Gastrointestinal Dysfunction
§ Heart failure § Syndrome or inappropriate antidiuretic hormone (SIADH) § Mechanical ventilation § After surgery § Oliguric renal failure § Increased intracranial pressure
Basics/Variations · Put stuff in mouths = increased infection · Lower esophageal sphincter (LES) not fully developed predisposes to reflux · Hydrochloric acid (digestion) sufficient at 6 months · Smaller bowel leads to absorption and diarrhea problems · Loss of fluids is > § 50% ECF in newborns vs. 30% in toddlers § 75% TBW in newborns vs. 45% in late adolescence · Renal immaturity and higher metabolic rate = insensible fluid loss (lungs, skin, respiratory tract, feces) · Conditions that require increased fluid requirements: § Fever § Vomiting, diarrhea § High output kidney failure § Diabetes insipidus § Diabetic ketoacidosis § Burns § Shock § Tachypnea § Radiant warmer, phototherapy § Postoperative bowel surgery · Conditions that require decreased fluid requirements: - - - - - · Daily Maintenance fluid requirements: § Body weight of 1-10kg: 100mL/kg of fluid § Body weight of 11-20kg: 1000mL plus 50mL/kg for each kg >10kg § Body weight of greater than 20kg: 1500mL plus 20 mL/kg for each kg >20kg
A. Abdominal pain C. Mucus, bloody stools
A nurse is caring for a child who has Meckel's diverticulum. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Abdominal pain B. Fever C. Mucus, bloody stools D. Vomiting E. Rapid, shallow breathing
A. Severe abdominal cramping occurs. C. It can lead to hemolytic uremic syndrome. D. It is a foodborne pathogen.
A nurse is teaching a group of parents about E. coli. Which of the following should be included in the teaching? (Select all that apply.) A. Severe abdominal cramping occurs. B. Watery diarrhea is present for more than 5 days. C. It can lead to hemolytic uremic syndrome. D. It is a foodborne pathogen. E. Antibiotics are given for treatment.
B. It is a bacterial infection. C. Bloody diarrhea is common. D. Transmission can be from house pets.
A nurse is teaching a group of parents about Salmonella. Which of the following should be included in the teaching? (Select all that apply.) A. Incubation period is nonspecific. B. It is a bacterial infection. C. Bloody diarrhea is common. D. Transmission can be from house pets. E. Antibiotics are used for treatment.
A. Offer frequent feedings. B. Thicken formula with rice cereal D. Position baby upright after feedings..
A nurse is teaching a parent of an infant about gastrointestinal reflux disease. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Offer frequent feedings. B. Thicken formula with rice cereal. C. Use a bottle with a one‑way valve. D. Position baby upright after feedings. E. Use a wide‑based nipple for feedings.
c. Antihistamines d. surgical removal of affected section of bowel. b. Thicken formula with rice cereal.
Constipation has recently become a problem for a school-age child who is being treated for seasonal allergies. The nurse should focus the assessment on what possibly related factor? a. Diet b. Allergies c. Antihistamines d. Emotional factors Therapeutic management of most children with Hirschsprung's disease is primarily: a. daily enemas. b. low-fiber diet. c. permanent colostomy. d. surgical removal of affected section of bowel. A 4-month-old infant diagnosed with gastroesophageal reflux disease (GERD) is thriving without other complications. What should the nurse suggest to minimize reflux? a. Place in Trendelenburg position after eating. b. Thicken formula with rice cereal. c. Give continuous nasogastric tube feedings. d. Give larger, less frequent feedings.
· Mild dehydrated child can be given 50mL/kg of oral rehydration solution · Moderate dehydrated child can be given 100mL/kg of oral rehydration solution
Dehydration · Nursing Care/Management · GOAL: To restore appropriate fluid balance and prevent complications · Take accurate history: fluid intake, urine output, diarrhea, emesis, tears · Assess s/s: altered LOC, irritability, lethargy, poor appetite, sick appearance, decreased skin elasticity/turgor, prolonged cap refill (>2sec), tachycardia, sunken eyes/fontanels, dry skin/mucus membranes, circulatory failure (decreased BP), lactic acid accumulation § Monitor for shock: tachycardia, low pulse ox reading, cool/mottled skin, low cap refill, oliguria/azotemia · Accurate I&O and daily weights · Frequent VS (Q15-30 minutes) with CRT · Record # of wet diapers or weighing diapers and voids (subtract dry weight from wet weight = output) · Monitor stools, vomitus, sweating. Give 10mL/kg for each stool or emesis · Monitor for symptoms of worsening or improvement · Oral Rehydration Solution (ORS) - replacement of fluid loss over 4-6 hours, replacement of continuing losses, and provision for maintenance fluid requirements § ORS is good for Mild-moderate dehydration: 1. Mild dehydration:__________________ 2. Moderate dehydration:__________________ § A child with diarrhea should have 10mL/kg for every loose stool § Small amounts (2-5ml) by spoon or syringe ever 2-3min if needed when the child is not thirsty § Amount and rate determined by body weight and severity of dehydration · Parenteral Therapy: initiated when the child can't ingest enough fluids to meet ongoing physiologic fluid losses, replace previous deficits, and replace ongoing abnormal losses. It is usually given to those with severe dehydration, uncontrollable vomiting, extreme fatigue/coma, and severe gastric distention 1. Initial: Normal Saline (NS) or Lactated Ringer's (LR) 20 ml/kg bolus over 5-20 minutes followed by maintenance fluids. 2. Subsequent therapy is given to replace deficits, meet maintenance water needs, and catch up with ongoing losses 3. Finally, Re-introduction of diet § **Rapid administration can cause cerebral edema
Soy formula
