Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder
A 10-year-old child has been diagnosed with type 1 diabetes. The child is curious about the cause of the disease and asks the nurse to explain it. Which explanation will the nurse provide?
"Special cells in a part of your body called the pancreas cannot make a chemical called insulin, which helps control the sugar level in your blood." Explanation: When providing instruction to a child, the nurse must consider the developmental age. Type 1 diabetes is a disorder that involves an absolute or relative deficiency of insulin, thus the blood glucose level remains high if an appropriate amount of insulin is not administered to the client. With type 2 diabetes, the body produces an adequate amount of insulin; however, the body is resistant to using the insulin properly to keep circulating blood glucose levels at a normal level. The rest of the statements provide incorrect information regarding the pathophysiology of type 1 diabetes.
A nurse is reviewing the blood sugar test results of a child diagnosed with type 1 diabetes: Before meal: 84 mg/dL (4.66 mmol/l) 1 hour after meal: 160 mg/dL (8.88 mmol/l) 2 hours after meal: 180 mg/dL (9.99 mmol/l) Middle of the night: 92 mg/dL (5.11 mmol/l) Which result would lead the nurse to notify the health care provider
2 hours after meal Explanation: Acceptable blood glucose levels for a child 2 hours after a meal would range from 80 to 150 mg/dL (4.44 to 8.32 mmol/l). This child's level is above the range at 180 mg/dL (9.99 mmol/l). The other levels are within the acceptable ranges (before meal—70 to 110 mg/dL (3.89 to 6.11 mmol/l); 1 hour after meal—90 to 180 mg/dL (5.0 to 10.0 mmol/l); and middle of night—70 to 120 mg/dL (3.89 to 6.66 mmol/l).
A pediatric client has just been diagnosed with diabetes. What would the nurse do first?
Check blood glucose levels. Explanation: The nurse must check the insulin level before it can be administered. Once a need is established, then insulin administration becomes the priority intervention. Stress management, glucose checks, and nutritional consultation can all be implemented once therapy with insulin begins
The nurse is providing care to a child with an intussusception. The child has a bowel movement and the nurse inspects the stool. The nurse would most likely document the stool's appearance as having what quality?
Currant jelly-like Explanation: The child with intussusception often exhibits currant jelly-like stools that may or may not be positive for blood. Greasy stools are associated with celiac disease. Clay-colored stools are observed with biliary atresia. Bloody stools can be seen with several gastrointestinal disorders, such as inflammatory bowel disease.
When providing diaper care to an infant after pyloric stenosis surgery, which approach is indicated?
Diapers should be folded so that the incision line does not become contaminated. Explanation: Folding diapers low so they do not contact the incision line can help prevent infection following surgery.
A parent brings a 2-year-old child to the health clinic with reports of diarrhea, vomiting, and abdominal pain. The father tells the nurse that he is a single parent and his child is enrolled in a local day care center. Based on this information, what gastrointestinal condition might the nurse suspect?
Gastroenteritis Explanation: Outbreaks of gastroenteritis routinely occur in day care centers, schools, institutions for the handicapped, and other places where overcrowding is prevalent and hygiene is inadequate. Typical signs and symptoms include diarrhea, nausea, vomiting, and abdominal pain.
After hospital discharge, the parent of a child newly diagnosed with type 1 diabetes mellitus telephones the nurse because the child is acting confused and very sleepy. Which emergency measure would the nurse suggest the parent carry out before bringing the child to see the health care provider?
Give the child a glass of orange juice. Explanation: The child is experiencing symptoms of hypoglycemia. Administering a form of glucose would help relieve them. This can be glucose tablets or a rapidly absorbable carbohydrate such as orange juice. This should be followed by a snack of complex carbohydrates and protein within 30 to 60 minutes. Insulin cannot be absorbed when taken orally and administering insulin would make the hypoglycemia worse. Withholding treatment waiting to get to the health care provider's office may cause the hypoglycemia to worsen and be a risk to the child's life. Children with diabetes and their parents need to be taught to recognize and treat the symptoms of hypoglycemia.
The parents of a boy diagnosed with Hirschsprung disease are anxious and fearful of the upcoming surgery. The mother states, "I'm worried about having to care for our son's ostomy." Which intervention would be most helpful for the parents?
Having a wound, ostomy, and continence nurse meet with them. Explanation: Although explaining about the diagnosis and surgery, reinforcing that the ostomy will be temporary, and teaching them about medications would be appropriate, the parents are voicing concerns about caring for the ostomy. Therefore, having a wound, ostomy, and continence nurse meet with them would address these concerns and help them deal with the anxieties and care of a newly placed stoma.
