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Head to toe:

  • V/S: Respiration (30-60 bpm) and apical pulse (120-160 bpm). Temp. – verify imperforate anus.

  • Weigh (6-9lbs) and height.

  • Head:

  • Fontanels “anterior (close 12-18 months), posterior (2-3 months).” should be flat, soft and firm. (Not sunken, not bulging).

  • Circumference: Head + chest and abdomen.

  • Tears.

  • Skin: Well-hydrated, Pink body color (check jaundice and cyanosis) and bluish extremities (acrocyanosis-newborn NORMAL).

  • Umbilical cord: Newborn 2 arteries, 1 vein (AVA), s/s of infection.

  • Reflexes: Eyes (Blinking/corneal, papillary, doll’s eye, Nose (glabellar, sneeze), Mouth and throat (sucking, rooting, extrusion), Extremities (grasp, babinski), General (Moro, startle, dance and so on).

  • Elimination: urine (5-6) and stool (2-5) (COCA).

  • Others: New born (lanugo, vernix caseosa, millia), circumcision, SLEEP, FEEDING (8-12).

  • Assess the MOTHER. (Parent-infant interaction).

  • FLACC scale for pain: Face, legs, activity, cry, consolability.

APGAR score: Evaluated at one minute and five minutes after birth. One minute: How well the baby tolerated the birthing process.

Five minutes: How the baby doing outside the womb.


Appearance: color.

Pulse: heart rate.

Grimace: reflex irritability.

Activity: muscle tone.

Respiration: respiratory effort.


7-10: Normal.

4-7: Fairly low (suctioning and give oxygen).

<3: Critically low (often requires resuscitation).

AquaMEPHYTON (vitamin K)

  • Prevent hemorrhagic disease of the newborn (HDN).

  • Coagulation factors synthesized in the liver depend on vitamin K, which is not synthesized until intestinal bacteria are present.

Administered at vastus lateralis muscle (0.5-1.0 m). 

Erythromycin (0.5%) and tetracycline (1%)

  • Administer within an hour after birth.

  • Prevent opthalmia neonatorum.

Bacteriostatic and bactericidal: provide prophylaxis against Neisseria gonorrhoeae and Chlamydia trachomatis.


  • Normal appears after the first 24 hours in full term neonates and 48 hours in premature.

  • Peak: Fifth day.


  • Encourage breastfeeding.

  • Prevent chilling (hypothermia can cause acidosis that interferes with bilirubin conjugation and excretion). Exposed baby to daylight or phototherapy.


  • Jaundice occurs before 24 hours (full term) and before 48 hours (preterm).

Indicate early hemolysis of RBC. (Notify physician).


  • Done 2-3 hours.

  • Burp during and after feeding.

  • Position newborn to right side after feeding.


  • Meconium stool: Greenish-black. Usually passed the first 24 hours.

  • Transitional stool: Greenish-brown. Loose consistency.

Seedy: Yellow stools in breast fed, pale yellow-brown in formula fed newborns. 


Autosomal recessive defect characterized by chronic generalized dysfunction of the exocrine gland.

-Thick, sticky, tenacious secretions that obstruct the exocrine gland.


  • Meconium ileus at birth

  • Pulmonary infections

  • Salty sweat

  • Steatorrhea (bulky, foul-smelling, fatty stool)

  • Malabsorption syndrome: not gaining weight (blocked pancreatic enzymes)

  • Abnormal sexual development: Sterility/infertility

Diagnostic test: Sweat chloride test.


  • Promote adequate respiration: Postural drainage, nebulization and oxygen, promote lung exercises, increase fluids.

  • Prevent infections: Standard precaution, limit contact.

  • Maintain nutrition: Balanced – high calorie and protein diet, administer ENZYMES a.c (viokase, pancreatin), encourage extra salt intake, increase fluid intake.


inflammation of the mucosa of the stomach and intestine. Rotavirus.

Signs and symptoms: Fever. Abdominal cramps. Diarrhea. Loss of appetite. N/V. Weight loss. Abdominal pain. S/S of dehydration.