Food Allergies · Food Allergy: an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food § Food intolerance exists when a food elicits a reproducible adverse reaction but does not have an established or likely immunologic mechanism. · Food Allergy Reaction can occur immediately (minutes to hours) or delayed (2-48 hours) · Food Allergy Manifestations are Divided into 4 categories of symptoms: § Systemic Food Allergy S/S: anaphylaxis, FTT § GI Food Allergy S/S: abdominal pain, V/D, cramping § Respiratory Food Allergy S/S: cough, wheezing, rhinitis, infiltrates § Cutaneous Food Allergy S/S: urticarial, rash, atopic dermatitis · Most common food allergies: nuts, eggs, wheat, legumes, soy, chocolate, milk, buckwheat, pork/chicken, strawberries/melon/pineapple, corn, citrus, tomatoes, spices · Gold standard for diagnosis is double-blind, placebo-controlled food challenge; skin prick test and serum IgE as adjunct · Sensitization refers to the initial exposure of an individual to an allergen, resulting in immune response; subsequent exposure causes more intense response · Infants more prone due to immature intestinal tract being more permeable to proteins → ↑ likelihood of immune response · With anaphylactic reactions, WATCH FOR BIPHASIC RESPONSE: Children can have immediate response, recover, then have recurrence · Recommendations to Parents Regarding Food Allergies: § Breastfeeding for at least 6 months § ____________________ is not recommended to prevent development of allergy § Introduction of complementary foods should not be delayed beyond 6 months of age § Hydrolyzed formula may be used in at-risk infants to prevent/modify food allergy § Maternal diet should not be restricted to prevent food allergy § Children should be vaccinated § Patients with severe egg allergy reactions should not get the flu vaccine without talking to their doctor
c. Elbow restraints d. Supine and side-lying positions
The nurse, caring for an infant whose cleft lip was repaired, should include which interventions into the infant's postoperative plan of care? (Select all that apply.) a. Postural drainage b. Petroleum jelly to the suture line c. Elbow restraints d. Supine and side-lying positions e. Mouth irrigations
b. Hepatitis B can be prevented by hepatitis B virus vaccine. c. Hepatitis B can be transferred to an infant of a breastfeeding mother. d. The onset of hepatitis B is insidious. e. Immunity to hepatitis B occurs after one attack.
Which statements regarding hepatitis B are correct? (Select all that apply.) a. Hepatitis B cannot exist in a carrier state. b. Hepatitis B can be prevented by hepatitis B virus vaccine. c. Hepatitis B can be transferred to an infant of a breastfeeding mother. d. The onset of hepatitis B is insidious. e. Immunity to hepatitis B occurs after one attack.
b. Encouraging and helping mother to breastfeed. d. Recommending use of a breast pump to maintain lactation until infant can suck.
A mother who intended to breastfeed has given birth to an infant with a cleft palate. Which nursing interventions should be included in the plan of care? (Select all that apply.) a. Giving medication to suppress lactation. b. Encouraging and helping mother to breastfeed. c. Teaching mother to feed breast milk by gavage. d. Recommending use of a breast pump to maintain lactation until infant can suck.
A. Fever B. Vomiting C. Watery stools
A nurse is assessing a child who has a rotavirus infection. Which of the following are expected findings? (Select all that apply.) A. Fever B. Vomiting C. Watery stools D. Bloody stools E. Confusion
A. Projectile vomiting B. Dry mucus membranes E. Constant hunger
A nurse is assessing an infant who has hypertrophic pyloric stenosis. Which of the following manifestations should the nurse expect? (SATA) A. Projectile vomiting B. Dry mucus membranes C. Currant jelly stools D. Sausage‑shaped abdominal mass E. Constant hunger
B. Initiate oral rehydration therapy. A. Perform a tape test. B. Prepare the family for surgery.
A nurse is caring for a child who has watery diarrhea for the past 3 days. Which of the following is an action for the nurse to take? A. Offer chicken broth. B. Initiate oral rehydration therapy. C. Start hypertonic IV solution. D. Keep NPO until the diarrhea subsides. A nurse is caring for a child who is suspected to have Enterobius vermicularis. Which of the following is an appropriate action for the nurse to take? A. Perform a tape test. B. Collect stool specimen for culture. C. Test the stool for occult blood. D. Initiate IV fluids. A nurse is caring for a child who has Hirschsprung's disease. Which of the following actions should the nurse take? A. Encourage a high‑fiber, low‑protein, low‑calorie diet. B. Prepare the family for surgery. C. Place an NG tube for decompression. D. Initiate bed rest.
B. Place the infant in an upright position. a. Fever d. Hypertonic dehydration
A nurse is caring for an infant who is postoperative following cleft lip and palate repair. Which of the following actions should the nurse take? A. Remove the packing in the mouth. B. Place the infant in an upright position. C. Offer a pacifier with sucrose. D. Assess the mouth with a tongue blade. Nurses must be alert for increased fluid requirements when a child presents with which possible concern? a. Fever b. Mechanical ventilation c. Congestive heart failure d. Increased intracranial pressure (ICP) Which type of dehydration results from water loss in excess of electrolyte loss? a. Isotonic dehydration b. Isosmotic dehydration c. Hypotonic dehydration d. Hypertonic dehydration
c. Whole grain breads d. Bran pancakes e. Raw carrots
A nurse is conducting dietary teaching on high-fiber foods for parents of a child with constipation. Which foods should the nurse include as being high in fiber? (Select all that apply.) a. White rice b. Avocados c. Whole grain breads d. Bran pancakes e. Raw carrots
d. Bacterial gastroenteritis c. Oral rehydration solution (ORS) a. Intravenous fluids
A stool specimen from a child with diarrhea shows the presence of neutrophils and red blood cells. This is most suggestive of which condition? a. Protein intolerance b. Parasitic infection c. Fat malabsorption d. Bacterial gastroenteritis Therapeutic management of the child with acute diarrhea and dehydration usually begins with what intervention? a. Clear liquids b. Adsorbents such as kaolin and pectin c. Oral rehydration solution (ORS) d. Antidiarrheal medications such as paregoric A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child will begin with which intervention? a. Intravenous fluids b. Oral rehydration solution (ORS) c. Clear liquids, 1 to 2 ounces at a time d. Administration of antidiarrheal medication
b. Dehydration b. Antibiotic therapy c. Rotavirus.
