POSTPARTAL PERIOD

– 1st 6 weeks following the birth of the infant.

– Healing process, a time wherein maternal changes occur
○ Retrogressive – uterus to normal state
○ Progressive – production of milk, parenting role.
A. Phases
a. Taking – in phase
i. “The time of reflection for a woman.”
ii.The woman is passive, letting other people do things for her and make decisions for her.
iii.Encourage her to talk about the wonderment of birth.
b. Taking – hold phase
i. “The woman begins to initiate action herself.”
ii.The woman shows great interest on caring for the baby.
iii.Woman may still feel insecure about her abilities in caring for the child
iv.Praise the mother.
c. Letting – go phase
i. “The woman finally defines her new role.”
ii.She gives up the fantasized image of her child for the real one.
B. Physiologic Changes during Puerpuerium
a. Reproductive Changes
i. Uterus
1. Involution – the process whereby the uterus returns to it nonpregnant state. (1 cm or fingerbreadth
per day).
2. Afterpains – are cramps similar to that felt with menstrual period, which is caused by the
contractions of the uterus. (common in multiparous, large babies)
3. Lochia – uterine flow consisting of blood, fragments of deciduas, WBC, mucus and some bacteria.
Type Color Duration Composition
Rubra Red 1 – 3 days Blood fragments of deciduas and mucous.
Serosa Pink / brown 4 – 10 Blood, mucus, and invading leukocytes.
Alba White / cream 11 – 21 (even 6 weeks) Large mucuc, leukocytes count increase.

a. Volume
i. Scant - < 5 cm (2”) = 10 mL
ii.Small - < 10 cm (4”) = 10 – 25 mL
iii.Moderate - < 15 cm (6”) = 25 – 50 mL
iv.Large - > 15 cm (>6 “) – 50 – 80 mL
ii.Cervix
1. Soft and malleable post pregnancy.
2. Contractions begin at once. After 7 days, external os is narrowed and it feels firm and non – gravid
again.
3. There is formation of new muscle cells.
iii.Vagina
1. Soft and few rugae, diameter is considerable less than normal.
2. Hymen is permanently torn and heals in small separate tags of tissue.
iv.Perineum
1. Portion may show ecchymosis from rupture of surface capillaries.
2. Labia majora and minora typically remain atrophic and softened.
3. Presence of episiotomy incisions.
b. Systemic Changes
i. Hormonal system
1. Pregnancy hormones produced by placenta is no longer present.
2. HCG in urine is negligible in 24 hours.
3. By week 1, progestin and estrogen are at pre – pregnancy level.
ii.Urinary system
1. Pressure of the fetal head during childbirth may leave the bladder with a transient loss of tone.
2. Assess the woman’s bladder frequently immediate postpartum.
3. Positive excessive dieresis on immediate postpartum to excrete the excess fluids (2000 – 3000
mL).
4. Increased nitrogen – increase muscular activity during labor process.
iii.Circulatory system

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 1. Reduced blood volume as a result of blood loss.
2. There is elimination of uteroplacental circulation reducing the maternal vasculature bed by 10 – 15
%.
3. Immediate after birth, pulse rate, stroke volume and cardiac output remain elevated for 30 – 60 per
minute.
*placenta – endocrine function – vasodilation.
*V/S – Increases BP – 4 days; respiratory function – 6 months.
*Blood components:
a. Hgb and Hct – increase in 3rd to 7th day
b. WBC – Normal
c. Coagulation Factors – elevated immediate postpartum.
C. Maternal Concerns and Feelings in the Postpartum Period
a. Shifting of Role – maternal and child bonding
b. Abandonment – family focus to newborn, abandonment feeling to the mother.
c. Disappointment
d. Postpartum blues – women experience a certain degree of overwhelming sadness, which they can’t account for
during the postpartum period.
*PPSR – Psycho – physiological somatic response.
D. Postpartum Complications
a. Postpartum Hemorrhage – any blood loss that is > 500 mL.
i. Early PH – within the last days of 6 weeks postpartum.
ii.Common causes
1. Uterine Atony
a. Refers to the lack of muscle tone that results in failure of the uterine muscle fibers to
contract firmly around blood vessels when the placenta separates.
b. Predisposing factors:
i. Overdistention of the uterus
1. Multiple pregnancy
2. Hydramnios
3. Large babies
ii.Caesarean birth – trauma introduced
iii.Pregnancies with placental anomalies.
iv.General anesthesia
1. SAB – Bupivacaine HCL
2. Epidural – Lidocaine HCl
3. SAB + Epidural = CSEA (hypertensive women)
v. Multiparity – more than 5 pregnancies
c. Clinical Manifestation
i. Gush of blood from the placental site.
ii.Uterine fundus that is difficult to locate.
iii.Uterine fundus located above the expected level.
iv.Soft / boggy fundus.
v. Excessive lochia.
vi.Uterine becomes firm when massaged but losses its tone when massage is
stopped.
d. Management
i. Apply uterine massage.
ii.IV infusion of dilute oxytocin (PNSS, LRS)
iii.Methergine (methylergonovine maleate) – acts directly to the uterus.
iv.Prostaglandin (analogue of prostaglandin) – prolongs the contraction of the
uterus.
v. Bimanual massage.
vi.Intravascular fluid replacement.
1. Blood transfusion.
2. Plasma expanders.
vii.Hysterectomy.
e. Nursing Considerations
i. Gentle massage.
ii.Close observation for the next 4 hours.
iii.Encourage voiding.
iv.Monitor signs and symptoms of hypovolemic shock.

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 2. Retained Placental Fragments
a. Bleeding may persist when placenta is not completely delivered.
b. Clinical manifestation
i. Apparent bleeding on immediate postpartum.
ii.Firmed and contracted uterus.
iii.High HCG result.
c. Management
i. Remove retained fragments.
ii.D & C may be indicated.
iii.Methothrexate in cases of placenta accrete
iv.Instruct the patient about normal lochia discharges.
3. Lacerations – episiorrhaphy
4. Hematomas – incision and drainage
5. DIC
6. Subinvolution
7. Sheehan’s syndrome ( atrophy of Adenohypophysis )
b. Puerperal Infection
i. Bacterial infection after birth.
ii.Fever of 38 °C or higher occulting at least 2 of the 10 days after the 1st 24 hours of postpartum (Joint
Committee of Maternal Welfare).
iii.Predisposing Factors
1. Caesarean Birth
2. Any trauma to maternal tissues.
3. Prolonged rupture of membranes
4. Postpartum hemorrhage.
iv.Common Puerperal Infection
1. Metritis
a. Metritis with pelvic cellulitis – involves deciduas, myometrium, parametrial tissue.
b. Complications
i. Oophoritis
ii.Salphingitis
iii.Peritonitis
c. Clinical Manifestation
i. Fever
ii.Chills
iii.Body malaise
iv.Anorexia
v. Abdominal pain and cramping
vi.Uterine tenderness
vii.Purulent foul smelling lochia.
d. Diagnostics
i. CBC – elevated WBC
ii.Culture and sensitivity (E. coli, Staph. Aureus)
iii.Urinalysis – increases pus cells
e. Management
i. IV administration of antibiotics
1. Mild to moderate infection
a. Ampicillin – only drug approved for pregnant.
b. cephalosporin
2. Prophylactic drugs for CS case.
a. Clindamycin
b. Gentamicin
f. Nursing Considerations
i. Fowler’s position.
ii.Give medication as directed.
iii.Comfort measures – use of abdominal binder.
iv.Health teachings.
2. Mastitis
a. Infection of lactating breast.
b. Occurs most often during 2nd and 3rd week after birth.
c. Clinical Manifestations

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 i. Flu like symptoms
ii.Fatigue
iii.Aching muscles
iv.Fever
v. Chills
vi.Headache
d. Complications – breast abscess (normal – 15 – 25 lobules)
e. Management
i. Antibiotic therapy
ii.Breast decompression
1. Breastfeeding
2. Breast pump manual extraction
iii.Analgesic
iv.Warm / cold compresses
v. Breast support
f. Nursing Considerations
i. Provide adequate information
1. Correct positioning of the infant.
2. Avoid nipple trauma and milk stasis.
a. Never apply oil
b. Let the infant suck the nipple.
c. Use plain water in cleansing.
ii.Change nursing pads as necessary.
3. UTI
a. Urinalysis
b. Antibiotic therapy
c. Hygiene
4. Wound infection
a. Episiotomy
b. Antibiotic therapy
5. Septic Pelvic Thrombophlebitis
a. Pain in groin, flank area, iliac.
b. Less common
c. Antibiotic
c. Deep Vein Thrombosis
i. Thrombus - collection of blood factors on a vessel wall.
ii.It affects the veins from the foot to ileofemoral region.
iii.Complication – Pulmonary embolism (sudden sharp chestpain, tachycardia)
iv.Causes
1. Venous stasis
2. Hypercoagulability
3. Injury to the intima (inner lining) of the blood vessel
v. Risk Factors
1. Inactivity
2. Obesity
3. Caesarean birth
4. Smoking
5. Varicose veins
vi.Diagnostics
1. Doppler ultrasonography
2. Impedance plethysmography
3. Venography – note for shellfish allergy
vii.Management
1. Prevent thrombus formation
a. Early and frequent ambulation
b. Use of antiemboli socks
c. Stirrup should be padded during childbirth
2. IV infusion of Heparin
3. Warfarin (oral)
E. The Newborn (Extrauterine Adaptation)
a. Neonatal Transition

