NUR 122- Peds Test 2-Gastrointestinal & Genitourinary Study Guide
Family history
*Ask about history of gastrointestinal illness with genetic influences such as celiac disease and inflammatory bowel disease.
Labs
*Bilirubin assessment, *Checking stool for ova or parasites, worms, etc *Testing for blood in stool
Acute Diarrhea-causes p. 1348
-Acute diarrhea is defined as three or more loose or watery stools per day. -Diarrhea can be caused by infections or other factors. Sometimes, the cause of diarrhea is not known. -motility disorder -alters fluid and electrolyte balance (fluid loss, proper nutrients not being received) -rapid dehydration in infants & small children-hypovolemic shock and death (children can dehydrate quickly and die)
Nephrotic Syndrome p. 1374-1375
-Alteration in the glomerular membrane (things that could not normally cross the membrane can now cross the membrane) -massive proteinuria- proteins going into the urine, loss in albumin and immunoglobins -hypoalbuminemia & hypoproteinemia--loss in urine -Edema-due to protein loss --> osmotic pressure change (retain Na+ and H2O) -Hyperlipidemia-r/t liver stim Altered immunity S/s: increased edema, anorexia, wt gain, HTN, irritability Dx: History, symptoms, labs Meds: Corticosteroids (12 wks)-diuretic- risk for swelling, watch I&O, potassium; Steroids-slowly stop and taper off, don't stop abruptly; -affects immunity-no one in fam should get live viruses -Monitor skin breakdown -child should eat nutritious meals -Anithypertensives-antibiotics IV albumin
Intussusception treatment:
-Health & promotion -abdominal x-ray/ultrasound ***-contrast air or barium enema-in many cases an enema can fix the problem, excretion will sometimes push the bowel back out) -no treatment can cause necrosis/death of bowel -stomach decompression- NG tube -surgery -educate fam, this can happen again
Normal Urine Output by weight:
-Infants: 2ml/kg/hr -Children: 0.5 to 1 ml/kg/hr -Adolescent/Adult-40 to 80 ml/hr (intake should match input) -difference due to kidney maturation
Treatment approaches for Enuresis- p. 1374
-Limiting fluids, Bladder exercises, timed voiding, enuresis alarms, reward system, medications (ex. Decompressin) -Family teaching: postive mgmt, training, eliminating/resolving stressors for child, we need to know as much about the child as we can to know how to provide effective treatment.
Acute Post-infectious Glomerulonephritis (Nursing Mgmt) p. 1379
-Monitor fluid status -prevent infection -prevent skin breakdown -meet nutritional needs -provide emotional support -teaching needs Test urine for RBC or mild proteinuria
Acute Post-infectious Glomerulonephritis p. 1377-1378
-Most common inflammation of glomeruli of kidney -Most often a response to: Group A beta hemolytic streptococcus (often due to strep not treated w/ antibiotics or pt did not complete antibiotic regimen), also maybe Hx of sore throat -Age 2-6 yrs old (younger school age child) -More common in males -Acute onset, not progressive -SIgns emerge 10-21 days after -Immune complex rxn on glomerular complex wall -Decreased Glomerular Filtration Rate (GFR), RBC excreted -Na+ & H2O retained causing edema
Protection of surgical site of the Hypospadias pt:
-Urethral stent-check color & amt of urine, small amt of blood only -encourage fluids -double diapering to protect the surgical site -usually best done during infancy, best to not wait to toddlerhood due to having fears -Restrictions: no babies on hip, do not put a lot of pressure in the front of the diaper (uncomfortable & we need to protect stent), urine leakage (urine needs to be coming out of the stent not around the stent, increase blood (only small amt)
Celiac disease (chronic malabsorption syndrome) p. 793-794
-baby unable to digest glutamine (gluten/gliadin/protein fractions) -builds up in body and affects intestines -child unable to absorb nutrients -results in accumulation of amino acid glutamine-toxic to mucosal cells in intestine -damage to villi impairs absorptive process in small intestine -s/s: chronic diarrhea, impaired growth, abdominal distension, decreased appetitie, decreased energy, muscle wasting due to malnourishment, protruding abdomen
Enuresis-p. 1373
-enuresis is repeated involuntary voiding by a child old enough that bladder control is expected, usually about 5 to 6 years of age. -Enuresis can occur either at night (nocturnal), during the day (diurnal), or both night and day. -Primary & Secondary enuresis -Hx & Dx: constipation can lead to enuresis (as bowel is cleared urine is produced), spina bifida (neurological defects), family Hx, etc. -Most common medication- Decompressin-nasal spray anticholinergic-helps prevent bladder spasms, bladder less likely to contract
