Packet 2: Child with Gastrointestinal Dysfunction
►Etiology of Acute Appendicitis: It is usually caused by an obstruction in the lumen; a fecalith [hard fecal material].
--Dietary habits may play a role. --Studies show that children with high Fiber diets have a lower incident of appendicitis compared to those with low Fiber intake.
Disorders of Motility:
-Diarrhea; -Constipation; -Hirschsprung Disease; -Vomiting; and -GERD
Ulcerative Colitis (UC):
Toxic megacolon and Hemorrhage from rectal bleeding (remember to monitor CBC values for associated anemia.)
What is the most reliable tool to diagnose PUD?
Upper endoscopy
Obstructive Disorders: Intussusception ►Clinical Manifestations:
~Classic presentation is a healthy child who suddenly develops abdominal pain. ~Pain is acute (episodic). ~May have vomiting, palpable mass (sausage shaped in Rt. upper quadrant), and bloody stools. ~Note: the bloody stools look like currant [red] jelly; this is fecal material with blood and mucous. ~Eventually fever, peritonitis.
2. Hypotonic Dehydration (hyposmotic or hyponatremic)
§May be caused by excessive perspiration, severe diarrhea, or administration of oral or IV fluids without electrolytes added. §Volume and Na+ should be replaced within 24 to 36 hours.
►PUD is an erosion of the mucosal wall of the stomach, pylorus, or duodenum. It is described as a primary or secondary ulcer
§Primary - occurs in the absence of a predisposing factor, occurs more frequently in older children and adolescents. §Secondary - also called stress ulcers, results from stress of a severe underlying disease or injury (ie. severe burns, sepsis, or multisystem organ failure), or from ingestion of ulcerogenic drugs (ie. salicylates, NSAID's, ferrous sulfate).
Malabsorption Syndromes: Celiac Disease ►Planning and Intervention:
§Promote optimal nutrition through education and support regarding dietary restrictions, which is indefinitely: gluten-free diet or "low" in gluten diet §supplemental vitamin, iron, and folate §temporary lactose-free diet for children with severe mucosal damage §avoidance of high-fiber foods such as nuts, raisins, raw vegetables, and fruits with skin until inflammation subsides. §temporary TPN in cases of severe malnutrition §refer parents for nutritional counseling in diet planning.
3. Hypertonic dehydration (hyperosmotic or hypernatremic)
§Related to severe diarrhea in infants.
►Acute Hepatitis
►Hepatitis is the inflammation of the liver. ►It is either caused by a virus, chemical or drug reaction, or some other disease process.
►Breastfeeding, if being done, should be continued as a supplement to the ORS.
►Once rehydration has occurred: Start School Age children on Bland foods while Older children may have a regular diet.
Structural Defects: Esophageal Atresia: ►In the immediate post-op period, an NG tube to low-suction, parenteral nutrition and the G-tube (if applicable) is open to gravity drainage.
►Post-op: Usually after surgery the infant is discharged with a gastrostomy tube for feeding till the wound is healed. --Parents need instructions on feeding and support regarding child's condition. --Non-nutritive sucking should be provided with a pacifier to promote oral stimulation. ►Survival rate is usually 100%.
►Solutions are comprised of fluid (the solvent) and particles (the solute) dissolved in the fluid. ►Changes in the level of solute concentration influence the movement of water between the fluid compartments.
►Since isotonic solutions have the same concentration of solutes as plasma, infused isotonic solutions do not move into the cells. ►Rather, it remains within the extracellular fluid compartment and is distributed between the intravascular and interstitial spaces, thus increasing intravascular volume.
►Infants and children with acute diarrhea usually are treated with oral rehydration solutions (ORS). ►ORS are balanced glucose-electrolyte solutions; i.e., Pedialyte (Ross).
►Soda, Fruit juices, gelatin or broth are not considered ORS. ---The glucose in the solution functions to facilitate the transport of Na+ across the bowel wall. (Remember: Water follows Na+).
►Metabolic Alkalosis can be caused by a gain in base or a loss of acid.
►Some Causative Clinical Condition for Metabolic Alkalosis: Vomiting; NG suctioning; and steroids.
►Respiratory Alkalosis is caused by a primary increase in the rate and depth of pulmonary ventilation, resulting in unusually large amounts of carbon dioxide being exhaled, or "blown off".
