Alterations in GI Functioning- PEDS Test 4

Post-operative nursing care with cleft lip or palate

-#1= airway mangement -feeding -suture care- "logan bow" suture -restraints- they will have "no no's" as upper arm restraints to keep them from pulling sutures (elbow immobilizers) -referrals to appropriate team members; identity and address home/family needs well in advance of discharge -dont allow the to suck-> don't let them suck thru regular bottle- best way to feed them is to get a catheter and attach it to a syringe and put a catheter in their mouth and give them a little bit of food at a time -position them supine or side lying on the opposite side from surgery -no hard objects in mouth -No oral temps, no pacifiers, spoons, fingers in mouth for 7 - 10 days. -goal: protect the suture line, prevent infection, and minimize pain

Hypertrophic Pyloric Stenosis: Diagnosis and Collaborative Crae

-Diagnosis: abdominal ultrasound, upper gastrointestinal (UGI) series (barium swallow) -blood tests: hypochloremia, hypokalemia, metabolic alkalosis -treat dehydration and electrolyte imbalances -treatment: pyloromyotomy (surgery)- the surgeon cuts the tight muscle between the stomach and small intestine

Enlargement, Stimulate, Swallow, Rest (ESSR) feeding method

-Enlarge the nipple (use a cleft palate nipple) -Stimulate the suck reflex -Swallow fluid appropriately -Rest when infant signals with facial expression -do frequent burping during the feeding then leave them alone after they eat to rest -put them in an upright position to prevent aspiration

Gastroesophageal Reflux (GER/GERD)

-GER: passage of gastric contents into the esophagus -GERD: symptoms/complications that may occur when gastric contents reflux into the esophagus or oropharynx ; immaturity (relaxation) of lower esophageal sphincter (LES) -they eat often but lose weight- they have a failure to thrive -major complications: bleeding in the esophagus and breathing problems -bleeding in the upper part of the GI tract= black/tarry -bleeding in the lower part of GI tract= red -blood in the vomit = red coffee grounds or just straight red

Summary of GI disorders

-GI disorders due to many internal and external causes -most involve pain, hydration risks, changes in the diet -preventative/post-treatment education a large part of a nurse's role

Gastroesophageal Reflux: Diagnosis

-H&P -esophageal pH probe preferred test): if the test is less than 7.0 indicates presence of acid -upper GI = barium swallow -endoscopy= visualization of esophageal abnormalities -gastric emptying study

Inguinal vs Umbilical Hernia

-Inguinal Hernia: Painless swelling extending toward or into the scrotum; elective surgery recommended -Umbilical Hernia: soft midline swelling in umbilical area; most resolve spontaneously; if strangulates- needs surgery; no tap, straps, or coins to reduce hernia

Metabolic acidosis vs metabolic alkalosis

-Metabolic acidosis: loosing bicarb by diarrhea -Metabolic alkalosis: loosing K+ by vomiting

"SIR" Hernia

-S: strangulated: blood supply is cut off, emergency surgery situation I: incarcerated: hernia is trapped outside the peritoneal cavity R: reducible: hernia moves back into peritoneal cavity

Nissen Fundoplication

-Stomach fundus wrapped around end distal end of esophagus (LES) -reinforces LES, making it less likely that acid will break up in the esophagus -after surgery: unable to burp/regurgitate

Cleft Lip and Cleft Palate

-affects the upper lip and roof of mouth -most common congenital birth defects -etiology: failure of oral cavity (cleft lip) and palatine palates (cleft palate) to fuse during embryonic development -unilateral, bilateral, midline -risk factors are multifactorial but could include family hx, maternal smoking, alcohol use, diabetes, folic acid deficiency, and use of antipileptic medications -problems: eating, talking, hearing, ear infections, tooth development

How to Prevent Intestinal parasitic disease

-always wash hands/fingernails with soap and water before eating and handling food and after feeding -discourage children from scratching bare and anal area -use super absorbent disposable diapers to prevent leakage -change diapers as soon as soiled and dispose of diapers in closed receptacle out of children's reach -dont rinse diapers in toilet -disinfect toilet seats and diaper-changing areas -drink water that is specially treated, especially if cramping -wash all raw fruits and vegetables or any food that has fallen on the floor or ground -teach children to defecate only in toilet, not ground -keep dogs and cats away from play grounds/sand boxes -avoid swimming in pools frequented by diapered children -wear shoes outside