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 i. Refer to the 1st few hours after birth wherein the newborn makes vital changes to maintain extrauterine life
and stabilizes respiratory and circulatory changes.
ii.Initiation of Respiration
1. Causes
a. Physical factors
i. Mechanical factors
1. Chest Compression – small amount of lung fluid is forced into the
upper air passages and expelled during birth.
2. Chest Recoil – creates negative intrathoracic pressure as the pressure
against the chest is released.
b. Chemical factors
i. Transitory Asphyxia – lowered PaO2 and pH, increased PaCO2
1. Cord clamping

c. Thermal Factors
i. Decrease of more than 20 °F from intra to extrauterine life
ii.Cold stress and respiratory depression result from excessive cooling.
d. Sensory Factors
i. Auditory stimuli
ii.Visual stimuli
iii.Tactile stimuli

Brain (MO); Carotid & aortic Chemoreceptors

Decreased O2 & pH; Increased CO2

Diaphragm stimulated
Internal Stimuli

Cold air/ touch/ noise, etc

1 st Breath
External Stimuli

iii.Cardiovascular Adaptation
1. Transition from fetal to neonatal circulation.
2. Shunts close and pulmonary vessels dilate at birth.
3. Transition occurs simultaneously within the first few minutes after birth.
a. Pulmonary blood vessels
i. Dilation of these vessels begins with the 1st breath taken by the newborn
resulting in lower pulmonary resistance which allows the blood to freely
circulate through the lungs to be oxygenated.
b. Ductus Arteriosus
i. Increases pressure in the aorta and oxygen in the blood cause a reversal of blood
flow in the ductus arteriosus resulting in more blood flowing through the
pulmonary arteries for oxygenation.
ii.Functional closure occurs within 15 – 24 hours and is permanent by 3 – 4 weeks.
(ligamentum arteriosum)
c. Foramen Ovale
i. Closes within minutes after birth because of the higher pressure in the left than
to the right.
ii.Increased blood flow in the lungs and decreased pressure in the right atrium and
the return of the blood from the lungs increases pressure in the left atrium.
iii.Closure is permanent in approximately 3 months. (fossa ovale)
d. Ductus Venosus
i. Blood ceases flowing through the umbilical vein to the ductus venosus and into
the inferior vena cava.
ii.Blood now flows through the liver and is filtered as in adult circulation.

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 iii.Fibrosis occurs by the end of the 1st week of life (ligamentum venosum).
iv.Neurologic Adaptation (Thermoregulation)
1. Maintenance of body temperature must begin at birth.
2. Factors affecting thermoregulation
a. Heat production
i. Newborn produces heat through general metabolism, muscular activity and
nonshivering thermogenesis.
ii.Brown fat – special fat found only in newborns utilized during nonshivering
thermogenesis. It can be found in the adrenal, around the kidneys, axilla,
abdomen, back of neck, in between scapula, etc.
b. Heat retention
i. Staying in flexed position which reduces the area of skin exposed to the
environmental temperature.
ii.Peripheral vasoconstriction.
c. Heat loss
i. Newborn has thin skin with blood vessels close to the surface and little
subcutaneous fat to prevent heat loss.
ii.Cold stress – excessive heat loss.
iii.Methods of losing heat
1. Evaporation → body to air
2. Conduction → body to solid objects (cold compress)
3. Convection → body to a cooler surrounding object (fever, aircon)
4. Radiation → body to a cold subject not in contact with the body
(thermal shift)
i. Hepatic Adaptation
1. Newborn’s liver is immature at birth.
2. Liver conjugates bilirubin for excretion.
3. Jaundice – staining of the skin first seen in the head and face.
a. Physiologic – after 24 hours of life.
b. Pathologic – within 24 hours of life (correlated with sickle cell anemia)
B. Immediate Care of Newborn
a. Goals:
i. Establish, maintain and support respiration.
ii.Promote warmth and prevent hypothermia.
iii.Ensure safety and prevent injury and infection.
iv.To identify actual or potential problems that may require immediate attention.
b. APGAR Scoring System (Virginia Apgar)
i. A quick method of assessing the newborn adjustment to extrauterine life and general condition.
ii.Take I minute and 5 minutes after birth.
1. < 120 – asphyxiated (excessive oxygen could result to retrolental fibroplasia)
2. >160 – distress
3. Newborns are nose breathers for 2 – 3 weeks.
iii.Factors that affect the APGAR score
1. Degree of physiologic maturity
2. Fetal cardiorespiratory and neurologic condition (e.g. cleft palate, PDA)
3. Maternal perinatal therapy such as use of analgesia during labor.
Special Consideration
• 1st 1 minute → determines general coneral condition of the baby
Next 5 Minute → determines the capability of the baby to adjust extrauterinely (most important)
• Next 15 minutes → optional → depndent on the 5 minutes apgar score
Components
A ppearance Color upon birth is slightly cyanotic
After first cry baby will be pink
P ulse Rate Take apical pulse at the lower left nipple
G rimace Determines reflex irritability using tangential foot slap and catheter insertion
A ctivity To determine the degree of muscle tone
R espiration

Newborns will cry within 30 seconds upon expulsion

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ASPHYXIA NEONATORUM → failure to cry within 30 seconds because mother received Demerol
NARCAN → antidote of Demerol

APGAR SCORING
Score
Criteria 0 1 2
Heart Rate Absent < 100 > 100
Respiratory Effort Absent Slow RR/ Weak Good strong cry
Muscle Tone Flaccid Extremities Some reflexes Well Flexed
Reflex Irritability
Catheter No Response Grimace Cough or sneeze
Tangential FS No Response Grimace Cry
Color Blue / Pale Acrocyanosis Pink
• High score means healthy baby

Interpretation
0-3
• Severely depressed
• Needs CPR
• Admission at NICU
4-6
• Moderate depression
• Additional suctioning

