12 - Pedia_Combined.pdf

PEDIATRIC NURSING | BOARD EXAM REVIEW Lecturer: Assoc. Prof. Rouena S. Villarama, RN, MEd PEDIATRIC NURSING: asphyxiation - a crying baby af...

PEDIATRIC NURSING | BOARD EXAM REVIEW Lecturer: Assoc. Prof. Rouena S. Villarama, RN, MEd PEDIATRIC NURSING: asphyxiation - a crying baby after birth is a NEONATES breathing baby IMMEDIATE DELIVERY ROOM CARE / ○ Freely encourage more crying because more ESSENTIAL INTRAPARTUM NEWBORN CARE (EINC) crying means better outcome The more he cries, the pinker the baby Neonate From birth to 28 days gets → he gets more oxygen STOP if the baby is turning bluer Infant From 1 month old to 12 months Transposition of the great vessels (TOGV): when suctioning, the baby cries Toddler 1 - 3 years old but he gets bluer → order oxygen (dependent nursing action) Rub the chest / rub the back Preschooler 3 - 6 years old HOW TO PREVENT: ASPIRATION Schooler 6 - 12 years old Assess if there is mucus clogging nose and mouth ○ Suction with bulb syringe PRN (if mucus is clear it Adolescent 12 - 18 years old is amniotic fluid no need to suction, but if it is green it is a meconium stain = suction) In support of the Millennium Goals 4, but in 2015 it became Suctioning is not routine in EINC Sustainable Development Goal: Good Health and well-being because it can hit the carina and lead to for People: TO REDUCE CHILDHOOD MORTALITY vagus nerve stimulation and bradycardia; and suctioning sucks oxygen reserves of neonate NURSING RESPONSIBILITIES Encourage to cry effectively to maximize lung expansion O2 PRECAUTION: Retrolental fibroplasia/ Retinopathy of A Airway Prematurity ○ GOLDEN RULE: After birth, infants should have pulse oximeters attached on their toes for the B Body Temperature doctor to see their response to crying. ○ Must be attached to an oxygen monitoring device, C Certify the birth but if the infant no longer needs it or has an oxygen level above 95%, turn off the oxygen D Determine adaptation to extrauterine life - APGAR because giving too much oxygen will do more harm than good. ○ Retrolental fibroplasia - for term newborn; too AIRWAY much oxygen can make him blind TIME BOUND INTERVENTIONS ○ Retinopathy of Prematurity - for preterm Prevent asphyxiation newborn; more vulnerable, more fragile retinal ○ Accounts for 31% of NB death blood vessels, could be blind more possibly Prevent aspiration BODY TEMPERATURE WHAT CAUSES ASPHYXIATION? TIME BAND/ TIME BOUND INTERVENTION Physiologic heat loss after birth (37.2 C down to 35.5 to 36.5 Umbilical Cord is clamped (when it is no longer pulsating) C) ↓ Extreme hypothermia can cause COLD STRESS causing No more O2 from placenta ACIDOSIS ↓ ○ When an infant is born, he is exposed to a new Hypoxia (decreased O2 in tissue) environment. We know very well the difference ↓ between intrauterine and delivery room Hypercapnia (increased CO2) environments which are air conditioned. This will ↓ cause the infant’s body temperature to go down to Acidosis: Buffer HCO3, Respiration, Urination adjust to the changes (physiologic resilience). ↓ Expected heat loss will take place but it should not CNS Depression: Respiration is depressed or go lower than 35.5 because it may lead to extreme slowed down; Kussmaul’s Breathing, LOC goes to comatose state hypothermia and cause cold stress. ↓ Death PRONE TO COLD STRESS DUE TO EXTREME HYPOTHERMIA EXTREME HYPOTHERMIA HOW TO PREVENT: ASPHYXIATION ↓ Umbilical cord must be clamped because autotransfusion will occur if not - when baby’ blood enters maternal sinuses or if NON-SHIVERING BURNS BROWN FAT FOR maternal blood enters fetal circulation (may result in ABO Rh THERMOGENESIS HEAT incompatibility reaction) ↓ ↓ Stimulate breathing Increases O2 consumption Ketones/ Fatty Acids ○ Neonates must breathe after birth! If not, ↓ ↓ asphyxiation may result (hypoxia, hypercapnea, Dec O2, Inc CO2 → Acidosis Acidosis acidosis) ○ Neonates breathe after birth by crying, so stimulate NB to cry effectively to prevent Hatdogs + JD | 1 NON-SHIVERING THERMOGENESIS CERTIFY BABY’S BIRTH: A reaction triggered by a cold environment. During the IDENTIFICATION & REGISTRATION process, the body burns oxygen to produce heat. This Plastic bracelet (ankle) and crib card causes a dec O2, Inc CO2 levels leading to Acidosis → ○ Used in the hospital to identify the baby baby turns blue ○ Plastic bracelets should be attached on the ankle to provide more security; ideally should be 2 ○ Crib card - blue for boy and pink for girls BURNS BROWN FAT FOR HEAT ○ Not ideal because both are detachable If the oxygen usage was not effective, the body burns fats to Footprints - more reliable (no longer recommended) produce heat. A newborn has more fats in his body, which is ○ Research have proven that one of the ways of called brown fat. Brown fats are not meant for insulation transmitting infection from one baby to another is purposes. These fats are usually located in the abdominal through the footprint stamp pad; cavity to support abdominal organs and sustain the position ○ Legally speaking, the footprint of the baby then because ligaments that support these organs are not yet in can no longer be relied on for his identification place which is why newborns are oftentimes still lying down. now. It is also located in their cheeks for sucking purposes. ○ If not done properly, it will not show any legal With absent carbohydrates, considering that they do not eat implications. To properly get the creases/footprint, yet, they use fats instead. The byproduct of fat metabolism is the nurse should wipe the foot of the newborn and ketones, a fatty acid which can lead to acidosis. make sure that there is no blood/vernix caseosa ○ NOTE: In adults, given the choices fats, proteins, before putting it on the stamp pad. carbohydrates, our body’s basic fuel is Most ideal: DNA test carbohydrates. ○ In most progressive countries, DNA bank is done Hypoxia and hypothermia can contribute to acidosis which wherein they could get the information about the can lead to CNS depression and death. baby and its DNA. ○ Still not readily available in the PH but CAN be MANAGEMENT done if REQUESTED Dry baby immediately after birth (heat loss by evaporation) Local Civil Registrar then PSA for Birth Certificate (Act ○ There should be at least 2 preheated towel 3753) ○ DRYING TECHNIQUE: Gentle but brisk drying ○ Requires registration of all relationships (already stimulating the