Clefts can cause:
-feeding difficulties, dental deformities, speech problems, otitis media, hearing problems -need for modified feeding or NPO based on severity -breast feeding moms should pump and baby should be fed with special nipple (lambs nipple-soft covers palate or preemie nipple) Note: -unilateral (one-side) cleft lip baby may be able to breastfeed -Allow extra time for feeding- due to infant not sucking effectively -burp frequently -upright position X 30 mins after feeding -apply restraints to keep child from putting hands in mouth
Intussusception nursing management:
-maintaing fluid/electrolyte balance -Pain mgmt- FLACC scale, child will remain in pain until issue is resolved -pre-op procedures -post-op procedures- if bowel sounds are good, slow feeding may occur, stool production is a good sign
Levels& Signs of dehydration (table 4-2, p. 1083):
-mild-up to 5% (40-50 ml/kg) -moderate- 6 to 9% (60-90 ml/kg) -severe- 10% or more (100 ml/kg) -check for skin turgor, amt of urine (I&O's), weight loss, decrease in BP, dizziness, check fontanel and suture lines in infants, sunken eyes, dry lips, mucous membranes
Intussusception symptoms (pic pg. 1336):
-one of the most frequent causes of intestinal obstruction during infancy -portion of intestines prolapses and telescopes back (collapses and goes back up into itself causing obstruction) -most common in infant males -abrupt onset (happens as soon as telescoping occurs) -Acute pain -Bilious vomiting/emesis (bile included) Stool-Brown w/ reddish "currant jelly"-small amt of blood & mucous -palpable abdominal mass-sausage looking
Pyloric stenosis symptoms (pic. pg. 1332):
-small amount of emesis gradually worsens due to thickening of pyloris, canal starts to close, the stomach starts to push harder to get through the narrow opening, stomach overworks and the force becomes so strong through tiny space it becomes projectile -occipital emesis/projectile vomiting occurs-baby not getting nutrition/fluids, stomach containing acid, metabolic alkalosis occurs -baby fussy and hungry -visible peristaltic waves -palpable olive sized mass-pyloris -hyperactive bowel sounds- bowels trying to get things moving but it's not working -Dehydration-electrolyte imbalance, children & elderly must receive treatment immediately
Genitourinary (GU) differences in a child/pediatric patient:
-smaller bladder capacity-children urinate more frequently - >Age 2: less efficient at: electrolyte and acid-base balance (kidneys not fully developed); excretion of drugs from body (be careful with meds w/ small children); concentrating urine (children unable to concentrate urine)
Cleft lip and palate
-structural defect -can occur together or separately -fusion of lip and palate occur separately during development -cleft lip can occur unilaterally or bilaterally -baby unable to compress/ suction -baby unable to feed due to dental deformity -speech issues -higher risk for otitis media (frequent infections can affect hearing)
GU assessments:
-urine characteristics (clear, cloudy, yellow, red, pink, odor, sediment, amount, etc.) -pain or discomfort, location of pain -edema (generalized, dependent, location) -appearance of genitalia- check for any abnormalities)
Pyloric stenosis (nursing management):
-weigh daily I & O's -** post-op-start small, frequent feedings (prevents vomiting) -keep baby upright and settled X 30 mins after feeding -** do not lift legs to change diaper- puts pressure on abdomen, turn baby on side -infection prevention-incision care, monitor temps and respiration -pain mgmt- pacifier, swaddling, meds, etc -evaluation-no vomiting, able to nurse, weight gain, no signs of infection, no pain
A 2 month old infant is brought to the pediatric clinic. The infant has had vomiting and diarrhea for 24 hours. The infant is irritable and his anterior fontanel is sunken. Which of the following will help confirm the diagnosis of dehydration?
Analysis of serum electrolytes
Celiac Disease (nursing management):
Dx: Fecal fat (unable to absorb fat-fatty stools occur), duodenal biopsy, clinical improvement (taking child off foods containing gluten--most used test, special serum antibodies Tx: lifelong gluten/gliadin free diet (difficult because gluten is in so many foods), seek help from dietician -teaching- allowed foods, risk of noncompliance
The nurse is teaching the familiy about nephrotic syndrome and explains the clinical manifestations are due to which of the following?
