Semi-finals

• Alleviating the Anxieties of Children

  1. Use pain-free or topical anesthetics

  2. Use sedatives to prevent and moderate pain environment

  3. For neonates: use oral glucose pacifiers

  4. Use procedural information and sensory information
• Factors to Support Coping during Illness and Hospitalization

  • Inner strengths, talents, and attributes of the child's ability to cope in situations with assistance of adult
  • Expertise of the nurse: Understand verbal and non-verbal behavior of the ill child, Discerning the meaning intended, Responding skillfully and accurately
  • Support of Families: Relationship between nurses and families, Climate of pediatric unit as supportive environment: feelings of safety and security
  • Play as therapeutic in facilitating coping: Active life progress, Attractive, well-equipped playroom, School room must provide opportunities for children to engage in play activities and learning designed to avert untoward effects of hospitalization
• Preparation of Children and Families for Hospitalization

  1. Provide information

  2. Encourage emotional expression

  3. Establish trusting relationships

  4. Teach coping strategies (through tour): Use of puppets, Medical play, Children's literature, Audio-visual media
• Pain in children


  Not only a hurting sensation, but it can also be a confusing one because a child does not anticipate the pain, does not have words to explain how it feels, and cannot always understand its cause
• Nociceptors


  • Free nerve endings with specific receptors found in tissue throughout the body
• Four reasons of pain

  • Reduced oxygen in tissues from impaired circulation
  • Pressure on tissue
  • External injury
  • Overstretching of body cavities with fluid or air
• Pain receptor


  A sensory neuron that responds to damaging or potentially damaging stimuli by sending "possible threat" signals to the spinal cord and the brain
• Pain Impulses Stimulated by the Neurotransmitters that are Conducted by

  • A-alpha and A-beta fibers: Large fibers that are myelinated, Conducts the response at a rapid rate, Transmits sharp, well-localized pain
  • A-delta nerve: Fibers that are smaller and conducts at a slower rate like light pressure and vibration
  • C-nerve: Fibers slowly-conducting unmyelinated axons that transmit, diffuse, dull, burning, and chronic pain
• Pain Impulses


  1. Joints Central Nervous System (CNS) fibers in the dorsal horn of the spinal cord

  2. Projected upward to the brain, where they will be perceived as pain
• Classification of Pain


  • Acute Pain: Sharp pain
  • Chronic Pain: Pain that lasts for a prolonged period (often defined as 6 months)
  • Cutaneous Pain: Arises from superficial structures, such as the skin and mucous membrane
  • Somatic Pain: Originates from deep body structures such as the muscles or blood vessels
  • Visceral Pain: Involves sensations that arise from internal organs
  • Referred Pain: Pain that is perceived at a site distant from its point of origin
• Mechanism/Flow of Pain


  1. Pain impulse

  2. Stimulated noxious stimuli (Mechanical, chemical, thermal) electrical activity, transduction, transmission

  3. Moves along peripheral-sensory nerves, spinal column and brain
• Gate Control Theory


  Pain impulses travel and interpreted in the body, Formulated by Patrick David Wall and Ronald Melzack in 1965, The spinal nerves acts as gates to let pain travel through to reach the brain, or closes these gates and prevent pain messages from getting through at all
• Pain Assessment and History (PQRST)


  • P = Presence of Pain
  • Q = Quality
  • R = Radiation or Location
  • S = Severity
  • T = Timing
• Assessment Measures


  • Objective Measures: Used by observer to score client behavior or physiologic parameters associated with painful response, HR, BP, and self-reporting instruments
  • Subjective (Self-rating) Measures: When children measure the pain themselves
• Pain Management


  • Non-Pharmacologic: Discretion, preparation, relaxation, cutaneous stimulation, self-exercises, hypnosis, Comfort methods: Repositioning, Singing of soft music, Rocking with the child in a rocking chair, Gentle stroking
  • Pharmacologic: Analgesics: NSAIDS, Local or regional anesthesia
• LBW Infants


  • SGA: Small for Gestational Age, Has Intrauterine Growth Retardation (IUGR)
  • SFD: Small for Date – birth weight, Falls below 10% percentile on intrauterine growth charts
  • AGA: Appropriate in weight for Gestational Age
  • LGA: Large for Gestational Age, Weight above 90% on intrauterine growth chart