baby to cry) Marriage license ○ The tactile stimulation is enough to stimulate the Birth certificate baby to cry, get oxygen, and produce heat. ○ Baby’s info will be submitted to the Local Civil Put on top of mother’s body: Skin to Skin Contact/ SSC Registrar (City Hall) first then forwarded to the (conduction) → “Unang Yakap” Philippine Statistics Authority (PSA). ○ First advantage is heat production, second is If the baby is born at UST Hospital, info bonding between the mom and infant is will be submitted to and acquired from strengthened. the Manila City Hall even if the Put a bonnet residential address of the parents is ○ Infants are bald → hair is important for insulation. Quezon City. This info will be forwarded ○ Anatomically, the biggest part of their body is the next to the PSA. head. It is where the heat is bound to evaporate ○ Within 6 weeks from being born, the baby must be from registered ○ Can also use hospital towel as an alternative JUS SANGUINIS - following the Put under the floor lamp, drop light or radiant warmer citizenship of the parent by blood ○ Can also use gooseneck lamp (Parents filipino, you are filipino) ○ Best to use is radiant warmer JUS SOLI – “soli” from “solar” which Provides even heat from head to toe means place. You get the citizenship of Provides more safety because distance the place where you were born. is fixed Ex. In the US. ○ In a home delivery setup, they usually iron the ○ This is done to ensure that the baby is recognized blanket and use it to cover the infant as a Filipino citizen and be given the proper rights. ○ HOT WATER BAG is not advisable because Ex. Korean neighbor – this process is scalding may happen → water may leak from the not applicable because they will be stopper and burn the baby registered by his own respective Korean ○ RADIANT WARMER embassy in the PH. There is a good distance between the heat source and the baby under the DETERMINE ADAPTATION TO EXTRAUTERINE LIFE warmer (24 inches or 2 feet distance) Emits heat evenly hitting the baby EXPLANATION: How to determine adaptation to extrauterine life? equally from head to toe Age of Gestation (AOG) Avoid putting crib near the cold wall (radiation) ○ Best indicator: If the baby is term, preterm or Avoid cold draft: aircon, fan, open window or door postterm (convection) Congenital Defects ○ The ducting of the air conditioner should not be ○ Presence of congenital defects at the moment of directly towards the baby. birth affects adaptation Postpone the bath until temperature is stable (6hrs) APGAR Scoring (by Virginia Apgar) ○ Allow the vital signs to stabilize first ○ RR, HR ○ The 6 hour period may be used for mother-infant ○ First scoring: 1 min after birth bonding + other non time bound interventions. ○ Second scoring: 5 mins after birth ○ Since the baby has not been bathed, do not touch At 1 min of life, look at certain parameters (APGAR). To see the baby with your bare hands, wear double the priority, change the sequence → PRAGA. Best evidence gloves to know that the child is alive – PULSE (“tumitibok ang Use warm water during bathing puso”) Hatdogs + JD | 2  APGAR SCORE - Done at 1 min then at 5 mins GRIMACE CRITERIA ASSESS 0 1 2 Response of the body to stimuli; a test for the baby’s CNS. 1 – ngiwi-ngiwi lang, mahina ang response, tinatamad PULSE Cardiac Absent ↓100 ↑100 2 – pulling away from the suctioning, umiiwas sa catheter kapag Rate sinusuction mo ang baby RESPIRATION Cry Absent Weak, Strong, APPEARANCE slow, regular irregular Least reliable indicator of adaptation. Babies are supposed to be born depending on race. ACTIVITY Muscle Limp Some Well ○ PINK: White, Caucasian, Mestiza Tone Floppy flexion, flexed ○ RED, DARKER RED: Kayumanggi, Dark skin Tone little and movement moving 0 – If the baby is born pale or blue → severe anemia & low oxygen level. 1 – Acrocyanotic (pink body, but blue extremities) baby is not GRIMACE Reflex No Grimace Cry, gag, much worrisome because it’s only peripheral. This condition is irritability response cough, only transient. REASONS INCLUDE: pulls ○ When the baby is inside the uterus, she is bent and flexed away but when she goes outside the space of the uterus, arms and legs are now stretched → takes a while for blood to APPEARANCE Color Pale/ Acrocyano Pink/ red reach distal parts/ extremities blue all sis all over ○ Cold environment – as the body’s response to immediate over change in temperature → vasoconstriction → blood vessels close → bluish fingers (normal for the first couple of minutes, i.e. 5 mins.) If it persists (>5 mins.), the condition might be serious. PULSE During cardiac assessment, DO NOT let murmurs affect your SCORE INTERPRETATION AND MANAGEMENT APGAR scoring. If you hear a murmur, do not lower the score. You are not assessing for cardiac rhythm/sound, but CARDIAC 0 to 3 Resuscitation needed/ NICU RATE only. Assessment of murmurs will be important later on to ○ Intubation, ambu-bagging, O2, emergency know if there’s congenital defects. POOR meds (naloxone, epinephrine) CONDITION ○ If acidotic due to hypoxia → NaHCO3 RESPIRATION ○ Cardiac message using 2 finger put in the sternum (in between 2 nipple lines) A crying baby is a breathing baby. 1 – crying is not satisfactory; less oxygen in the lungs; lung 4 to 6 Closer monitoring expansion quality is not good Baby goes to NICU 2 – malakas ang iyak dahil maraming hangin ang pumasok FAIR ○ Babies with 4-6 scoring came from a mother CONDITION with a medical problem (thyroid problem, ACTIVITY BUT asthma) GUARDED ○ If hypoglycemic → check CBG 0 - Floppy tone does not mean that the baby is dead. There’s still ○ We CANNOT let the baby out of our sight; NO heartbeat → Find out why he is limp/floppy (arms and legs are ROOMING IN YET with mom; baby stays in open like a frog) the NICU ○ Premature baby ○ Hypoglycemic baby because mom is diabetic 7 to 10 Allowed to do “Unang Yakap” ○ Baby is affected by medications given to the mother when ○ Put the baby on the mother’s abdomen, she was in labor (narcotics for Twilight Deliveries). GOOD breastfeeding is done Twilight delivery – painless delivery CONDITION ○ The father can also be there (Kangaroo Care) Morphine Rooming - in Demerol for pain → respiratory depression → baby becomes “bangag”/limp/floppy → MD will order PERFECT SCORE: 10 – but it is NOT expected in the first minute. NALOXONE (narcotic antagonist) First minute, the highest possible score is 