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Paediatric Nursing & Palliative Care UHPAB CN21 2025 JUNE Revision Guide
SECTION A: Objective Questions (20 marks)
👶 Paediatric Focus: Remember growth milestones, immunization schedules, and the unique physiological differences in children compared to adults!
1
Which of the following activities is NOT performed by nurses in the young child clinic?
(c) Examination of the mothers
Young child clinics (under-5 clinics) focus exclusively on child health. While maternal health is crucial, the clinic's specific mandate is child-centered care. Maternal examinations are performed in antenatal/postnatal clinics, not pediatric clinics. Nurses in child clinics perform immunizations, growth monitoring using child health cards, and screen for common childhood illnesses (malnutrition, anemia, infections).
CHILD CLINIC ACTIVITIES: "IM-GROW-SICK" - Immunisation, Monitoring growth, Growth assessment, Referral, Observation, Weighing, Screening Ill children, Checking health
2
The recommended time for initiating breastfeeding after birth is within ........ hour(s).
(a) 1 hour
WHO and UNICEF recommend initiating breastfeeding within the first hour of life (the "golden hour"). Immediate skin-to-skin contact and early breastfeeding provide colostrum rich in antibodies, promote bonding, stimulate oxytocin release for placental separation, and reduce neonatal mortality by 22%. Delays beyond 1 hour increase risk of hypoglycemia, hypothermia, and breastfeeding failure.
🕐 Golden Hour Critical! Colostrum is liquid gold - high in IgA antibodies, vitamin A, and growth factors. Immediate initiation also reduces postpartum hemorrhage risk.
3
The dosage for Vitamin A that nurses administer to children below 6 months of age is ..........iu.
(a) 50,000 IU
WHO protocol for vitamin A supplementation: Infants 0-5 months receive 50,000 IU orally once at any contact with health system. This prevents vitamin A deficiency which causes xerophthalmia, increased infection risk, and increased mortality. The dose is age-specific: 6-11 months = 100,000 IU every 6 months; 12-59 months = 200,000 IU every 6 months. Overdosing can cause toxicity (bulging fontanelle, vomiting).
VITAMIN A DOSES: "0-5-12" = 0-5 months = 50,000, 6-11 months = 100,000, 12+ months = 200,000
4
The first step in treatment of severe acute malnutrition includes
(d) Resuscitating with intravenous fluids
Severe acute malnutrition (SAM) with complications is a medical emergency. The first 24-48 hours (stabilization phase) focuses on treating life-threatening complications: hypoglycemia, hypothermia, sepsis, dehydration before any feeding. IV fluids (Ringers Lactate with dextrose) are given ONLY for shock; otherwise use oral/NG rehydration with ReSoMal (reduced sodium, increased potassium). Iron is delayed until day 3-7 (causes free radical damage to already stressed liver).
🚨 10 DEADLY SINS of SAM Management: DON'T give iron, DON'T give high protein, DON'T give normal IV fluids for dehydration, DON'T give high sodium, DON'T overfeed in first week!
5
The nurse performing physical examination for a new born records a head circumference as normal if the circumference in centimeters is
(a) 34 – 35 cm
Normal term newborn head circumference is 33-35 cm, approximately 2 cm larger than chest circumference. Microcephaly (<32 cm) suggests intrauterine growth restriction, congenital infections, or chromosomal abnormalities. Macrocephaly (>37 cm) may indicate hydrocephalus, intracranial hemorrhage, or genetic syndromes. Measurement is taken at the occipitofrontal circumference (widest circumference) using non-stretchable tape.
NEWBORN MEASUREMENTS: "3-3-3 Rule" - Head = 33-35 cm, Chest = 31-33 cm, Length = 50-52 cm, Weight = 2.5-4 kg
6
For which of the following reasons do nurses restrict bathing of the newborn?
(c) Maintaining warmth
Newborns have poor thermoregulation - large surface area to body weight ratio, thin subcutaneous fat, immature shivering mechanism, and brown fat limited to neck/shoulders. Bathing causes evaporative and convective heat loss, leading to hypothermia (<36.5°C) which triggers cold stress, increases oxygen consumption, causes hypoglycemia, and increases mortality. First bath is delayed 24 hours; when given, use warm water (37-38°C) and warm environment, dry immediately, and cover head.
