REPUBLIC of the PHILIPPINES

City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
CENTER OF NURSING
J.P Rizal Extension, West Rembo, Makati City 1215
Telephone No.: (+632) – 881 – 1571

NURSING MANAGEMENT AND LEADERSHIP

MATERNAL AND CHILD HIGH RISK TOPICS

Submitted by:

Balaoy, Ruth C.

Templo, Sheana Camille T.

Terrado, Debbie

4AN3B
 TETRALOGY OF FALLOT

Tetralogy of Fallot is a rare condition caused by a combination of four heart defects that are present at
birth (congenital).

These defects, which affect the structure of the heart, cause oxygen-poor blood to flow out of the heart
and to the rest of the body. Infants and children with tetralogy of Fallot usually have blue-tinged skin
because their blood doesn't carry enough oxygen.

Tetralogy of Fallot is often diagnosed during infancy or soon after. However, tetralogy of Fallot might not
be detected until later in life in some adults, depending on the severity of the defects and symptoms.

With early diagnosis followed by appropriate surgical treatment, most children and adults who have
tetralogy of Fallot live relatively normal lives, though they'll need regular medical care throughout life
and might have restrictions on exercise.

Etiology

Theory: destruction of the neuronal crest cells during embryogenesis

In the laboratory setting, destruction of these cells reproduced results displayed with certain cardiac
malformations.

Symptoms

Tetralogy of Fallot symptoms vary, depending on the extent of obstruction of blood flow out of the right
ventricle and into the lungs. Signs and symptoms may include:

 A bluish coloration of the skin caused by blood low in oxygen (cyanosis)

 Shortness of breath and rapid breathing, especially during feeding or exercise

 Loss of consciousness (fainting)

 Clubbing of fingers and toes — an abnormal, rounded shape of the nail bed

 Poor weight gain

 Tiring easily during play or exercise

 Irritability

 Prolonged crying

 A heart murmur
Tet spells

Sometimes, babies who have tetralogy of Fallot will suddenly develop deep blue skin, nails and lips after
crying or feeding, or when agitated.

These episodes are called tet spells and are caused by a rapid drop in the amount of oxygen in the blood.
Tet spells are most common in young infants, around 2 to 4 months old. Toddlers or older children might
instinctively squat when they're short of breath. Squatting increases blood flow to the lungs.

Causes

Tetralogy of Fallot occurs during fetal growth, when the baby's heart is developing. While factors such as
poor maternal nutrition, viral illness or genetic disorders might increase the risk of this condition, in most
cases the cause of tetralogy of Fallot is unknown.

The four abnormalities that make up the tetralogy of Fallot include:

 Pulmonary valve stenosis. Pulmonary valve stenosis is a narrowing of the pulmonary valve — the
valve that separates the lower right chamber of the heart (right ventricle) from the main blood
vessel leading to the lungs (pulmonary artery).

Narrowing (constriction) of the pulmonary valve reduces blood flow to the lungs. The narrowing
might also affect the muscle beneath the pulmonary valve. In some severe cases, the pulmonary
valve doesn't form properly (pulmonary atresia) and causes reduced blood flow to the lungs.

 Ventricular septal defect. A ventricular septal defect is a hole (defect) in the wall (septum) that
separates the two lower chambers of the heart — the left and right ventricles. The hole allows
deoxygenated blood in the right ventricle — blood that has circulated through the body and is
returning to the lungs to replenish its oxygen supply — to flow into the left ventricle and mix with
oxygenated blood fresh from the lungs.
 Blood from the left ventricle also flows back to the right ventricle in an inefficient manner. This
ability for blood to flow through the ventricular septal defect reduces the supply of oxygenated
blood to the body and eventually can weaken the heart.

 Overriding aorta. Normally the aorta — the main artery leading out to the body — branches off
the left ventricle. In tetralogy of Fallot, the aorta is shifted slightly to the right and lies directly
above the ventricular septal defect.

In this position the aorta receives blood from both the right and left ventricles, mixing the oxygen-
poor blood from the right ventricle with the oxygen-rich blood from the left ventricle.