Intussusception: Collaborative Care

-diagnosis: H&P; abdominal x-ray/US -CBC- leukocytosis -stool-occult/visible blood -hydrostatic reduction (barium enema): 70-90% of cases; passage of brown stool if successful -NPO; IV/NG tube -surgery

Medications used to treat GER/GERD

-antacids: these neutralize gastric acids: calcium carbonate (TUMS) -histamine-2 receptor antagonists: inhibit gastric acid secretions: ranitidine (Zantac) and Famotidine (Pepcid) -proton-pump inhibitors: block gastric acid secretions: Lansoprazole (Prevacid), Omeprazole (Prilosec), Esomeprazole (Nexium) -Prokinetic Agents: Accelerates gastric emptying/stimulate GI motility: Metoclopramide (Reglan) and Low-Dose Erythromycin (EES)-> question this is bowel sounds are already hyperactive/if they have lose, watery stools already (diarrhea) -Mucosal Surface Agents: coats the stomach lining: Sucralfate (Carafate)-> can't give any other meds with this bc they wont be absorbed bc it coats the stomach so much; give other meds 1 hr before or 2 hrs after this -All these medications help prevent aspiration pneumonia in medically fragile children

Hypertrophic Pyloric Stenosis: Pyloromyotomy Pre-operative nursing care

-assess for dehydration, electrolyte, and acid/balance imbalances -must treat the dehydration and electrolyte imbalance before surgery -examine abdomen and listen for bowel sounds -keep accurate I&O's and daily weights -they must be NPO, give IV fluids, and weigh all diapers, and monitor NG tube drainage -promote rest and give comfort -protect from infection -supportive care for parents

Post operative Nursing care

-assess for shock -vital signs -I&Os -intravenous fluids -gradually increase feeding after NG tube removal -discharge teaching

Pre-operative nursing care for Cleft Lip and Cleft Palate

-assessing family reactions -providing emotional support -facilitating feeding bc they can't coordinate suck, swallow, and breathe and they get a lot of air in so they need a special shape of "nipple" -providing parent education -assisting parents with coordinating care and maintaining a healthy environment -making referrals -remember the psycho-social implications for these children and families bc facial deformities can be devastating to families so remind the parents that the defect is operable and show them pics of it corrected

Assessment of the GI System

-auscultate before you palpate-> palpate last bc once you start touching things you could cause fake bowel sounds-> inspection, auscultation, percussion, palpation -to measure abdominal girth, measure above the umbilicus which the child lays down and compare it to other measure

Oral Rehydration Therapy (ORT)

-avoid fluids that are high in sugar- soft drinks, jello, fruit drinks, tea -give pedialyte, infalyte, rehydralyte, cresol, lytren, nutralyte, ricelyte, hydralyte, cerealyte, reVital, KaoL electrolyte, equalyte, pediatric oral maintenance solution ORS, WHO/UNICEF oral rehydration solution -give 50-100 mL/kg within 4 hours

Barium

-barium sulfate makes structures shine so you can see it in the X-ray -the passage of the barium through the esophagus, stomach, and small intestine is monitored -barium liquid is instilled into the large intestine through the anus -these are not nephrotoxic-> only nephrotoxic if it goes through an IV

Hirschsprung Disease: Pull-Through Procedure

-before pull-through surgery: the diseased segment doesn't push stool -step 1: the diseased segment is removed -step 2: the healthy segment is attached to the remaining rectum

Collaborative care with Cleft Lip and Cleft Palate

-cleft lip repair: during the first 6 months (let the child grow up a little; not an emergency) -cleft palate repair: by 18 months (let the child grow up a little; not an emergency) -multidisciplinary team: involving many specialists including plastic surgeons, nurses, ear, nose, and throat specialists, orthodontists, audiologists, and speech therapists -reconstruction begins in infancy and can continue through adulthood -homecare by the family prior to surgery

Diaphragmatic Hernia

-congenital condition -diaphragm fails to close completely -abdominal contents enter chest cavity -prevents lungs from expanding or developing

Esophageal Atresia/Tracheoesophageal Fistula (TEF)