🌡️ BATHE THE BABY LATER! WHO recommends delayed bathing (24 hours) to prevent hypothermia and allow skin-to-skin contact. Vernix is protective and moisturizing.
7
The immunity of an infant acquired from the mother during intra-uterine life is referred to as
(b) Passive natural
Passive natural immunity is transfer of maternal antibodies across placenta (IgG) and in breast milk (IgA). The infant receives ready-made antibodies without active immune response. Protects against measles, mumps, rubella, tetanus for first 3-6 months. No memory cells formed, so protection is temporary. Contrast with active immunity where body produces its own antibodies after infection/vaccination.
IMMUNITY TYPES: "P-A-N" - Passive Natural (maternal), Active Natural (infection), Passive Artificial (injection), Active Artificial (vaccination)
8
Erickson defines development tasks of the infant as learning to
(a) Trust or mistrust
Erikson's first psychosocial stage (0-18 months) is "Trust vs Mistrust". Infants learn whether the world is safe and reliable based on consistent, responsive caregiving. Successful resolution develops basic trust and security. Failure leads to mistrust, anxiety, and insecurity affecting future relationships. This is foundational for all later development. Trust is built through meeting needs promptly (feeding, comforting, diaper changes) with warm, consistent care.
ERIKSON'S STAGES: "T-A-I-G-I-L" - Trust, Autonomy, Initiative, Industry, Identity, Intimacy, Generativity, Integrity
9
The nurse advices that baby's wet napkins and clothes should be frequently changed and replaced by clean ones to prevent heat loss by
(d) Evaporation
Wet clothes cause evaporative heat loss - water on skin/clothing evaporates, drawing heat from the baby's body. This is the most significant heat loss mechanism in newborns, causing up to 25% of heat loss. Wet diapers, clothes, or bathing without immediate drying rapidly cool the infant. Newborns have large surface area, minimal subcutaneous fat, making them extremely vulnerable. Change wet clothes immediately and keep baby dry.
HEAT LOSS 4 WAYS: "C-C-E-R" - Conduction (Contact), Convection (Air currents), Evaporation (Wet), Radiation (Infrared)
10
Which of the following fat-soluble vitamins are found in the breast milk?
(d) A, D, E & K
Breast milk contains all fat-soluble vitamins (A, D, E, K) but in varying amounts. Vitamin A is abundant (especially in colostrum). Vitamin D is low (requires supplementation 400 IU/day from birth). Vitamin E is adequate. Vitamin K is low, requiring intramuscular prophylaxis at birth (1 mg) to prevent hemorrhagic disease of newborn. Water-soluble vitamins (B-complex, C) are also present but not listed in options. The question specifically asks about FAT-soluble vitamins.
FAT-SOLUBLE VITAMINS: "A-D-E-K" - All Dogs Eat Kittens (or Any Dietary Excess Kills - toxic in overdose)
11
The aim of palliative care is to
(d) Provide comfort, support and relief of suffering
Palliative care is holistic care for patients with life-limiting illnesses (cancer, organ failure, neurodegenerative diseases) at ANY stage, not just end-of-life. It focuses on quality of life through pain and symptom management, psychosocial support, spiritual care, and family support. Can be provided alongside curative treatment. WHO definition: "improves quality of life of patients and families facing life-threatening illness." Not limited to cancer or dying patients only.
PALLIATIVE CARE PRINCIPLES: "H-O-P-E" - Holistic care, Optimal symptom relief, Patient-centered, Early integration, Family involvement
12
Where can palliative care be provided?
(a) In any setting
Palliative care is a philosophy of care, not tied to a location. It can be provided anywhere the patient is: hospital wards, dedicated palliative care units, hospice facilities, patient's home, nursing homes, clinics, and even via telehealth. The key is that it's integrated into existing health services and adapted to available resources. Community-based palliative care is especially important in low-resource settings.
🏡 Setting Agnostic: Palliative care follows the patient, not the location. In Uganda, home-based care is crucial due to limited hospital beds and cultural preference for dying at home.