7 – 10
• Good and healthy

CARDIOPULMONARY RESUSCITATION
• CPCR → cardiopulmonary and cerebral resuscitation
• 5 minutes of 02 deprivation will cause irreversible brain damage
• Priority: Airway, Breathing, Circulation
a. Establish respiration and maintain clear airway
i. Measures to establish and maintain normal respiration.
1. Wipe secretion from the mouth and nose after delivery using sterile gauze.
2. Suction secretions from the mouth and nose.
a. Gently suction to prevent:
i. Irritating the mucous membrane
ii.Mucosal edema
iii.Reflex bradycardia from vagal stimulation.
iv.Laryngospasm
v. Cardiac arrhythmias.
3. A crying infant is a breathing infant. Stimulate baby to cry if the baby does not cry spontaneously
or if cry is weak.
a. Normal infant cry: loud and lusty.
b. Abnormal manifestation
i. High pitched cry – hypoglycemia and increased ICP
ii.Weak cry – prematurity
iii.Hoarse cry – sign of laryngeal stridor
iv.Grunting respirations – respiratory distress syndrome
v. Unable to initiate to maintain respiration
1. Neonatal asphyxia requiring resuscitation
vi.Cardinal signs of newborn’s RDS
1. Tachypnea
2. Nasal flaring
3. Grunting
4. Intercostal retraction
5. Cyanosis
4. Oral mucous may cause the NB to choke, cough or gag during the 1st 12 hours of life.
a. Trendelenburg or sidelying position.
5. Proper positioning
a. Right sidelying after feeding
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 b. Supine during sleep (prevent SIDS)
6. Make sure diapers, clothing and blankets are loose enough
a. Allow maximum lung expansion
b. Avoid overheating
7. Keep nares/nose patent
a. Obligatory nose breather for 2 – 3 weeks old.
8. In some hospital, a catheter is passed into the stomach to remove amniotic fluid, blood, and
mucus.
a. Normal in newborn
i. Short periods of apnea, periodic respiration without cyanosis.
ii.Rapid respiration up to 80 that slows down to 30 – 60 bpm
iii.Irregular respiratory depth, rate, rhythm.
b. Provide warmth and maintain normal body temperature
i. Principles for preventing hyporthermia in NB.
1. Delivery in a warm room.
2. Drying thoroughly after birth.
3. Wrapping in a dry warm cloth while keeping the baby out of draughts on a warm surface.
4. Giving the baby to the mother asap after birth.
ii.Measures to prevent heat loss and maintain normal temperature
1. Dry the NB’s head and body immediately after birth.
2. Wrap with dry and warm blanket before giving to the mother to hold.
3. Place NB in a pre heated environment. (radiant warmer.)
4. Perform any extensive examination or procedure under radiant warmer to prevent heat loss.
5. Keep NB away from air conditioning vents that can promote heat loss.
6. Maintain ambient temperature of DR and nursery at 24 degrees celcius.
7. Delay initial feeding for at least 2 hours or until temp is stabilized.
8. Warm objects that will be used to examine or cover the NB.
c. Prevent infection
i. Principles of cleanliness at birth
1. Clean hands
2. Clean perineum
3. Nothing unclean to be introduced into the vagina.
4. Clean delivery surface.
5. Cleanliness in cutting the umbilical cord.
6. Cleanliness for cord care of the NB.
ii.Care for the eyes (Crede’s prophylaxis)
1. It is part of the routine care of the NB to give prophylactic eye treatment
a. Within the 1st hour after delivery.
b. Gonorrheal conjunctivitis
c. Opthalmia neonatorum
2. Eyes should be cleaned at birth and once everyday.
a. Use cotton swab soaked in PNSS.
3. Sticky eyes are managed by frequent cleansing or instillation of 10 % sulphacetamide eyedrops
every 2 – 3 hours.
4. Instillation of human colostrums for sticky eyes may be indicated.
iii.Opthalmia neonatorum
1. Any conjunctivitis with discharge occurring during the 1st 2 weeks of life.
2. Typically appear 2 – 5 days after birth but may appear as early as 1st day or as late as 13th day.
3. Most often, eyelids become swollen an red with purulent pus.
4. Corneal damage with ulceration perforation synechiae and panopthalmia develop if there is
delayed treatment.
iv.Using erythromycin/tetracycline ointment (commonly used)
1. Don’t cause much irritation as silver nitrate
2. More effective to chlamydial conjunctivitis.
3. Apply ointment over lower eyelids then manipulate to spread medication over the eyes.
4. Wipe excess ointment after 1 minute with sterile cotton ball moistened with sterile water.
5. Don’t rinse eyes.
v. Measures to prevent infection.
1. Proper hand washing technique.
2. Hand washing by health personnel.
a. Before entering the nursery/caring for the baby.
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 b. In between NB handling.
c. Before treating the cord.
d. After changing soiled diapers.
e. Before preparing formula milk.
3. Always use a single use tube pack of eye ointment.
4. Each NB should have her own bassinet and individual supplies to prevent cross infection.
5. NBs should be handled with gloves until after 1st bath.
6. Persons with infectious diseases should not be allowed in the nursery.
7. Used bulb syringe should be replaced every 24 hours and boiled for 10 minutes before reuse.
d. Prevent Hemorrhage
i. Hemorrhagic disorder of the NB
1. Self limited hemorrhagic disorder of the 1st 3 days of life.
2. Onset
a. Early – 0 – 24 hours
b. Classic – 2 – 5 days
c. Late – 1 – 12 weeks
3. Clinical manifestation
a. Spontaneous bruising or excessive bleeding after minor injury.
b. Nose bleeds
c. Oozing or bleeding from the umbilicus.
d. Dark vomit
e. Black tarry stools.
f. Blood in the diaper from hematuria.
g. Excessive bleeding from skin lesions.
h. Less specific warning signs: pallor, irritability, jaundice.
4. Prevention:
a. Vitamin K administration
i. Vitamin K1 – green leafy vegetables
ii.Vitamin K2 – microorganisms
iii.Vitamin K3 – synthetic vitamin K.
iv.Known as aquaMEPHYTON, phytomenadione, konakion.
v. Administered prophylactically to prevent a transient deficiency of coagulation
factors II(prothrombin), VII(proconvertin), IX(plasma thromboplastin), X
(stuart-prower factor).
vi.0.5 to 1 mg is injected IM in the lateral anterior aspect of the mid thigh within
the 1st hour of life.
vii.Oral vitamin K
1. 1st dose – 1st hour of life.
2. 2nd dose – 1 – 2 weeks of age
3. 3rd dose – 1 month of age
b. Cord care
i. The cord is clamped and cut in the delivery room about 8 inches from the
abdomen.
ii.Check the number of blood vessel. (1 artery = esophageal atresia)
iii.Another clamp is applied ½ - 1 inch from the abdomen then cut above the
clamp.
iv.Clean the cord with antiseptic.
v. Cord clamp is removed after 48 hours when the cord has dried.
vi.Instruction to mothers
1. No tub bathing until cord falls off.
2. Do not apply anything on the cord except prescribed antiseptic.
3. Avoid wetting the cord.
4. Leave cord exposed to air.
5. Monitor for bleeding.
6. Report signs of infection.
a. Foul odor in the cord.
i. Presence of discharge.
ii. Redness around the cord.
iii.The cord remains wet and does not fall off within 7 –
10 days.

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 iv.fever
e.Newborn Identification
i. Important to prevent switching of babies.
ii.Done in the delivery room after the mother or parents have had chance to meet and inspect their infant.
iii.Identification or band
1. Placed around the infant’s wrist or ankle.
2. Around mother’s wrist.
3. Information:
a. Mother’s maiden
b. Date and time of delivery.
c. Hospital/admission number of the mother
d. Sex of baby
e. Physician’s name
4. Traditional ID band
a. Consists of plastic bracelet with permanent locks.
iv.Foot prints
1. Considered permanent and fool proof method of newborn identification.
v. Finger prints
vi.Colored photograph of the newborn.
vii.Storage of blood (DNA genptyping).
f. Immunization
i. BCG, OPV, Hep B
B. Newborn Screening
a. RA 9288 / Newborn Screening Act of 2004
i. Testing every NB for certain harmful or potential fatal disorders that are not apparent at birth.
b. Disorders that can be detected:
i. Congenital Hypothyroidism
1. Congenital metabolic disorder characterized by insufficient thyroid hormones that result in
retarded growth and brain development.
2. 3 thyroid hormones:
a. T4 – thyroxine
b. T3 – triiodothyronine
c. Thyrocalcitonin
3. Terms: Cretinism (infant); myxedema (adult)
4. Causative factors
a. Congenital absence or underdevelopment of the thyroid glands.
b. Hereditary condition
c. Maternal iodine deficiency.
d. Maternal intake of anti – thyroid drugs during pregnancy.
5. Clinical manifestations:
a. Lowered v/s
b. Changes in skin color
c. Poor weight gain and growth.
d. Delayed milestone (sitting, walking, talking)
e. Mental retardation.
*Adult – Hashimoto’s syndrome – autoimmune disease attacking the thyroid gland.
6. Management
a. Replacement therapy
i. Synthroid
ii.Levothroid
*Check the pulse rate before administering.
*Withhold if PR = >80 – 100 (adult)/ >120 (infant); then refer.
b. Warm environment.
* Thyroidectomy
Nx Considerations
A – irway
- positioning: sandbag on both head sides.
- observe for stridor – airway problem
- tracheostomy set is ready at bedside.
B – leeding
- check for the nape (external bleeding)

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 - frequent swallowing ( Internal Bleeding)
C – alcium check
- check for tetany (muscle constricture)
- give 10 % calcium gluconate
D – etermine the voice of the patient
- may indicate destroyed laryngeal nerve.
- hoarseness of voice
- aphonia
E – mergency
- monitor / be prepared for assessing thyroid storm
- increased v/s – palpitation; hyperthermia
- icebath / thermal blanket.
ii.Congenital Adrenal Hyperplasia
1. Autosomal recessive disease resulting from mutations of genes fro enzymes mediating the
biochemical steps of production of cortisol from cholesterol by the adrenal glands.
(steroidogenesis)
2. Clinical manifestation:
a. Poor feeding
b. Vomiting
c. Diarrhea
d. Metabolic acidosis
3. Management:
a. Replacement therapy (hydrocortisone)
b. Corrective surgery for enlarged clitoris (1 – 3 y/o)
* Addison’s syndrome, Cushing, Hirsutism
iii.Phenylketonuria
1. Metabolic disorder characterized by lack of enzyme phenylalanine hydroxylase
2. Clinical manifestation
a. Delayed milestone
b. Mental retardation
3. Management:
a. Low phenylalanine diet (lofenalac)
b. Foods to be avoided
i. Milk and all dairy products
ii.Meat and poultry
iii.Fish
iv.Eggs
v. Nuts and peanut butter
vi.Dried beans
vii.Regular flour
viii.Aspartame / artificial sweeteners
iv.Galactosemia
1. Rare genetic metabolic disorder characterized by lack of the enzyme galactose – 1 – phosphate
uridyl transferase.
2. Clinical manifestation
a. Failure to gain weight
b. Poor feeding
c. Lethargy
d. Irritability
3. Management
a. Lactose free formula
b. Calcium and vitamin D supplements
c. Foods to be avoided
i. Milk and all dairy products
ii.Processed and pre – packaged foods
iii.Tomato sauce
iv.Some candies
v. Certain meds
vi.Some fruits and vegetables
v. G6PD Deficiency
1. X – linked recessive hereditary disease characterized by abnormally low levels of G6PD enzymes