 Right ventricular hypertrophy. When the heart's pumping action is overworked, it causes the
muscular wall of the right ventricle to thicken. Over time this might cause the heart to stiffen,
become weak and eventually fail.
Some children or adults who have tetralogy of Fallot may have other heart defects, such as a hole between
the heart's upper chambers (atrial septal defect), a right aortic arch or abnormalities of the coronary
arteries.
Risk factors

While the exact cause of tetralogy of Fallot is unknown, various factors might increase the risk of a baby
being born with this condition. These risk factors include:

 A viral illness during pregnancy, such as rubella (German measles)

 Alcoholism during pregnancy

 Poor nutrition during pregnancy

 A mother older than age 40

 A parent who has tetralogy of Fallot

 The presence of Down syndrome or DiGeorge syndrome

Treatment for the acute setting of hypercyanosis

 Asymptomatic infants need no special medical treatment.

 Place the baby on the mother's shoulder with the infant's knees tucked up underneath. This
provides a calming effect, reduces systemic venous return, and increases SVR.
 Oxygen is of limited value, as the primary abnormality is reduced pulmonary blood flow.
 Morphine sulfate, 0.1-0.2 mg/kg intramuscularly (IM) or subcutaneously (SC), may reduce the
ventilatory drive and decrease systemic venous return.
 Phenylephrine, 0.02 mg/kg IV, is used to increase SVR.
 Most infants have adequate saturations and usually undergo elective repair.
 knee-chest position may prove helpful in addition to administering oxygen.
 In severe episodes, IV propranolol (Inderal) may be administered, which relaxes the infundibular
muscle spasm causing right ventricular (RV) outflow tract obstruction (RVOTO).
 Palliative surgery = Blalock-Taussig shunts, or BT shunts, are used for defects that affect the flow
of blood from the right ventricle, through the pulmonary artery, and to the lungs.
A shunt is a small tube made out of synthetic material called Gore-Tex. The BT shunt is about 3
to 3.5 cm in diameter. It attaches a section of the aorta to the pulmonary artery, creating a sort of
detour. This allows enough blood to pass through the lungs and pick up more oxygen. The shunt
relieves any cyanosis or blueness the child might have been experiencing.
Nursing Interventions for Tetralogy of Fallot

Nursing Diagnosis : Decreased Cardiac Output r / t ineffective circulation, secondary to the presence
of cardiac malformations

Goal: Children can maintain adequate cardiac output

 Vital signs are normal with age.
 There is no dyspnea, rapid breathing and deep, cyanosis, anxiety / lethargy, tachycardia,
murmurs.
 Peripheral pulse strong and equal on both extremities.
 Capillary refill time less than 3 seconds.

Intervention:

1. Monitor vital signs, peripheral pulses, capillary refill by comparing measurements at both
extremities while standing, sitting and lying down if possible.
2. Assess and record the apical pulse for 1 full minute.
3. Observation of cyanotic attacks.
4. Give a knee-chest position in children.
5. Observe for signs of decreased sensory: lethargy, confusion, and disorientation.
6. Monitor intake and output adequately.
 7. Provide adequate rest time for children and accompany children during activity.
8. Serve foods that are easily digestible and reduce the consumption of caffeine.
9. Collaboration in the examination serial ECGs, chest radiographs, administration of anti
dysrhythmias.
10. Collaboration of oxygen.
11. Collaboration IV fluid administration.

RESPIRATORY DISTRESS SYNDROME

 DEFINITION
Also known as Hyaline membrane disease (HMD), is a disease manifesting within 6 hours of
birth being related to deficiency of surfactant in the alveoli, leading to acute respiratory distress with
fatal termination if not treated promptly.