13
The team that provides holistic palliative care is
(d) Dynamic and changes with the needs of the client and family
Palliative care employs an interdisciplinary team approach that adapts to patient/family needs. Core team includes doctors, nurses, social workers, chaplains, and counselors. Extended team may include pharmacists, physiotherapists, occupational therapists, nutritionists, and trained volunteers. Nurses often lead community-based palliative care in resource-limited settings. Team composition flexes based on symptoms (add psychologist for anxiety), family needs (social worker for financial issues), or disease progression.
PALLIATIVE TEAM: "N-DOC-SC" - Nurses, Doctors, Occupational therapy, Counseling, Social work, Chaplaincy
14
Which of the following is a common barrier to a good assessment?
(b) Lack of time and privacy
Effective assessment requires confidential, uninterrupted time with patient/family to explore physical, psychosocial, and spiritual concerns. Palliative care assessments are sensitive, discussing prognosis, fears, and end-of-life wishes. Rushed assessments in busy wards or public spaces compromise quality of information gathered. Privacy enables honest disclosure about pain, anxiety, and family conflicts that wouldn't be shared in front of others or when staff are hurried.
⏰ Assessment is the Foundation: Spend quality time initially to save time later. A rushed 5-minute assessment leads to unmanaged symptoms requiring repeated interventions. Invest 30-60 minutes upfront!
15
Which of the following terms is related to a belief in the afterlife?
(b) Spirituality
Spirituality encompasses personal beliefs about meaning, purpose, and existence, including concepts of afterlife, transformation, and transcendence. It's broader than religion and can exist outside organized faith. In palliative care, addressing spiritual distress about death, afterlife, and legacy is crucial. Patients often ask "What happens after I die?" or express fears about judgment, reunification with loved ones, or unknown. Spirituality helps make sense of suffering and death.
SPIRITUAL ASSESSMENT: "FICA" - Faith/beliefs, Importance, Community, Address/Apply in care
16
Which of the following statements appropriately defines pain?
(a) What the patient says hurts
Pain is ALWAYS subjective. The gold standard definition by Margo McCaffery: "Pain is whatever the experiencing person says it is, existing whenever he says it does". This principle acknowledges that pain is a personal, multidimensional experience with sensory, emotional, cognitive, and spiritual components. In children and non-verbal patients, we use behavioral pain scales (FLACC, Wong-Baker FACES) as proxy, but the principle remains - we believe the patient's report. Denying pain because objective signs are absent is unethical and leads to undertreatment.
🗣️ Believe the Patient! Pain rating of 10/10 is VALID even if patient appears comfortable. Never say "You can't be in that much pain." Assess, believe, and treat accordingly.
17
Which of the following statements relates to nociceptive pain?
(a) Stimulation of the pain receptors when tissues are damaged
Nociceptive pain is normal physiological pain from tissue injury. Nociceptors (pain receptors) are activated by mechanical, thermal, or chemical stimuli from tissue damage. It serves a protective function. Types: somatic (skin, bone, muscle - well-localized) and visceral (internal organs - diffuse, referred). Responds well to opioids and NSAIDs. Contrast with neuropathic pain (nerve damage) and psychogenic pain (psychological origin).
PAIN TYPES: "N-N-P" - Nociceptive (tissue), Neuropathic (nerve), Psychogenic (mind)
18
Which of the following drugs do nurses administer to palliative care patients with severe pain?
(a) Morphine
Morphine is the WHO Step 3 opioid for severe cancer and end-of-life pain. It's the gold standard due to proven efficacy, multiple routes (oral, IV, SC, rectal), and low cost. No ceiling dose - titrated to effect. Used when Step 1 (paracetamol, NSAIDs) and Step 2 (codeine, tramadol) fail. Side effects: constipation (universal, must prevent with laxatives), respiratory depression (rare when titrated properly), nausea, sedation.