9 because of acrocyanosis. If breathing is also affected, not crying and moving but with Babies with Poor and Fair condition (0-3, 4-6 scores) are transferred heartbeat → MD will insert ET tube → ambu bag the baby → to a radiant warmer (where aggressive interventions are done like narcotic antagonist (naloxone) will be given thru ET tube → blood CPR). Reasons include we don’t want the mother to see these will be on the pulmonary and cardiovascular systems → blood will interventions. be circulated into the body → baby will now move. Sometimes, EPINEPHRINE may also be given aside from naloxone. If the baby is born with a physical defect such as cleft lip, cleft palate, etc. Let the parents be aware, and let them see the baby. The MD has 1 – baby is moving with some flexion but not satisfactory that to prepare the mother. If they do not let the mother see the baby may be due to immediately at the ER, they could easily turn their back on the baby ○ Residual effect of the drugs given to the mother or could be and refuse. d/t the mother being a drug addict. A baby from a mother who is a drug addict is also a passive drug addict baby What if the baby died in the DR, it’s the MD who would tell the mother. ○ Hypoglycemia After which, give the mother the chance to hold the baby if she likes to. Hatdogs + JD | 3 Wrap the baby with the cloth and ask the mother if she likes to hold her Normal hemolysis: 2nd day of life → baby for a while. Give them privacy for them to grieve. they turn yellow because the normal byproduct of blood hemolysis is bilirubin If Baby Maker/Surrogate/Uterus for Hire: Usually, the owner of the ○ PATHOLOGIC JAUNDICE: baby is there. The baby will NOT be shown to the mother who gave If the baby comes out with yellow birth (surrogate). The nurse will wrap the baby after the baby has been skin or they turn yellow less than 24 given EINC and will be given directly to the adoptive parents. The hours of life → undergo hemolysis surrogate mother is aware of this agreement but if in case the within the womb. This may occur due to surrogate requests to see the baby after birth, it is in their discretion to various reasons such as blood allow the surrogate mother to see the baby. incompatibility and infection If the blood was not hemolyzed: NON-TIME BOUND INTERVENTIONS Polycythemia → clumping of blood → it Done to all newborns but NOT the main priority may result in thrombi/thrombus which The priority → life-saving interventions: Airway, Temperature, may lead to cerebral thrombosis If milking was done → too much blood Identification band, Initial assessment (polycythemia) → hyperbilirubinemia → high bilirubin can go to the brain of the EYE CARE (CREDE’S PROPHYLAXIS) baby and causes brain damage which To prevent the occurrence of infection to the newborns is known as kernicterus (especially to mothers that didn't receive prenatal check-up) Extra information: babies with tetralogy Prevents OPHTHALMIA NEONATORUM due to maternal of fallot compensate by producing more gonorrhea or chlamydia blood or having polycythemia since they ○ PREVENTION: Tetracycline, erythromycin, or lack oxygen betadine eye drops on the lower conjunctival sac Count the number of BV: AVA DOSAGE: the size of half a grain of rice ○ 2 Arteries, 1 Vein Economic waste if “dulo dulo ○ Refer if there is an absence of an umbilical BV yung pag lagay” since the size ○ Absence of 1 artery may indicate organ defects of half a grain of rice can (heart, kidneys) cover the whole eyes Not fatal, but should be REFERRED to In the past, silver nitrate was used but it the doctor is ONLY effective with gonorrhea (not Kidney problem - One artery may chlamydia), and it can cause irritation indicate one kidney/ kidney agenesis resulting to chemical conjunctivitis (can still survive - adult); lifestyle (redness in the eyes) modifications to accommodate only AFTERCARE: 1 minute after instilling having 1 kidney the silver nitrate, nurses would irrigate it Increase fluid intake, trauma with saline solution (inner to outer should be avoided, avoid canthus) contact sports MISCONCEPTION: The vision of the baby will be impaired Refer to the doctor if the baby due to the medications → Their vision is not yet fully has streptococcus infection developed at this stage since they came from a very dark (boils, throat infection) place. It will take several days before their vision becomes Streptococcus infection clearer targets two organs: kidney Done to ALL babies delivered either CS or NSD after initial and heart → can cause bonding/complete breastfeeding because infection may enter glomerulonephritis. inside the uterus PREVENT INFECTION BOARD EXAM QUESTION: When is it done? After the initial ○ Umbilical cord - #1 entrance of infection in bonding or first breastfeeding. We need to make sure the newborn (IMCI) baby is breathing and warm before eye care ○ Can happen if the cord was not taken care of properly CORD CARE ○ If there is a fecal material, urine, etc. → instruct Clamp when no longer pulsating, at 2 cm and 5 cm from the mother how to clean it well base. DON’T MILK Clean with soap and water if soiled ○ Preferably, NO pulsations at 3 minutes Do NOT use betadine, hydrogen ○ CLAMPED: at 5 mins max peroxide, alcohol, powder - irritating and ○ In the past, they milked the cord because they NOT necessary wanted to prevent the splatter of blood. Another ○ SIGNS OF INFECTION: reason, they believed that by milking the cord, they Redness at the site are giving more nutrients to the baby. Foul smell and discharge (pus) ○ DON’T MILK! To avoid the baby from having IMMEDIATE checkup at the hospital → circulation overload → neonates are already need to be given antibiotics because polycythemic (Blood serves as a vehicle or sign of infection transport medium between the fetus and the Most common area of entrance of mother. By nature, babies were given more blood infection is through the cord in order to get the necessary nutrients and oxygen PROMOTE DRYING that they needed.) ○ Expose to air Newborn RBC – 6 to 8 million ○ Should FALL-OFF between 7-10 days compared to Adults RBC – 4. 