 INCIDENCE
RDS is at the top 3 of Infant mortality leading causes as of 2009 with a number of 2,438 per 1000
live births. (© DOH)

 RISK FACTORS
 Preterm infants
 Infants of diabetic mothers
 Infants born by cesarean birth
 Baby boy
 The baby has a sibling born with RDS

 DIAGNOSIS
 Antenatal Period
o Examination of Amniotic fluid - Lecithin sphingomyelin ratio; < 1.5
 Laboratory tests
o pCo2 elevated
o pO2 low
o Calcium low
o Serum glucose low
 Chest Xray
o “ground – glass appearance” or “ white wash lung”

 NURSING INTERVENTIONS
1. Clearing of airway, ensuring adequate breathing and circulation are the first line of management.
A baby in obvious respiratory distress needs to be on continuous pulse oximeter monitoring to
decide when intubation and ventilation is required.
 2. Warm, humidified oxygen is given. Oxygen should be given in the correct dose, as it is toxic to
preterm neonates.
3. Maintenance of correct temperature is essential. RDS is aggravated by hypothermia.
4. Surfactant is the drug of choice in a baby with RDS. This may be given either prophylactically if
the baby is less than 28 weeks of gestation or within the first two hours of onset of symptoms in
older babies. Prophylactic surfactant is given in the labour room after the baby has been
stabilized.
5. Fluid and electrolyte management: Electrolyte balance, fluids, calcium and glucose homeostasis
are all equally important.
6. All preterm babies with respiratory distress should be started on broad spectrum antibiotics. In
term babies, decision to start antibiotics would depend on the clinical situation.
7. Maintenance of respiration with ventilation support, if necessary.

 COMPLICATIONS
 Pulmonary Hemorrhage
 Pneumothorax
 Bronchopulmonary
 Neurological abnormalities

 PATHOPHYSIOLOGY
 SUDDEN INFANT DEATH SYNDROME

 DEFINITION
SIDS is the sudden death of an infant under one year of age which remains unexplained after a
thorough case investigation, including performance of a complete autopsy, examination of the death
scene, and review of the clinical history.
 INCIDENCE
The annual mortality rate per 100,000 people from sudden infant death syndrome in Philippines
has decreased by 15.8% since 1990, an average of 0.7% a year.
 RISK FACTORS
 Smoke
 Sleeping.
 Maternal age
 Anemia
 Genetics
 DIAGNOSIS
 Postmortem laboratory tests are done to rule out other causes of death (for example, electrolytes
are checked to rule out dehydration and electrolyte imbalance; bacterial and viral cultures are
obtained to evaluate whether an infection was present).
 An autopsy provides clues as to the cause of death. In 15%-25% of sudden, unexpected infant
deaths specific abnormalities of the brain or central nervous system, the heart or lungs, or
infection may be identified as the cause of death.
 A thorough investigation of the death scene consists of interviewing the parents, other caregivers,
and family members, collecting items from the death scene, and evaluating that information.

 NURSING INTERVENTIONS
 Health teaching
o Sleeping practices
• Back to sleep for every sleep, no side sleeping
• Use a crib/bassinet that conforms to the safety standards
• Firm sleeping surface
• No loose soft objects in bed
• Room sharing without bed sharing
• Avoid overheating
• Offer a pacifier during sleep
• No sleeping in sitting devices (car seats, swings)
• No devices promoted to make bed sharing protected (wedges, positioners)
o Feeding practices
• Promote breastfeeding
o Health care maintenance
• Regular prenatal care
• Avoid smoke exposure, alcohol, illicit drug use during pregnancy and after birth
• Immunizations in accordance with the AAP recommendation.
 INTUSSUSCEPTION

It is the invagination of one portion of the intestine into another, usually occurs in the second half of the
first year of life. The point of invagination is generally at the juncture of the distal ileum and proximal
colon.

In infants younger than 1 year, intussusception generally occurs for idiopathic reasons. In infants older
than 1 year, a “lead point” (polyp or tumor) on the intestine likely cues the invagination. It can be caused
by lymphoid hyperplasia, enlargement of lymph tissue. There are tons of tiny lymph nodes sprinkled to
the intestines called “Peyer’s patches” and they are particularly common in the ileum. When a child
caught off some sort of viral infection in the gastrointestinal tract usually caused by rota virus, the lymph
nodes enlarge to light off infection and sometimes becomes a lead point that drags the ileum into the
cecum which causes intussusception. Can also be caused by MECKEL’S DIVERTICULUM-
outpouching of GI tissue, or bowel tumors.