An infant is brought to the emergency department with poor skin turgor, sunken fontanel, lethargy, and tachycardia. This is suggestive of which condition? a. Overhydration b. Dehydration c. Sodium excess d. Calcium excess What is a common cause of acute diarrhea? a. Hirschsprung's disease b. Antibiotic therapy c. Hypothyroidism d. Meconium ileus The viral pathogen that frequently causes acute diarrhea in young children is: a. Giardia organisms. b. Shigella organisms. c. Rotavirus. d. Salmonella organisms.
identify infants that have not passed a stool in first 24 hours or has stool coming from somewhere besides the anus
Anorectal Malformation · Anorectal Malformation: these malformations range from simple imperforate anus to complex anomalies of the GU and pelvic organs § Can occur alone or with other congenital syndromes · Rectal atresia is a complete obstruction of the rectum requiring surgical intervention · Rectal stenosis may not be noticed until later in infancy with difficulty stooling, ABD distention, and ribbon-like stools · Identify other associated, life-threatening defects · Nursing responsibility is to ___________________________________ § NPO, IV fluids, surgery is often delayed for 24 hours to evaluate for presence of fistula or other anomalies § Post-op care is directed towards wound care and prevention of other complications. Colostomy care, skin protection, managing pain
applying heat to the abdomen or using laxatives/enemas, which stimulate bowel motility and increase risk of perforation
Appendicitis · Appendicitis: inflammation of the vermiform appendix. Obstruction of the appendix lumen usually by fecalith (but can be by pinworms), which compresses blood vessels → necrosis → perforation or rupture § most common cause of childhood surgery § Average age is 10 years · Assessment of Appendicitis § Periumbilical pain, nausea, RLQ pain/burning (McBurney point), vomiting, fever, decreased bowel sounds, constipation, anorexia, pallor, lethargy/irritability, stooped posture (guarding), rigid ABD, tachycardia, rapid/shallow breathing § elevated WBC and C-reactive protein (CRP) § diagnosed by H&P and CT scan § If perforated: sudden relieved pain (IMMEDIATELY PREPARE FOR SURGERY) § Peritonitis: fever, increased pain, diffuse tenderness, rigid abdomen, shallow breathing · Requires 7-10 days IV antibiotics and fluid replacement · Nursing Care of Appendicitis · Avoid _________________________ · Appendectomy: Laparoscopic repair or open repair if perforation; wound may be closed or left open § Pre-op: antibiotics, IV fluids/electrolytes · NGT decompression if complicated or perforation § post-op: · If perforation: IV fluids, NPO, antibiotics, NG tube to low suction · Assess for bowel sounds and function; monitor airway/O2 · If drain is present, monitor output and maintain patency · Provide wound care: irrigation with antibacterial solution · Pain management: analgesics regularly · Monitor for peritonitis/perforation: fever, sudden relief of pain after perforation, then diffuse increase in pain, rigid ABD, tachycardia, rapid breathing, pallor, chills
RLQ pain/burning (McBurney point)
Appendicitis · Appendicitis: inflammation of the vermiform appendix. Obstruction of the appendix lumen usually by fecalith (but can be by pinworms), which compresses blood vessels → necrosis → perforation or rupture § most common cause of childhood surgery § Average age is 10 years · Assessment of Appendicitis § Periumbilical pain, nausea, _____________________________ pain, vomiting, fever, decreased bowel sounds, constipation, anorexia, pallor, lethargy/irritability, stooped posture (guarding), rigid ABD, tachycardia, rapid/shallow breathing § elevated WBC and C-reactive protein (CRP) § diagnosed by H&P and CT scan § If perforated: sudden relieved pain (IMMEDIATELY PREPARE FOR SURGERY) § Peritonitis: fever, increased pain, diffuse tenderness, rigid abdomen, shallow breathing · Requires 7-10 days IV antibiotics and fluid replacement
1 Jaundice (first seen in sclera) persists beyond two weeks of age especially if direct bilirubin (conjugated ) is elevated 2 Dark yellow urine, white or tan stools, hepatomegaly, splenomegaly later, abdominal distention, poor fat metabolism (FTT and poor weight gain), pruritis, irritability, difficulty comforting infant
Biliary Atresia · Biliary Atresia: a progressive inflammatory process that causes intrahepatic and extrahepatic bile duct fibrosis, resulting in eventual ductal obstruction. § It is not seen on ultrasound or in the newborn and is manifested a few weeks after birth · Manifestations of Biliary Atresia: 1. 2. · Diagnostics of Biliary Atresia: § Liver biopsy most accurate or exploratory laparotomy § nuclear scan (takes five days)
Vitamins A, D, E and K; Iron (Fe+), zinc, and selenium
Biliary Atresia · Biliary Atresia: a progressive inflammatory process that causes intrahepatic and extrahepatic bile duct fibrosis, resulting in eventual ductal obstruction. § It is not seen on ultrasound or in the newborn and is manifested a few weeks after birth · Manifestations of Biliary Atresia: § Jaundice (first seen in sclera) persists beyond two weeks of age especially if direct bilirubin (conjugated ) is elevated § Dark yellow urine, white or tan stools, hepatomegaly, splenomegaly later, abdominal distention, poor fat metabolism (FTT and poor weight gain), pruritis, irritability, difficulty comforting infant · Diagnostics of Biliary Atresia: § Liver biopsy most accurate or exploratory laparotomy § nuclear scan (takes five days) · Treatment of Biliary Atresia: § Kasai procedure (hepatic portoenterostomy) to correct § 1/3 of infants regain liver function and are free of jaundice, 1/3 have residual liver damage, 1/3 require liver transplant · Nursing Care of Biliary Atresia: § Supplement ___________________________________ § Aggressive nutritional support via gastronomy feedings or TPN § Phenobarbital to stimulate bile flow and ursodeoxycholic acid to decrease cholestasis and pruritis may be ordered § Support family during care, teach medication regimen, and nutritional needs § For itching: oatmeal colloidal baths, trim fingernails
a. Eradicate Helicobacter pylori a. liver transplantation. a. Jaundice