A group of nursing students are reviewing the components of the endocrine system. The students demonstrate understanding of the review when they identify what as the primary function of this system?
Hormonal secretion Explanation: The endocrine system consists of various glands, tissues, or clusters of cells that produce and release hormones. Hormones are chemical messengers that stimulate and/or regulate the actions of other tissues, organs, or endocrine glands that have specific receptors to a hormone. Along with the nervous system, the endocrine milieu influences all physiologic effects such as growth and development, metabolic processes related to fluid and electrolyte balance and energy production, sexual maturation and reproduction, and the body's response to stress. The release patterns of the hormones vary, but the level in the body is maintained within specified limits to preserve health.
What should be included in the teaching plan for a child with type 1 diabetes who is going home on insulin therapy?
It is absolutely normal for the growing child to require an increase in insulin; this does not mean his/her condition is getting worse. Explanation: Children show a decreased need for insulin shortly after glucose control has been established, which is referred to by some as the "honeymoon phase" and should be described to parents so that they do not get any false hope that the child does not need insulin. As children grow, they will require increased doses of insulin to maintain glucose control, and not all children need to receive two types of insulin. Insulin treatment should be based on each individual child.
A young child has presented to the pediatric unit with a swollen abdomen, edema, thin patchy hair, and irritability with growth retardation and muscle wasting. The nurse suspects a malnutrition disorder. The nurse identifies this child to most likely have which condition
Kwashiorkor Explanation: The symptoms presented are classic signs of Kwashiorkor due to the protein deficiency.
A group of students are reviewing information about oral diabetic agents. The students demonstrate understanding of these agents when they identify which agent as reducing glucose production from the liver?
Metformin Explanation: Metformin, a biguanide, reduces glucose production from the liver. Glipizide, glyburide, and nateglinide all stimulate insulin secretion by increasing the response of β cells to glucose.
Which findings should the nurse expect to assess when completing the health history of a child admitted for possible type 2 diabetes? Select all that apply.
Polyuria Polydipsia Polyphagia
In caring for an infant diagnosed with pyloric stenosis the nurse would anticipate which intervention?
Prepare the infant for surgery. Explanation: In pyloric stenosis, the thickened muscle of the pylorus causes gastric outlet obstruction. The treatment is a surgical correction called a pyloromyotomy. The condition is not painful, so no analgesics would be needed until after surgical repair. The condition is not related to lactose in the diet, so changing to lactose-free formula would not correct the condition. A barium enema would be used to diagnose intussusception
The nurse is caring for an infant recovering from surgery for pyloric stenosis. Which nursing diagnosis should the nurse use to guide care during the immediate postoperative period?
Risk for infection of incision line, related to disruption of skin barrier during surgery Explanation: Because the incision line for a pyloric stenosis repair is near the diaper area, the child is at risk of developing a surgical infection. The diagnosis risk for infection of incision line is the most appropriate during the immediate postoperative period. Anxiety might be appropriate after the immediate postoperative period has passed. There is not enough information to determine if the infant is being given excessive fluid or if the infant is experiencing ineffective tissue perfusion
A child presents to the primary care setting with enuresis, nocturia, increased hunger, weight loss, and increased thirst. What does the nurse suspect?
Type 1 diabetes mellitus Explanation: Signs and symptoms of type 1 diabetes mellitus include polyuria, polydipsia, polyphagia, enuresis, and weight loss.
A nurse should recognize that which laboratory result would be most consistent with a diagnosis of diabetes mellitus?
a fasting blood glucose greater than 126 mg/dl Explanation: A fasting blood glucose greater than 126 mg/dl is diagnostic for diabetes mellitus.
The nurse is providing care for a child who has been diagnosed with rickets. What is the nurse's priority intervention?
administration of adequate vitamin D Explanation: Rickets results from inadequate vitamin D; supplements are necessary. There is no direct need to increase calorie, thiamine or protein intake.
The nurse completes a 1-month-old's feeding and sits the infant up to burp. The infant vomits back the feeding. Which is the nurse's primary concern?
aspiration Explanation: The primary concern for the nurse is that the infant aspirates vomit into the lungs. Aspiration after vomiting may lead to respiratory concerns such as apnea and pneumonia. Nutritional deficiencies may occur if the vomiting continues. This is a concern but not the primary concern. Stomach irritation and stunted growth is not a typical concern at this time.
A child has presented to the clinic with diarrhea. The nurse should teach the parent to give which item to properly care for the child?
bananas Explanation: Milk may cause diarrhea to worsen. Only unsalted crackers and soups should be used to prevent further exacerbation of diarrhea. Bananas in small amounts provide nutritive value and do not exacerbate diarrhea.