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 2. Clinical manifestations:
a. Paleness
b. Rapid heartbeat
c. Rapid breathing/ shortness of breath
d. Dark tea colored urine
e. Jaundice
f. Spleenomegaly
3. Management: blood transfusion
C. Newborn Assessment
a. Gestational Age
i. Measured from the 1st day of the mother’s LNMP
ii.Assessment of birth weight
1. Appropriate for gestational age (AGA)
a. When NB’s weight falls between the 10th and 90th percentiles expected for GA.
2. Large for GA (LGA)
a. Above the 90th percentile expected for GA.
3. Small for GA (SGA)
a. NB’s weight is below 10th percentile expected for GA.
*Nx Alert: body weight and GA
iii.Ballard Scoring System – assesses physical and neuromuscular maturity
b. Physical Assessment
i. Vital signs
1. Temperature
a. Axillary – 36.5 – 37.5
b. Rectal – 36.6 – 37.2 –
i. initially to rule out imperforated anus
1. clinical manifestation
a. no meconium : earliest sign
b. abdominal distention
c. foul odor breath
d. vomitus of fecal matter
e. can apirate – respiratory problem
2. management: surgery with temporary colostomy
ii.taken once
iii.1 inch insertion.
*Atretic – no anal opening
*Agenetialism – no genital
*Stenos – has opening
2. Heart Rate
a. 120 – 160 bpm
b. Apical pulse – left lower nipple
c. Radial pulse – if present = PDA
d. Femoral pulse – if absent = COA
e. Murmur – an extra unusual sound heard during heartbeat.
3. Respiration
a. 30 – 60 bpm
b. Count for 1 full minute
c. May want to do before waking up the infant.
d. Rate will be elevated with crying / fever.
e. Signs of potential distress or deviation from expected findings:
i. Persistent fine crackles
ii.Asymmetrical chest movements
iii.Apnea (15 seconds)
iv.Tachypnea (> 60bpm)
v. Excessive mucus
vi.Retractions
vii.Nasal flaring
viii.Stridor
ii.General managements
1. Head circumference – 33 – 35 cm (2 – 3 cm larger than the chest)
2. Chest circumference – 30.5 - 33 cm

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 3. Weight – 2500 – 4000 gm (5lbs8oz – 8 lbs13oz)
4. Length – 48 – 53 cm (19 – 22 inches)
iii.Skin
1.Acrocyanosis
2.Pinkish
3.Cyanosis
4.Vernix caseosa – whitish cheese – like substance
5.Lanugo
a. Moderate in full term
b. Abundant in preterm
c. Absent for post term
6. Mongolian spots
a. Slate gray or bluish discoloration patches commonly seen across the sacrum or buttock
due to accumulation of melanocytes.
b. Disappear by 1 y/o
7. Milia
a. Plugged or unopened sebaceous glands
b. White pinpoint patches on nose, chin cheeks.
c. Disappear in 1st 2 – 3 weeks of life.
8. Erythema toxicum
a. Common rash in newborn composed of small pustular lesions.
b. Newborn rash/ fleabite dermatitis.
c. Peak incidence is 24 – 48 hours of life
d. Cause is unknown and no treatment.
9. Harlequin’s Sign
a. Color of the NB’s body appears to be half pale and half red.
b. This condition is transitory and usually occurs with lusty cry.
10. Jaundice
a. Refer to the yellow color of the skin and whites of the eyes caused by excess bilirubin in
the blood.
b. Management: Phototherapy (neon – blue light) – consists of exposing an infant’s skin to
light which breaks bilirubin down into its part that is easier to excrete in stool and urine.
c. Nx considerations:
i. Cover eyes
ii.Cover genitals – prevent priapism
iii.Change position regularly
iv.Increase fluid intake
v. Monitor I&O and v/s.
11. Birth Marks
a. Telangiectic nevi (stork bites)
i. Appears as pale pink or red spots
ii.Due to stretching (dilation) blood vessels.
iii.Most stork bites on the face eventually go away completely in about 18 mos.
Stork bites on the back of the neck /nape usually don’t go away.
b. Hemangiomas – simply a collection of extra blood vessels in the skin.
i. Types:
1. Nevus flameus (port wine stain)
a. Birthmark in which swollen blood vessels create a reddish –
purplish discoloration of the skin.
2. Strawberry hemangiomas / nevus vasculosus
a. Dilated capillaries in the entire dermal or subdermal area.
b. Disappear at 10 years of age.
3. Cavernous hemangioma
a. Communication network of venules in the subQ tissue that
never disappear with age – most dangerous – intestinal
hemorrhage.
iv.Head
1. Assess fontanels and sutures – observe for signs of hydrocephalus and evaluate neurologic status.
2. Craniosynostosis: premature fusing of the sutures
3. Micro and macrocephaly
4. Cephalhematoma (weeks) – blood in the subperiosteal area

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 5. Caput succedaneum – fluid accumulation
6. Molding
v. Eyes
1. Visual acuity – 20/150 – 20/190
2. Optimal visual field – 8 – 12 inches
3. Reflexes
a. Red eye reflex – may indicate blindness, cataracts, congenital infection (rubella), calcium
metabolism abnormality.
b. Blink reflex
c. Corneal reflex
d. Papillary reflex
4. Tears – 3 – 4 mos.
5. Opthalmia neonatorum – STI
6. Doll’s eye – disappear in 10 days
vi.Ears
1. Pinna – in line with outer canthus
2. If lower – low set ears = trisomy 21/Down Syndrome
3. Startle reflex – upper & lower extremities toward chest.
vii.Nose
1. Congenital choanal atresia
a. Blocked posterior nasal passage
b. Emergency case
2. Excessive discharge – congenital syphilis
viii.Mouth and throat
1. Epstein pearls
a. Accumulation of epithelial cells usually found on the palate.
b. Disappear within 2 weeks.
2. Reflexes:
a. Rooting reflex
b. Sucking reflex
c. Gagging reflex
d. Extrusion reflex
3. Abnormalities
a. Cleft lip (cheiloplasty)/ palate(uranoplasty)
i. Use small spoon (cleft lip); bigger spoon (cleft palate)
ii.Rule of ten before surgery
1. 10 weeks
2. 10 lbs
3. 10 hgb
b. Macroglossia – premature baby
c. Protruding tongue – Down syndrome
d. Oral thrush – oral candidiasis/moniliasis
ix.Neck
1. Short for chubby
2. Tonic neck / fencing reflex
3. Short neck may indicate the possibility of Kippel – feil syndrome
4. Abnormalities
a. Congenital torticollis / wryneck
i. Shortening of the sternocleidomastoid muscle (normally or by injury); spasm on
one side/
b. Webbing of the neck / webbed neck
i. Redundant extending skin fold.
x. Chest
1. Wide spaced nipples and shield like appearance – Turner’s Syndrome
2. Redness and purulent discharges – mastitis
3. Witch’s milk – disappear in 1 week
xi.Abdomen
1. Absent bowel sound can indicate ileus
2. Umbilical cord – check stump for bleeding or infection
3. Umbilical hernias – midline outpouching from the sternum to the umbilicus with weak abdominal
musculature (diastasis recti)

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 4. Inspection, auscultation, percussion, palpation
5. Abnormalities
a. Hematoma
b. Omphalocele – protrusion of abdominal organs
c. Infection/bleeding
xii.Anus
1. Imperforated anus
2. Meconium pass within 24 hours
xiii.Genitalia
1. Male genitalia
a. Undescended testes
b. Smegma – normal
c. Hydrocele
d. Cremasteric reflex – T8 – T10
i. Disappear by 10th day of life
2. Female Genitalia
a. Ambiguous genitalia
3. Abnormalities
a. Chordee
b. Chryptorchidism
c. Hypospadias
d. Epispadias
xiv.Extremities
1. Multiple fracture indicates osteogenesis imperfect
2. Reflexes
Palmar Grasp Reflex
• When a solid object is placed on the palm then the baby will grasp the object
• To cling to the mother for safety
• Disappears at 3 months
Step – in/ Walk – in Place Reflex/ Dance Reflex
• Neonate placed on a vertical position with their feet touching on hard surface will take a few quick alternating steps
• Placing reflex  almost the same with the dance reflex except that is when you are touching the anterior surface of newborns
leg
Plantar Grasp Reflex
• When an object touches the sole of the newborn’s foot at the base of his toes, the toes grasp in the same manner as the fingers
do
• Disappears @ 8 – 9 months in preparation for walking
Tonic Neck Reflex/ Fencing/ Boxing reflex
• When the newborn lies on its bact, their heads usually turns to one side, the arm and the leg on the side to which the head
turns extend to the opposite arm and legs contract
Moro Reflex/ Startle Reflex
• With a loud voice or by a jarring the base of the crib, the baby will assume a c position
• Test for neurologic integrity
Magnet Reflex
• When there is pressure at the sole of the foot, the baby pushes back against the pressure
Crossed extension Reflex
• While supine and the sole of the foot is stimulated by a sharp object, it causes the foot to raise and the other foot to extend
• Test for spinal nerve integrity
Trunk Incurvation Reflex/ Galant Reflex
• While in prone position and the parabvertebral area is stimulated, it causes flexion of the trunk and swing his pelvis towards
the touch
Landau reflex
• While the infant is placed on a vertical position with the hand underneath supporting the trunk the baby exhibit some muscle
tone
• Present at 3 months
• Test for muscle tone
Parachute Reflex
• When the infant is placed on a vertical suspension with the change in equilibrium, it causes the extension of the hands and
legs
• Present at 6 – 9 months
Babinski Reflex

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 • When the sole of the foot is stimulated by inverted j, it causes fanning of the toes
• Disappears by 2 months but may persist till 2 years old
1. Abnormalities:
a. Amelia/ phocomelia
b. Hypotonia
c. Club foot
d. Webbing/syndactyl
e. Extra / polydactyl
f. Absence of gasp reflex
B. Growth and Development

Growing  complex phenomenon of a structure or whole ○ FINE MOTOR ADAPTIVE  ability to