Bismuth subsalicylate may be prescribed for a child with a peptic ulcer to effect what result? a. Eradicate Helicobacter pylori b. Coat gastric mucosa c. Treat epigastric pain d. Reduce gastric acid production The best chance of survival for a child with cirrhosis is: a. liver transplantation. b. treatment with corticosteroids. c. treatment with immune globulin. d. provision of nutritional support. What is the earliest clinical manifestation of biliary atresia? a. Jaundice b. Vomiting c. Hepatomegaly d. Absence of stooling
d. Hepatitis A a. Not indicated b. Hepatitis B vaccine d. Metabolic alkalosis
Careful hand washing before and after contact can prevent the spread of which condition in day care and school settings? a. Irritable bowel syndrome b. Ulcerative colitis c. Hepatic cirrhosis d. Hepatitis A A mother shares with the clinic nurse that she has been giving her 4 year old the antidiarrheal drug loperamide. What conclusion should the nurse arrive at based on knowledge of this classification of drugs? a. Not indicated b. Indicated because it slows intestinal motility c. Indicated because it decreases diarrhea d. Indicated because it decreases fluid and electrolyte losses Which vaccine is now recommended for the immunization of all newborns? a. Hepatitis A vaccine b. Hepatitis B vaccine c. Hepatitis C vaccine d. Hepatitis A, B, and C vaccines An infant diagnosed with pyloric stenosis experiences excessive vomiting that can result in which condition? a. Hyperchloremia b. Hypernatremia c. Metabolic acidosis d. Metabolic alkalosis
1 Petroleum jelly to operative site for several days to prevent dryness 2 Elbow restraints for 7-10 days 3 Position on side, back, or in car seat for immediate post-op 4 Avoid placing straws, rigid utensils, sippy cups, or suction equipment (palate)
Cleft Lip/Cleft Palate · Cleft Lip/Cleft Palate: Failure of lip or palate to close in utero. Cleft lip results from incomplete fusion of the oral cavity in utero and causes a visible separation from the upper lip to the nose. Cleft palate results from the incomplete fusion of the palates in utero and causes a visible/palpable opening of the palate connecting the mouth and the nasal cavity. They can appear alone or together · Preoperative Care Cleft Lip/Palate Repair: § Inspect cleft lip/palate, assess ability to suck, assess baseline weight § Observe interactions between infant/parents; determine family support § Refer parents to support groups § Consult social services to provided needed infant services to family · Post-Operative Care Cleft Lip/Palate Repair: § Protect Integrity of Surgical Site: 1. 2. 3. 4. · Possible syringe feedings for 7-10 days · Position upright when feeding, use a soft diet (no hard chips, cookies, toasts) § For cleft lip: monitor integrity of postop protective device · Position infant on the back/upright or on side during immediately post-op period · Apply elbow restraints, removed periodically to assess skin, allow movement, and provide comfort · Use water/diluted hydrogen peroxide to clean surgical site · Aspirate secretions from nose/mouth to prevent respiratory complications § For cleft palate: change position frequently to facilitate drainage and breathing. Place in side-lying position immediately after surgery · Maintain IV fluids until infant can eat/drink · Infant is usually NPO for 4 hr, then allowed only liquids for 3-4 days, then progressed to a soft diet · No straws, tongue depressors, rigid utensils, etc in mouth · Elbow restraints · Close observation for manifestations of airway obstruction, bleeding, or laryngeal spasm · Use a face mask to deliver O2 · Complications § Recurrent otitis media · Prevention interventions: feed upright, monitor temperature, · Pressure-equalizing ear tube placement § Speech/language impairment: refer to SLP § Dental problems and malocclusion: refer to dental care and promote healthy dental hygiene
use a bottle with a wide base of the nipple and provide cheek support (squeeze cheeks together) to improve lip seal; encourage breast feeding
Cleft Lip/Cleft Palate · Cleft Lip/Cleft Palate: Failure of lip or palate to close in utero. Cleft lip results from incomplete fusion of the oral cavity in utero and causes a visible separation from the upper lip to the nose. Cleft palate results from the incomplete fusion of the palates in utero and causes a visible/palpable opening of the palate connecting the mouth and the nasal cavity. They can appear alone or together · Nursing Care of Cleft Lip/Cleft Palate: § Nutrition: · for cleft lip, __________________________ · For cleft palate: position infant upright with head supported in hand or cradled in arm to allow gravity flow of liquid; use special needs feeder or pigeon bottles (have a one-way valve and specially cut enlarged nipple) · BURP DURING/AFTER FEEDINGS due to increased air swallowing § Teach parents how to identify when infant is sick § Aspiration prevention § Reflux § Parent coping/bonding § Cleft Lip Repair - between 2-3 months of age § Cleft Palate Repair - between 6-12 months of age (most require 2nd surgery)
position infant upright with head supported in hand or cradled in arm to allow gravity flow of liquid; use special needs feeder or pigeon bottles (have a one-way valve and specially cut enlarged nipple)
Cleft Lip/Cleft Palate · Cleft Lip/Cleft Palate: Failure of lip or palate to close in utero. Cleft lip results from incomplete fusion of the oral cavity in utero and causes a visible separation from the upper lip to the nose. Cleft palate results from the incomplete fusion of the palates in utero and causes a visible/palpable opening of the palate connecting the mouth and the nasal cavity. They can appear alone or together · Nursing Care of Cleft Lip/Cleft Palate: § Nutrition: · for cleft lip, use a bottle with a wide base of the nipple and provide cheek support (squeeze cheeks together) to improve lip seal; encourage breast feeding · For cleft palate: _________________________________ · BURP DURING/AFTER FEEDINGS due to increased air swallowing § Teach parents how to identify when infant is sick § Aspiration prevention § Reflux § Parent coping/bonding § Cleft Lip Repair - between 2-3 months of age § Cleft Palate Repair - between 6-12 months of age (most require 2nd surgery)
§ Maternal smoking, ETOH, anticonvulsants, retinoids, steroids § Prenatal infection § Prenatal folate deficiency § Certain medications during pregnancy § syndromes