-congenital defects of the esophagus -failure of the GI tract to separate properly from respiratory tract early in prenatal life; the esophagus doesn't go into stomach -atresia- incomplete formation of esophagus (doesn't develop as a continuous tube); drooling -TEF: there is a fistula between the trachea and esophagus; abnormal connection between the esophagus and the trachea -priority nursing diagnosis: risk for aspiration -

Omphalocele

-congenital malformation in which intraabdominal contents herniate through the umbilical cord and they are covered with a translucent sac -herniated viscera sac: the bowel and liver are present -associated anomalies: common (50%) -location of defect: umbilicus -mode of delivery: vaginal/cesarean -surgical management: non urgent -prognostic factors: associated anomalies

Gastroenteritis: Complications

-dehydration: mucus membranes dried, cracked; decreased elasticity of skin; de[ressed fontanels, eyes sunken and tearless; decreased urinary output, dark; listless and irritable -metabolic acidosis: pH less than 7.35; HC03= less than or equal to 22 mEq/L -deficient fluid volume -risk for electrolyte imbalance -imbalanced nutrition: less than body requirements

Appendicitis: Collaborative Care

-diagnosis: abdominal ultrasound/ CT scan (CT scans are dangerous bc of all of the radiation) -appendectomy (open of laparoscopic) -NPO with NG tube until bowel function returns -IV fluids, VS, I&O -IV antibiotics (ampicillin, clindamycin, gentamicin) -pain management with morphine -monitor wound site/wound care -discharge planning

Hirschsprung Disease: Diagnosis and Collaborative Care

-diagnosis: history and physical; rectal biopsy- absence of ganglionic cells in bowel mucosa (definitive diagnosis)' rectal manometry; barium enema (x-ray) -mangement: daily colonic lavage (saline); preoperative bowel prep; surgical intervention- pull through procedure, colostomy, and resection

Parasitic Disorders: Collaborative Care

-diagnosis: stool ova and parasite exam: to identify causative organism; nightly anal test (sticky tape) for pinworm; complete blood count for eosinophilia -treatment: anthelmintic medications (like piperazine and mebendazole) -preventive teaching: good hygiene practices; take prescription drugs as directed

Diaphragmatic Hernia: Collaborative Care

-diagnostic chest x-ray (reveals mass with air-filled bowel on affected side) -immediate intubation with mechanical ventilation -oro/nasogastric tube (gastric decompression) -IV fluids -position infant with affected side down to aid ventilation of the "good" lung (good lung up) -cluster care/minimal handling -surgical correction -parental support and education

Appendicitis: Clinical manifestations

-earliest symptoms: periumbilical pain, vomiting, rebound tenderness -followed by: pain migrating to right lower quadrant (classic sign), pain most intense at McBurney's point, increases with movement -low-grade fever, nausea, vomiting, diarrhea or constipation; anorexia; abdominal swelling -WBC count > 10,000; shift to the left -ruptured appendix = sudden pain relief followed by diffuse pain -rebound tenderness: a clinical sign that is elicited during physical examination of a patient's abdomen by a doctor or other health care provider. It is indicative of peritonitis. It refers to pain upon removal of pressure rather than application of pressure to the abdomen -iliopsoas test: you life the leg straight up and get pain -obturator test: you bend the knee and lift back and get pain

Esophageal Atresia/Tracheoesophageal Fistula (TEF): Diagnosis and Collaborative Care

-early diagnosis: ultrasound, radiopaque catheter inserted in the esophagus to illuminate defect on X-ray -pre-op care: prevent aspiration and hydrate: maintain airway, keep NPO and give IV fluids, elevate HOB 45 degrees, suction PRN, and give prophylactic antibiotics -surgery: one-or-two-stage repair: thoracotomy and anastomosis -post-operative nursing care: maintain airway, maintain nutrition (gastrostomy tube feedings), prevent trauma, monitor complications (constipation or diarrhea, blockage of esophagus, and infection), monitor weight, growth and developmental achievements

Hirschsprung Disease: Clinical Manifestations

-failure to pass meconium -severe constipation -abdominal distension -reluctance to feed -bilious vomiting (vomit with bile in it) -failure to thrive -liquid or ribbon-like stools -recurrent fecal impaction -watery, bloody diarrhea -weight loss, fatigue, dehydration -enterocolitis: serious complications: severe diarrhea, hypovolemic shock, and death-> principal cause of death in HD-> high mortality rate