GROWTH use hand movements
• Increase in physical size of a structure or whole ○ GROSS MOTOR SKILLS  ability to use
• Quantitative large body movements
• 2 parameters
○ Weight
MATURATION
 Most sensitive measurement for
• Synonymous with development
• Readiness/ learning is effortless
Weight gain: COGNITIVE DEVELOPMENT
2x = 5 – 6 mos. • Ability to learn and understand from experiences, to
3x = 1 year acquire and retain knowledge, to respond to a new
4x = 2 – 2½ years situation and to solve problems
○ Height
 ESTROGEN  responsible for LEARNING  change of behavior
increase in height in female
 TESTOSTERONE  responsible IQ= [Mental Age/ Chronological Age] x 100
for the increase in height in male Normal IQ = 90 - 110
 Stoppage of height coincide with GIFTED CHILD  > 130 IQ level
the eruption of the wisdom teeth
BASIC DIVISIONS OF LIFE
• Prenatal
↑ - 1”/ mo – 1 – 6 mos ○ Conception to birth
 - 1.5”/ mo – 7 – 12 mos
• Infancy
↑ - 50 % - 1st Year
○ Neonatal  first 28 days
○ Formal Infancy  29th – 1 year
• Early Childhood
HEIGHT COMPARISON ○ Toddler  1 – 3 y/o
9 y/o  male = female ○ Preschool  4 – 6 y/o
12 y/o  Male < Female • Middle Childhood
13 y/o  Male > Female ○ School Age  7 – 12 y/o
DEVELOPMENT • Late Childhood
• Increase in the skills or capacity to function
• Qualitatively
○ Pre – adolescent  11 – 13 y/o
• How to measure development ○ Adolescent – 12 – 13 y/o to 21
○ By simply observing the child doing simple
task
○ By noting parent’s description of the child’s
progress
○ Measure by DENVER DEVELOPMENTAL
SCREENING TEST (DDST)
• MMDST
○ Metro Manila Developmental Screening
Test
○ Philippine Based exam
• Main Rated Categories
○ LANGUAGE  ability to communicate
○ PERSONAL/ SOCIAL  ability to interact

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PRINCIPLES OF GROWTH AND DEVELOPMENT
• Growth and development is a continuous process (WOMB TO TOMB PRINCIPLE)  begins from conception and ends
with death
• Not all parts of the body grows at the same time or at the same rate (ASSYCHRONOUS GROWTH)
• Each child is unique
• Growth and development occurs in a regular direction reflecting definite and predictable patterns or trends
○ Directional Terms
 Cephalocaudal/ Head to Tail
 It occurs along bodies long axis in which control over head, mouth and eye movemens and
precedes control over upper body torso and legs
 Proximo – Distal/ Centro – Distal
 Progressing from center of the body to the extremities
 Symmetrical/ Each side of the Body
 Develop at the same direction at the same time and at the same rate
 Mass – Specific
 Differentiation – SIMPLE TO COMPLEX; BROAD TO REFINED
○ Sequential Trend
 Involves a predictable sequence of growth and development to which the child normally passes
 Locomotion
 Creeps → Stands → Walks → Run
 Language and Social Skills
 Cry → coo
○ Secular Trend
 Refers to the worldwide tend of maturing earlier and growing larger as compared to succeeding generation

• BEHAVIOR → most comprehensive indicator of developmental stages

○ act @ your age
• PLAY → universal language
• A great deal of skills is learned by practice
• There is optimum time for initiation of experience or learning
• Neonatal reflexes must be lost first before development can proceed
○ persistent primitive infantile reflexes is a possible case of cerebral palsy

PATTERNS OF GROWTH AND DEVELOPMENT ○ Period of most rapid growth and

• Renal → digestive → circulatory → musculoskeletal development
○ childhood ○ Prone to develop anemia
• Brain → CNS → Neurologic Tissue  rapidly grows • Toddler
with in 1 – 2 years ○ Period of slow growth and development
○ Brain achieves its adult proportion @ 5 • Toddler and preschool
years ○ Period of alternating rapid and slow growth
○ Rapid growth and development of brain and development
from1 – 2 years • School Aged
○ Malnutrition may result to Mild Mental ○ Slower growth and development
Retardation ○ Least to develop anemia
• Lymphatic System (Lymph Nodes) • Adolescent
○ Grows rapidly during infancy and childhood ○ Period of rapid growth
○ Provide protection against infection ○ Secondary prone to anemia
○ TONSIL reach its adult proportion @ 5
years Two Primary Factors Affecting Growth and Development
• Reproductive • Heredity
○ Grows rapidly during puberty ○ Race
○ Sex
RATES OF GROWTH AND DEVELOPMENT ○ Intelligence
• Fetal and Infancy ○ Nationality

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 Developmental Task
• Environment • A skill or growth responsibility arising at a particular
○ Quality of Nutrition time in the individual’s life.
○ Socio Economic Status • The successful achievement of which will provide a
○ Health foundation for the accomplishments of the future
tasks
○ Ordinal Position in the family
○ Parent – Child Relationship SIGMUND FREUD’S PSYCHOSEXUAL THEORY
• 1856 – 1939
*Universal Principle: F are born < wt. than M by 1 oz.; F are
• An Austrian Neurologist
born < lt. than M by 1 in.
• Founder of Psychoanalysis
THEORIES OF DEVELOPMENT
• 1st to introduce Personality Development

Age Site of Activities Task

Phase Gratification
Oral Phase 0 – 18 Mouth • Biting • Provide oral stimulation even if baby is
mos. • Crying place NPO (use pacifier)CBQ
• Sucking (enjoyment • Never discourage thumb sucking
and release of
tension)
Anal Phase 19 mos. – Anus • Elimination • Help the child achieve bowel and bladder
(stage where 3 yrs. • Retention/ control even if the child is hospitalized
OC are Defecation of Feces • Principle of holding on and letting go
developed) • Mother wins or child wins
• Child Wins
○ Holding on
○ Child turns to be hardheaded,
antisocial, stubborn, unreliable,
irresponsible
• Mother Wins
○ Letting go
○ Child turns to be kind, obedient,
perfectionist
○ Meticulous, OCs, reliable,
responsible
Phallic Phase 4 – 6 yrs. Genital • May show • Accept the child fondling his own genetalia
exhibitionism as normal area of exploration
• Have or increase • Divert attention from masturbation
knowledge of 2 • Answer the child’s question directly
sexes • Human sexuality
Latent Phase 7 – 12 yrs. School aged • Period of • Help the child achieve (+) experiences so
suppression that he’ll be ready to face the conflicts of
• No obvious adolescents
development, slower
growth
• Child’s energy or
Libido is diverted
into more concrete
type of thinking
Genital Phase 12 – 18 Genitalia • Achieve sexual • Give opportunity to relate to opposite sex
yrs maturity and learn to
establish satisfactory
relationship with the
opposite sex

ERIK ERICKSON’S STAGES OF PSYCHOSOCIAL THEORY

•
• Former student of Freud

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 • Stresses the importance of culture and society to the development of one’s personality
• “environment”
○ words and symbols are not yet available
1. Trust vs. Mistrust ○ communication through senses
• 0 – 18 months
• TRUST is the foundation of all psychosocial 1. Schema 1: Neonatal Reflex
tasks ○ 1 month
• Theme: Give and Receive ○ Early reflexes
• Trust is developed via 2. Schema 2: Primary Circular Reaction
○ Satisfying needs of infants on time ○ 1 – 4 months
○ Care must be consistent and adequate ○ Activities related to body; repetition of
○ Give experiences that will add security behavior
 Hugs, kisses, touch, eye to eye ➢ Example: thumbsucking
contact, soft music 1. Schema 3: Secondary Circular Behavior
1. Autonomy vs. Shame & Doubt ○ 4 – 8 months
• 18 mos. to 3 years ○ Activities not related to the body
• Theme: independence and self – government ○ Discover person and object’s permanence
• Give opportunity for decision making, offer ○ Memory traces are present and anticipate
choices familiar events
• Encourage the child to make decision rather than 1. Schema 4: Coordination of Secondary Reaction
judge ○ 8 – 12 months
• Parents has a moral obligations to set limits
○ Exhibit goal directed behavior
1. Initiative vs. Guilt
• 4 – 6 years old ○ ↑ sense of permanence and separateness
• Learns how to do BASIC things ○ Play activities: Throw and retrieve
• Give opportunity exploring new places and 1. Schema 5: Tertiary Circular Reaction
events ○ 12 – 18 months
• Right time for amusement park and zoos ○ use trial and error to discover characteristic
• Activity recommended: modeling clay and finger of places and events
painting ○ “Invention” of new means
• Enhances creativity and imagination ○ capable of space and time perception
and facilitates fine motor development 1. Schema 6: Invention of New Means thru Mental
1. Industry vs. Inferiority Coordination
• 7 – 12 years old ○ 18 – 24 months
• Learns how to do things well ○ Symbolic representation
• Give appropriate short assignments and projects ○ Transitional phase to the pre-operational
• Unfinished project will develop inferiority thought period
1. Identity vs. Role Confusion
• 12 – 18 or 20 years old 1. Pre-operational Thought
• Learns who he is or what kind of person he will 1. Pre – conceptual Thought
become by adjusting to new body image and ○ 2 – 4 years old
seeking EMANCIPATION/ freedom from ○ Concrete, literal, static thinking
parents ○ CBQ EGOCENTRIC – unable to view
1. Intimacy vs. Isolation
• 18 – 25 or 30 years old anothers viewpoint
• Career focus ○ CBQ (-) REVERSIBILITY – in every action
• Looking for a lifetime partner there is opposite reaction; cause and effect
1. Generativity vs. Stagnation ○ Concept of time is only now and concept of
• 30 – 45 years old distance is only as far as they can see
1. Ego Integrity vs. Despair ○ CBQ ANIMISM – consider inanimate
• 45 years old and above object as alive
1. Intuitive Thought
JEAN PIAGET’S STAGES OF COGNITIVE ○ Beginning of causation
DEVELOPMENT
• Reasoning powers 1. Concrete Operational
• Swiss Psychologist ○ 7 – 12 years old
• Genetic Epistemologist ○ SYSTEMATIC REASONING as solution to
problems
1. Sensorimotor ○ Concept of (+) reversibility
• 0 – 2 years old ○ Concept of Conservation – constancy
• Also called Practical Intelligence
despite of transformation
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 ○ Activity recommended: Collecting and
Classifying
KOHLBERG’S THEORY OF MORAL DEVELOPMENT
1. Formal Operational • Recognized the theory of moral development as
○ 12 years old and above considered to closely approximate cognitive stages of
○ Period when cognition achieve its final form development
○ Can solve hypothetical problem with • Stages of Moral Development
SCIENTIFIC REASONING ○ Infancy
○ Can deal with past, present and future ○ Premoral
○ Capable of ABSTRACT, mature thought ○ Amoral
and formal reasoning ○ Pre-religious
○ Activity recommended: talk time; focus on
opinions and current events
Age Descritption
Stage
PRECONVENTIONAL (Level I)
0 – 3 yrs 1 • PUNISHMENT/ OBEDIENCE/ ORIENTATION
○ Heteronomous morality
○ Child does right because PARENT tells him to and to avoid punishment
4 – 7 yrs. 2 • INDIVIDUALISM
○ Instrumental purpose and exchange
○ Carries out action to satisfy own needs rather than society
○ Will do something for another if that person does something for the child
CONVENTIONAL (Level II)
4 – 10 yrs. 3 • ORIENTATION TO INTERPERSONAL RELATIONS OF MUTUALITY
○ Child follows rules because of need to be a “good person” in own eyes and eyes of
others
10 – 12 yrs. 4 • MAINTAINANCE OF SOCIAL ORDER, FIXED RULES AND AUTHORITY
○ Child finds following rules satisfying
○ Following rules of authority figures as well as parents in an effort to keep the
“system” working