  
• Gestational Age


  • Premature (pre-term) infants: Regardless of birth weight are those who are delivered before 37 weeks from 1st day of LMP
  • Full term infants: Born between 37 and 42 weeks gestation
  • Post-mature infants: Born after a prolonged gestation (after 42nd week) regardless of birth weight

  
• Pre-term infant/prematurity


  • A preterm infant is traditionally defined as a live-born infant born before 37th week of gestation, Another criterion used is a weight of less than 2500g (5lbs. 8oz), Pre-term neonate is at risk for complications because the organ systems are immature, The degree of complications depends on gestational age

  
• Causes of Preterm Birth

  • Multiple pregnancy
  • Adolescent pregnancy
  • Lack of pre-natal care
  • Substance abuse
  • Smoking
  • Previous pre-term delivery
  • High, unexplained Alpha Fetoprotein level in 2nd trimester
  • Abnormalities of the uterus
  • Cervical incompetence
  • Premature Rupture of Membranes (PROM)
  • Placenta previa
  • Pregnancy Induced Hypertension (PIH)

  
• Clinical Manifestations of Preterm Infants

  • Respiratory manifestations: Tachypnea, Grunting, Nasal Flaring, Retractions, Cyanosis, Decreased oxygen saturation, Decreased oxygen levels, Abormal arterial blood gas (ABG) values
  • Cardiovascular manifestations: Poor tissue perfusion, Hypotension, Patent ductus arteriosus
  • Gastrointestinal manifestations: Feeding intolerance, Gastric reflux, Vomiting, Gastric residuals
  • Altered fluid status: Fluid excess - Edema, Congestive Heart Failure, Fluid deficit - Tachycardia, Poor skin turgor, Decreased urine output, Abnormal electrolyte levels, Decreased blood pressure
  • Iatrogenic anemia: Lowered hematocrit (Hct) and hemoglobin (Hgb) count, resulting from large or frequent removal of blood samples, Tachycardia, Pallor, Decreased BP, Increasing O2 requirements, Apnea, Infection, Hypo/hyperglycemia, Ineffective temperature control (inability to maintain core body temperature)
  • Neuromuscular system: Decreased suck and swallow reflex, Hypotonia, Altered state transition, Hyperbilirubinemia, Rapid destruction of RBCs, Jaundice, Lethargy, Kernicterus

  
• Diagnostic tests for Preterm Infants


  • Chest X-ray
  • ABG analysis
  • Head ultrasound
  • Echocardiography
  • Eye examination – retinal specialist
  • Serum glucose
  • Serum bilirubin
  • Euglobulin lysis time
  • CBC
• Medical Management for Premature Neonates

  • Cared for by a specially trained staff in the Neonatal Intensive Care Unit (NICU), Top priority is supporting the cardiac and respiratory system, Providing thermoregulation, Starting IV, Gavage nutrition

  
• Nursing Management for Premature Neonates

  • Assess heart sounds for presence of murmurs, Assess apical pulse, Assess perfusion, Monitor vital signs, Maintain an environment like intrauterine environment, Provide adequate fluid, electrolyte, and nutrition, Maintain a neutral thermal environment, Prevent infection, Assess for readiness for selected interventions, Provide stimulation when appropriate to infant state and readiness, Encourage flexion in the supine position by using blanket rolls, Provide the newborn with body boundaries through swaddling or using blanket rolls against the newborn's body and feet, Promote parent-newborn attachment, Initiate phototherapy as required

  
• Complications of Preterm Infants

  • Respiratory Distress Syndrome (RDS)
  • Retinopathy of Prematurity (ROP)
  • Patent Ductus Arteriosus
  • Necrotizing Enterocolitis (NEC)
  • Bronchopulmonary Dysplasia (BPD)
  • Apnea of Prematurity
  • Anemia