WHO ANALGESIC LADDER: "1-2-3 PM" - Step 1 (Paracetamol/NSAID), Step 2 (Paracetamol + Codeine), Step 3 (Morphine +/- adjuvants)
19
Shortness of breath can be made worse by
(a) Anxiety
Anxiety creates a vicious cycle with dyspnea. Fear of suffocation triggers sympathetic response (tachycardia, rapid shallow breathing, muscle tension) which increases work of breathing and sensation of breathlessness. This is particularly prominent in COPD, cancer, and heart failure patients who develop "air hunger panic". Anxiety also reduces ability to use breathing techniques and increases metabolic demand. Treating anxiety with benzodiazepines, relaxation techniques, and reassurance significantly improves breathlessness.
😰 Anxiety-Dyspnea Cycle: Shortness of breath → Anxiety → Faster breathing → More shortness of breath → More anxiety. Break the cycle with reassurance, breathing exercises, and low-dose benzodiazepines!
20
Which of the following nursing interventions prevents sores among bed ridden patients?
(b) Turning the immobile client regularly
Pressure injury prevention #1 intervention is regular repositioning to relieve pressure and allow tissue perfusion. Turn every 2 hours minimum (more frequently if high risk). Reduces duration and intensity of pressure on bony prominences (sacrum, heels, trochanters). Combined with pressure-relieving mattress, this is the most effective prevention. Palliative patients may have reduced turning frequency if it causes distress, but must balance with skin integrity.
PRESSURE INJURY PREVENTION: "TURN-SKIN" - Turn every 2 hours, Undernutrition manage, Reduce moisture, Nutrition, Surface (pressure-relieving), Keep moving, Inspect daily, No massage
Fill in the Blank Spaces (10 marks)
21
The first stool produced by new born babies is called
Meconium
Meconium is thick, sticky, greenish-black stool composed of amniotic fluid, mucus, bile, and shed intestinal cells. Passage within 24-48 hours indicates patent GI tract. Delayed passage (>48 hours) suggests intestinal obstruction (meconium ileus, Hirschsprung disease) or hypothyroidism. Abnormal in consistency (thin/watery) may indicate infection. Inhalation of meconium-stained amniotic fluid causes meconium aspiration syndrome.
22
A method of care performed for new born babies to ensure skin to skin contact with their parent is known as
Kangaroo Mother Care (KMC)
KMC involves continuous skin-to-skin contact between mother (or father) and newborn, exclusive breastfeeding, and early discharge. Prevents hypothermia, improves weight gain, reduces infections, and promotes bonding. Especially life-saving for preterm/low birth weight babies. Position: baby upright between mother's breasts, head to side, secured with cloth. Maintain 24/7 except for bathing. Also provides pain relief during procedures.
KMC BENEFITS: "WARMTH" - Weight gain, Attachment, Regulate temperature, Milk production, Thermoregulation, Health, Bonding
23
Tetracycline eye ointment is applied to all newborn babies' eyes to prevent a condition called
Ophthalmia neonatorum (neonatal conjunctivitis)
Caused by Neisseria gonorrhoeae or Chlamydia trachomatis acquired during birth. Presents with purulent eye discharge, eyelid swelling 2-5 days after birth. Can cause corneal ulceration, perforation, and blindness if untreated. WHO/UNICEF recommend prophylactic tetracycline 1% or erythromycin 0.5% ointment within 1 hour of birth. Also screen and treat maternal STIs. Silver nitrate is no longer used due to chemical conjunctivitis.
24
A mother who breastfeeds her new born baby more than 10 times a day is said to be practicing
breastfeeding on demand
Demand feeding means feeding baby whenever they show hunger cues (rooting, hand-to-mouth, fussing) rather than on a rigid schedule. Newborns feed 8-12 times/24 hours (every 2-3 hours). This establishes milk supply, prevents engorgement, ensures adequate weight gain, and respects infant's natural feeding pattern. Contraindicated only in specific medical conditions (galactosemia). Emphasized in Baby-Friendly Hospital Initiative.
25
The anti-infective factor found in breast milk which prevents multiplication of pathogens in the gut is called
Lactoferrin (or Lysozyme, Secretory IgA, Oligosaccharides - multiple correct factors)
Lactoferrin binds iron, making it unavailable to pathogenic bacteria (E. coli, Salmonella) inhibiting their growth. Lysozyme destroys bacterial cell walls. Secretory IgA coats intestinal mucosa preventing bacterial attachment. Oligosaccharides act as prebiotics promoting beneficial bacteria and blocking pathogen adhesion. These factors make breast milk sterile and protect against diarrhea, the leading cause of infant mortality. Formula lacks these bioactive factors.