- “TELESCOPING” because of how it folds in to itself

- usually happens in the ileocecal region- where ileum of small intestine and cecum of large
intestine meets
- almost all intussusception happens when the ileum folds into the cecum
 INVAGINATION- The action or process of being turned inside out or folded back on itself to
form a cavity or pouch.
RISK FACTORS:

Having one previously

Having a sibling with intus
Having intestinal malrotation

ASSESSMENT

- Intermittent abdominal pain- children with this disorder suddenly draw up their legs and cry as if
they are in severe pain; they may vomit. After the peristaltic wave that caused the discomfort
passes, they are symptom-free and play happily. In approximately 15 minutes, the same
phenomenon of intense abdominal pain strikes again.
- Vomitus will begin to contain bile because the obstruction is invariably below the ampulla of
Vater, the point in the intestine where bile empties into the duodenum.
 - Approximately after 12 hours, blood occurs in the stool and possibly in vomitus, “Currant jelly”
appearance
- The abdomen becomes distended as the bowel above the intussusception distends.
- If necrosis (cell death) occurs, children generally have an elevated temperature, peritoneal
irritation (their abdomen feels tender; they may guard it by tightening their abdominal muscles)
- Increased WBC count, often rapid pulse.

Always ask a parent:

 Duration (lasts short time with intervals in between)

 Intensity (severe)
 Frequency, (15-20mins)
 Description (child pulls up legs when crying
 Any other way (vomiting, refuses food, states stomach feels full)

SIGNS and SYMPTOMS PATHO

Intussusception

There’s a pressure on walls of trapped bowel

Which squeeze shut blood vessels

Causing ISCHEMIA (lack of blood flow)

INFARCTION (Death of tissue) -INTESTINAL TEARING- RELEASE OF BACTERIA-

SEPSIS/FEVER

ISCHEMIA and INFARCTION causes SLOUGHING OFF (shedding off) OF INTESTINAL MUCOSA,
BLOOD AND MUCUS RED CURRANT JELLY
INTUSSUSCEPTION can also prevent food and fluid from passing through the body causing an
obstruction. This can lead to a large mass in the intestines which can potentially cause the intestines to be
twisted “VOLVULUS”

DIAGNOSIS:

- In children, it may be felt during rectal examination, but a definite diagnosis often requires
imaging techniques: Ultrasound, xray, CT scan which will reveal a “BULL’S EYE” or a
telescoped intestine on end which is a sign of intestinal obstruction
TREATMENT:

- Because of the potential for ISCHEMIA, RAPID TREATMENT is necessary.

- A barium or Air Enema can unfold an intussusception (A barium enema is a type of X-ray
imaging test that allows doctors to examine your lower intestinal tract. It involves delivering a
contrast solution that contains the metallic element barium into your rectum while a technician
takes X-ray images of the area. The barium solution will be delivered using an enema — a
process in which your doctor pushes a liquid into your rectum through your anus. The barium
solution helps to improve the quality of the X-ray images by highlighting certain areas of tissue.
The X-ray used in this procedure is known as fluoroscopy. It allows the radiologist to see your
internal organs in motion by tracking the flow of the barium solution through your intestinal
tract.)
- SURGERY: Telescoped intestine is freed; obstruction is cleared; dead tissue is removed.
- Reduction of Intussusception must be done promptly by either instillation of a water-soluble
solutiob, barium enema, or air (pneumatic insufflation) in the bowel or surgery to reduce
invagination before necrosis of the affected portion of the bowel occurs. If there is no lead point,
just the pressure of these non-surgical techniques may reduce intussusception. After this type of
reduction, children are observed for 24 hours because some children will have a recurrence of the
intussusception within this time.
NURSING DIAGNOSIS

- Pain related to abnormal Peristalsis

- Risk for deficient fluid volume related to bowel obstruction
 SMALL FOR GESTATIONAL AGE

An infant is SGA if the birth weight is below the 10th percentile on an intrauterine growth curve for that
age. SGA infants may be born preterm (before week 38 of gestation), term (between 38 weeks and 42), or
post term (after 42 weeks.) SGA infants are small for their age because they have experienced intrauterine
growth restriction (IUGR) or failed to grow at the expected rate in utero.

Normal birth weight- 7.5lbs (3.5kg); 5.5lbs (2.5kg) and 10lbs (4.5kg) are still normal.