Cleft Lip/Cleft Palate · Cleft Lip/Cleft Palate: Failure of lip or palate to close in utero. Cleft lip results from incomplete fusion of the oral cavity in utero and causes a visible separation from the upper lip to the nose. Cleft palate results from the incomplete fusion of the palates in utero and causes a visible/palpable opening of the palate connecting the mouth and the nasal cavity. They can appear alone or together · Problems seen in Cleft Lip/Cleft Palate: § May be diagnosed via ultrasound before birth or after birth by direct observation § Feeding difficulties because the infant cannot create suction to feed § Altered dentition § Delayed/altered speech § Otitis media § Regurgitation § Difficulty forming seal around nipple/areola · Risk Factors for Cleft Lip/Cleft Palate: - - - - -
environmental changes (stress, like using bathrooms at school due to lack of privacy) or related to potty training
Constipation · Constipation: a decrease in bowel movement frequency or trouble defecating for more than 2 weeks. It is often associated with painful bowel movements, blood-streaked or retained stool, ABD pain, lack of appetite, and stool incontinence. § Obstipation: extremely long intervals between stools § Encopresis: constipation with fecal soiling § Idiopathic Constipation: constipation with no known cause (most common) § Chronic Constipation: environment, psychosocial, or both · Constipation may be secondary to other disorders, like strictures, ectopic anus, Hirschsprung disease, hypothyroidism, hypercalcemia, chronic lead poisoning, antacids, diuretics, antihistamines, opioids, or spinal cord lesions. · Constipation in Newborn: § Meconium passage normally occurs in the first 24-36 hours after birth. § Newborns that don't pass meconium should be assessed for intestinal atresia, Hirschsprung disease, hypothyroidism, meconium plug, or meconium ileus § Meconium plug is caused by meconium that has reduced water content and may require irrigations or digital removal § Meconium ileus (initial finding of cystic fibrosis) is the luminal obstruction of the intestine by meconium. It can be related to disease process in the newborn · Constipation in Infancy: § Often related to diet or Hirschsprung disease, hypothyroidism, or strictures § Not common in breastfed babies, who have less stools because of more complete digestion with little residue § When switching from formula to milk, may need to increase amount of cereal, vegetables, fruit, and fluids to correct constipation · Constipation in Childhood § Often due to ______________________________________________
Meconium plug
Constipation · Constipation: a decrease in bowel movement frequency or trouble defecating for more than 2 weeks. It is often associated with painful bowel movements, blood-streaked or retained stool, ABD pain, lack of appetite, and stool incontinence. § Obstipation: extremely long intervals between stools § Encopresis: constipation with fecal soiling § Idiopathic Constipation: constipation with no known cause (most common) § Chronic Constipation: environment, psychosocial, or both · Constipation may be secondary to other disorders, like strictures, ectopic anus, Hirschsprung disease, hypothyroidism, hypercalcemia, chronic lead poisoning, antacids, diuretics, antihistamines, opioids, or spinal cord lesions. · Constipation in Newborn: § Meconium passage normally occurs in the first 24-36 hours after birth. § Newborns that don't pass meconium should be assessed for intestinal atresia, Hirschsprung disease, hypothyroidism, meconium plug, or meconium ileus § _________________________ is caused by meconium that has reduced water content and mar require irrigations or digital removal § Meconium ileus (initial finding of cystic fibrosis) is the luminal obstruction of the intestine by meconium. It can be related to disease process in the newborn
Hypertonic Dehydration
Dehydration · Dehydration is a fluid disturbance that occurs when the total output of fluid exceeds the total intake, regardless of underlying cause It is often the result of abnormal losses (vomiting, diarrhea) · Gastrointestinal Disorder Findings § Fatigue, behavior changes, change in stool pattern, poor appetite, weight loss, and pain § Untreated dehydration leads to hypovolemic shock § Deteriorate quickly → intervene quickly · Types of Dehydration · _____________________: this dehydration results from water (H2O) loss in excess of electrolyte loss (often caused by increased intake of electrolytes or decreased intake of H2O) § With this dehydration, fluid moves from ICF to ECF; and Sodium (Na+) > 150 mEq/L § This is the most dangerous dehydration. It can occur in infants with diarrhea who are given fluids by mouth that contain large amounts of solute or in children who receive high-protein NG tube feedings (overloads kidneys) § CNS symptoms (seizures, LOC changes, poor attention, lethargy, increased muscle tone, hyperreflexia, hyperirritability to sensory stimuli) are more likely to occur. These are dangerous and can result in permanent damage. § S/S of Hypertonic Dehydration: · skin: gray, may be cold or hot, fair turgor, thick/doughy texture · mucus membranes: parched · tearing/salivation: absence · Eye: sunken · Fontanel: sunken · Body temp: subnormal or elevated · Pulse: moderately rapid · Respirations: rapid · behavior: marked lethargy with extreme hyperirritability on stimulation
Hypotonic Dehydration
Dehydration · Dehydration is a fluid disturbance that occurs when the total output of fluid exceeds the total intake, regardless of underlying cause It is often the result of abnormal losses (vomiting, diarrhea) · Gastrointestinal Disorder Findings § Fatigue, behavior changes, change in stool pattern, poor appetite, weight loss, and pain § Untreated dehydration leads to hypovolemic shock § Deteriorate quickly → intervene quickly · Types of Dehydration · __________________________: this dehydration occurs when electrolyte deficit exceeds H2O deficit, leaving the serum hypotonic § Water (H2O) moves from ECF to ICF in an attempt to correct → increased ECF loss; and Sodium (Na+) is less than 130mEq/L § can have shock-like symptoms; physical symptoms are more severe with smaller fluid loss § s/s of Hypotonic Dehydration: · skin: gray, cold, very poor skin turgor, clammy · mucus membranes: slightly moist · tearing/salivation: absent · Eye: sunken · Fontanel: sunken · Body temp: subnormal or elevated · Pulse: very rapid · Respirations: rapid · behavior: lethargic, comatose, seizures