Nursing interventions: “DWISS”

Dehydration: ●OReSol (Oral Rehydration Solution), pedialyte/gastrolyte–home. ●Continue to breastfeed. ●IV and I&O monitoring. ●Assess or teach S/S of dehydration. ●No fatty, spicy, caffeine and other irritants. ●No soft drinks and fruit juices.

Weight loss: ●Breastfeeding and encourage to eat. ●BRAT diet.

Infection control: ●Proper HANDWASHING. ●Isolation precaution (remove to daycare/school). ●Proper attachment and disposal of diaper. ●Disinfect of contaminated surfaces.

Skin integrity: ●Change diaper frequently. ●Clean buttocks with soapy water. ●Apply zinc oxide if buttocks are irritated. ●Avoid alcohol.

Support: ●Teach about the disease. ●Encourage family collaboration and provide comfort for the child.

SIDS: Sudden death of infant < 1 y/o


  • Put sleeping baby on his back.

  • No cosleeping.

  • Bed should be firm and flat (no soft beddings and toys).

  • Provide a smoke free environment.

  • Room temperature should be at least (18-21˚).

  • Continue to breastfeed.

Extra teaching: Immunization,  no honey under 1 y/o.


S. pneumoniae and H. influenza. Common in 6 months to 2 y/o. Middle ear infection or inflammation.

Risk factors: Bottlefeeding, cold and other resp. infection

Clinical manifestations:

  • Fever.

  • Ear pain.

  • Irritability.

  • Fluid buildup in the middle ear.


  • No propping of bottles.

  • Antibiotic therapy.

  • Analgesics and antipyretics.


  • Gradual replacement of retina by fibrous tissue and blood vessels.

  • Caused by: prematurity and use of supplemental oxygen (longer than 30 days).

  • Assessments: Leukoria, vitreous hemorrhage, myopia, strabismus, cataracts.

Interventions: Laser photocoagulation surgery.

CROUP: (Laryngotracheobronchitis)

- is a general term applied to a symptom complex characterized by hoarseness, a resonant cough described as “barking” or “brassy” (croupy), varying degrees of inspiratory stridor, and varying degrees of respiratory distress resulting from swelling or obstruction in the region of the larynx; the trachea and bronchi may also be affected.

- Parainfluenza virus – common to 3 months to 3 y/o.


  • Airway maintenance: O2 and nebulization (racemic epinephrine and corticosteroids)


  • Cool mist humidifier at home (hoods and tents)

  • Warm humid compress on the larynx

  • Warm mist by steam from running hot water in closed bathroom/boil water in a casserole or exposure to cold air.

  • If mild: encourage fluid and cool fruit juice.

  • Teach when to notify MD: S/S of respiratory distress.

HIRSCHSPRUNG'S DISEASE (Congenital anganglionic megacolon)

-Congenital anomaly with functional obstruction of the colon caused by LACK OF NERVE CELLS in the colon walls resulting to absence of peristalsis.

Clinical manifestations:

  • Intestinal obstruction: Failure to pass meconium

  • Vomiting bile-stained or fecal materials

  • Obstipation.

  • Ribbon like stool.

  • Abdominal distention.

  • Palpable fecal mass.

  • Nutrient malabsorption.

Management: SURGERY (Resection)

  • Post-op care for abdominal surgery

  • Teach parents about colostomy care

  • Accurate recording of stools (COCA and frequency)

  • Offer support groups – and help of ostomy nurse (please refer to ostomy care).


Narrowing of the pylorus (Lower part of stomach). If narrowed, it prevents gastric emptying to small intestine causing projectile vomiting. (Risk for dehydration and electrolytes imbalance.)

Other signs and symptoms: Constipation (decrease stools) or mucus stools, failure to gain weight and lethargy. Olive like lump in the abdomen (during assessment).

Surgical intervention: Pylomyotomy.

Position baby on their side if vomiting.


Spontaneous telescoping of one portion of the intestine into another leading to mechanical obstruction.

Clinical manifestations:

  • Colicky, abdominal pain.

  • Red currant jelly.

  • Vomiting.

  • Distended, tender abdomen, sausage shape mass in RUQ

  • Late sign: fever, shock.


  • Barium enema to reduce telescoping through hydrostatic pressure.

  • Surgery: as last resort

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