5 to 5 ○ Do not use abdominal binders million Fold the waistband of the diaper Newborn Hemoglobin – 16 to 20 downwards to expose the cord compared to Adult Hemoglobin – 12 to ○ 7 days after birth - postpartum checkup and baby 14 checkup ○ Since babies are polycythemic, they should If the cord is still fresh, evaluation is hemolyze the excess blood. necessary to do to know what the ○ PHYSIOLOGIC JAUNDICE: mother is doing wrong Hatdogs + JD | 4  Teach the mother to not put baby dehydration. Prevents fluid volume powder when drying the cord deficit ○ Baby is sticky ○ A lot of vernix on premature baby BEFORE: They remove it with mineral oil → soap and water → baby feels cold so they put in radiant warmer or floor lamp DANGER: oil is hard to remove in the skin even if it is washed with soap and water. If baby is placed under the floor lamp, it may cause burns (Not safe) VITAMIN K Not done anymore To promote the synthesis of prothrombin ○ If baby has a lot of vernix → DESQUAMATION ○ Liver is not yet able to perform the task very well Normal process of peeling on all Neonates cannot synthesize Vit K because of absent newborns but lesser in amount only intestinal bacterial flora HOME BATH ○ Sterile GI tract ○ CONCERN: Nurse does the first/ initial bath of the ○ Once the baby received milk then it stopped being baby sterile Give instructions to the mother. We also 1 mg IM in the thigh muscle (VASTUS LATERALIS) - biggest need to demonstrate to the mother how muscle mass and most highly developed to do the bath ○ Vitamin K: Aquamephyton, Phytonadione, etc. Make sure they return the demonstration to prevent any accidents when bathing AGA (Appropriate SGA (Small for the baby at home for Gestational Age) Gestational Age ○ Done ANYTIME as long as baby is NOT SICK and not immediately after feeding No tub bath, sponge bath will do 1mg of Vit K 0.5mg only at birth Don't do it right after feeding. Postpone if the baby is full. Because the baby Medication Doctors will decide when might vomit. Dose the next 0.5 mg will be Make bathing enjoyable for you and the given before they will be baby. discharged Gentle, don't be quick, because the baby might rattle; assess while bathing. 5.5 - 7.5 lbs 40C), seizures can happen so it’s negative blood. So, there is no problem if the positive mother important to control temperature. has a baby with negative or positive. The problem is ABO incompatibility. Remember the source of infection is not the other. But if the baby got sick because of the mother, then stop breastfeeding if still sick ABO INCOMPATIBILITY and is the source. But if the mother is well, continue breastfeeding. Type A ↔ Type B For instance, if the mother is type A, then she may receive blood A, O, but NOT B. Type B ↔ Type A If the mother is type B, she can receive B, and O because there is no antibody, but type A is not allowed because it has antigen. Type O ↔ Type A & B Type O is a universal donor, can give to anyone, but not the universal recipient. They can't receive from A and B, only O. But people with type O have a large population so it’s not a problem. Type AB ↔ No problem Rarest blood type. Type AB has a smaller population, but still they are the universal recipient so they can receive A, B, AB, and O. Hatdogs + JD | 17 In blood transfusion, the type-specific is better to receive. For example, Cesarean Section (CS) delivery. She will not be allowed to go into if you have type B Blood type and will choose between type B and O, labor. then type B is the best choice. Universal donor: O negative, because it can be donated to A, B, AB, O, negative and positive. CASE SCENARIO: In the emergency room, the person got hit by the train. Blood pressure is 40 palpable undergoing shock and hypovolemia. Since there is no time to check blood type, the doctor will order, “Transfuse 2 units O-neg!” Regardless of blood type. QUESTION (BLOOD TYPE ANALYSIS): Is it possible for the baby to get the blood type of the mother? The mother is Type O, and father type B. It is possible for the children to get Type O blood, but NOT from their mother’s side. Rather, the baby may get the blood type of the mother parent of EXPLANATION: their father (grandma) who is Type O. Blood type is still from the husband. If the baby is expelled, the utero-placental barrier is torn in the process. The placenta is still inside. Remember the blood of the placenta is positive. Thus, the blood will enter the open maternal sinuses. If the placenta gets detached, it will leave wounds or openings in the maternal uterus (open sinuses). This will be the access to maternal blood or circulation. So, the positive blood in the placenta will enter the wound in the endometrium/ uterus. This will trigger a response. EXPLANATION: The first baby is not affected. The mother is the big circle and is Rh negative. The baby is Rh positive. The blood type of the mother is the same as the blood of the uterus. Inside the womb, the baby happens to be Rh positive. Placenta belongs to the baby, not the mother. What is the proof that it is for the baby? During the delivery, the baby will be expelled and followed by the placenta. If there are retained placenta, no matter how small it is, it can kill the mother. This is why doctors perform D&C to extract the retained placenta. The mother reacts to the placenta because it is a foreign object for the mother, even the fetus. This is called autorejection. The mother reacts to the baby inside the EXPLANATION: womb because it is also foregign object. The antibodies released by The mother is negative and receives positive blood. The D antigen the mother could kill the fetus. enters the maternal circulation. Therefore, the mother will counteract with antibodies to make it harmless to her body. Though the blood In the picture, the placenta is also Rh positive. The baby owns the entered is not enough to cause hemolysis, it is enough to trigger the placenta. Why is the first baby not yet affected by the Rh problem? mother to produce an anti-Rh antibody. This is the cause of the Because in the first pregnancy, there is no direct exchange between problem. mother and baby’s blood, no mixtures happen. Where does the baby get the food, oxygen? It’s not through the uterus, placenta, or umbilical cord to give baby O2 and nutrients and exchange waste and the mother will be the one who is excreted through the GI and lungs. There is no exchange happening between the mother and baby blood through a utero-placental barrier. It has the ability to select what to cross. Oxygen can cross. Oxygen can cross the barrier in exchange for CO2. The process takes place through the membrane like what happens in lungs. Likewise, the lungs have alveolar sacs, or an