Isotonic Dehydration
Dehydration · Dehydration is a fluid disturbance that occurs when the total output of fluid exceeds the total intake, regardless of underlying cause It is often the result of abnormal losses (vomiting, diarrhea) · Gastrointestinal Disorder Findings § Fatigue, behavior changes, change in stool pattern, poor appetite, weight loss, and pain § Untreated dehydration leads to hypovolemic shock § Deteriorate quickly → intervene quickly · Types of Dehydration · ___________________________: this dehydration occurs in conditions in which electrolyte and water (H2O) deficits present in balanced proportions. It is the most common in children. Sodium and water are lost in equal amounts. § major fluid loss is from ECF, and plasma Sodium (Na+) levels WNL (130-150) § hypovolemic shock is greatest risk to life § S/S of Isotonic Dehydration: · skin: gray, cold, poor turgor, dry · mucus membranes: dry · tearing/salivation: absent · Eye: sunken · Fontanel: sunken · Body temp: subnormal or elevated · Pulse: rapid · Respirations: rapid · behavior: irritable to lethargic
§ 5-10% loss of body weight in infants § 3-6% loss of body weight in children
Dehydration · Evaluating the Degree of Dehydration -Moderate Dehydration: § ________________ loss of body weight in infants § ________________ loss of body weight in children § Pulse: slightly increased § Respiratory rate: slight rapid, tachypnea § BP: normal to orthostatic (10mmhG change) § Thirst: moderate § Behavior: irritable and thirsty § Mucus membranes: dry § Tears: decreased § Fontanel: normal to sunken § Jugular vein: not visible except with supraclavicular pressure § Skin: slow cap refill (2-4sec), decreased turgor § Urine: oliguria
§ More than 10% loss of body weight in infants § More than 6% loss of body weight in children
Dehydration · Evaluating the Degree of Dehydration -Severe Dehydration: § More than ____________ loss of body weight in infants § More than ____________ loss of body weight in children § Pulse: very increased § Respiratory rate: deep, rapid, hyperpnea § BP: orthostatic to shock § Thirst: intense § Behavior: hyperirritable to lethargic § Mucus membranes: parched § Tears: absent, sunken eyes § Fontanel: sunken § Jugular vein: not visible at all § Skin: cap refill greater than 4 seconds, tenting, cool skin, acrocyanotic, mottled § Urine: oliguria or anuria
§ Less than 5% loss of body weight in infants § Less than 3% loss of body weight in children
Dehydration · Evaluating the Degree of Dehydration Mild Dehydration: § Less than ___________ loss of body weight in infants § Less than ___________ loss of body weight in children § Pulse: normal § Respiratory rate: normal § BP: normal § Thirst: slight § Mucus membranes: normal (moist) § Tears: present § Fontanel: normal § Jugular vein: visible when supine § Skin: cap refill greater than 2 seconds § Urine: decreased
Normal Saline (NS) or Lactated Ringer's (LR) 20 ml/kg bolus over 5-20 minutes followed by maintenance fluids.
Dehydration · Nursing Care/Management · GOAL: To restore appropriate fluid balance and prevent complications · Take accurate history: fluid intake, urine output, diarrhea, emesis, tears · Assess s/s: altered LOC, irritability, lethargy, poor appetite, sick appearance, decreased skin elasticity/turgor, prolonged cap refill (>2sec), tachycardia, sunken eyes/fontanels, dry skin/mucus membranes, circulatory failure (decreased BP), lactic acid accumulation § Monitor for shock: tachycardia, low pulse ox reading, cool/mottled skin, low cap refill, oliguria/azotemia · Accurate I&O and daily weights · Frequent VS (Q15-30 minutes) with CRT · Record # of wet diapers or weighing diapers and voids (subtract dry weight from wet weight = output) · Monitor stools, vomitus, sweating. Give 10mL/kg for each stool or emesis · Monitor for symptoms of worsening or improvement · Oral Rehydration Solution (ORS) - replacement of fluid loss over 4-6 hours, replacement of continuing losses, and provision for maintenance fluid requirements § ORS is good for Mild-moderate dehydration: · Mild dehydrated child can be given 50mL/kg of oral rehydration solution · Moderate dehydrated child can be given 100mL/kg of oral rehydration solution § A child with diarrhea should have 10mL/kg for every loose stool § Small amounts (2-5ml) by spoon or syringe ever 2-3min if needed when the child is not thirsty § Amount and rate determined by body weight and severity of dehydration · Parenteral Therapy: initiated when the child can't ingest enough fluids to meet ongoing physiologic fluid losses, replace previous deficits, and replace ongoing abnormal losses. It is usually given to those with severe dehydration, uncontrollable vomiting, extreme fatigue/coma, and severe gastric distention 1. Initial Fluids: __________________________________ 2. Subsequent therapy is given to replace deficits, meet maintenance water needs, and catch up with ongoing losses 3. Finally, Re-introduction of diet § **Rapid administration can cause cerebral edema
Intractable (Infancy) Diarrhea
Diarrhea · Chronic Diarrhea: increase in frequency and H2O content for greater than 14 days; usually due to IBS, immunodeficiency, food allergy, lactose intolerance or other · __________________: diarrhea syndrome that occurs in first months of life with no known cause for greater than 14 days and is refractory to treatment; usually caused by ineffective treatment for acute infectious diarrhea · Chronic Nonspecific Diarrhea: diarrhea syndrome common in children ages 6-54 months; loose stools and undigested food particles for greater than 14 days; usually diet-related or excessive juice intake
160-165 degrees
Diarrhea · Prevention of Diarrhea § Rotavirus Vaccine PO - RotaTeq or Rotarix § Personal hygiene, showering frequently; wash bed linens and underwear daily for several days (avoid shaking linens) § Disposal of dirty diapers § Isolation of sick family members; keep child's toys away form other children's toys and clean them § Clean water supply § Careful food preparation, quick refrigeration of meet/perishables § Never let food thaw on the counter or let it sit outside of the refrigerator for more than 2 hours § Handwashing, cleaning utensils and work areas with hot/soapy water after contact with raw meat § Cook meats to at least __________________ degrees until brown/gray inside; check with fork to ensure no pink meat § Use soap or weak bleach solution to wash vegetables/fruits that can't be peeled § Breastfeeding