►Some Causative Clinical Conditions for Respiratory Alkalosis: CHF; PE; Fear; Pain; Asthma; Fever; Sepsis; Hyperventilating
►Extensive testing is unnecessary for uncomplicated diarrhea, without dehydration.
►Stool specimens may reveal: bacterial infections, ovum and parasites.
►The intracellular fluid is the fluid inside of cells, and
►The extracellular fluid is the fluid outside of the cells (interstitial = fluid between cells & vascular = fluid in the blood vessels).
1. Isotonic Dehydration (isosmotic or isonatremic)
►The major loss involves extracellular components and circulating blood volume, making the child susceptible to hypovolemic shock.
Malabsorption Syndromes: Celiac Disease ►Pathophysiology:
►Unable to digest the gliadin faction, resulting in an accumulation of a toxic substance that is damaging to the mucosal cells. ►This damage reduces the absorptive surface of the small intestine.
6 Types of Hepatitis:
-HAV -HBV -HCV -HDV -HEV -HGV
Daily Maintenance Fluid Requirements
1-10 kg --------------------100 mL/kg 11-20kg ------------------- 1000 mL/kg + 50 mL/kg > 10 kg > 20 kg ------------------- 1500 mL/kg + 50 mL/kg > 20 kg
►Cleft palate (CP) is a midline fissure of the palate that results from failure of the two sides to fuse.
CP alone occurs in the midline and may involve the soft and hard palate.
Also, with the onset of diarrhea, avoid caffeinated drinks since the diuretic effect causes more loss of water and sodium; and do not give chicken or beef broth since it contains excessive sodium and inadequate carbohydrates.
Infants and children with diarrhea who are unable to drink due to N/V or lethargy; NEED IV Fluids to replace their loses of fluids & electrolytes
►It is a significant Pediatric problem because early diagnosis is delayed because the child cannot verbalize the symptoms or it is mistaken for other illnesses.
Acute Appendicitis
What is the leading cause of illness in children younger than 5 y.o.?
Acute Diarrhea: ►More often it is caused by an inflammatory process of infectious origin. ►The infectious origin may be viral, bacterial, or a parasite. ►Rotavirus is the most frequent cause of acute diarrhea in young children. ~~~Rotavirus attacks the absorptive cells of the small bowel, causing watery diarrhea.
Dehydration Pathophysiology: ~Depending on the cause and nature of the fluid loss, a child will loose both water and electrolytes. ~~Dehydration is classified into 3 categories which is dependent on serum Na+ concentration and osmolality. ~~~(Dehydration is described according to plasma sodium concentration (isonatremic, hyponatremic or hypernatremic) since sodium is the primary osmotic force that controls fluid movement between the major fluid compartments.)
Clinical Manifestations: Weight loss, poor skin turgor, increased heart rate, increased respiratory rate, lethargy, decreased urine output, dry mucous membranes, decrease tear production, sunken eyes, and depressed fontanel.
►Cleft lip (CL) can be unilateral or bilateral.
Deformed dental structures are associated with CL.
►5. Hepatitis E (HEV) -
Epidemic transmission after natural disasters (ie. flood) because of fecal contaminated H20 or food. Not chronic. No carrier state.
Obstructive Disorders ►Hypertrophic pyloric stenosis (HPS):A narrowing of the outlet from the stomach to the small intestine (called the pylorus) that occurs in infants. ►Obstruction at the pyloric sphincter by hypertrophy (increased size) and hyperplasia (increased mass) of the circular muscle of the pylorus. ►Seen after birth with vomiting that becomes progressively more severe and projectile. ►Five times more common in males than in females.
Etiology: Cause of the increased size of the pyloric musculature is unknown. There is a familial tendency.
Dehydration: Definition: Excessive loss of water from the body tissues. Total fluid output exceeds intake; see below for possible causes.
Etiology: Excessive N/V, Excessive diarrhea, Prolonged High Fever, DKA, Severe Burns, and Insufficient Fluid Intake
Obstructive Disorders: Intussusception Defined: invagination or telescoping of one portion of the intestine into an adjacent portion, causing obstruction.
Etiology: Cause is unknown. It may be associated with viral infections, intestinal polyps, Meckel's diverticulum or lymphoma. Typically affects children between the ages of 3 months and 5 years. It is twice as common in males as females.
►3. Hepatitis C (HCV); also known as [Non-A, Non-B] Transmission largely by blood transfusion or percutaneous inoculation (ie. IV drug users sharing needles). Incubation period ranges from 14 days to 6 months.