Increased permeability of the glomeruli
Assessment guidelines for The Child With a Gastrointestinal Condition:
Inspect, auscultate, palpate, percuss, mouth and esophagus, nutrition, stool, family history
Nephrotic Syndrome (Nursing mgmt)
Interventions: -monitor side effects of meds -prevent infection -prevent skin breakdown -meet nutritional & fluid needs -promote rest-schedule rest periods (don't overdo activities) Support and home care teaching *****(Steroid treatment is major difference from Acute Glumerolonephritis)*****
Closure of anterior and posterior fontanel:
The anterior fontanel closes within 18 months, whereas the posterior fontanel closes within 8 to 12 weeks.
The predominant signs of or symptoms of hydrocephalus are different in infants as compared to older children.
True (due to anterior and posterior fontanels closures in infants)
Acute Diarrhea (nursing care plan, p. 1085-86):
Tx: depends on severity and cause, slow losses, rehydrate w/ adequate electrolytes and nutrition (PO or IV) -preventing dehydration by treating cause to slow down diarrhea
Cryptorchidism (reproductive)
a condition in which one or both of the testes fail to descend from the abdomen into the scrotum. -most descend spontaneously by 3 mths -orchiopexy/orchidopexy- 1 yrs old-surgery to undescend testical and permanently fix it there -hernia repair, if needed -normally hereditary -Post-op care: bed rest, monitor voiding, ice to surgical area, analgesics -Teaching: incision care, keep site clean dry, meds PRN, no tub bath X 2 days, avoid straddling on hip or straddling on toys X 2 weeks S/s of infection: redness, swelling
Gastroenteritis
acute illness, major killer of young children, characterized by extreme vomiting and diarrhea, results in dehydration and hypovolemic shock
The nurse is caring for a 14 year old girl with celiac disease. The nurse knows that the patient understands the diet instructions by ordering which of the following meals?
cheese, banana slices, rice cakes and whole milk (must be gluten free)
Cardiac sphincter
circular muscles located where the lower end of the esophagus joins the stomach. The muscle serves as the valve that contracts to prevent acid reflux and relaxes to allow food to pass.
Nursing Care Plan: the infant With a Cleft Lip or Palate
p. 1325-1327
Health Promotion the Child With Cleft lip or Cleft Palate
p. 1329
FLACC pain management scale for infants:
p. 969
Epispadias (urinary tract), pic on p. 1369
the canal is open on the dorsal (upper) surface. -bladder outside body -defect from bladder to top of penis -rare but major defect
Hypospadias (urinary tract), pic on p. 1369
the urethral canal/meatus is open on the ventral (underlying) surface of the penis rather than tip of penis. -most often noted at birth -non-emergent -male normally not circumcised, extra tissue used for repair -Dx: Prenatal U.S., observation during newborn assessment -Tx: Surgical -Meds: Analgesics, prophylactic antibiotics, anticholinergics (helps to reduce bladder spasms)
The nurse is caring for a 4 year old who weighs 15 kg (33lbs). At the end of a 10- hour period, the nurse notes the urine output to be 150 mL. The nurse determines that the urinary output for this child during the period is:
within the expected range of output---(child normal range is 0.5 to 1ml/kg/hr)
Operation smiles
works on childrens palates from 3rd world countries
Secondary enuresis
—Child who has been reliably dry for at least 6 months begins bed-wetting; associated with stress, infections (UTI), and sleep disorders. -may be 1st sign of diabetes if onset gradual -may avoid sleeping to prevent bedwetting -correcting the issue is necessary
Abdomen—auscultation
• Auscultate for bowel sounds in all four quadrants prior to palpation.
Mouth and esophagus
• Note the presence of increased oral secretions. • Note the presence of cleft lip or palate.
Nutrition
• Note tolerance of feedings, spitting up, emesis, and recurrent respiratory infections. • Observe amount, color, and frequency of emesis. • Note if emesis is associated with feeding and whether or not it is projectile. • Note amount of intake, frequency of feedings, and growth.
Stool
• Observe color, consistency, and size of stool. *Note any changes in stool patterns.
Abdomen—inspection
• Observe the shape of the abdomen. • Note any abdominal distention. Measure abdominal girth. • Observe the umbilicus for protrusion. • Observe for peristaltic waves (visible rhythmic contractions of the intestinal wall smooth muscle). • Observe for jaundice, bruising, and increased bleeding.
Abdomen—palpation
• Palpate the abdomen and note if it is soft or firm. • Palpate the size of the umbilical ring. • Does the child complain of pain or tenderness during palpation? Does the infant cry? • Describe any masses palpated by location, shape, size, and consistency. • Palpate the liver for size and tenderness. • Palpate the spleen for size and tenderness.