POST – CONVENTIONAL (Level III)

Older than 5 • SOCIAL CONTRACT, UTILITARIAN LAW – MAKING PERSPECTIVE
12 ○ Follows standards of society for the good of the people
6 • UNIVERSAL ETHICAL PRINCIPLE ORIENTATION
○ Follows internalized standards of conduct
○ Only few people achieved this level
○ Only saints and holy

DEVELOPMENTAL MILESTONES
• Major marker of growth and development
• Determines developmental delays

TEETH QUESTIONS
6 mos.
Eruption of first temporary teeth 2 LOWER CENTRAL INCISORS
30 mos. Temporary teeth complete
20 decidous teeth
POSTERIOR MOLAR --> last to appear
Time to go to Dentist
Begins to brush teeth
3 years Tooth brushing with minimal supervision
6 years Tooth brushing alone
Temporary teeth begins to fail
1st permanent teeth → 1st MOLAR

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 Last to appear → WISDOM TOOTH

BOWEL/ BLADDER CONTROL

Bowel Control → 18 months / 1 ½ years
Day Time Bladder Control→ 2 years
Night Time Bladder Control → 3 years

MILESTONES

Infancy • Fear: Stranger Anxiety

• Solitary play ○ Begins: 6 – 7 months
○ Consider when choosing a play ○ Peaks: 8 months
➢ Safety ○ Diminishes: 9 months
➢ Age appropriateness
➢ Hygiene
Neonate • Eruption of first temporary teeth ( Lower 2 central
• Complete head lag incisors)
• Largely reflex visual fixation for human face • Vowel sounds “ah, eh”
• Hands fisted with thumbs in • Uses palmar grasp; handless bottle well
• Cries without tears because lacrimal glands are not • Recognizes strangers
fully developed
7 months
1 month • Transfer objects from hand to hand (6 – 7 months)
• Dance reflex disappears • Likes objects that are good sized for transferring
• Looks at mobile; follows midline
• Alert to sound, regards face 8 months
• Sits without support
2 months • Peak of stranger anxiety
• Holds head up when in prone • Plantar reflex disappear (6-8 months)
• Social smile, cries with tears, cooing sound
• Closure of posterior fontanel (2-3 months) 9 months
• Head lag when pulled to sitting position • Creeps or crawls; need space for creeping
• No longer clinches fist tightly • Neat pincer grasp reflex, probes with forefinger
• Follows object past midline • Finger feeds, combine 2 syllables “mama & dada”
• Recognizes parents
10 months
3 months • Pulls self to stand
• Holds head and chest up when in prone • Understand the word no
• Holds hands open at rest • Respond to name
• Hand regard, follows object past midline • Peek – a – boo, pat a cake, since they can clap
• Grasp and tonic neck reflexes are fading
• Reaches for familiar people or object 11 months
• Anticipates feeding • Cruising, stand with assistance
• Walking while holding to his crib’s handle
4 months • One word other than mama and dada
• Head control complete
• Turns front to back; needs space to turn 12 months
• Laughs aloud; Babbling sound • Stands alone
• Babinski Reflex disappears • Walk with assistance
• Drink from cup, cooperates in dressing
5 months • Says two words other than mama and dada
• Turn both ways (roll over) • Pots & pans, pull toys and nursery rhymes
• Teething rings, handles rattle well • Imitates actions, comes when called
• Moro reflex disappears (5 – 6 months) • Follows one – step command and gesture
• Enjoys looking around environment • Uses mature pincer graps, throws objects

6 months Toddlerhood
• Reaches out in the anticipation of being picked- up • Parallel Play – 2 toddlers playing separately
• Sits with support • Provide 2 similar toys for 2 toddlers
• Puts feet in mouth in supine position • Toys

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 ○ Squeaky frogs to squeeze • 50 – 200 words (2 word sentences), knows 5 body
○ Waddling ducks to pull parts
○ Trucks to push • Walk upstairs alone, still using feet on the same step
○ Building blocks at same time
○ Pounding peg • Daytime Bladder Control
• Fear: Separation Anxiety • CBQ best time to bring the child to dentist: 2 – 3
○ Begins: 9 months years or when temporary teeth is complete
○ Peaks: 18 months
○ 3 stages 30 months
• Makes simple lines or stroke or crosses with pencil
 Protest
• Can jump down from chair
 Despair
• Knows full name, holds up finger to show age
 Denial
• Copy a circle
○ Prevent:
 Do not prolong goodbye
• CBQ Temporary teeth complete (posterior molar: last
to erupt)
 Say goodbye firmly
 Say when you’re back • CBQ 20 deciduous teeth
• CBQ tooth brushing: 2 – 3 years
Toddler Characteristic Traits
• Negativistic: says no most of the time 36 months
• Saying no – way of developing independence • TRUSTING THREES
• Limit questions, offer choices • Tooth brushing with little supervision
• Rigid, ritualistic and stereotyped • Unbutton buttons
• Ritualistic – way to gain mastery • Draws a cross, learns how to share
• Temper Tantrums • Knows full name and sex
○ Stomping of feet • Speaks fluently, 200 – 900 words
○ Holding breath • NIGHTIME BLADDER CONTROL achieved
• Rides tricycle
○ Screaming
○ Head banging
Preschoolers
○ NC: Ignore the behavior • Cooperative play – playhouse
• Scaphoid abdomen – underveloped abdominal • Role playing is usual
muscle • Fears:
• Physiologic Anorexia  food fad, food jag that last ○ Castration/ Body Mutilation
for a short period of time due to the preoccupation to ○ Dark places and witches
environment ○ Thunder and lightning
○ Ghost
15 Months
• Curious, creative, imaginative and imitative
• Plateau stage
• CBQ WALKS ALONE – lateness in walking is a Preschooler’s Characteristic Traits
sign of mild mental retardation • Telling tall tales
• Puts small pellets into small bottle
• Creep upstairs
• Imaginary friend  way of relieving tension and
anxiety
• 4 – 6 words
• Scribbles voluntarily with pencil, holds spoon well, • Sibling rivalry→ jealousy to a newly delivered baby
seat self in a chair • Regression
○ Signs: bedwetting
18 Months ○ Thumbsucking
• Height of POSSESIVENESS – favorite word MINE ○ Baby talk
• Bowel control achieved ○ Fetal position
• No longer rotates a spoon • Masturbation
• Can run and jump in place ○ Sign of boredom
• Walks up and downstairs holding on to a person’s ○ Divert attention
hand or railing, typically places both feet on one step ○ Offering toy
before advancing
• Names one body part 4 years old
• FURIOUS FOUR
24 months • Noisy, aggressive and stormy
• TERRIBLE TWOS • Buttons button
• Turns pages one at a time, removes shoes, pants, etc • Copy square
• Can open doors by turning door knobs, unscrew lids • Catches ball, jumps, skips
• Alternates feet going downstairs