In 50% of the patients acutely infected, the disease progresses to chronic hepatitis, causing cirrhosis and hepatocellular carcinoma.
Obstructive Disorders: Intussusception ►Pathophys:
Invagination typically begins with hyperperistalsis in an intestinal segment, most often at or near the ileocecal valve. ►Peristalsis continues to pull the invaginated segment along the bowel; intestinal edema and obstruction occur and blood supply to the area is cut off. ►Intussusception rarely reduces spontaneously. ►Initial treatment focuses on reduction through barium enema (hydrostatic reduction); if this proves unsuccessful, surgical reduction is required. ►If treatment is delayed for longer than 24 hours, bowel strangulation may occur, leading to necrosis, hemorrhage, perforation, peritonitis, and shock. ►If untreated, intussusception is incompatible with life.
►Malnutrition is a common feature of IBD (inflammatory bowel disease).
It is a problem for children and adolescents since it alters the body composition and disturbs the Growth and Sexual maturation process.
►4. Hepatitis D (HDV) -
Occurs only in patients infected with HBV. HDV relies on HBV replication and cannot replicate independently. The disease develops into a chronic state. Transmitted via sexual intercourse and needle sharing. Treatment is prevention of HBV.
Structural Defects: Cleft Lip/Palate ►Preoperatively:
Provide mouth care to prevent infection.
Malabsorption Syndromes: Celiac Disease ►Clinical Manifestations:
S/S typically appear within 3 to 6 months after introduction of gluten to the diet. (ie. wheat, barley, rye, oats) S/S from impaired fat absorption: ►Steatorrhea and exceedingly foul smelling stools. ►Stools are watery and pale in color. S/S from impaired absorption of nutrients: malnutrition (wt. loss, growth failure), muscle wasting, edema in lower extremities d/t hypoproteinemia, anemia, anorexia, abdominal distention, vomiting, abdominal pain, intestinal bleeding from disturbed blood coagulation d/t inadequate vitamin K absorption and ecchymosis. S/S in behavioral changes: irritability, apathy, uncooperativeness.
►Metabolic Acidosis can be produced by the gain of nonvolatile acids or the loss of bicarbonate. §(Strong acid gain and bicarbonate loss.)
Some Causative Clinical Condition for Metabolic Acidosis: renal failure; DKA; diarrhea; starvation; salicylate intoxication
►Acidosis (both metabolic and respiratory) has clinical signs of
depression of the Central Nervous System (CNS), manifested by lethargy, diminished mental capacity, delirium, stupor, and coma.
►Fluid and electrolyte disturbances (due to diarrhea, vomiting, fever) occur more frequently and develop more rapidly in infants and young children than
in older children and adults.
►6. Hepatitis G (HGV) =
is an RNA virus with a structure similar to that of hepatitis C virus (HCV). HGV is blood-borne. High risk groups include transfusion recipients, IV drug users, and individuals infected with HCV. Virus is responsible for approx. 0.3% of cases of acute viral hepatitis. Individuals with the virus are often asymptomatic, and most infections are chronic.
►Alkalosis (both metabolic and respiratory) produces clinical manifestations of
nervous system stimulation and excitement, including overexcitability, nervousness, tingling sensations, and tetany, that may progress to seizures.
►Several studies have examined the effectiveness of_____________________________for infants with GER.
positioning therapy
Objectives of therapy for children with Peptic Ulcers is to
relieve discomfort, promote healing; Histamine (H2)receptor antagonists - ie. Tagamet (cimetidine) is usually prescribed for the treatment of PUD. Antacids - usually a liquid aluminum or magnesium preparation is also helpful. •These are administered every 1-3 hours after each meal and at bedtime. •Diarrhea may occur with large amounts of magnesium containing antacids. Triple drug therapy is the standard first line treatment regimen for H. pylori and has demonstrated 90% efficacy in the eradication of H. pylori. Nursing Goal - Promote healing of the ulcer through compliance with the medication regimen.
In terms of acute appendicitis, what becomes inflamed?
veriform appendix
►Management of simple constipation consists of a plan to promote regular bowel movements by
~changing the diet to provide more fiber and fluids, ~eliminating foods known to be constipating, and ~establish a bowel routine for regular passage of stool.