BREAST MILK IMMUNITY: "L-L-S-O" - Lactoferrin, Lysozyme, Secretory IgA, Oligosaccharides
26
An organization that provides palliative care in a variety of settings is called
Hospice
Hospice is a philosophy and organization providing palliative care in hospitals, free-standing facilities, and home-based programs. Examples: Hospice Africa Uganda, Mildmay Uganda. Provides holistic care for life-limiting illnesses, focusing on comfort rather than cure. Services include pain management, symptom control, psychosocial support, spiritual care, and bereavement support for families. Often relies on trained volunteers for home visits in resource-limited settings.
27
The principle of respecting the uniqueness of an individual and giving them the right and freedom to make their own decision is referred to as
Autonomy
One of four fundamental principles of biomedical ethics (Beneficence, Non-maleficence, Autonomy, Justice). In palliative care, autonomy means providing information, respecting choices about treatment (including refusing treatment), and honoring advance directives. Especially important for end-of-life decisions (DNR, artificial nutrition, place of death). Must assess decision-making capacity; if impaired, use substituted judgment from family or court-appointed guardian.
28
Burning, stabbing or stinging are characteristics of ....................................................pain
Neuropathic
Most accurate answer: Neuropathic pain. Characterized by burning, shooting, electric-shock-like, stabbing sensations due to nerve damage. Examples: diabetic neuropathy, post-herpetic neuralgia, cancer-related nerve compression. Difficult to treat; responds poorly to opioids alone, requires adjuvants (gabapentin, amitriptyline). Somatic pain can also be sharp/stabbing (e.g., fracture) but burning is more specific to neuropathic.
🔥 Neuropathic Pain Clues: Burning, shooting, electric, allodynia (pain from light touch), hyperalgesia (exaggerated pain). Add gabapentin or amitriptyline if morphine alone doesn't work!
29
Severe muscle wasting is called
Cachexia
Cachexia is complex metabolic syndrome of involuntary weight loss, muscle wasting, fatigue, and anorexia seen in advanced cancer, AIDS, heart failure, COPD. Not just starvation - involves inflammatory cytokines (TNF-α, IL-6), insulin resistance, and increased protein breakdown. Resistant to nutritional support alone. Requires combination of nutrition, exercise, anti-inflammatories, and appetite stimulants. Poor prognostic indicator in palliative care.
CACHEXIA FEATURES: "C-A-C-H-E" - Cancer/HIV/Heart failure, Anorexia, Cytokines, Hypermetabolism, Energy deficit, Xtra weight loss
30
The period of sadness felt after the loss of a loved one is called
Grief
Grief is the emotional response to loss (sadness, anger, denial, bargaining, acceptance - Kübler-Ross stages). Bereavement is the state of having lost someone. Mourning is the cultural expression of grief. In palliative care, nurses support anticipatory grief (before death) and bereavement support for 12+ months after death. Normal grief lasts 6-12 months; prolonged grief disorder (>12 months) requires specialist intervention. Cultural practices greatly influence mourning.
SECTION B: Short Essay Questions (20 marks)
31
(a) State five (5) factors that hinder successful lactation. (5 marks)
(b) State five (5) milestones achieved by a normal baby by 12 months of age. (5 marks)
(b) State five (5) milestones achieved by a normal baby by 12 months of age. (5 marks)
(a) Factors Hindering Successful Lactation:
1. Poor attachment and positioning: Baby not properly latched leads to ineffective milk transfer, nipple pain/trauma, and reduced milk production from inadequate stimulation. Mother gives up due to pain.
2. Maternal stress and anxiety: Elevated cortisol inhibits oxytocin release, reducing milk ejection reflex. Stress from postpartum depression, family conflict, or lack of support negatively impacts supply.
3. Inadequate nutrition and fluid intake: Poor maternal diet (<1800 kcal/day) and dehydration reduce milk quantity and quality. Requires extra 500 kcal/day and 3L fluid daily.