Constipation

-fewer than normal bowel movements, hard or lumpy stool consistency -signs and symptoms: poor appetite, straining with stools -additional symptoms: blood may occasionally be seen. tenderness in colon and small intestines, rectal fissures -nursing care: focus: dietary intake, keeping the bowel relatively empty; fluids, fiber, physical activity regular diet (fruits and fiber); stool softeners (osmotic laxative- Miralax); chronic constipation may include bowel cleansing, maintenance therapy and bowel retraining

BRAT Diet

-for milder cases of diarrhea in the older child: B: bananas R: rice A: apple sauce T: toast

Gastroenteritis/Acute Diarrhea

-gastroenteritis: inflammation of lining of stomach and intestines; most common symptoms = diarrhea, anorexia, nausea and vomiting, crampy, abdominal pain, irritability -diarrhea: disturbance of intestinal tract that alters motility and absorption, characterized by an increase in frequency, fluid content, and volume of stools; most common symptoms= dehydration, hyponatremia, hypokalemia, metabolic acidosis -most commonly virus (ex: rotavirus, norovirus, adenovirus) -bacterial causes 20% (ex: Salmonella, Shigella, Escherichia coli, clostridium difficile) -parasites fewer than 5% (ex: giardia lamblia)

Parasitic Disorders: Clinical Manifestations

-giardiasis: An intestinal infection caused by a giardia parasite-> diarrhea, vomiting, anorexia, failure to thrive -pinworm: a human parasitic disease caused by the pinworm-> itching around anus at night leading to irritability/restlessness -general symptoms of intestinal worms in children: decreased appetite, weight loss, nutritional deficiencies, nausea and vomiting, abdominal pain

Gastroesophageal Reflux: Clinical manifestations of the children

-heartburn or chest pain -abdominal pain -dysphagia -wheezing, stridor, cough, hoarseness -ear infections, sinus problems -recurrent pneumonia/asthma -regurgitation

Gastroschisis

-herniation of abdominal viscera outside the abdominal cavity (usually small intestine and ascending colon) -this is more severe bc intestines are unprotected -a lot of times intestines get abrasions and so they end up cutting out the bad parts and they can end up with short bowel syndrome -herniated viscera sac: bowel only -associated anomalies: uncommon (less than 10%) -location of defect: right of umbilicus -mode of delivery: vaginal -surgical management: urgent -prognostic factors: condition of bowel

Esophageal Atresia/Tracheoesophageal Fistula (TEF): Clinical manifestations

-history of polyhydramnios during pregnancy can suggest a high gastrointesnstinal obstruction -excessive amounts of salivation/mucus, frothy bubbles (drooling- drooling is abnormal in newborns or in infants less than 4 months) -Three C's" coughing, chocking, and cyanosis when fed -food may be expelled through the nose immediately following the feeding -rattling respirations and frequent respiratory problems such as aspiration pneumonia -gastric distention if there is a fistula

Laboratory tests with the GI

-if you get a stool sample, don't vacuum pack it and put it in the tube system, walk it down to the lab; there are many different types of stool samples depending on what you're looking for: *which blood cells *ova and parasite *bacterial cultures *fecal fat *stool pH *rotazyme (rotavirus) *blood (hemoccult) -erythrocyte sedimentation rate: if this is elevated it means there is inflammation somewhere in the body (nonspecific)-> the child probably has an infection somewhere, if the sed rate is going down, then it means the infection is getting better

Gastroenteritis: Clinical Manifestations

-increase in peristalsis -large volume stools (loose, watery, green) -increase in frequency of stools -nausea, vomiting, cramps -increased heart and resp. rate, decreased tearing and fever -complications: dehydration and metabolic acidosis

Appendicitis

-inflammation and obstruction of the blind sam at the end of the cecum -medical emergency: appendectomy only cure -most common cause of emergency surgery in children -children ages 10-19 years -ruptured appendix = peritonitis= abscess, obstruction, electrolyte imbalances, septicemia, shock, and death

Hernias

-inguinal hernias- protrusion of abdominal cavity contents through the inguinal canal; elective surgery recommended -umbilical hernias: weak closed umbilical rings; common in childhood; protrudes with coughing, crying, or straining; if strangulates the bowel- needs surgery -diaphragmatic- abdominal contents protrude into thoracic cavity through an opening in the diaphragm: life-threatening condition; intubation required immediately; continued intensive care- level III NICU

Staged surgery

-intestines placed in Silastic silo or pouch to slowly and gently lower the intestines back (by the force of gravity) into the abdominal cavity. May take several weeks; then a final surgery to close the abdominal wall.