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 • CBQ LACES SHOES
• Vocabulary of 1500, knows the basic color 10 years old
• Says song or poem from memory • Age of special talents
• Write legibly
5 years old • Ready for competitive games
• FRUSTRATING FIVES • More considerate and cooperative
• Jumps over low obstacles • Joins organizations
• Spreads with a knife • Well mannered with adults and critical with adults
• Draws 6 part man, copy triangle
• Imaginary playmates 11 – 12 years old
• 2100 words • Pre adolescent
• Identification with same sex • Full of energy and constantly active
• Attachment to opposite sex • Secret languages are common
• Share secrets with friends
School – Aged • Sense of humor is present
• Competitive Play: Tug of war • Social and coopoerative
• Fears
○ School Phobia  orienting child to his new School – Aged Characteristic Traits
environment • Industrious
○ Displacement from school • Modest
○ Death
• Significant Person Signs of Sexual Maturity in Female
○ Teacher I ncrease in size of breast and genitalia – telarche –
○ Peer of same sex 1st sign
W idening of hips
• Stoppage of height coincide with the eruption of
A ppearance of pubic axilliary and pubic hair -
wisdom tooth
adrenarche
• Prone to fracture: Common Green stick M enarche – last sign
• Mature vision
○ 20/200 legal blindness Signs of Sexual Maturity in Male
• They’ll Cheat → can’t afford to lose A ppearance of axilliary and pubic hair
D eepening of voice
6 years old D evelopment of muscle
• Temporary teeth begins to fall, permanent teeth I ncrease in size of penis and scrotum – 1st sign
begins to appear (1st: First Molar) P roduction of viable sperm – last sign
• Tooth brushing alone
• A year of continuous motion, clumsy moving Adolescence
• 1st grade teacher becomes authority figure • Fear
○ nail biting → sign of strict teacher ○ Acne
• Beginning interest with God ○ Obesity
○ Homosexuality
7 years old ○ Death
• Age of assimilation ○ Replacement from friends
• Copies a diamond • Peer of opposite sex  significant other
• Enjoys teasing and playing alone • Experiences conflicts between his needs for sexual
• Quieting down phase satisfaction and societal expectations
• Core Concern
8 years old ○ Change of body image
• Expansive age ○ Acceptance of the opposite sex
• Smoother movements • Nocturnal Emission: Wet dreams
• Normal homosexual ○ Hallmark of adolescence
• Loves to collexct objects
• Counts backwards • CBQ distinctive odor due to stimulation of apocrine
gland
9 years old • Testes and scrotum increases until age 17
• Coordination improves • Sperm is viable by age 17
• Tells time correctly • Breast of female and genitalia increases until age 18
• Hero worship • Signs of sexual maturity
• Stealing and lying are common • Characteristic traits
• Takes care of body needs completely ○ Idealistic, rebellious, reformers
• Teachers find their group difficult to handle ○ Parent child conflict
○ Very conscious with body image
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 ○ Peer pressure
• Problems Concept of Death
○ Vehicular accident 6 years old  death is reversible
○ Smoking CBQ 7 – 9 years old  personification of death, permanent
○ Alcoholism loss of the corporal life
○ Drug Addiction A.
○ Pre Marital Sex B. Congenital Heart Diseases/ Defects

CONGENITAL HEART DISEASE ○Systolic murmur at the upper

• Common in Boys border of the sternum with no
○ Transposition of the great artery (TOGA) significant sign
○ Truncus Arteriosus ○ Cardiac catheterization reveals
○ Tetralogy of Fallot increase oxygen saturation at
the right side of the heart
• Common in Girls ○ 50% of the blood goes to the
○ Patent Ductus Arteriosus right atrium
○ Atrio Septal Defect • Management
○ Open heart surgery
• Causes ○ Placing the client on a long
○ Familial tendency tern antibiotic therapy to
○ Exposure to rubella/ German measles – 1st prevent the development of
month sub-acute bacterial
○ Failure of the Heart Structure to progress endocarditis

Two Major Types 1. Endocardial Cushion Defect

• Acyanotic Heart Defects  shunting from left to
right
• Cyanotic Heart Defects  from right to left
Acyanotic Heart Defects with Increase Pulmonary Blood Flow
1. Vetricular Septal Defect
• Opening Between 2 ventricles
• Signs and symptoms
○ Systolic murmur at lower
border of the sternum and no
other significant sign
○ Cardiac catheterization reveals
increase oxygen saturation at
the right side of the heart
○ ECG reveals hypertrophy of
the right side of the heart
○ Only 50% of the oxygenated
blood will go to the aorta
• Management
○ Open heart surgery
○ Placing the client on a long
Acyanotic Heart Defects with Decrease Pulmonary Blood
tern antibiotic therapy to
Flow
prevent the development of
sub-acute bacterial
endocarditis
○ Protect site of catheterization
(right femoral vein)
○ Avoid flexion of joints
1. Atrial Septal Defect
• Failure of the foramen ovale to close
• Signs and symptoms
• AV canal affecting both the tricuspid
and the mitral valve
• Signs and symptoms
○ Only confirmed by
cardiaccatheterization
○ Valves are closed
1. Patent Ductus Arteriosus
• Failure of the Ductus Arteriosus to
close
• Signs and symptoms
○ Prominent radial pulse
○ Continuous machinery like
murmur
○ ECG reveals hypertrophy of
the left ventricle
• Management
○ Indomethacine – prostaglandin
inhibitor that facilitate closure
of PDA
○ Ligation of PDA by 2 – 4 years
old
1. Pulmonary Stenosis
• Narrowing of valve of pulmonary artery
• Signs and symptoms
○ Typical systolic ejection
murmur
○ S2 sound is widely split
○ ECG reveals right ventricular
hypertrophy
○ Only 50% of the blood goes to
the lungs

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 • Management
○ Balloon Stenotomy
1. Aortic Stenosis
• Narrowing of valve of aorta
• Signs and symptoms
○ Typical systolic ejection
murmur
○ Murmur
○ ECG reveals right ventricular
hypertrophy
○ Only 50% of the blood goes to
the body
○ Angina like symptoms may be
present when active
• Management
○ Balloon stenotomy
1. Duplication of Aortic Arch
• Doubling of arch of the aorta causing
compression to the trachea and
esophagus
• Signs and symptoms
○ Dysphagia – due to esophageal
compression
○ Dyspnea – due to tracheal
compression
○ Left ventricular hypertrophy
○ Only 50% of the blood goes to
the body
• Management
○ Close heart surgery
1. Coarctation of Aorta
• Narrowing of ach of aorta
• Outstanding signs
○ Absent femoral pulse
○ BP is higher on the upper
extremities and ↓ on the lower
extremities
○ Epistaxis
○ Lesser blood goes to the lower
extremities
• Management
○ Take BP on 4 extremities
○ Close hear surgery
Cyanotic Heart Defects with Increase Pulmonary Blood Flow
1. Transposition of Great Arteries
• Aorta is arising from the right ventricle
while the pulmonary artery is arising
from the left
• Signs and symptoms
○ Cyanosis after 1st cry
○ Polycythemia because of
increase production of RBC, a
compensatory mechanism to
the ↓ oxygen supply to the
Audray Kyle Saydoven
body, the blood become
viscous
○ Polycythemia will lead to:
 Thrombus
 Embolus
 Stroke (CVA)-
cererbrovascular
accident
○ ECG reveals Cardiomegaly
• Management
○ Palliative repair – Rash Kind
repair
○ Complete repair – Mustard
repair
1. Total Anomalous Pulmonary Venous Return
• Situation wherein pulmonary vein
instead of entering the left atrium enters
the right atrium or superior vena cava
• Signs and symptoms
○ Open foramen ovale
○ Mild – moderate cyanosis
○ Absent spleen
• Management
○ Restructuring of the heart
1. Truncus Arteriosus
• Situation in which pulmonary artery and
aorta is arising in one common trunk or
a single vessel with ventricular septal
defect
• Signs and symptoms
○ Cyanosis after 1st cry
○ Polycythemia because of
increase production of RBC, a
compensatory mechanism to
the ↓ oxygen supply to the
body, the blood become
viscous
○ Polycythemia will lead to:
 Thrombuis
 Embolus
 Stroke (CVA)
• Management
○ Restructuring the heart
1. Hypoplastic Left Heart Syndrome
• Non functioning left ventricle
• Signs and symptoms
○ Cyanosis after 1st cry
○ Polycythemia because of
increase production of RBC, a
compensatory mechanism to
the ↓ oxygen supply to the
body, the blood become
viscous
○ Polycythemia will lead to:
 Thrombuis
 Embolus
Page 25
  Stroke (CVA) the ↓ oxygen supply to the
• Management body, the blood become
○ Heart transplant viscous
○ Polycythemia will lead to:
Cyanotic Heart Defects with Decrease Pulmonary Blood Flow  Thrombuis
 Embolus
1. Tricuspid Atresia  Stroke (CVA)
• Failure of the tricuspid valve to open ○ Severe dyspnea  relieved by
• Signs and symptoms squatting position because it
○ Open foramen ovale will prevent venous return and
○ Cyanosis facilitate maximum lung
○ Polycythemia because of expansion
increase production of RBC, a  Knee chest position in
compensatory mechanism to infants
the ↓ oxygen supply to the ○ There is growth retardation
body, the blood become ○ TET Spells – blue spells or
viscous short episode of hypoxia
○ Polycythemia will lead to: ○ Syncope – faintaing
 Thrombuis ○ Mental retardation
 Embolus ○ Clubbing in fingernails
 Stroke (CVA) because of tissue hypoxia –
• Management late and last sign
○ Fontan Proledum ○ X – ray reveal a boot shape
heart
1. Tetralogy of Fallot • Management
• 4 Anomalies Present (PVOR) ○ Oxygen therapy
○ Pulmonary Stenosis ○ Morphine sulfate – for hypoxic
○ Ventricular Septal Defect episode
○ Overriding of Aorta ○ Propanolol (inderal) – decrease
○ Right Ventricular Hypertrophy heart spasm
• Signs and symptoms ○ Palliative repair – BLT or
○ High degree of Cyanosis  Blalock Taussig Shunt
outstanding Sign Procedure
○ Polycythemia because of ○ Complete repair – Brock
increase production of RBC, a Procedure
compensatory mechanism to