ETIOLOGY

- A woman’s nutrition during pregnancy plays a major role in fetal growth, so lack of nutrition
may be a major contributor to IUGR.
- Pregnant adolescents have a high incidence of SGA infants. Because adolescents must meet their
own nutritional and growth needs, needs of a growing fetus can be compromised.
- Most common cause of IUGR is placental anomaly: either the placenta did not obtain sufficient
nutrients from the uterine arteries or it was inefficient at transporting nutrient to the fetus.
- Placental damage such as partial placental separation with bleeding, limits placental function
because the area of placenta that separated becomes infarcted and fibrosed, reducing the placental
surface available for nutrient exchange.
- Women with systemic disease that decrease blood flow to the placenta, such as diabetes mellitus
or pregnancy induced hypertension (both are diseases are which blood vessel lumens are
narrowed), are at higher risk for delivering SGA babies than others.
- Women who smoke heavily or use narcotics also tend to have SGA infants.

ASSESSMENT/ DIAGNOSTICS

- SGA infant can be detected in utero when fundal height during pregnancy becomes progressively
less than expected. However, if a woman is unsure of the date of her last menstrual period, this
discrepancy can be hard to substantiate. A sonogram can then demonstrate the decreased size.
- A biophysical profile including non-stress test, placental grading, amniotic fluid amount, and
ultrasound examination can provide additional information on placental function.
- If poor placental function is apparent from such determinations, it can be predicted the infant will
do poorly during labor because of periods of relative hypoxia during contractions may result. CS
is the birth method of choice in such circumstances.
APPEARANCE

- Generally, an infant who suffers nutritional deprivation early in pregnancy, when fetal growth
consists primarily of an increase in the number of body cells, is below average in weight, length
and head circumference. Regardless of when deprivation occurs, an infant tends to have an
overall wasted appearance.
- Small liver- which can cause difficulty regulating glucose, protein and bilirubin levels after birth,
- Poor skin turgor
- Generally, appear to have large head because the rest of the body is so small,
- Skull sutures may be widely separated from lack of normal bone growth
- Hair is dull and lusterless
- Abdomen may be sunken
- Umbilical cord appears dry and may be stained yellow

The SGA infant needs careful assessment for possible congenital anomalies occurring as a result of poor
nutritional intrauterine environment.

 Polycythemia (increased rbc) which happens because anoxia (absence of oxygen) stimulates the
development of RBC.
 Polycythemia causes increase blood viscosity, a condition that puts extra work of on the infant’s
heart because it is more difficult to effectively circulate thick blood. As a result, Acrocyanosis
(blueness of hands and feet) are prolonged.
 Because SGA infants have decreased glycogen stores, one of the most common problems is
hypoglycemia (Decreased blood glucose, less than 45 mg/dL). Such infants may need IV glucose
to sustain blood sugar until they are able to suck vigorously enough to take sufficient oral
feedings.

NURSING DIAGNOSIS

- Ineffective breathing pattern related to underdeveloped body systems at birth

- Risk for ineffective thermoregulation related to lack of subcutaneous fat
 LARGE FOR GESTATIONAL AGE (LGA
Large for gestational age/macrosomia is a term used to describe babies who are born weighing more than
the usual amount for the number of weeks of pregnancy. LGA babies have birthweights greater than the
90th percentile for their gestational age, meaning that they weigh more than 90 percent of all babies of the
same gestational age.

The average baby weighs about 7 pounds at birth. About 9 percent of all babies weigh more than 4,000
grams (8 pounds, 13 ounces). Rarely do babies weigh over 10 pounds.

Although most LGA babies are born at term (37 to 41 weeks of pregnancy), a few premature babies may
be LGA.

LGA infants are large, obese, and plethoric. The 5-min Apgar score may be low. These infants may be
listless(lacking energy) and limp(weak movement) and feed poorly

What causes LGA?

Some babies are large because their parents are large; genetics does play a part. Birthweight may also be
related to the amount of weight a mother gains during pregnancy. Excessive weight gain can translate to
increased fetal weight.
By far, maternal diabetes is the most common cause of LGA babies. Diabetes during pregnancy causes
the mother's increased blood glucose (sugar) to circulate to the baby. In response, the baby's body makes
insulin. All the extra sugar and the extra insulin production can lead to excessive growth and deposits of
fat, thus, a larger baby.