Hypertrophic Pyloric Stenosis: Pyloromyotomy Post-operative nursing care

-keep I&O's -comfort/pain relief -feeding: clear liquids, observe/record the infant's response to feeding -position with head elevated -assess surgical site to prevent infection -parent teaching

Important point about GI

-many GI issues require surgical intervention -nursing interventions will often include general pre and post op care -a bulky, frothy stool may indicate malabsorption -drooling in the newborn is pathological bc the salivary glands don't develop for several months (drooling before 4 months is abnormal) -conditions requiring immediate medical attention: *bilious vomiting (bright yellow to dark green color in the vomitus, often with fecal appearance and smell) is a sign of GI obstruction *blood in vomit or stool *persistent vomiting, watery diarrhea, intractable abdominal pain *signs of dehydration (ex: very dry mouth, no tears, less than 1 mg/kg/hr of urinary output

Hirschsprung Disease (Aganglionic Megacolon)

-mechanical obstruction of the colon= born with bowel that doesn't have the nerves -absence of ganglion cells in rectum and upward colon -prevents peristalsis at that portion of the colon -megacolon: mechanical obstruction of the colon -they have liquid stools (not real stool) from fecal impaction -symptoms: failure to gain weight; severe constipation -newborns: failure to pass meconium (they should pass the meconium within 24 hrs-> 1st thing to think is cystic fibrosis (meconium ileus) and the second thing is this); abdominal distention; bilious vomiting -most common obstruction in newborns

Volvulus: Clinical Manifestations and Collaborative Care

-most common during 1st month of life -intermittent bilious vomiting -firm abdomen with distention -irritability secondary to pain -passage of blood stools -signs of obstruction -diagnosis: GI series/contrast studies -treatment: emergency surgery

Hypertrophic Pyloric Stenosis

-obstruction of the pyloric canal (stenosis of passage between stomach and duodenum) -narrowing of the pyloric sphincter -delayed emptying of the stomach -2-8 weeks after birth -typically: healthy male infant; new onset NON-BILIOUS vomiting 30-60 minutes after feeding, progressing to projectile vomiting about 3 feet (comes out forcefully) -vomiting= metabolic alkalosis -it is caused by the thickening of the muscle between the stomach and small intestine. The hypertrophied ring of muscle causes symptoms of projectile vomiting and visible peristalsis

Intussusception

-one portion of bowel prolapses/telescopes into another portion- causes obstruction; may need surgery (a form of bowel obstruction) -most common cause of intestinal obstruction in young children -infants 9-24 months and more common in males -bowel "telescopes" within itself -medical emergency -extreme paroxysmal pain (subsides then recurs) -vomiting -stools- resemble currant jelly (stool looks like jelly coming out) -sausage-shaped abdominal mass in the RUQ -dehydration -primary concern = bowel necrosis, perforation, sepsis -this is so painful that children may begin to bite themselves

Medically fragile children

-one who, because of an accident, illness, congenital disorder, abuse or neglect, has been left in a stable condition, but is dependent on life sustaining medications, treatments, or equipment, and has need for assistance with activities of daily living. A medically fragile child may: • Have chronic health care conditions such as traumatic brain injury or cerebral palsy (CP); • Require special health care support, such as tube feedings, oxygen therapy, suctioning, tracheostomy care, or a ventilator; • Have limited mobility and require special health care support due to paralysis or chronic disease.

Anorectal Malformations (Imperforate Anus)

-opening to anus is missing or blocked -usually found with 1st rectal temp at birth -signs and symptoms: failure to pass meconium within 24-48 hours after birth; missing or abnormal opening to the anus; stool passes out of the vagina, base of the penis, scrotum, or urethra (fistula); swollen belly area (abdominal distention) -treatment: colostomy, PSARP procedure, and dilations, colostomy closure -nursing care: NPO, IV fluids, NG tubes, I&O, emotional support for parents, post-surgical wound care, colostomy care, nothing per rectum!