Insulin deficiency, in association with increased levels of counter-regulatory hormones and dehydration, is the primary cause of:
diabetic ketoacidosis. Explanation: Insulin deficiency, in association with increased levels of counter-regulatory hormones (glucagon, growth hormone, cortisol, catecholamines) and dehydration, is the primary cause of diabetic ketoacidosis (DKA), a life-threatening form of metabolic acidosis that is a frequent complication of diabetes. Liver converts triglycerides (lipolysis) to fatty acids, which in turn change to ketone bodies. The accumulation and excretion of ketone bodies by the kidneys is called ketonuria. Glucosuria is glucose that is spilled into the urine.
Pyloric stenosis has been diagnosed in a 3-week-old male infant who has frequent vomiting after feedings. An important preoperative nursing intervention is:
maintaining NPO status while restoring hydration and electrolyte balance. Explanation: NPO is needed to avoid vomiting and aspiration during surgery. Hydration and electrolyte replacement is often needed because of the history of vomiting, which causes loss of both fluid and electrolytes. Feeding when surgery is pending would not be safe. Hourly abdominal assessment would not yield needed information and would further disturb the infant. Pain is not the source of crying. The infant is hungry.
The nurse is caring for a 19-month-old toddler with a history of diarrhea for 2 days (above). The primary health care provider prescribes oral rehydration over 2 hours followed by discharge home. What will the nurse include in the discharge teaching for this client? Select all that apply.
monitoring of wet diaper output encouraging food and fluid intake at home With acute diarrhea, the priority is to maintain hydration. The parents can support this by encouraging normal intake and watching output/wet diapers to ensure adequate hydration. High-sugar beverages are not recommended because they may worsen diarrhea; soda or juice should be diluted. Antidiarrheal and antibiotic medications are not routinely recommended
The nurse is assessing a 5-year-old child whose parent reports the child has been vomiting lately, has no appetite, and has had an extreme thirst. Laboratory work for diabetes is being completed. Which symptom would differentiate between type 1 diabetes from type 2 diabetes?
recent weight loss Explanation: Weight loss is unique to type 1 diabetes, whereas weight gain is associated with type 2. Hypertension is consistent with type 2 diabetes. Both type 1 and type 2 diabetes cause delayed wound healing. The increase in blood glucose in diabetes causes damage to the inner lining of the arteries that cause the arteries to develop plaque and harden. These damages to the blood vessels result in a decrease in the ability of oxygen-rich blood to be transported effectively to the tissues to promote wound healing. Loose stools or repeated loose stools (diarrhea) is a common side effect of the oral medication metformin, which is prescribed for clients with type 2 diabetes. Insulin, the treatment for type 1 diabetes, has constipation as one of the side effects.
The caregiver of a child diagnosed with celiac disease tells the nurse that the child has large amounts of bulky stools and what looks like fat in the stools. The clinical manifestation this caregiver is describing is:
steatorrhea. Explanation: Celiac disease is an immunologic response to gluten, which causes damage to the small intestine. Steatorrhea (fatty stools) is a classic symptom of celiac disease. Symptoms also include abdominal distention or bloating, constipation, and nutritional deficiencies. Currant jelly stools are a sign of intussusception. Projectile vomiting is a sign of pyloric stenosis. Severe diarrhea could be caused by a bacteria or virus. Projectile stools represent severe diarrhea
The nurse is advising a group of new parents on how to care for their infant at home if the baby develops mild diarrhea. Which statement indicates that teaching has been effective?
"I should offer Pedialyte after 1 hour and frequently thereafter to prevent dehydration." Explanation: Mild diarrhea is not considered serious and at the end of approximately 1 hour, parents can begin to offer an oral rehydration solution such as Pedialyte in small amounts. Infants may develop a temporary lactase deficiency after diarrhea that leads to lactose intolerance. With this, a child cannot take formula or breast milk without new diarrhea beginning. Parents should alert their health care provider if they feel this is happening as the infant will need to be introduced to a lactose-free formula initially before being returned to the usual formula or to breast milk. An elevated temperature is seen in severe diarrhea. The parents should be cautioned to contact their health care provider prior to initiating over-the-counter drugs such as kaolin and pectin (Kaopectate) to halt diarrhea because toxic levels of these can occur quickly.
The client calls the health care provider's office stating that her preschooler drank laundry detergent from under the sink. Which statement by the parent needs further instruction?
"I will use syrup of ipecac to get it out of my child's system." Explanation: The CDC no longer recommends that the syrup of ipecac be used in the home for treatment of poisoning and, furthermore, recommends that it be disposed of safely. All the other statements are accurate. Depending on the amount of detergent ingested, the parent is instructed to first terminate any exposure and then possibly transport the child to a health care facility
A child with diabetes reports that he is feeling a little shaky. Further assessment reveals that the child is coherent but with some slight tremors and sweating. A fingerstick blood glucose level is 70 mg/dl. What would the nurse do next?