alveolocapillary membrane which allows diffusion to take place. Same thing happens to the placenta. Glucose can also cross the placenta, in exchange for waste products. Likewise, the kidney also brings glucose to blood and urea, creatinine is excreted to the urine called osmosis. It has active and passive transport. That’s also how placenta works. Blood does not cross. Ex. Bloodborne condition. Mother has HIV/ AIDS. The blood of the mother does not exchange with the fetus during pregnancy as long as the barrier is intact, it will prevent the baby from getting HIV. The infection might happen if during the pregnancy, there EXPLANATION: is a tear in the membrane, so mother should be careful not to get into Mother got pregnant with baby #2. The baby is also Rh positive, as accidents like falls, bleeding, tear in membrane. Moreover, during well as the placenta. Remember from the 1st pregnancy, the mother labor, if the uterus contracts, the membrane can also be torn and the produces anti-Rh antibodies from the first baby. The second baby is baby might get the blood. Therefore, the best mode of delivery is positive again. Though there is still a barrier, it allows the antibody to Hatdogs + JD | 18 cross. In OB, IgG crosses the membrane through the process of pinocytosis where the antibody can cross. Since D-antigen antibody is an antibody, it will enter the system of the fetus. Since the baby is positive, it will hemolyze the baby’s blood. Within the uterus, there is already a resulting hemolysis. The evidence is jaundice, the baby is yellow. If the baby suffers from severe hemolysis inside the womb, the baby will be born dead. The baby will appear macerated, but can't be recognized because it's too soft like an overcooked squash called HYDROPS FETALIS (FETAL HYDROPS). That is the worst consequence. Therefore, we must know the blood type of the mother and the husband to know what needs to be done if ever they have different blood types. Coordinate with the obstetrician and tell them your blood type to anticipate the problem. SUMMARY FIRST BABY (RH POSITIVE) - not affected but it stimulates the mother (Rh negative) to respond by producing antibody (Anti-Rh positive) ○ After giving birth to the first baby, the mother will be given RhoGam so the second baby will not be affected. If it is an unmanaged case, the consequence of death will be anticipated. SECOND BABY (RH POSITIVE) - will be affected. His blood will be destroyed by the antibody (Anti-Rh positive) from the mother Possible IUFD Alive but with Pathologic Jaundice MANAGEMENT FOR PREVENTION If mother is not compatible with baby, then RhIg (RHOGAM) is given to mother within 72 hours after delivery or abortion of an incompatible fetus ○ RHOGAM will “cover” or “cloak” the Rh positive blood that entered the mother’s system making it unrecognizable by the mother’s immune responses; no antibodies will be made Should be given within 3 days, if not given the immune system will start to make antibodies MANAGEMENT OF THE SECOND BABY IF AFFECTED No prevention was done If alive, the baby can still be managed and prevent its death EXCHANGE TRANSFUSION ○ Removal of baby’s blood and replacement with fresh whole blood (Rh Negative) Rh (-): universal donor Problem is the scarcity of Rh (-) Mother cannot donate blood because the antibodies came from her; we can get from her siblings or relatives that are Rh (-) ○ His blood right now is useless because it is hemolyzed (not all) ○ Stopcock - two-way flow Blood from baby sucked out then to waste blood Every after 50-100 ml donor blood will be open which enters the baby ○ Blood mostly replaced are those circulating in the major vessels Those infused in the other parts and organs may still be there but in minimal amount Decision will be done based on the CBC result ○ Hgb count is very low ○ Bilirubin count is increased Best intervention: prevention Hatdogs + JD | 19 NEWBORN WITH INBORN ERROR IN METABOLISM ○ To maintain normal growth and dev’t. If not R.A. 9288: Newborn Screening Act of 2004 managed → cretinic/bansot Problems brought about by metabolic conditions will not be Only condition that can be anticipated to manifest by the experienced after a day or two by the baby, some may be baby through the mother’s condition: seen 2 weeks or 9-10 days after birth ○ Thyroid imbalance/problem either hypo- or hyper- The heel / “sakong” of the baby will be pricked, then the (MOTHER) → baby also has thyroid problem blood will be collected in the “4 circles” → bring to laboratory (CRETINISM) → send to physician (they’re the first to know the results then ○ EUTHYROID - normal thyroid levels should be coordinate with the parents) achieved by mothers with thyroid problem before becoming pregnant CONGENITAL ADRENAL HYPERPLASIA (CAH) ○ Managed by 2 doctors: OB and Endocrinologist Decreased cortisol, severe salt loss- dehydration. If not ○ A pregnant mother with hyperthyroidism treated, death in 9-13 days May have spontaneous abortion → give ○ Dehydration can happen in any part of the body. TSH (thyroid suppressing hormones) What if it happens in the brain cells? → CNS TSH PROBLEM: It crosses the placenta depression → death ○ Hyponatremia can decrease CNS function Sodium causes excitability and irritability of the CNS Most fatal because it is affecting the adrenal glands (vital gland because it performs many functions) Adrenal glands balances important electrolytes (sodium which brings with it water) ○ If not fully functioning → inability to produce MAPLE SYRUP DISEASE (MSUD) cortisol → sodium balance is a problem Rare genetic disorder characterized by deficiency of an Immediate intervention: 0.9 NaCl IV enzyme that is required to break down (metabolize) the three MGT/ Maintenance: NaCl supplement (oral; lifetime) amino acids (BCAAs) leucine, isoleucine, and valine ○ Amino acids important for brain development GALACTOSEMIA ○ A problem triggered by milk Inability to metabolize galactose in milk– vomiting, diarrhea, Symptoms are not seen at birth. It develops as the baby liver damage, cataract, growth failure and brain damage continuously intake milk not accepted by their body. ○ Child is given food (breastmilk/ formula milk) → SX: distinctive sweet odor of infants’ urine (some may have baby’s body rejects it (vomiting, diarrhea) ants in diapers), poor feeding, vomiting, lack of energy Laboratory shows no problem in the GI (lethargy), and delayed