►Uncompensated:
§--pH is abnormal §--Either CO2 or HCO3 is abnormal
►Partially Compensated:
§--pH is abnormal §--Both CO2 and HCO3 are abnormal
►Compensated:
§--pH is normal §--Both CO2 and HCO3 are abnormal
Malabsorption Syndromes: Celiac Disease Diagnosis
§Biopsy of the small intestine revealing flat mucosal surface, absence or atrophy of villi, and deep visible crypts. §These characteristic lesions return to normal after dietary restriction of gluten. §Stool analysis for fecal fat level. §Low iron level and inadequate vitamin B12 and folic acid.
►Water is the major constituent of body tissues. Body water is expressed as a percentage of body weight; this percentage varies with age:
§In Infants: total body water constitutes 80% of body weight. §By age 3 years, total body water constitutes about 65% of body weight. §By age 15 years, total body water constitutes about 60% of body weight.
Structural Defects: Cleft Lip/Palate ►Postoperatively:
►1. Assess airway patency and V.S.; observe for edema and respiratory distress. ►2. Use mist tent; minimize edema, liquefy secretions and minimize distress. ►3. Positioning: -After CL repair (cheiloplasty) = Place child on his/her back in an infant seat, or propped on side to avoid injury to operative site. ►If prescribed by the physician; Apply thin layer of antibiotic ointment to suture line. -After CP repair (palatoplasty) = Place child on his/her abdomen to facilitate drainage. ►4. Use elbow restraints to maintain suture line integrity (some surgeons do not support that practice. ) -Remove every 2 hours for ROM and opportunity for cuddling and body contact. ►5. Keep Logan's Bow in place for children with CL repair. (Not mentioned in Wong's text). -(A metal appliance to relax the surgical site and prevent tension on suture line caused by crying or other facial movement. Taping would work also.) ►6. Narcotics may be given post-op for pain. ►7. (For both, rinse mouth with water after feedings.) -CL = Clear liquids with special Needs feeder, then when the lip is healed may use baby bottle. -CP = fluids are best given with an open cup (prevent disruption of suture line) then advance to a soft diet. Caution children not to rub their tongue against the roof of the mouth.
Obstructive Disorders: Intussusception ►Dx: Barium enema; The use of barium as a contrast agent is becoming less routine. Water soluble contrast and air pressure to reduce intussusceptions are being used. ►Treatment:
►First: NON-surgical hydrostatic reduction by water soluble contrast, air pressure or barium enema at the time of diagnostic testing. ***Note: if by chance a child passes normal brown stool prior to the hydrostatic reduction notify the physician, because the intussusception may have resolved on its own. ►Second: If hydrostatic reduction is not successful, then surgery. ►Nursing Responsibilities: Nurses observe for passage of barium (if barium used during hydrostatic reduction) and stool pattern after hydrostatic reduction.
Celiac Disease is: ►chronic inability to tolerate foods containing gluten ►exact cause of CD is unknown; possibly an abnormal immunologic response. ►occurs more frequently in Europe than in U.S. and rarely in African Americans or Asians.
►Foods allowed for Gluten-free diet: Meats: beef, pork, poultry & fish. Eggs. Dairy Products: milk, cream, cheese. 🍓All Fruits/Vegs 🌽Grains: rice, corn, gluten-free wheat flour, puffed rice, corn flakes, corn meal, precooked gluten-free cereals ►Food not allowed: Beer, ale, wheat, rye, oats, or barley.
►The basic elements related to fluid and electrolyte balance include: body water; electrolytes and pH. ►The obvious physical difference between young children and adults is size.
►However, children are NOT miniature adults. The child's body composition and homeostatic controls differ from those of the adult.
Structural Defects: Esophageal Atresia ►Nursing Responsibilities: For detection of this serious malformation begins immediately after birth.
►If the infant swallows normally but suddenly coughs and struggles and has excessive amount of frothy saliva in the mouth and coming through the nose, unexplained episodes of cyanosis then suspect TEF/EA. (Esophageal Atresia (EA) with Tracheoesophageal Fistula (TEF) ) ►Note: for this reason the infant is given plain water for the first feeding or nurse should be present for the first feeding, ie. Breast feeding.
Umbilical Hernia: a protrusion of the bowel through an abnormal opening in the abdominal wall; in children, most commonly at the umbilicus
►In umbilical hernia, incomplete closure of the umbilical ring results in protrusion of portions of the omentum and intestine through the opening. ---The defect usually closes spontaneously by 3 to 5 years; surgical correction is necessary if closure does not occur or if the herniated bowel becomes trapped (incarcerated). ►s/s of umbilical hernia is a soft swelling or protrusion around the umbilicus, usually reducible with the finger. ►A trapped or incarcerated hernia causes irritability, tenderness at the site, anorexia, abdominal distention, and difficulty defecating; may lead to complete intestinal obstruction and gangrene.