Post-operative Nursing Care with Omphalocele and Gastroschisis

-pain management -prevent infection -fluid and electrolyte balance -assess for ileus -maintain parenteral feedings -provide support to the parents -facilitate parent-infant bonding

Overall: Appendicitis

-peak incidence 10-12 years -begins as dull,steady pain in periumbilical area -progresses over 4-6 hours and localizes to right lower quadrate -low grade fever -nausea -anorexia -sudden pain relief may indicate rupture of appendix (leads to peritonitis) -diagnosis: clinical signs, increase WBC, abdominal sonogram, exploratory lap, rebound pain or tenderness (RLQ) at McBurney's Point

Hirschsprung Disease: Nursing Care

-pre-op: fluid and electrolyte balance -vital signs -colonic lavage (saline) -pt/parent teaching -post-op: NPO, vital signs (never take a rectal temperature), assessment, pt/parent teaching- colostomy care, skin care, nutrition -nothing per rectum!

Omphalocele and Gastroschisis: Collaborative care

-pre-operatively: protect visceral contents/sac; provide intravenous fluids: cover with warm, sterile, saline-soaked dressings; maintain temperature- esp. with gastroschisis (radiant warmer/isolette); sterile wrap or sterile bowel bag -may place silo or silastic material over the gut -transfer these pts to the NICU -nutrition: NPO and TPN through a central venous line -keep a strict I&O and take VS hourly -gastric distention: NG tube -infection control: broad spectrum of antibiotics

Gastroenteritis: Collaborative Care

-prevention of spread of diarrhea: contact/enteric precautions; meticulous hand washing (soap and water), rotavirus vaccination -stools: onset, frequency, color, amount, and consistency -assess for dehydration: monitor I&O, vital signs, daily weights; skin color, temperature, turgor, capillary refill, assessment of fontanels; ask caregiver about vomiting, fever, number of wet diapers during previous 24 hours -skin care -promotion of rehydration; correction of electrolyte imbalances: oral rehydration (pedialyte, inflyte, rehydralate); IV rehydration (lactated ringers or 0.9% NS- give 20 mL/kg over 5 mins 3 times 15 mins apart (bolus) -provision of age-appropriate nutrition -prevention of complications -support of child and family

Hypertrophic Pyloric Stenosis: Clinical manifestations

-projectile vomiting -constant hunger -fussiness -visible peristaltic waves -dehydration -metabolic alkalosis -olive-sized mass

Parasitic Disorders

-protozoa or helminths (worms): protozoa- single-celled organisms (often found in contaminated water sources); helminths (worms)- multicellular organisms with complex body structure and organ systems -on the rise in the U.S. -common causes: cramping, sandboxes, ingested untreated water, exposure to pets, wildlife -young children in childcare most at risk -treated with an anthelmintic

Gastroesophageal Reflux: Clinical manifestations of the infant

-recurrent regurgitation/vomiting is the most common sign -cranky, excessive crying, irritable, spitting up, refusing to feed -they have poor growth/weight gain; failure to thrive; anemia -life threatening risk/complications: esophagitis, blood loss/ aspiration pneumonia, wheezing/apnea, apparent life threatening events (ALTE)

Diaphragmatic Hernia: Clinical Manifestation

-scaphoid (concave) abdomen -respiratory distress -cyanosis -asymmetric chest movements (2 degree to the hypo plastic lung) -absent breath sounds on the affected side (2 degrees to the hypo plastic lung) -shifted heart sounds -bowel sounds in the chest

Vomiting

-signs and symptoms: assessment includes description of onset, duration, quality, quantity, appearance, presence of undigested food and precipitating event, dehydration, fever, diarrhea, headache, and ear pain -nursing care: treatment of the cause and prevent of complications, bowel is allowed to rest, oral or parental rehydration, bland solids reintroduced, antiemetic drugs, dehydration, monitor fluid intake and output, oral hygiene