Calculating urinary output:
Check: Pediatric Urine Output Calculation. The expected urine output for an adult is > 0.5mL/kg/hour, so an average adult of 70kg would be expected to produce 35-40ml/hour of urine. For children, the expected urine output is closer to 1ml/kg/hour. The normal urine output for adults is 1 ml/min, regardless of weight.
Urinary output ranges:
Check: The normal range for 24-hour urine volume is 800 to 2000 milliliters per day (with a normal fluid intake of about 2 liters per day). Oliguria is urine output < 500 mL in 24 h (0.5 mL/kg/h) in an adult. Oliguria is urine output < 1 L in 24 h (1 mL/kg/h) in a child.
Primary enuresis
Child has never had a dry night; attributed to maturational delay and small functional bladder; not associated with stress or psychiatric cause. -delayed neuromuscular maturation-unable to stay dry -small bladder capacity-unable to get to toilet quick enough -may improve as children grow -school age child may become embarrassed, not at fault, unable to control
A nurse is caring for a child recently diagnosed with cerebral palsy and the parents of the child ask the nurse about their disorder. The nurse bases her response on understanding that cerebral palsy is:
A chronic disorder characterized by impaired muscle movement and posture.
Metabolic alkalosis
A disorder caused by too much or too little metabolic acid is called a metabolic acid-base imbalance.
Peristalsis
A progressive, wavelike muscular movement that occurs involuntarily throughout the gastrointestinal tract.
Grains containing gluten:
Barley, rye, wheat and sometimes oats
Treatment of Acute diarrhea:
Mild to moderate-Oral rehydration is the treatment of choice to treat mild and moderate dehydration in children. -oral rehydration successfully treats the dehydration caused by many gastrointestinal illnesses and prevents hospitalization for many infants and young children. -Commercially available solutions contain water, carbohydrate (sugar), sodium, potassium, chloride, and lactate. (Ex. Pedialyte, Infalyte, Rehydralyte, Ric-elyte, Resol, Nutrilyte, Hydralyte, and Lytren. -Some clinicians allow lactose-free milk, breast milk, or half-strength milk to be given in addition to oral rehydration therapy solution. -Oral rehydration may be accompanied by ondansetron to decrease vomiting in the child and its resultant continued dehydration. **Severe-When the child is severely dehydrated, electrolytes are measured by lab analysis, and isotonic IV fluid is given, often accompanied by oral rehydration. The IV fluid is commonly Ringer lactate or dilute saline, such as one half or one quarter normal saline (see Table 44-4 for types of intravenous fluids and their uses). The fluid combination replenishes the extracellular fluid volume and adds solutes to return the body fluid back to normal. -Note that only isotonic solutions are used for rapid infusion, and D5W is avoided for this treatment. -The child may be hospitalized or treated with intravenous fluids in a short-stay unit until the dehydration is controlled. Once hydrated, the child resumes an age-appropriate diet. ---some trad'l Tx are not approp. today due to high sugar content
A 2 year old is admitted to the neurosurgical unit following a head injury. The nurse is using the Glasgow Coma Scale to measure neurological functioning. Which of the following assessment findings indicate the lowest level of functioning for this child?
No response to painful stimuli
Which of the following will the nurse recognize as a major goal of treatment for children with cerebral palsy?
Promoting a maximum level of independence
A nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the preoperative period, the priority nursing diagnosis would be:
Risk for infection
Acute Post-infectious Glomerulonephritis (S/S, Labs & Tx)
S/S: -many children asymptomatic -child may complain of flank pain or abdominal pain -urine may be tea-colored due to microscopic amts of blood or they may be really sick w/ gross red blood in urine -Edema around eyes (peri-orbital) & generalized edema (ankles, feet, etc.) -may not be producing urine at all Labs: -kidney labs (GFR, creatine, etc.) Tx: -Relief of S/S & supportive care -Bedrest, Tx edema, HTN **Child eventually recovers, no real Tx**
GI differences in a pediatric patient:
Small stomach capacity (spits up more if full & fed more often in smaller amts); relaxed cardiac sphincter (When relaxed, a sphincter allows materials to pass through the opening. When contracted, it closes the opening.); bowel mvmts several x per day; decreased enzymes (difficulty digest proteins except for breast milk); belly distention from gas (colicky, gasey); immature liver (decreased enzymes for digestion); usually health babies, sometimes premies
The nurse is caring for a 4-month old infant who has had an isolated cleft lip repair. What is the best position for the child in the immediate postoperative period?
Supine