►Constipation may occur due to organic disorders, structural disorders, or systemic disorders.
►It can also be caused by a wide range of drugs: i.e.. ~Antihistamines, ~opioids (narcotics), ~iron supplements, ~antacids, ~diuretics and ~Dilantin.
►Daily Maintenance Fluid Needs (DMFN) represent the fluid a patient needs over 24 hours.
►It combines maintenance fluids (both orally and parenterally), medications, diluent for medications, and fluids used to flush the injection port. ►The amount of maintenance fluid required varies according to weight.
Structural Defects: Cleft Lip/Palate ►Etiology:
►Majority of cases are consistent with multifactorial inheritance; could be a result of chromosomal abnormalities, environmental factors, or teratogens (any substance that interferes with normal development) at a critical point in embryonic development. ►CL = 1 out of 600 births, common among boys. ►CP = 1 out of 2500 births, common among girls.
►Children may have associated dental malformations, speech problems, and frequent otitis media (from improper functioning of the Eustachian tubes).
►Note: Even with good anatomic closure, the child may have problems with otitis media secondary to improper drainage of the middle ear from an inefficient Eustachian tube. ►Pathophysiology: §CL = occurs between 7-8 weeks of gestation. §CP = occurs between 7-12 weeks of gestation.
Hepatic Disorders (6 types of Hepatitis) Treatment: ►Hepatitis B immune globulin (HBIG) is effective in preventing HBV infection after exposure. ►HBIG must be administered less than 2 weeks after exposure. ►Hepatitis C: The goal of HCV treatment is to cure the virus, which can be done with a combination of drugs.
►Nursing Considerations: --Hand washing is the single most critical measure in reducing risk of hepatitis transmission in any setting. --Important to explain to parents and children how HBV (parenteral route) and HAV (oral-fecal route) are spread.
Structural Defects: Cleft Lip/Palate ►Clinical Assessment: Rule out CP by palpating the palate with the finger during the newborn assessment. Also observe mouth when child cries.
►Nursing Dx: ►Altered family process. -Severe parental reaction to the defect. ►Altered Nutrition: less than body requirements. ►Ineffective infant feeding pattern.
►Osmolality, which is usually used to describe fluids inside the body, refers to the solute concentration in fluid by weight: the number of milliosmols (mOsm) in a kilogram (kg) of solution.
►Osmolarity refers to the solute concentration in fluid by number of mOsm per liter (L) of solution. ►Because 1Liter of water weighs 1 Kg, the normal ranges are the same and the terms are often used interchangeably.
►S/S of a ruptured appendix: Sudden relief of pain at time of perforation and fever due to peritonitis.
►Pain Management: Allow the child to assume a position of comfort to relieve the abdominal discomfort. Usually side lying with legs flexed. A small pillow placed against the abdomen may provide some relief. ►Do NOT administer laxatives, enemas, or apply heat to the abdomen when there is severe pain. ►These will stimulate bowel motility and can increase the risk of perforation of the appendix.
Structural Defects: Cleft Lip/Palate ►Long-term Care:
►Stress to parents the importance of speech therapy, correcting dental defects, and having child's hearing evaluated and the possibility for increased chance of otitis media.
►Vomiting is not a contraindication to ORS. ►Spoon-feeding seems to minimize the vomiting.
►The ORS should be given in small amounts at frequent intervals.
►Compared with isotonic solutions, hypotonic solutions have a lower concentration, or tonicity, of solutes (electrolytes). ►Infusing a hypotonic solution into the vascular system causes an unequal solute concentration among the fluid compartments.
►The infusion of hypotonic crystalloid solutions lowers the serum osmolality within the vascular space, causing the fluid to shift from the intravascular space to both the intracellular and interstitial spaces. ►These solutions will hydrate cells, although their use may deplete fluid within the circulatory system.
►Compared with isotonic solutions, hypertonic solutions have a higher tonicity or solute (electrolytes) concentration. ►Infusing a hypertonic solution into the vascular system causes an unequal pressure gradient between the inside and outside of the cells.
