT drainage, stools, weight.
Keep warm
Monitor I & O, IV, weight
Feed about 2 – 8 hours or 4 – 6 after with dextrose water; only by RN in the first 24 – 48 hours as vomiting tends to continue in immediate postoperative period.
Frequent burping – before, during, and after feeding






IMPERFORATE ANUS

Congenital anorectal malformation where the rectum ends in a blind pouch or with a fistula connecting it to the vagina (rectovaginal fistula) or to the urethra (rectourethral fistula).
Signs and Symptoms
No anal opening on inspection
Non-insertion of the rectal thermometer
Progressive abdominal distension
Difficult defacation, inability to defecate
No meconium stool in the first 24 hours
Meconium from inappropriate opening (fistula)
C. Diagnosis Wangesteen – Rice method
Infant held upside down
As the child cries, gas in colon rises to reveal pouch in relation to anal membrane
X-ray pictures taken (no need for dye – danger of aspiration)
D. Treatment: Surgery
Anoplasty for the simple type
Pull-through operation with or without temporary colostomy
E. Nursing Care
1. Provide preoperative care:
NPO
Vital signs monitoring – prepare parents for surgical procedure and for temporary colostomy if necessary
NGT to decompress stomach
Warmth provision
2. Provide postoperative care:
Prevent infection
Meticulous skin care: provide perirectal care with anoplasty or pull-through procedure observing strict aseptic techniques
b. administer and maintain IV fluids
Monitor rate of flow (single most important in caring for a child with IV therapy)
Maintain strict I & O
Check weight daily
c. Provide oral feedings
With pull-through, begin oral feedings slowly whem peristalsis returns.
With colostomy, begin oral feedings slowly, stools are passed.
d. Provide parental teaching: colostomy care if appropriate
Empty pouch as needed
Skin care
Change pouch as necessary
Clean peristomal areawith mild soap and water, dry thoroughly, apply clean pouch
Use skin barrier as ordered to protect skin from irritation


HIRSCHSPRUNG’s DISASE/CONGENITAL MEGACOLON

A mechanical obstruction of the bowels due to the absence of autonomic parasympathetic nerve ganglion cells in the distal bowel – inadequate motility.
Etiology: real cause is unknown
C. Signs and symptoms:
a. Newborn
No meconium stools in 24 – 48 hours
Bile-stained vomitus
Feeding difficulties
Abdominal distention
Abdominal pain: Irritability, crying
b. Infants:
Chronic constipation – hallmark of megacolon
Abdominal distention
Explosive diarrhea
Bile-stained vomiting
Failure to thrive malnutrition
c. Older children:
Chronic constipation – hallmark
Ribbon-like stools – like pellets
Palpable fecal masses
Fecal odor of the breath
Abdominal distention
Visible peristalsis
Anemia- malnutrition
D. Diagnosis:
Barium Enema
Rectal biopsy – confirms megacolon
Abdominal X-ray
E. Treatment: Surgery
Bowel resection with temporary colostomy
Abdomino-perineal pull-through by about 1 year
F. Nursing Care:
1. Provide PREOPERATIVE CARE
NPO – pacifier (newborn)
NGT
I & O
Provide emotional need – touch, pacifier
consistent parental care
administer – low residue, high-protein, high calorie diet if appropriate (childhood) – parental nutrition as ordered
bowel cleansing – liquid diet – stool softeners as ordered – digital removal – daily isotonic saline enemas/colonic irrigation

Volume of fluid:
Infant - 150 – 250 ml
Preschool - 300 – 500 ml
Toddler - 250 – 350 ml
School - 500 – 700 ml

2. Provide POSTOPERATIVE CARE
Monitor VS
I & O, electrolytes
Stools
Respiratory status
Bowel sounds
b. Maintain hydration and nutrition
Oral fluid as soon as bowel sounds return, advance diet s tolerated
Monitor for abdominal distention
c. Keep incision site clean and dry
d. Assess for correct colostomy functioning provide colostomy care: emphasize meticulous skin care.
e. Provide pain relief – analgesics PRN
f. Monitor for signs of complications
Skin infection
Respiratory infection; coughing, deep-breathing, turning every 2 hours
g. Maintain NG tube to low Gomco suction; maintain patency
h. Provide psychological support
stroke, hold cuddle infant
explain to parents diagnostic and treatment procedure














SPINA BIFIDA

A congenital defect of the spinal/neural tube; incomplete closure of the spinal column.
Classifications
Spina bifida oculta – missing L5-S1; usually asymptomatic; seldom creates health problems; no treatment
Meningocele – sac-like cyst that contains meninges and spinal fluid that protrudes through the bony defect

3. Meningomyelocele – herniated sac of meninges, spinal fluid, and portion of the spinal cord and its nerves that protrudes through the defect in the spine; 80 % in the lumbosacral region
C. Etiology/Incidence – Exact cause unknown
D. Signs and Symptoms
Visible sac-like structure or dimpling of the skin at any point on the spinal E.
E. Nursing Care:
1. Provide skin care to prevent infection of the site
Clean site with H2O2, sterile saline (NSS).
Apply sterile, moist soaks to site 2 – 4 hours as ordered.
Prevent pressure on the site.
Position properly: Prone
Turn every 2 hours: side-prone-side
Doughnut ring around site.
NO DIPERS until site has been repaired or healed.
d. provide meticulous skin care to areas around the site; apply lotion to areas of skin 3 times a day.
2. Maintain hydration and nutrition
Use soft nipples for feeding
Elevate head for feeding
Feed slowly
Maintain strict I & O







Filename: Pediatric Review
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