Breastfeeding
Disorders of Nutrition · Vitamin Imbalances · Vitamin D deficiency, rickets: § exclusively breastfed infants beyond six months without maternal vitamin D supplementation § premature infants with inadequate intake of vitamin D/A § children with dark skin pigmentation who are exposed to sunlight because of socioeconomic, religious, or cultural beliefs or housing in urban areas with high levels of pollution, or who live where sunlight does not produce enough vitamin D § TREATMENT: 400 UI of vitamin D for infants · Vitamins A&D deficiency: Cystic Fibrosis or short bowel syndrome · Vitamin C deficiency: children taking high-dose ASA; excess vitamin A causes dry, scaly skin, desquamation, fissures, anorexia, vomiting, bulging fontanels · Vitamins A, D, E & K deficiency: thalassemia (also Ca+ and Mg+ ) · Vitamin A deficiency: should be supplemented in children with Measles due to risk of blindness; · Mineral Imbalances § Low iron (Fe+): anemia § Low Zinc: FTT § High Zinc: causes low copper § Low Ca+ & PO4-: common in infants given whole milk instead of formula § Children receiving radiation, HIV, SCD, CF, GI malabsorption, nephrosis, and premature infants at high risk · Prevention § ________________ for at least 6 months, and preferrable up to one year or longer § Iron (Fe+) fortified cereal up to 18 months, and Iron (Fe+) supplementation at 4 months if exclusively breastfed § Vitamin b12 supplementation if mom is not taking vitamin supplements § Wide variety of food in infancy and early years
Sandifer syndrome
Gastroesophageal Reflex (GER) · Gastroesophageal Reflex (GER): transfer of gastric contents into esophagus. GERD is tissue damage from GER § GER occurs more frequently after meals, at night, within first year of life, and normally resolves § GER can be related to neurological condition, hiatal hernia, obesity § ___________________________ is uncommon and characterized by repetitive strength and arching of the head and neck that can be mistaken for a seizure. IT represents a physiologic neuromuscular response to prevent acid reflux from reaching the upper portion of the esophagus. · Manifestations of Gastroesophageal Reflex (GER): § Infants may have arching/stiffening of head and neck with crying/irritability during feeding, irritability, frequent spitting up or vomiting (bloody), respiratory problems (cough, wheeze, stridor, gagging, chocking), hematemesis, FTT, apnea spells or ALTE § Children have heartburn, ABD pain, noncardiac chest pain, chronic cough, dysphagia, nocturnal asthma, recurrent pneumonia · Gastroesophageal Reflex (GER) Diagnosed by history, UGI series, 24-hour intraesophageally pH monitoring (gold standard), or endoscopy
transmitted through blood, semen, and saliva (blood transfusions, perinatal transition) § Those at risk include 1 those with hemophilia, 2 children involved in IV drug abuse, 3 institutionalized children, 4 preschool children in endemic areas, 5 those engaged in sexual activity with an infected person.
Hepatitis · Hepatitis: an acute or chronic inflammation of the liver that can result from infectious or non-infectious reasons. · Hepatitis A: transmitted via fecal-oral route, associated with poor food/hand hygiene. Often causes diarrhea · Hepatitis B: ____________________________- - · Hepatitis C: most common cause of chronic liver disease and cirrhosis; transmitted parenterally through blood exposure or perinatally. · Hepatitis D: caused by a defective RNA virus that requires helper function of hepatitis B virus. It is transmitted through blood and sexual contact · Hepatitis E: transmission occurs through fecal-oral route or from contaminated water. It is not a chronic condition and does not cause chronic liver disease.
transmission occurs through fecal-oral route or from contaminated water. It is not a chronic condition and does not cause chronic liver disease.
Hepatitis · Hepatitis: an acute or chronic inflammation of the liver that can result from infectious or non-infectious reasons. · Hepatitis A: transmitted via fecal-oral route, associated with poor food/hand hygiene. Often causes diarrhea · Hepatitis B: transmitted through blood, semen, and saliva (blood transfusions, perinatal transition) § Those at risk include 1 those with hemophilia, 2 children involved in IV drug abuse, 3 institutionalized children, 4 preschool children in endemic areas, 5 those engaged in sexual activity with an infected person. · Hepatitis C: most common cause of chronic liver disease and cirrhosis; transmitted parenterally through blood exposure or perinatally. · Hepatitis D: caused by a defective RNA virus that requires helper function of hepatitis B virus. It is transmitted through blood and sexual contact · Hepatitis E: _______________________________
hand washing, vaccines
Hepatitis · Hepatitis: an acute or chronic inflammation of the liver that can result from infectious or non-infectious reasons. · Hepatitis A: transmitted via fecal-oral route, associated with poor food/hand hygiene. Often causes diarrhea · Hepatitis B: transmitted through blood, semen, and saliva (blood transfusions, perinatal transition) § Those at risk include 1 those with hemophilia, 2 children involved in IV drug abuse, 3 institutionalized children, 4 preschool children in endemic areas, 5 those engaged in sexual activity with an infected person. · Hepatitis C: most common cause of chronic liver disease and cirrhosis; transmitted parenterally through blood exposure or perinatally. · Hepatitis D: caused by a defective RNA virus that requires helper function of hepatitis B virus. It is transmitted through blood and sexual contact · Hepatitis E: transmission occurs through fecal-oral route or from contaminated water. It is not a chronic condition and does not cause chronic liver disease. · Manifestations of Hepatitis: § Anorexia, malaise, lethargy, fatigue § Fever § Nausea, vomiting, epigastric or RUQ pain/tenderness § Jaundice, dark urine, pale stools, itching § Weight loss § Hepatomegaly § Encephalopathy, coagulation defects, ascites, increase WBC, mental status changes (all with HBV, HCV and fulminant hepatitis) · Nursing Care of Hepatitis: § Prevention: _____________________ § Explain medication regimens; use caution when administering OTC drugs due to inability of the liver to detoxify and excrete them (toxicity) § Encourage well-balanced diet and a schedule of rest and activity