►The osmotic pressure gradient draws water out of the intracellular space, increasing extracellular fluid volume. ►Because of this property, hypertonic solutions are used as volume expanders. ►Note: Colloid solutions are also know as volume expanders or plasma expanders since they contain molecules too large to pass through semipermeable membranes , such as capillary walls, and thus remain in the intravascular compartment.
Obstructive Disorders: HPS ►Pathophys & Mgmt.:
►The pylorus narrows because of progressive hypertrophy (increase in size) and hyperplasia (increase in # of cells) of the circular pyloric muscle. ►The muscle may grow to twice its size. ►This leads to obstruction of the pyloric sphincter, with subsequent gastric distension, dilatation and hypertrophy. ►Pyloromyotomy (creation of a longitudinal incision along the anterior pylorus to split the muscle) is commonly performed to relieve obstruction.
►Goal of therapeutic management in cases of diarrhea is to correct the fluid imbalance and treat the underlying cause.
►The use of antidiarrheal medications with acute infectious diarrhea is NOT recommended. ----May have adverse effects due to the slowed intestinal motility and possibly develop an ileus.
►The body water which is also called body fluid contains electrolytes.
►These include Na+, K+, Ca++, Mg++, Cl-, and inorganic phosphorus (Pi).
►Newborn and premature infants have less homeostatic buffering capacity than do older children.
►They have a tendency toward metabolic acidosis, with pH averages slightly lower (7.30-7.35) than normal.
►Clefts of the lip and palate are facial malformations that occur during embryonic development. ►It is a congenital anomaly (appearing at birth).
►They may appear separately or, more often, together. ►Cleft lip (CL) results from failure of the maxillary and median nasal processes to fuse.
Structural Defects: Esophageal Atresia ►Position: §Infant with TEF is positioned with the head elevated to prevent aspiration of either mouth or stomach secretions.
►Treatment:Prevention of pneumonia and surgical repair. --For prophylactic reasons the infant is started on broad spectrum antibiotics to prevent pneumonia. --When EA with TEF is suspected, the infant is immediately deprived of oral intake, IV fluids initiated. --Accumulated secretions are suctioned frequently from the mouth and pharynx. --In some cases a G-tube is inserted and left open so that any air entering the stomach through the fistula can escape.
►At this time, the available information suggests, the prone position (lying on stomach) be used by either up on the shoulder or across the lap after feeding.
►Use of the prone position while the infant is sleeping is still controversial. The American Academy of Pediatrics recommends the supine position to decrease the risk of sudden infant death syndrome, even in infants with GER.
Hirschsprung Disease (Megacolon) ►Pathophysiology:
♦It is the failure of the ganglion cells to migrate craniocaudally. The aganglionic segment almost always includes the rectum and a proximal portion of the large intestine. ♦♦Absence of peristalsis in the aganglionic bowel causes accumulation of intestinal contents and distention of the bowel proximal to the defect: thus megacolon. ♦♦♦This aspect of a megacolon contributes to the development of enterocolitis (inflammation of the small bowel and colon); it is the leading cause of death in children with Hirschsprung disease.
►2. Hepatitis B (HBV) - Wide spectrum of acute and chronic infection. Virus is transmitted in contaminated serum in blood transfusion, by sexual contact with an infected person, or by the use of contaminated needles and instruments.
♦♦♦Contaminated fluids splashed into the mouth or eyes can cause infection. ♦♦♦Most HBV in children is acquired perinatally: mother infected with HBV or was a carrier of HBV during pregnancy.
►1. Hepatitis A (HAV) - Acute and mild illness. No known carrier state. Highly contagious and is transmitted from one person to another primarily by the fecal-oral route.
♦♦♦Direct contact through fecal contaminated food or H20. ♦♦♦Wash hands after urinating and after bowel movements. ♦♦♦Prophylaxis with immune globulin is effective in household and sexual contacts. ♦♦♦Incubation period 4 weeks approximately.
►Rebound tenderness is NOT a reliable sign of acute appendicitis and is extremely painful to the child.
⚠ RLQ abdominal pain ⚠ Fever ⚠ Rigid abdomen ⚠ Decreased or absent bowel sounds ⚠ Vomiting; Constipation; Diarrhea ⚠ Anorexia ⚠ Tachycardia; Rapid, shallow breathing ⚠ Pallor; Lethargy; Irritability ⚠ Stooped posture
GERD Treatment ►No therapy is needed for the infant who is thriving and without respiratory complications.