Gastroesophageal Reflux: Collaborative Care

-small frequent feedings of breast milk, predigested formula or thickened formula- give small and thickened feedings q3h and hold the infant upright for 30 mins after -frequent burping while feeding -positioning: upright position for the infant: right side with head elevated or prone position the GERD is severe- don't lay them prone in the crib bc that is dangerous, hold them in your arms with their head up and stomach down and walk around -for an older child, reflux wedge to keep their head elevated -avoid soft bedding, pillows, and loose sheets -avoid excessive handling after feedings so they can rest -give medications -do surgery called nissen fundoplication for very bad cases- they take the upper part of the stomach and wrap it around the spinster and suture it-> this is permanent

Volvulus

-twisting of intestine can lead to necrosis of the bowel surgical emergency (a form of bowel obstruction)

Omphalocele and Gastroschisis Repair

-under general anesthesia, an incision is made to remove the sac membrane -bowel is examined for signs of damage or additional birth defects -damaged or defective portions are removed and the healthy edges stitched together -viscera may be place in silastic pouch and slowly returned to abdomen using gravity over several weeks

Goals of Operation for Cleft Lip and Cleft Palate

1. Maintain nutrition (ensure adequate intake of food and fluids) 2. Prevention of aspiration -keep the bulb syringe and suction equipment at bedside -special feeding devices may be used -may breast feed if has small cleft lip -feed slowly in upright position and burp frequently -position on side after feeding -all these measures focus on ways to decrease ASPIRATION -be aware of the lack of proper seal around the nipple to create necessary suction bc they can have excessive air intake -you can use feeder with compressible sides and syringes with tubing

A 4 week old infant with a history of vomiting after feeding has been hospitalized with a tentative diagnosis of pyloric stenosis. Which of these actions is priority for the nurse? A. Begin an intravenous infusion B. Measure abdominal circumference C. Orient family to the unit D. Weigh infant

A. Begin an intravenous infusion

While performing a newborn assessment the nurse notices the infant is having difficulty breathing. Nasal flaring, cyanosis, and retractions are observed and there are no breath sounds on the left side. The atypical pulse is auscultated on the right side of the chest. The nurse would notify the physician immediately because he or she suspects: A. Diaphragmatic hernia B. Pyloric stenosis C. Cleft palate D. Omphalocele

A. Diaphragmatic hernia

The mother of a child undergoing an emergency appendectomy tells the nurse "If I had brought him in yesterday when he complained of an upset stomach, this wouldn't have happened." The nurse's best response is: A. "It's okay; you got him here just in time before it ruptured." B. "It is often difficult to predict when a simple complaint will become more serious." C. "Next time he seems sick, you should bring him in immediately." D. "Sometimes parents can make a mistake without meaning to do so."

B. "It is often difficult to predict when a simple complaint will become more serious."

An infant returns from initial surgery for Hirschsprung's disease. Because pf the type of surgery the child had, the nurse would exclude from the routine postoperative plan-of-care instructions to: A. Maintain the child NPO until bowel sounds return B. Monitor rectal temperature every 4 hours C. Reunite the parents with the child as soon as possible D. Assess the surgical site every 2 hours

B. Monitor rectal temperature every 4 hours

A child with Hirschsprung's disease is being discharged after Soave endorectal pull-through procedure for colostomy closure. Which of these measures should the nurse include in the home care plan? A. Refer the parents to an enterostomal therapist for ostomy care B. Teach parents how to perform weekly rectal irrigations C. Teach parents signs and symptoms of infection D. Teach parents PCA pain-control methods

B. Teach parents how to perform weekly rectal irrigations

The nurse is reviewing nursing notes and sees a notation of "ESSR" in the medical record. "ESSR" refers to: A. The feeding method for children with gastroesophageal reflux. B. The feeding method for children with cleft lip or palate. C. The procedure for repair of pyloric stenosis D. The procedure for repair of Hirschsprung's disease

B. The feeding method for children with cleft lip or palate.

The nurse is caring for an infant vomiting an infant vomiting secondary to pyloric stenosis. The mother questions why the vomitus of this child appears different from that of her children when they have the flu. The nurse would explain that the emesis of an infant with pyloric stenosis doesn't contain bile because: A. The GI system is still immature in newborns and infants. B. The obstruction is above the bile duct C. The emesis is from passive regurgitation D. The bile duct is obstructed

B. The obstruction is above the bile duct

The best rationale to give parents who are questioning the use of elbow restraints with their child who has had cleft palate repair is: A. "This device is frequently used postoperatively to protect the IV site in small childcare." B. "The restraints will help us maintain proper body alignment." C. "Elbow restraints are used postoperatively to keep their hands away from the surgical site." D. "The restraints help us remember that the child is NPO after surgery."