Give 10 to 15 grams of a simple carbohydrate. Explanation: The child is experiencing hypoglycemia as evidenced by the assessment findings and blood glucose level. Since the child is coherent, offering the child 10 to 15 grams of a simple carbohydrate would be appropriate. Insulin is not used because the child is hypoglycemic. A complex carbohydrate snack would be used after offering the simple carbohydrate to maintain the glucose level. Intramuscular glucagons would be used if the child was not coherent.
A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease?
Hirschsprung disease Explanation: The nurse should suspect Hirschsprung disease when the newborn does not pass meconium in the first 24 hours after birth, and has bilious vomiting or abdominal distention and feeding intolerance with bilious aspirates and vomiting. Typical signs and symptoms of gastroenteritis include diarrhea, nausea, vomiting, and abdominal pain. The characteristic GI manifestation of UC is bloody diarrhea accompanied by crampy, typically left-sided lower abdominal pain. Clinical manifestations of untreated SBS include profuse watery diarrhea, malabsorption, and failure to thrive.
A young child has presented to the pediatric unit with a swollen abdomen, edema, thin patchy hair, and irritability with growth retardation and muscle wasting. The nurse suspects a malnutrition disorder. The nurse identifies this child to most likely have which condition?
Kwashiorkor Explanation: The symptoms presented are classic signs of Kwashiorkor due to the protein deficiency.
In caring for an infant diagnosed with pyloric stenosis the nurse would anticipate which intervention?
Prepare the infant for surgery. Explanation: In pyloric stenosis, the thickened muscle of the pylorus causes gastric outlet obstruction. The treatment is a surgical correction called a pyloromyotomy. The condition is not painful, so no analgesics would be needed until after surgical repair. The condition is not related to lactose in the diet, so changing to lactose-free formula would not correct the condition. A barium enema would be used to diagnose intussusception.
Noah is an 18-month-old boy who is brought to the emergency department with flu-like symptoms. He is diagnosed with pneumonia secondary to aspiration of stomach contents. The nurse explains to the parents that this condition is most likely the result of which of the following?
gastroesophageal reflux disease Explanation: The child with gastroesophageal reflux disease may present with the physical findings of pneumonia secondary to aspiration of refluxed stomach contents. In this situation, pneumonia is not associated with cystic fibrosis, Hirschsprung disease, or inflammatory bowel disease.
A nurse is reviewing information about the various types of insulin that are used to treat type 1 diabetes mellitus. Integrating knowledge about the duration of action, place these types in the order from shortest to longest duration.
aspart regular NPH glargine Explanation: Aspart has a duration of action of 3 to 5 hours; regular insulin has a duration of 5 to 8 hours; NPH has a duration of 10 to 16 hours; and glargine has a duration of 12 to 24 hours.
The nurse is caring for a 19-month-old toddler with a history of diarrhea for 2 days (above). The primary health care provider prescribes oral rehydration over 2 hours followed by discharge home. What will the nurse include in the discharge teaching for this client? Select all that apply.
monitoring of wet diaper output encouraging food and fluid intake at home With acute diarrhea, the priority is to maintain hydration. The parents can support this by encouraging normal intake and watching output/wet diapers to ensure adequate hydration. High-sugar beverages are not recommended because they may worsen diarrhea; soda or juice should be diluted. Antidiarrheal and antibiotic medications are not routinely recommended
A child with type 1 diabetes is brought to the emergency department. The nurse suspects diabetic ketoacidosis (DKA) based on which assessment findings? Select all that apply.
fruity odor on the breath decreased level of consciousness poor skin turgor If insulin deficiency persists and ketone bodies continue to be excreted, the child begins to experience stomach pains, vomiting, and continued weight loss. Dehydration quickly develops as DKA progresses. The degree of dehydration is assessed while the child is weighed and examined. Assessment includes examining the mucous membranes for moistness, the eyeballs for degree of depression, the skin for turgor, and the anterior fontanel (fontanelle), if present, for depression. The child may also show signs of impending shock: tachypnea, decreased output, decreased level of consciousness, slowed capillary refill, and tachycardia. A late sign of shock in children is hypotension. DKA is most commonly present in new-onset T1DM or during crises in children with known type 1 diabetes, but it may also be found in newly diagnosed type 2 diabetes in the adolescent age group. Kussmaul respirations and changes in mental status may ensue. The breath develops a fruity odor in all children with DKA. If the child becomes somnolent and advances into a coma, these are ominous signs of cerebral edema.