〰Avoid vigorous play after feedings and avoid feeding just before bedtime. 〰Breast-feeding may continue. 〰Avoid feeding the child spicy foods or any foods that aggravate the symptoms (such as: caffeine, chocolate, tobacco smoke, and alcohol when breast-feeding.)
►When regurgitation is severe and growth is a problem, medications, NG tube feedings and possible surgical intervention may be indicated:
🔰Prescribed cimetidine [Tagamet] a Histamine (H2)receptor antagonists or proton pump inhibitor (PPIs) should be given 30 minutes before the morning and evening feeding so that peak plasma concentrations occur with mealtime. 🔰NG tube feedings may decrease the amount of emesis and provide constant buffering of gastric acid. 🔰The Nissen fundoplication is only done on infants with GER in severe cases with complications.
►The American Academy of Pediatrics no longer advises withholding food and fluids for 24 hours after the onset of diarrhea, or administration of the BRAT diet (banana, rice, applesauce and tea or toast).
A BRAT diet is contraindicated for the child and especially for the infant with acute diarrhea, since this diet has little nutritional value (low in energy and protein), is high in carbohydrates, and is low in electrolytes.
Infants and very young children are more vulnerable to alterations in fluid and electrolyte balance because their bodies have:
1. A higher proportion of H20 content and a greater surface area. 2. Greater proportion of fluid in the extracellular spaces. 3. A higher metabolic rate that increases the rate at which body water must be replenished (also called H20 turnover). a. Infants and young children's metabolic rate is two times higher per unit of weight than that of adults. b. Increased metabolic rate results in greater metabolic wastes. 4. Functionally immature kidneys a. The infants kidneys are unable to concentrate urine effectively. b. As a result, the infant is less able to handle large quantities of solute-free H20, more apt to become dehydrated when given concentrated formula or over-hydrated when given excessive H20. 5. Greater insensible H20 loss; proportionately greater body surface area. 6. An inability to shiver or sweat to control temperature. a. Infants and children have a much greater tendency to become highly febrile than do adults. b. Fever increases insensible H20 loss by approx. (7 ml / kg / 24 hrs.) for each degree rise in temperature above 99 degrees F. Note: Important to increase fluid requirements when a child has a fever.
Hirschsprung Disease: Treatment: Treatment is primarily surgery to remove aganglionic portion of the bowel to permit normal bowel motility. This is accomplished in two stages:
1st. Temporary ostomy site proximal to aganglionic segment. (Bowel rest is the goal.) 2nd. Complete correction via "Soave endorectal pull-through procedure." (Ostomy is closed during this time.) ►2nd. Complete correction via "Soave endorectal pull-through procedure." Ostomy is closed during this time. §Note: "Soave endorectal pull-through procedure" consists of pulling the end of the normal bowel through the muscular sleeve of the rectum, from which the aganglionic mucosa has been removed.
Crohn Disease (CD):
abdominal pain with cramps, Fistulas, Abscesses, perianal lesions, Perforation and growth retardation (malabsorption and anorexia).
Structural Defects: Cleft Lip/Palate ►Planning and Implementation: Ensure adequate nutrition and prevent aspiration.
►1. Provide special nipples or feeding devices (ie. soft pliable bottle with soft nipple with enlarged opening). -The child is unable to suck adequately on standard nipples due to the CL / CP. -Liquid taken into the mouth tends to escape via the cleft through the nose. -Various feeding nipples: i.e. Special Needs Feeder (formerly Haberman bottle), and Pigeon bottles use a one-way flow valve that allows the infant to feed by compressing the nipple chamber between the tongue and the intact palatal segments. ►2. Hold the child in an semi-upright position and direct the feeding away from the cleft and towards the back of the tongue. -Resist the temptation to remove the nipple because of the noise the infant makes or for fear that the infant will choke. -An indication that the infant needs to stop feeding momentarily is the facial signal, which involves elevated eyebrows and a wrinkled forehead; the nipple may be gently removed to allow the infant to swallow formula in the mouth without getting upset. ►3. Feed the infant slowly and burp frequently since these infants swallow excessive amounts of air.
Acute Appendicitis Treatment: ►Surgical removal of the appendix (appendectomy), preferably before the appendix ruptures. ►Post-operative for a non-perforated appendix: post-op care is the same as any abdominal surgery.