4. Infant factors: Prematurity (weak suck), cleft lip/palate (can't create seal), tongue-tie (restricted movement), illness (lethargy), leading to insufficient emptying of breast and reduced supply.
5. Cultural practices and misinformation: Pre-lacteal feeds (water, glucose), scheduled feeding (vs demand), belief that breast milk is insufficient, early introduction of formula reduces stimulation and signals body to produce less milk.
(b) Milestones by 12 Months:
1. Gross motor: Walks independently or with minimal support, cruises holding furniture, can stand momentarily without support. Climbs stairs with help.
2. Fine motor: Pincer grasp (thumb and index finger) to pick up small objects, bangs two blocks together, releases objects voluntarily, feeds self with fingers.
3. Language: Says "mama" and "dada" specifically, uses 2-3 words meaningfully, understands simple commands ("give me"), babbles with inflection, waves bye-bye.
4. Social/emotional: Shows stranger anxiety, plays simple games (peek-a-boo), imitates adult actions, shows preference for certain people and toys.
5. Cognitive: Object permanence fully developed (looks for hidden toys), explores objects in multiple ways (shaking, banging, throwing), follows one-step commands.
32
(a) List five (5) non-pharmacological methods of relieving pain in palliative care. (5 marks)
(b) Outline five (5) manifestations of impending death in a patient on palliative care. (5 marks)
(b) Outline five (5) manifestations of impending death in a patient on palliative care. (5 marks)
(a) Non-Pharmacological Pain Relief:
1. Massage and therapeutic touch: Increases circulation, reduces muscle tension, promotes relaxation, releases endorphins. Avoid areas with tumors, thrombosis, or skin breakdown.
2. Distraction and guided imagery: Redirects attention from pain to pleasant thoughts or activities (music, nature sounds, visualization). Effective for mild-moderate pain and as adjunct.
3. Application of heat or cold: Heat relaxes muscles and improves blood flow for muscle spasms; cold reduces inflammation and numbs area for acute pain. Always protect skin.
4. Positioning and support: Proper positioning using pillows reduces pressure on painful areas, improves breathing, prevents contractures. Frequent repositioning prevents pressure sores.
5. Relaxation and breathing techniques: Slow, deep breathing reduces anxiety and muscle tension that exacerbate pain. Progressive muscle relaxation helps patient gain sense of control.
(b) Impending Death Manifestations:
1. Circulatory changes: Peripheral cyanosis (cold, mottled extremities), weak thready pulse, hypotension, prolonged capillary refill. Skin becomes pale and waxy as blood shunts to core organs.
2. Respiratory changes: Cheyne-Stokes respiration (periods of apnea alternating with rapid breathing), noisy "death rattle" from secretions, shallow irregular breathing, increased work of breathing then sudden slowing.
3. Neurological changes: Decreased level of consciousness, agitation/restlessness (terminal agitation), unresponsiveness to stimuli, glassy-eyed stare, impaired swallowing reflex.
4. Decreased intake/output: Refusal of food and fluids, inability to swallow, anuria or oliguria, dry mouth, sunken eyes. Bowel movements cease as GI motility stops.
5. Temperature dysregulation: Fever (terminal fever from cytokine release) or hypothermia as hypothalamus fails. Patient may feel hot to touch while feeling cold internally.
⚰️ Death is a Process, Not an Event: These signs develop over hours to days. Provide comfort: reposition, moisten mouth, reduce external stimuli, reassure family this is normal dying process. No need for aggressive interventions like IV fluids or antibiotics at this stage.
SECTION C: Long Essay Questions (50 marks)
33
(a) Explain five (5) reflexes a nurse observes for while examining a new born. (10 marks)
(b) Describe five (5) specific nursing actions performed in the daily care of a new born baby. (10 marks)
(c) State five (5) anti-infective factors found in breast milk. (5 marks)
(b) Describe five (5) specific nursing actions performed in the daily care of a new born baby. (10 marks)
(c) State five (5) anti-infective factors found in breast milk. (5 marks)
(a) Newborn Reflexes:
1. Moro reflex (startle reflex): When head suddenly dropped back, baby abducts and extends arms with fingers fanned, then brings arms back together with cry. Present at birth, disappears by 4-6 months. Absence indicates severe CNS depression; asymmetry suggests brachial plexus injury or fracture.