C. "Elbow restraints are used postoperatively to keep their hands away from the surgical site."

A mother arrives at clinic with her 6-month-old child. While the nurse is assessing the child, the mother points to the umbilicus and says: "What am I going to do about this? Which he cries, it looks like it's going to burst." The nurse's best response would be: A. "It's the best if you don't let him cry. Just let him do what he wants." B. "It probably wont rupture unless he gets real. I wouldn't worry about it." C. "I know it looks scary, but it really wont burst." D. "Put a binder around it, and that will keep it from bursting when he gets mad."

C. "I know it looks scary, but it really wont burst."

A 9-year-old with severe esophagitis is 12 hours status/post-Nissen fundoplication for gastroesophageal reflux. To implement appropriate nursing care, the nurse should: A. Encourage him to take small amounts of clear liquids every 4 hours B. Administer NG or gastronomy feedings every 4 hours C. Ask him to choose a face on the FACES pain rating scale. D. Insert a pH probe to monitor esophageal acidity

C. Ask him to choose a face on the FACES pain rating scale.

A 3 month-old-infant has severe gastroesophageal reflux (GERD). The mother wants to know if there is anything she can do differently to decrease the reflux. Which of the following interventions should the nurse suggest to minimize reflux? A. Discontinue breast-feeding immediately B. Decrease frequency of feedings as much as possible C. Place the baby in prone position with the head elevated D. Place the infant in a care seat after feeding

C. Place the baby in prone position with the head elevated

A 10-year-old body has been admitted with a diagnosis of "rule out appendicitis." While the nurse was conducting a routine assessment, the boy stated, "It doesn't hurt anymore." The nurse suspects that: A. The boy is afraid of going to surgery B. The boy is having difficulty expressing his pain adequately C. The appendix has ruptured D. This is a method the boy uses to receive attention

C. The appendix has ruptured

A 16-year-old is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which of the following nursing interventions is most appropriate to facilitate normal growth and development? A. Allow the family to bring in the child's favorite computer games. B. Encourage the parents to room-in with the child C. Encourage the child to rest and read D. Allow the child to participate in activities with other individuals in the same age group when the condition permits

D. Allow the child to participate in activities with other individuals in the same age group when the condition permits

Which of the following is NOT a unique characteristic of the digestive system of infants? A. Decreased emptying time (stomach empties a lot quicker) B. Small stomach capacity (10-20 mLs) C. Immature relaxed lower esophageal sphincter (LES) D. Increased gastric acidity level

D. Increased gastric acidity level -they have an increased gastric pH which is a decrease in gastric acidity -they reach normal acidic levels at age 6

By which of the following are Ascarisas (roundworm) infections diagnosed? A. Presence of larvae on the skin B. Seeing the worm in the stool C. A "Scotch tape test" in the early morning D. Laboratory examination of stool specimen

D. Laboratory examination of stool specimen

Pediatric differences

•Children with vomiting and/ or diarrhea dehydrate quickly. They have increased extracellular fluid, which is more easily lost; increased body surface area & increased insensible fluid loss; little fluid reserve in intracellular fluid; high metabolic rate requires increased fluid. •They have less acid and higher gastric pH. Which causes them to have less resistance to viral and bacterial infection bc the acidity of the stomach usually protects against infections. -The pancreatic amylase secretion not developed until 4 months of age so too early exposure to food (before 4 months) = stomach ache, gas, constipation, diarrhea, spits. •Diaphragm is the primary breathing muscle until age 6 or so. Any distention in the abdomen, therefore, can interfere significantly with breathing. -extrusion reflex (makes them spite out anything in their mouth) disappears around 4-6 months so you can start feeding solid food •Abdominal pain in children can be very challenging to diagnose (can have multiple etiologies) -they have poor swallowing control-> 32-34 weeks they coordinate the suck, swallow, and breath without checking -increased peristalsis -drooling is ABNORMAL in infants less than 4 months