  
• Post-term infant


  • Post-term infant is born after the 42nd week of pregnancy, After 42 weeks in the uterus, the infant is at special risk because a placenta appears to only function effectively for 40 weeks (placental insufficiency), If the placenta continues to function well: Fetus will continue to grow, resulting to an LGA infant who may manifest problems like Birth trauma, Hypoglycemia, If the placenta function decreases: Fetus may not receive adequate nutrition, Fetus will utilize its subcutaneous fat stores for energy, Wasting of subcutaneous fat occurs, resulting in fetal dysmaturity syndrome
• 3 Stages of Fetal Dysmaturity Syndrome

  • Stage 1: Chronic Placental Insufficiency - Dry, cracked, peeling, lose, and wrinkled skin, Malnourished appearance
  • Stage 2: Acute Placental Insufficiency - All features of Stage 1, Meconium staining, Perinatal depression
  • Stage 3: Subacute Placental Insufficiency - Findings of Stage 1 and 2, Green staining of skin, nails, cord, and placental membrane

  
• Placenta


  • If it loses ability to carry nutrients effectively to the fetus, the fetus may die or develop post-term syndrome/complications
• If the placenta continues to function well

  Fetus will continue to grow, resulting to an LGA infant who may manifest problems like birth trauma and hypoglycemia
• If the placenta function decreases

  1. Fetus may not receive adequate nutrition

  2. Fetus will utilize its subcutaneous fat stores for energy

  3. Wasting of subcutaneous fat occurs, resulting in fetal dysmaturity syndrome
• 3 Stages of Fetal Dysmaturity Syndrome

  • Stage 1: Chronic Placental Insufficiency
  • Stage 2: Acute Placental Insufficiency
  • Stage 3: Subacute Placental Insufficiency
• Stage 1: Chronic Placental Insufficiency

  • Dry, cracked, peeling, lose, and wrinkled skin
  • Malnourished appearance

  
• Stage 2: Acute Placental Insufficiency


  • All features of Stage 1
  • Meconium staining
  • Perinatal depression
• Stage 3: Subacute Placental Insufficiency


  • Findings of Stage 1 and 2
  • Green staining of skin, nails, cord, and placental membrane
  • A higher risk of fetal intrapartum or neonatal death
  • Newborn is at increased risk of developing complications related to compromised uteroplacental perfusion and hypoxia (e.g. Meconium Aspiration Syndrome)
  • Chronic Intrauterine Hypoxia causes increased fetal erythropoietin and red blood cell production resulting in polycythemia
  • Post-term infants are susceptible to hypoglycemia because of the rapid use of glycogen stores

  
• Assessment Findings


  • Long, thin newborn with wasted appearance
  • Parchment-like skin
  • Meconium-stained skin, nails, and umbilical cord
  • Long fingernails
  • Absence of lanugo
• Meconium Aspiration Syndrome


  • Fetal hypoxia
  • Blue or pale skin
  • Low HR
  • Weak muscle tone
  • Weak cry/no cry
  • Difficulty of breathing
  • Meconium staining of amniotic fluid
  • Respiratory distress at delivery
  • Meconium-stained vocal cords

  
• Diagnostic Findings


  • Hematocrit may be elevated due to polycythemia and dehydration
  • Sonogram measures the biparietal diameter
  • A non-stress test or complete biophysical profile determines if the placenta is functioning adequately

  
• Nursing Management


  1. Manage Meconium Aspiration Syndrome (MAS)

  2. Obtain serial blood glucose measurements

  3. Provide early feeding to prevent hypoglycemia, if not contraindicated by respiratory status

  4. Maintain skin integrity
• Small for Gestational Age (SGA)


  An infant whose length, weight, and head circumference are below the 10th percentile of the normal variation for gestational age, as determined by neonatal examination

  
• Maternal conditions associated with SGA babies

  • Hypertension (chronic or pregnancy-induced)
  • Cardiac, pulmonary, or renal disease
  • Diabetes mellitus
  • Poor nutrition
  • Use of alcohol, tobacco, or drugs
  • Age
  • Multiple gestation
  • Placental insufficiency
  • Placental fetal abnormalities
• Fetal conditions associated with SGA infants

  • Normal genetically small infant
  • Chromosomal abnormality
  • Malformations
  • Congenital infections, especially rubella and cytomegalovirus