development. If untreated, can lead ○ Secondary to failure to convert galactose to seizures, coma, and death (galactose transferase) to glucose (food of the cell) ○ Brain activity is observed as they grow Can cause liver damage, dehydration, electrolyte imbalance, MGT: Limit the 3 amino acids, KETONEX®-1, an amino will not grow properly acid-modified infant formula with iron MGT: No Animal source milk/ NO BREASTFEEDING ○ Milk with low level of leucine to limit cause of prob ○ Soy Formula- Isomil, Nursoy, Prosobee ○ Ketonex bought at drug stores ○ Almond milk, coconut milk ○ Some doctors allow breastfeeding for immunoglobulin and is not exclusive (alternate PHENYLKETONURIA (PKU) feeding with bottle feeding) Inability to utilize an essential amino acid causing mental retardation Coming from the protein part of milk - phenylalanine ○ May cause brain damage ○ Phenylalanine is converted to tyrosine → tyrosine to melanin (fxn: gives color to skin, hair) ○ If phenylalanine is not converted to tyrosine it accumulates in its dangerous form → phenyl pyruvic acid which causes brain damage → mental retardation Milk and cheese are not allowed MGT: Special formula- Lofenalac/ Phenelac GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) Breakdown of RBC causing anemia It has “triggers” There should be a consult with a nutritionist ○ Usually foods from the “beans” family Mung beans, peanuts, sitaw, peanut butter, kare-kare, peanut oil MGT: Avoid “triggers” like beans, naphthalene (moth balls), sulfas, antimalarial drug CONGENITAL HYPOTHYROIDISM (CRETINISM) Deficiency in thyroid hormones causing physical, developmental and mental delay Usually macrosomic baby (big) due to inadequate thyroid in the uterus (recall: hypothy- fat; hyper- payat) Thyroid tests done; Immediately given treatment after birth Characteristic appearance: limp muscle tone (hypotonic), protruded tongue MGT: Thyroid supplement for life (Synthroid) Hatdogs + JD | 20  NEONATES WITH CONGENITAL DEFECTS Anticipate more serious problem since sac may contain content NEURAL TUBE DEFECTS of the brain itself CAUSES: MULTIFACTORIAL ETIOLOGY - drugs, radiation, Location: Occipital or parietal area (common) inadequate intake of FOLIC ACID during pregnancy, AFP test may be done to identify the existence of the condition chemicals UTZ may be used to know the presence, location and size. There are 4 types of neural tube defect SPINA BIFIDA OCCULTA Usually not visible externally Location: Posterior laminae of the vertebrae fails to fuse (5th lumbar or 1st sacral) A dimple with hair is seen at the bifurcation area of the buttocks Mildest defect; no mgt and concern. Normal as long as there is no problem in terms of motor and sensory functioning Letting the parents see the photo of before and after surgery may help alleviate their anxiety MANAGEMENT Surgical closure preferred within 24-48 hours after birth to prevent local infection and trauma to the exposed tissues The longer the sac stays may result in more serious problems such as infection, etc. SPINA BIFIDA CYSTICA OVERALL OBJECTIVES OF NURSING CARE Lump / cyst on the spine → there is CSF inside Vertebral discs also fail to fuse Herniation: meninges and CSF (meningocele) There’s a chance client can still move the extremities because spinal cord is not affected Delivery of the baby : ○ Must be through cesarean section ○ Clients must be placed in a prone position. If side lying, make sure it will not be touching the linens or bed MENINGOCELE Consist of sac-like cyst meninges filled with spinal fluid Location: Sacral area To differentiate meningocele and meningomyelocele: continuous Protect the sac against pressure, injury and infection assessment of the lower extremities ○ No position is acceptable other than PRONE ○ Cannot see the content from the outside since not ○ You can put the baby in a SUPINE position if you are going transparent to feed them but you have to INSTRUCT the person ○ Sac not always even in shape and it vary in size carrying the baby to avoid putting pressure on the sac Legs: Moving; Extremities: with sensation ○ You cannot put diapers directly on them, you can only use it as their draw sheets ○ Use light materials in covering a sac such as clean wrap MENINGOMYELOCELE (saran) A protrusion of a sac-like cyst containing meninges, spinal fluid and a portion of spinal cord with its nerves (hair-like structures) Worst among the 3 types mentioned above since it affects the SUMMARY spinal cord; pt may have bowel or bladder dysfunction- incontinence (loss of bladder control) SB Meningocele Meningo- Encephal Location: Sacral area Occulta myelocele ocele Legs: No movement; Extremities: No sensation. Clubbed foot (talipes equinovarus) Presence of sac None ✔︎ ✔︎ ✔︎ Lumbo- Sacral Occipital/ Location Sacral sacral Parietal Meninges, spinal Brain Sac- CSF Spinal fluid fluid, tissue, content spinal cord spinal fluid nerves ENCEPHALOCELE May be Surgery MGT Herniation of the brain and meninges through a defect in the normal (closure within 24-48 hrs after birth skull that produces a fluid-filled sac Hatdogs + JD | 21  HYDROCEPHALUS NEONATES WITH CONGENITAL DEFECTS “Hydro”: water; “cephalus”: head CONGENITAL HEART DISEASES Retention or inability of the cerebral spinal fluid to flow Secondary to mother when being sick while she is pregnant, normally hereditary Sunset eyes, thin skulls, distended scalp veins, high pitched Mothers experiencing German Measles; having infections; cry, increased ICP with a possible effect of headache treating their skin; exposure to radiation Transillumination ○ RUBELLA SYNDROME ○ Simple way that a nurse can do to diagnose a The skull and brain of the baby is small hydrocephalus Congenital cataract ○ Placing flashlight with a good beam by the head to see the fluid inside; if the light didn’t pass through or can’t penetrate it has tumor EFFECT OF INCREASED ICP ON THE BRAIN Pupils no longer responsive to light GCS: 3 VS: ○ Decreased HR ○ Decreased RR ○ Increased Systolic and Normal Diastolic (widened pulse pressure) NURSING CARE OF HYDROCEPHALUS Position: side lying (especially if opisthotonic: arched backwards) Assessment of signs of increased ICP: Blood delivers oxygen to vital organs and cells, and once O2 ○ Measure HCOD (Head Circumference Of the Day) is released, it becomes deoxygenated which then returns to ○ Earliest sign: Altered LOC, sleepy, restless, the R side of the heart thru the