2. Rooting reflex: When cheek or corner of mouth is stroked, baby turns head toward stimulus and opens mouth. Present birth-4 months. Essential for successful breastfeeding. Weak or absent in preterm infants, those with neurological impairment, or severely ill babies.
3. Sucking reflex: When nipple/teat placed in mouth, baby begins rhythmic sucking motions. Present at birth (32 weeks gestation). Coordinates with swallowing and breathing. Absence indicates prematurity, CNS depression, or severe illness. Assessed during feeding.
4. Palmar grasp reflex: When object placed in palm, baby automatically grasps it tightly. Present birth-5-6 months. Absence indicates neurological problems. Plantar grasp (toes curl when sole stroked) also tested.
5. Babinski reflex: When sole of foot stroked from heel upward along lateral aspect, toes hyperextend and fan outward (positive Babinski) in newborns. Present until 12-24 months. Persistence beyond 2 years or asymmetry indicates upper motor neuron lesion (cerebral palsy, lesion).
6. Tonic neck reflex (fencing position): When head turned to one side, arm and leg on that side extend while opposite side flexes (fencer's posture). Present 1-4 months. Persistence beyond 6 months suggests cerebral palsy or other neurological dysfunction.
(b) Daily Nursing Care of Newborn:
1. Thermoregulation maintenance: Ensure warm environment (25-28°C), dress baby appropriately (one extra layer than adult), keep head covered (50% heat loss), practice skin-to-skin contact, and monitor temperature every 4-6 hours to prevent hypothermia or hyperthermia.
2. Feeding support and monitoring: Assist with breastfeeding every 2-3 hours, ensure proper latch, monitor intake (8-12 feeds/day), watch for hunger/satiety cues, and record output (6+ wet diapers/day). Weigh daily to assess adequacy.
3. Umbilical cord care: Keep cord stump clean and dry, observe for signs of infection (redness, discharge, foul odor), apply antiseptic if indicated (chlorhexidine in high-risk settings), and educate parents not to cover with diaper. Cord separates in 7-10 days.
4. Hygiene and skin care: Daily gentle cleaning with warm water, especially of face, neck folds, diaper area. Change diapers frequently to prevent rash. Avoid daily bathing in first week. Apply barrier cream to prevent diaper dermatitis. Observe for jaundice, rashes, infections.
5. Infection prevention and surveillance: Hand hygiene before handling, ensure exclusive breastfeeding, avoid unnecessary crowds/sick visitors, observe for danger signs (poor feeding, lethargy, fever, breathing difficulty), and administer prophylactic medications (vitamin K, eye ointment).
(c) Anti-Infective Factors in Breast Milk:
1. Secretory Immunoglobulin A (sIgA): Lines the intestinal mucosa preventing attachment and invasion of pathogens like E. coli, rotavirus, and poliovirus. Specific to mother's environment, providing targeted protection.
2. Lactoferrin: Iron-binding protein that deprives bacteria of iron needed for growth, inhibiting proliferation of E. coli, Salmonella, and Candida. Also has anti-inflammatory properties.
3. Lysozyme: Enzyme that lyses bacterial cell walls, particularly effective against gram-positive bacteria like Staphylococcus aureus. Concentration increases as infant ages, compensating for waning maternal antibodies.
4. Oligosaccharides (prebiotics): Complex sugars that promote growth of beneficial bacteria (bifidobacteria) and act as decoy receptors blocking pathogen attachment to intestinal cells. Over 200 types specifically nourish infant gut microbiome.
5. White blood cells (macrophages, neutrophils, lymphocytes): Living immune cells that phagocytose pathogens and produce antibodies locally in infant's gut. Provide active cellular immunity particularly important for preterm infants.
🛡️ Breast Milk = Liquid Vaccine! Colostrum has 2x higher concentration of these factors. Exclusive breastfeeding for 6 months prevents 13% of under-5 deaths globally!