►Administer analgesics to provide pain relief. ►Nonopiods are effective on peripheral nervous system and Opiods are effective on the CNS. ►Post-operative Care for a Ruptured appendix: -A child will have an NG tube to low intermittent suction. --The purpose of the NG tube is to prevent abdominal distention. ---It will remain until there is bowel motility, (ie. Bowel sounds, passing of flatus, or stool).
►Infants ingest and excrete a relatively greater daily water volume than adults. As a result, they are more vulnerable to fluid volume deficit
►Although adults may be able to tolerate fluid imbalances for days, infants may tolerate similar disturbances for only hours before the situation becomes acute.
►Bacterial causes include Escherichia Coli (E. coli), Salmonella and Shigella.
►Antibiotics are also a common cause of acute diarrhea in children. §Antibiotics disrupt the normal flora of the GI tract.
►Nursing Considerations for UC & CD include:
►Assisting the family with dietary management. ►►►Since growth failure is common serious complication in Crohn's Disease: Nutritional management for Crohn disease includes increased protein (for healing) and high-calorie diet (for adequate energy and minimize growth failure). ►Teaching the adolescent to cope with increase stress and learn to deal with chronic illness. ►Surgery is indicated for UC when medical and nutritional therapies fail to prevent complications. ►►►Prepare the child and parents for the possibility of diversionary bowel surgery (subtotal colectomy or ileostomy [leaves a rectal stump as a blind pouch].
Acute Appendicitis ►Diagnosis: Pain is the major feature. History & physical exam, plus an elevated WBC.
►Clinical Manifestations: Most suggestive of acute appendicitis is abdominal pain that is most intense at McBurney Point (midway between Right Anterior Superior Crest and the Umbilicus). ►Classically, the first symptom of appendicitis is periumbilical pain (around the umbilicus), followed by nausea, as the inflammation progresses the pain descends to the right lower quadrant pain (McBurney Point), and, later, vomiting with fever. ►The pain is the cardinal feature which is initially generalized (usually periumbilical).
►Respiratory Acidosis results from diminished or inadequate pulmonary ventilation that causes an elevation in plasma CO2. ►Some Causative Clinical Conditions of Respiratory Acidosis: CNS Disorder; Overdose; Pneumonia; Muscular Dystrophy.
►Conditions that produce respiratory acidosis can originate at three levels in the respiratory system. §1. Factors that depress the respiratory center §2. Factors that affect the lung proper and §3. Factors that interfere with the bellows action of the chest wall.
Obstructive Disorders: HPS ►Clinical Manifestations: ►Usually no abnormal signs in the first weeks after birth. ►Regurgitation or nonprojectile vomiting beginning by age 3 weeks; emesis is not bile stained and contains only gastric contents but may be blood tinged, and contain stale milk.
►Dx: Upper GI radiographic studies Ultrasound is accurate and less traumatic for diagnosis of HPS ►Treatment: Pyloromyotomy ►Post-op: Four to six hours post-op feedings of small amts. Of glucose water are started; if retained then 24 hrs later formula is given. Discharge 2-3 days later after surgery. Child may have an NG tube post-operatively.
Structural Defects: Cleft Lip/Palate ►Management:
►Early correction of CL enables more normal sucking patterns and facilitates bonding. ►CL = Surgical correction usually in several stages. -CL repair typically occurs when the baby is between 2 and 3 months old. ►CP = Surgical correction may require several stages. -CP repair is typically completed between 6 and 12 months. -Delayed or large defects may require the use of orthodontic appliances. -Early correction of CP enables development of more normal speech patterns.
Structural Defects: Esophageal Atresia
►Esophageal Atresia (EA) with Tracheoesophageal Fistula (TEF) ►Atresia means absence of a normal body opening or abnormal occlusion. §Congenital atresia of the esophagus and Tracheoesophageal Fistula (TEF) are rare malformations. §It is failure of the esophagus to develop as a continuous passage. Cause is unknown. ►Definitive Diagnosis: Radiographic studies are done to determine the extent of the anomaly.
Peptic Ulcer Disease (PUD) ►Occurs more frequently in infancy and childhood.
►Etiology: exact cause unknown regarding peptic ulcers, possible suspect factors; infectious, genetic, and environmental. §A strong relationship exists between helicobacter pylori and upper GI disease. §Nearly all duodenal ulcers have H. pylori gastritis.
Daily Maintenance Fluid Requirements Examples
►Example: Find the DMFN for a 16kg patient. 1000mL + [ 50mL X (16kg-10)] = 1000mL + [50mL X 6 ] = 1000mL + 300mL = 1300mL