SVC (upper body part) and incessantly crying IVC (lower body part) → R atria. Blood passes thru the Measures to prevent increased ICP tricuspid valve to the R ventricle → pulmonic valve → pulmonary artery → delivers blood to the lungs → lungs SURGICAL MANAGEMENT oxygenates the blood → oxygenated blood → delivered by Ventriculostomy to relieve pressure the pulmonary vein, enters the L side of the heart→ L Insertion of shunt to bypass the point of obstruction atrium → mitral/bicuspid valve → L ventricle → aortic valve → aorta, to supply oxygenated blood to the body ○ Artery = away from the heart ○ Vein = “vabalik” ○ L ventricle = heart’s main pumping chamber Higher pressure; higher ejection fraction ○ Aorta: descending, abdominal Three branches of aortic arch: ○ Brachiocephalic trunk, left common carotid artery and left subclavian artery (from net) Receive oxygen from the left side via the aorta (distributes blood to the body) ○ Problem: Aorta receives deoxygenated blood Babies develop defect in any of the structure of the heart (within or outside) ○ Possibility for the wrong blood (deoxygenated) to be delivered to the body ○ Mixture of 2 bloods (which should never mix) due to defect ○ Common: septal defect 2 ways blood mixes: ○ ACYANOTIC Left to Right shunt Aorta does not get deoxygenated blood ○ CYANOTIC Right to Left shunt Aorta gets deoxygenated blood ↓ O2 levels → cyanosis ○ Will the aorta get deoxygenated blood? YES → cyanotic (all begins with T ) NO → acyanotic (Anim (6) conditions) ACYANOTIC CYANOTIC Left to right side shunt Right to left side shunt Aorta does not get unoxygenated Aorta gets unoxygenated blood blood Ventricular Septal Defect Transposition of the Great (VSD) Vessels Hatdogs + JD | 22  Atrial Septal Defect (ASD) Tetralogy of Fallot VENTRICULAR SEPTAL DEFECT (VSD) Patent Ductus Arteriosus Truncus Arteriosus (not A hole in the septum separating the ventricles (lower (PDA) common) chambers) Coarctation of the Aorta ○ Oxygenated blood crosses thru the hole (L (CoA) ventricle → R ventricle) Aortic stenosis COMPLICATION: CHF Pulmonic stenosis PATENT DUCTUS ARTERIOSUS (PDA) ACYANOTIC CONDITIONS Fetus in utero ○ Ductus arteriosus → bypass the pulmonary system ACYANOTIC CONDITIONS ○ Fetal circulation: pressure is higher in the right side (blood from the placenta enters thru the right) ASD VSD PDA Placenta → umbilical vein (connected to the IVC) Lungs are not yet expanding (pressures remain high) At birth: lungs begin to expand → decreasing pressure in the lungs → pulmonary vein brings the pressure to the left side of heart → ↑ pressure on the left More crying = more oxygen → the elevation of O2 in the body (chemical) causes the spasm of ductus arteriosus → which causes for its closing Increased pressure in the left ventricle is the one that will prevent the hole in the foramen ovale to deliver blood from the right to the left (during fetus). PULMONIC Crying = inc. pressure on the left side of the heart, decrease COA AORTIC STENOSIS pressure on the right. With the persistence of the opening of STENOSIS the connection, ductus arteriosus, malakas ang pressure sa left side so pag-agos ng dugo through the aorta → some of it will go down through the ductus arteriosus to go the pulmonary artery. Dati pa kabila yung blood sa left ventricle papunta sa pulmonary artery noong fetus tayo malakas ang pressure dito. The blood from the left ventricle should not go to the lungs. Ang nangyayari pumupunta yung blood dito bukas yung ductus arteriosus papunta yung blood sa aorta hindi siya lumiliko sa kaliwa or kanan kasi ito yung papunta sa lungs. The blood from the right ventricle noon fetus ka pa papasok sa pulmonary artery through the ductus arteriosus joining the blood that goes to your body. (after birth) ATRIAL SEPTAL DEFECT (ASD) After birth if it remains open = problem ○ Pressure on the left is high/ increased. Blood from Fetus in utero: two structures the LV → aorta → some of the blood from the ○ Foramen ovale aorta goes down through the ductus arteriosus ○ Ductus arteriosus (PDA) → pulmonary aorta → eventually to go Once the neonate is born, the structures close in a couple of down = bumabalik yung blood sa RV weeks, in one month max. ○ QUESTION: Is the aorta getting unoxygenated ○ Fetus: lungs are bypassed blood? The blood should not go to the lungs ○ ANSWER: NO which was done by using the two ○ RATIONALE: Hindi nakakatanggap ng structures unoxygenated blood ang aorta kaya acyanotic ito. ○ After birth: lungs begin to function and structures Therefore the same problem, which is heart must close congestion because the RV cannot empty The structures did not close → ASD completely. Hindi maka-eject ang blood out of the When the heart beats, the blood in the left atrium will flow RV because as it contracts nasasalubong niya down to the left ventricle. However, there’s a hole between yung blood ng pababa galing sa aorta (na malakas the atria (upper chambers), so some of the blood will cross ang pressure). Bumabalik yung blood sa RV → RV thru the defect (L atrium → R atrium → stained with becomes congested. It compensates– it enlarges, oxygenated blood) it beats faster PROBLEM: Right atrium is overwhelmed with more blood Loudest murmur (blood returning from VC + coming from L atrium) → Very audible S3 congestion → muscles stretching beyond normal, activating its response (contractility) → heart compensates (beats faster) → hypertrophy → heart exhaustion (myocardium may COARCTATION OF THE AORTA (COA) not contract effectively anymore) Very obvious acyanotic Normally at birth, a neonate’s heart beats fast (which is not Problem: the blood from the LV should go to the body for the easily discerned if it’s normal or a beginning sign of problem) distribution (systemic circulation). Makipot ang daluyan/ ○ Also, foramen ovale may still be there hours after daanan → some of the blood goes up to the UE (to the birth, which may not also indicate a possibility of a head) but the others cannot (bumabalik yung blood). There’s defect incomplete emptying of the LV → Congestion of LV ○ S/sx of a defect becomes obvious when the Unique symptoms: Higher BP in the arms, increased pulse in newborn begins to experience complications the radial, Low pulse in the LE COMPLICATION: Congestive heart failure ○ High blood pressure before point of coarctation ○ Low blood pressure beyond point of coarctation BP is significant. Hatdogs + JD | 23  ○ When more blood goes to the arms and less blood DIAGNOSTIC TEST goes to the legs. You will remember the effect of Chest x-ray (pulmonary edema and cardiomegaly) the BP. More blood in the arms = higher the BP in ○ In Chest X-Ray the 1st clue that will give the the arms; less blood going to the legs= lower the doctor a bigger tip/ clue that there’s a problem = BP in the legs. cardiomegaly that is not normal for a baby ○ Normal BP arms (average adult): around 120/80 Echocardiography / MRI - identifies type and size of defect ○ Normal BP legs/ LE (average adult): +20mmHg ○ Will rule-out all of what is causing it =140/100 ○ A more detailed assessment courtesy of MRI ○ In a normal person: Expect a higher BP from the ○ Nursing considerations for echocardiography: legs because mas malaki siya sa arms & it has Allow the parent (mother) to go with the child to more blood. ease their fears and anxiety. On a child with COA you will not see ○ In MRI the baby will be put into mild sedation by that because mas marami siyang blood giving oral meds (ex. Oral- Benadryl) sa arms kaysa sa legs niya. Cardiac catheterization - identifies pressure inside the ASSESSMENT: HTN present on the heart (CHF) arms; lower BP taken on the leg ○ To identify if the heart is still coping ○ Increase ejection fraction = patient is delikado na ○ Capable of aspirating specimen for pt that will AORTIC STENOSIS undergo blood culture & sensitivity from the blood Milder valvular defect in the heart Rare/ not common ○ Used to introduce a contrast medium for a pt with Narrowing of the aortic valve opening possible obstruction in the heart’s blood vessels Very similar to the COA ○ Used as an interventional catheterization – with Congestion of the LV the use of the same approach where a catheter is ○ Unable to empty into the systemic circulation inserted into the heart. It is already capable of ○ It compensates by beating faster. Eventually carrying a stent that could be inserted on the point causing the heart to tire out → CHF of obstruction → allowing now the blood to flow BP: both low in the arms and legs freely. ○ Less blood on both areas of the body unlike in ○ ROUTE: Inguinal area COA Want to go to the right side of the heart: retrograde approach PULMONIC STENOSIS ○ POST-OP apply sandbag over puncture site for Narrowing of the pulmonary artery 4-6 hours; don’t move the legs; assess affected RV cannot completely empty → CHF leg (refer if with sx of circulatory impairment) Acyanotic in nature Check distal pulse: pedal 1st hr: weak/irregular SUMMARY OF ACYANOTIC CONDITIONS (expected) Acyanotic cardiac condition → Congestion of cardiac 2nd hrs onwards: same chamber → Compensation by increasing rate of contraction quality of pulsation on both → Congestive heart failure extremities Left sided failure: PULMONARY CONGESTION - dyspnea, ○ Refer if it remains productive cough, rales/crackles irregular/weak Right sided failure: SYSTEMIC CONGESTION - distended Avoid too much pressure on the neck veins, pedal edema, ascites, hepatomegaly puncture site to prevent obstruction of circulation. Check every 15 mins Electrocardiography CORRECTIVE SURGERY If the defect is large (no possibility of spontaneous closure) and heart is in failure ○ Smaller defects = capable of spontaneous closer OPEN HEART: defect is inside the heart ○ Induction of asystole Induced by administering of potassium ○ Induction of hypothermia → to dec. brain’s demand for O2 NUR RESP: induce hypothermia by putting ice all over the body esp brain; CLINICAL MANIFESTATION using hypothermia blanket Impaired cardiac function - TACHYCARDIA (earliest ○ Uses bypass machine Extracorporeal Membrane manifestation usually omitted in the assessment in the Oxygenator (ECMO) nursery) ○ With septal defects Left sided failure: PULMONARY SYMPTOMS - dyspnea Valvular defects → with interventional (refuses to feed / profuse scalp sweating while nursing catheterization (NO NEED to open the [sympathetic response]), productive cough, rales/crackles, heart) frothy, pink sputum Opening of pulmonary artery ○ Pink sputum- pulmonary edema can sometimes is dilated cause the rupture of the blood vessels in the CLOSE HEART: defect is outside the heart alveolocapillary sac ○ No induction of asystole or use of ECMO Right sided failure: SYSTEMATIC: venous congestion ○ Induction of hypothermia ○ For PDA Not for parents to decide which treatment their child should undergo Heart-Lung Machine / ECMO Hatdogs + JD | 24  ○ Before blood enters the R side of the heart, it is TRANSPOSITION OF THE GREAT VESSELS (TOGV) delivered to a reservoir to be oxygenated by the PROBLEM: Aorta and pulmonary artery are switched machine. From the oxygenation membrane it goes ○ Oxygenated blood travels to the pulmonary artery to a pump that delivers the blood back to the aorta, and goes back again to the lungs - body does not which delivers it to the rest of the body receive oxygenated blood ○ Newborn may die within 24 hours depending on MEDICAL / NURSING MANAGEMENT the presence of another defect, an atrial septal defect or PDA will increase chances of survival In defects with Non-closure of foramen OBJECTIVE 1: Prevent CHF ovale, Higher pressure from the left side will cause the oxygenated blood to Improve cardiac output transfer to the right side of the heart ○ Cardiac glycoside - digoxin (increases strength of eventually entering the aorta contraction) + slows down HR In VSD, blood from the left ventricle Positive inotropic, negative chronotropic shunts to the defect going to the right ○ Nursing responsibilities: ventricle → leading to aorta Check PR before adm (PR depends on age group) In PDA, blood from left atrium → left Infants: home mgt is not possible ○ INTERVENTION: Focused on symptoms DIAGNOSTICS: Lateral Neck X-ray Do not insert anything (tongue depressor) into the mouth SYMPTOMS OF SPASMODIC CROUP / ○ Triggers gag reflex → throat spasms → causing LARYNGOTRACHEOBRONCHITIS (LTB) further swelling of epiglottis Hoarseness (brassy spasmodic “seal-like” cough) Airway by Tracheostomy Inspiratory stridor ○ On standby Fever ○ Insert airway access past/below the obstruction; Possible respiratory distress due to LARYNGOSPASM ET tube is not used because there’s obstruction ○ Breathing can be occluded due to swelling ○ Inform caregiver that it’s temporary – to aid MANAGEMENT FOR SPASMODIC CROUP / breathing LARYNGOTRACHEOBRONCHITIS (LTB) Ready the