ACQUIRED HEART DISEASE

Rheumatic Heart Disease

• Inflammatory disease following an infection caused by Group A Beta Hemolytic Streptococcus
• Affected body parts
○ Musculoskeletal
○ Cardiac muscle
○ Integumentary system
○ CNS
• Tonsillitis due to love of sweets with no oral hygiene serving a good medium for bacterial growth causing inflammation
• Group A Beta Hemolytic Streptococcus will release toxin and enters circulation
• Group A Beta Hemolytic Streptococcus is an anaerobic organism and will stay at the left side of the heart or the mitral valve
as an ASCHOFF BODIES
• ASCHOFF BODIES – round nodules with multi nucleated cell and fibroblast that stays in the miral valve
• Left sided heart failure because of mitral stenosis due to increase in the size of Aschoff Bodies
• Diagnostic Exam: JONE’S CRITERIA
Major Minor
Polyarthritis – multi joint pain Low grade fever
Athralgia – joint pain Diagnostic Exams
CHOREA/ Sydenhamm’s Chorea/ St. Vitous Dance – involuntary, purposeless • Antibody
movement of the hand and shoulder accompanied by grimacing • C reactive protein
• ESR
• Anti Streptolysin Titer
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 Carditis – signs of tachycardia
Erythema Marginatum – macular rashes
Subcutaneous nodules
Presence of 2 major or 1 major and 2 minor plus a history of sore throat will confirm diagnosis

• Management
○ Bed rest
○ Avoid contact sports
○ Throat swab for C & S
○ Antibiotics – purpose is to prevent recurrence
○ Aspirin Therapy or salicylates – act as an anti-inflammatory agent in RHD
○ Side effect: Reye’s Syndrome  encephalopathy accompanied by fatty infiltration of the organs such as the heart
and liver

RESPIRATION
• Normal Values = 30 – 60 bpm irregular
• Either abdominal or diaphragmatic breathing with short period of apnea without cyanosis
• Normal apnea in newborn is 15 seconds or less

Age Rate
Newborn 40 – 90
1 year old 20 – 40
2 – 3 years old 20 – 30
5 years old 20 – 25
10 years old 18 – 22
15 and above 12 – 20

Breath Sounds Heard on Auscultation

Vesicular • Soft, low pitched, heard over periphery of lungs, aspiration is longer than expiration
Normal
Bronshovesicular • Soft, medium pitched heard over major bronchi, inspiration equals expiration
Normal
Bronchial • Loud, high pitched, heard over the trachea, expiration is longer than inspiration
Normal
Ronchi • Snoring sound made by air moving through mucus in bronchi
Normal
Rales • Crackles (like Celophane) made by air moving through fluid in alveoli
Abnormal • Denotes pneumonia, fluid in the lungs or pulmonary edema
Wheezing • Whistling on expiration made by air being pushed through narrowed bronchi
• Denotes children with asthma or foreign body airway obstruction
Abnormal
Stridor • Crowing or roster like sound made by air being pulled through a constricted larynx
• Indicative of Respiratory Obstruction
Resonace • Loud, low tone, percussion sound over normal lung tissue
Hyper Resonance • Louder, lower sound than resonance, percussion sound over hyperinflated lung tissue

1. RESPIRATORY DISTRESS SYNDROME

• Lack of surfactant within 24 hours of life
• Aka Hyalin Membrane Disease
• Common in preterm babies
• The alveoli cannot expand properly
• Signs and symptoms
○ Present within 4 hours of life
○ Using the Silverman Anderson Scoring to determine RDS
○ ↑ RR with retraction (1st sign of RDS)
○ Expiratory Grunting (major sign)
○ Xiphoid retraction

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 ○ Flaring nasal flares
○ Cyanosis
○ Respiratory acidosis
• Management
○ Head elevated
○ Proper suctioning
○ O2 administration with ↑ humidity
○ Client placed on
 CPAP Continuous Positive Airway Pressure
 PEEP Positive End Expiratory Pressure
 Purpose id to maintain the alveoli partially open and prevent alveolar collapse
○ Monitor for acidosis
○ Surfactant replacement

1. LARYNGOTRACHEO BRONCHITIS (LTB)

• Most common form of croup
• Viral infection of the larynx, trachea and bronchi
• Signs and symptoms
○ BARKING or CROUPY COUGH  outstanding sign
○ Inspiratory Stridor
○ Respiratory acidosis
○ Cyanosis
○ Death
• Diagnostic Exams
○ Throat swab for c & s
○ ABG
○ Chest and x-ray to ruyle out epiglotitis
• Management
○ Racemic Epinephrine – bronchodilator
○ Humidified Oxygen

1. BRONCHIOLITIS
• Inflammation of the bronchioles characterized by production of tenacious mucus
• FLU – LIKE SYMPTOMS – outstanding sign
• ↑ RR
• Causative Agent: Respiratory Syncitial Virus
• Drug: Antiviral – Ribavirin

LTB and Bronchiolitis ends with Epiglotitis

1. EPIGLOTITIS
• Inflammation of the epiglotitis
• Sudden onset
• The child always assume the tripod position
• Less than 18 months cannot cough – must be placed on mist tent or “Croup tie” – make sure that the edges are tucked
in
○ Provide washable plastic toys or materials
○ Avoid toys that crate friction
○ Avoid toys that are hairy or furry

Blood Pressure
• Newborn – 80 – 46 mmHg
• After 10 days – 100/ 50 mmHg
• BP taking begins by 3 years old
A. Congenital Disorders
a. Hydrocephalus
i. Excess CSF

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 1. Overproduction of CSF
2. Occlusion of canals
ii.Types:
1. Communicating
2. Noncommunicating
iii.Rapidly increasing head circumferences enlarged fontanels, sunsetting eyes, high pitched cry.
iv.Ventriculoperitoneal shunt – shunt to drain CSF from the ventricle into the peritoneal cavity
*Monro – Kellie hypothesis
- CSF/blood/brain tissue = fixed
- cranial compartment is incompressible
b. Spina Bifida
i. Spinal cords and the other membranes protrude through a gap in the laminae of the vertebrae
ii.Paralysis and sensory loss
iii.Monitor ICP, head circumference, prone/sidelying, saline, gauze, check for leaks.
iv.Mother – didn’t take folic acid during her pregnancy.
v. Types:
1. SB Occulta
2. SB with meningocele – CSF; meninges
3. SB with myelomeningocele – CSF; meninges, SC
4. SB with myeloschisis - open
c. Cerebral palsy
i. Resulting from neuromuscular disorder due to damage / altered brain structure that controls motor
functions.
ii.Therapy: PT/OT; speech therapy
iii.Nx Considerations: assist with ADL, help child learn as many self – care activities; safe environment.
d. Cognitive disorders
i. Down Syndrome (trisomy 21)
1. Most common genetic disorder causing moderate to severe mental retardation
2. Surgery + supportive care management
e. Skeletal Congenital Disorder
i. Talipes Equinovarus (TEV) – Club foot
1. Congenital malformation of the lower extremities that causes abnormal, twisting of the ankles,
heels, toes, and feet.
2. Plantar flexed foot with inverted heel and adducted forefoot, unilateral or bilateral defect, rigid
limb that can’t be manipulated into neutral position
3. Tx: serial manipulation and casting (6 – 18 mos); surgery (12 – 16mos); use of Dennis brown
shoes
ii.Congenital Hip Dysplacia
1. Head of the femur is improperly notched in the acetabulum.
2. Hip dislocation, asymmetry of leg position, asymmetric fat folds, and diminished movement on
the affected side.
3. Tx: Pavlik’s harness, von rosen splint, stiff shell cast, total hip surgery
4. Types: Dysplastic; dislocated
f. Chromosomal Disorders
i. Turner’s syndrome
1. Medical disorder which is the result of a problem with a girl’s chromosome.
2. Short stature(4’7”); lack of sexual development, webbed neck, ptosis, extra fluids in the
extremities.
3. Growth hormone treatment; estrogen replacement.
ii.Klinefelter’s Syndrome
1. Chromosomal condition that affects male sexual development.
2. Testosterone treatment
3. Clinical manifestation
a. Tall stature
b. Narrow shoulder
c. Small testes
d. Infertility
e. Gynecomastia
f. Wide hips
g. Fewer chest hair
h. Poor beard growth

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