Why is LGA a concern?

Because LGA babies are so large, delivery can be difficult. Delivery problems may include the following:

 Prolonged vaginal delivery time

 Difficult birth
 Birth injury
 Increased risk of cesarean delivery
Because many large babies are born to diabetic mothers, many problems of LGA babies are related to
problems with glucose regulation. These may include the following:

 Hypoglycemia (low blood sugar) of baby after delivery

 Increased incidence of birth defects
 Respiratory distress (difficulty breathing)
Many babies with LGA also have hyperbilirubinemia (jaundice or yellowing of the skin, eyes, and
mucous membranes).

How is LGA diagnosed?

During pregnancy, a baby's birth weight can be estimated in different ways. The height of the fundus (the
top of a mother's uterus) can be measured from the pubic bone. This measurement, in centimeters, usually
corresponds with the number of weeks of pregnancy. If the measurement is high for the number of weeks,
the baby may be larger than expected. Other diagnostic procedures may include the following:
 Ultrasound (a test using sound waves to create a picture of internal structures) is a more accurate method
of estimating fetal size. Measurements can be taken of the fetus' head, abdomen, and femur to estimate
fetal weight.

 A mother's weight gain can also influence a baby's size. Excessive maternal weight gain in pregnancy
may correspond with a big baby.

Babies are weighed within the first few hours after birth. The weight is compared with the baby's
gestational age and recorded in the medical record.

Treatment for LGA

Specific treatment for large for gestational age will be determined by your baby's doctor based on:

 Your baby's gestational age, overall health, and medical history

 Extent of the condition
 Your baby's tolerance for specific medications, procedures, or therapies
 Expectations for the course of the condition
 Your opinion or preference
If ultrasound examinations during pregnancy show a fetus is quite large, some doctors may recommend
early delivery. A planned cesarean delivery may also be recommended depending on the ultrasound
estimate of the baby's weight.

After delivery, a LGA baby will be carefully examined for any birth injuries. Blood glucose testing is also
performed to check for hypoglycemia.

Prevention of LGA
Prenatal care is important in all pregnancies, especially to monitor fetal growth when a baby seems to be
too small or too large. Examinations during pregnancy that show a large baby can help identify a mother
who may have undetected diabetes, or other problems. Careful management of diabetes and proper weight
gain, according to your doctor's recommendations, can help lower some of the risks to the baby.

Nursing Management

a. Clavicle fracture

 Confirm by x-ray.
 Assess the infant for crepitus, hematoma, or deformity over the clavicle; decreased movement of
arm on the affected side; and asymmetrical or absent. Moro reflex.
 Limit arm motion by pinning the infant’s sleeve to the shirt.
 Manage the pain

b. Facial nerve injury

 Assess for symmetry of mouth while crying.

 Wrinkles are deeper on the unaffected side.
 The paralyzed side is smooth with a swollen appearance.
 The nasiolabial fold is absent.
  If the eye is affected, protect it with patches and artificial tears.

c. Erb-Duchenne palsy and Klumpke paralysis (Weakness or lack of ability to use specific muscles of the
shoulder or arm)

 Erb-Duchenne palsy. Assess for adduction of the affected arm with internal rotation and elbow
extension. The Moro reflex is absent on the affected side. The grasp reflex is intact.
 Klumpke paralysis. Assess for absent grasp on the affected side. The hand appears claw-shaped.
 Management includes:
 X-ray studies of the shoulder and upper arm to rule out bony injury
 Examination of the chest to rule out phrenic nerve injury
 Delay of passive movement to maintain range of motion of the affected joints until the nerve
edema resolves (7 to 10 days)
 Splints may be useful to prevent wrist and digit contractures on the affected side
d. Phrenic nerve palsy

 Assess for respiratory distress with diminished breath sounds.

 X-ray usually shows elevation of the diaphragm on the affected side.
 Provide pulmonary toilet to avoid pneumonia during the recovery phase (1 to 3 months).
e. Skull fracture.