34
(a) Outline five (5) causes of anorexia in patients on palliative care. (5 marks)
(b) State ten (10) clinical manifestations of anorexia. (10 marks)
(c) Describe five (5) non-pharmacological measures nurses implement to manage anorexia in patients on palliative care. (10 marks)
(b) State ten (10) clinical manifestations of anorexia. (10 marks)
(c) Describe five (5) non-pharmacological measures nurses implement to manage anorexia in patients on palliative care. (10 marks)
(a) Causes of Anorexia in Palliative Care:
1. Cancer-related cachexia: Cytokines (TNF-α, IL-6) cause direct hypothalamic suppression of appetite center, alter taste perception, and induce early satiety. Metabolic changes increase protein breakdown.
2. Side effects of treatment/medications: Chemotherapy causes nausea, mucositis, altered taste (metallic). Opioids cause nausea and delayed gastric emptying. Antibiotics alter gut flora affecting digestion.
3. Psychological factors: Depression and anxiety suppress appetite. Fear of vomiting, anticipatory nausea, and learned food aversion from previous negative experiences. Existential distress reduces interest in physical needs.
4. Physical symptoms: Pain reduces desire to eat. Constipation causes fullness and nausea. Dyspnea makes eating exhausting. Ascites compresses stomach causing early satiety. Oral thrush makes eating painful.
5. Organ dysfunction: Liver failure causes anorexia and altered taste. Renal failure leads to uremic nausea and taste changes. Heart failure causes GI congestion and early satiety.
(b) Clinical Manifestations of Anorexia:
1. Weight loss and muscle wasting: Visible loss of subcutaneous fat, prominent bones (clavicles, ribs), loose skin, decreased muscle mass leading to weakness and sarcopenia.
2. Reduced food intake: Eats <50% of normal portions, refuses favorite foods, leaves meals untouched, reports early satiety after few bites.
3. Gastrointestinal symptoms: Nausea (with or without vomiting), bloating, constipation, dyspepsia, altered taste perception (dysgeusia), dry mouth.
4. Behavioral changes: Avoids meal times, expresses food aversion, becomes anxious when food presented, socially isolates during meals, reports food smells make them nauseous.
5. Weakness and fatigue: Inability to complete ADLs, increased somnolence, reduced mobility, decreased concentration, and overall functional decline.
6. Dehydration signs: Dry mucous membranes, sunken eyes, decreased urine output, orthostatic hypotension, poor skin turgor due to inadequate fluid intake.
7. Emotional distress: Sadness about weight loss, body image changes, irritability, depression, and anxiety about prognosis worsened by cachexia.
8. Laboratory changes: Anemia, hypoalbuminemia, electrolyte imbalances (hypokalemia, hyponatremia), and elevated inflammatory markers (CRP).
9. Immune compromise: Increased susceptibility to infections, delayed wound healing, and pressure ulcer development due to malnutrition and protein deficiency.
10. Cognitive changes: Confusion, delirium, inability to concentrate due to malnutrition, dehydration, and metabolic derangements from inadequate intake.
(c) Non-Pharmacological Management of Anorexia:
1. Small, frequent, nutrient-dense meals: Offer 6-8 small meals/snacks instead of 3 large ones. High-calorie foods (avocado, peanut butter, full-fat dairy). Rationale: Reduces overwhelm, manages early satiety, maximizes caloric intake without large volume.
2. Oral care before meals: Brush teeth, rinse mouth, treat oral thrush, use saliva substitutes. Rationale: Improves taste, reduces nausea from oral odor, makes eating more pleasant, reduces infection-related discomfort.
3. Environmental modifications: Eat with others if tolerated, create pleasant atmosphere, avoid cooking odors that trigger nausea, allow food choice. Rationale: Reduces anxiety, social eating stimulates appetite, empowers patient with control.
4. Gentle exercise before meals: Short walk or range-of-motion exercises 30 minutes before eating. Rationale: Stimulates metabolism and gastric motility, improves mood, may enhance appetite.
5. Complementary therapies: Acupuncture, relaxation techniques, music therapy. Rationale: Reduces anxiety and nausea, may improve taste perception, addresses psychological component of anorexia.
🍽️ Anorexia is NOT Starvation! Forcing food in advanced cancer is futile and distressing. Focus on comfort, small amounts of favorite foods, and family involvement. Sometimes the best intervention is to stop pressuring and allow natural progression.