strangulated hernia
Hernias · Hernia: a protrusion of a portion of an organ or organs through an abnormal opening. · Danger arises when blood flow is cut off to the protruding organ and impairs function (___________________ hernia) · Umbilical hernia is common in infants · Inguinal hernias are common in boys · Incarcerated hernias are those that cannot be reduced easily
· Stabilize fluid and electrolyte balance: low-fiber, high-calorie/protein diet · Saline enemas to empty bowels and antibiotics to prevent infection · observe for signs of enterocolitis (bowel inflammation) or bowel perforation: VS and BP for signs of shock, fever, ABD distention, vomiting, increased pain, irritability, dyspnea or cyanosis · measure abdominal circumference to assess increased ABD distention · education about colostomy care for child and parents and future reversal. Reassure them when colostomy is temporary to prevent anxiety, but inform them that it will require another surgery
Hirschsprung Disease · Hirschsprung Disease: a congenital anomaly that causes constipation due toinadequate motility and absence of ganglion cells in affected area. The absence of ganglion cells causes loss of recto-sphincteric reflex and lack of the internal sphincter to relax and normal peristalsis. · Nursing Care of Hirschsprung Disease Surgery: § Pre-op: 1. 2. 3. 4. 5. § Post-op: · Maintain airway and O2, vitals, manage pain · They may have an NG tube to low suction · Monitor stool output, fluid/hydration status (prevent dehydration) · high protein/high calorie/low fiber diet · TPN may be needed, electrolyte replacements · bowel sounds in all 4 quadrants and bowel function · Foley catheter care PRN · wound care and ostomy care as needed; prevent infection § Complications: enterocolitis, anal stricture, incontinence
Olive-shaped mass
Hypertrophic Pyloric Stenosis · Hypertrophic Pyloric Stenosis: thickening of the pyloric sphincter causing an obstruction (genetic). This usually develops in the first few weeks/months of life and causes nonbilious vomiting after feedings, dehydration, metabolic alkalosis, and failure to thrive § Gastric outlet obstruction § Leads to FTT, dehydration, jaundice § Requires surgery usually in the first 2 months of life · Manifestations of Hypertrophic Pyloric Stenosis: § Increasing forceful projectile vomiting, may be ejected 3-4 feet from child when in side lying position or 1 foot or more in supine; occurs shortly after feeding or intermittently; nonbilious, may be blood tinged § Infant is constantly hungry, avid feeder, eagerly accepts feeding after vomiting § Weight loss, dehydration, visible peristaltic waves moving from left to right § _____________________________ palpated when stomach is empty and muscles are relaxed § Metabolic alkalosis from dehydration/vomiting (and weight loss, pallor, cool lips, dry skin, decreased skin turgor, oliguria, thirst, rapid pulse, sunken eyes) § Intestinal Obstruction: · Colicky ABD pain, ABD distention, constipation/obstipation, dehydration, rigid board-like ABD, diminished/absence bowel sounds · Respiratory distress occurs as diaphragm is pushed up into pleural cavity · Shock results from loss of fluids and electrolytes · Sepsis results from bacterial proliferation and invasion into circulation
clear liquids 4-6 hr after surgery; breastfeeding's begin after 12-24hr with small/frequent feedings of electrolyte solutions. If clear liquids are maintained, breast feedings/formulas are advanced as tolerated per surgeon.
Hypertrophic Pyloric Stenosis · Manifestations of Hypertrophic Pyloric Stenosis: § Increasing forceful projectile vomiting, may be ejected 3-4 feet from child when in side lying position or 1 foot or more in supine; occurs shortly after feeding or intermittently; nonbilious, may be blood tinged § Infant is constantly hungry, avid feeder, eagerly accepts feeding after vomiting § Weight loss, dehydration, visible peristaltic waves moving from left to right § Olive-shaped mass palpated when stomach is empty and muscles are relaxed § Metabolic alkalosis from dehydration/vomiting (and weight loss, pallor, cool lips, dry skin, decreased skin turgor, oliguria, thirst, rapid pulse, sunken eyes) § Intestinal Obstruction: · Colicky ABD pain, ABD distention, constipation/obstipation, dehydration, rigid board-like ABD, diminished/absence bowel sounds · Respiratory distress occurs as diaphragm is pushed up into pleural cavity · Shock results from loss of fluids and electrolytes · Sepsis results from bacterial proliferation and invasion into circulation · Nursing Care § IV fluids (correct electrolyte imbalance/dehydration) § NG tube for decompression, NPO, strict I/O, daily weights § Monitor vitals for signs of fluid/electrolyte imbalance § Surgery: pyloromyotomy · Preop: NPO, I/O, daily weights, IV hydration, correct metabolic alkalosis, NG decompression · Postop: _______________________________________ § Post op vomiting is common and can occur for 24-48 hours, so administer IV fluids and position on side/upright (aspiration risk) § Pain management, I/O, daily weights § Monitor surgical site for infection; wound care
Ulcerative Colitis
Inflammatory Bowel Disease (IBD) · Inflammatory Bowel Disease (IBD): this term describes two chronic forms of intestinal inflammation (Chron Disease and Ulcerative colitis) · ____________________: intestinal inflammation is limited to the colon and rectum, with distal colon commonly affected. Thickening of the bowel wall and fibrosis are unusual. Toxic megacolon is the most severe form § S/S: · Rectal bleeding: common · Diarrhea: often severe · Pain: less frequent · Anorexia: moderate or mild · Weight loss: moderate · Growth delay: usually mild · Anal/perianal lesions: rare · Fistulas/strictures: rare · Rashes: mild · Joint pain: mild to severe
Chron Disease
Inflammatory Bowel Disease (IBD) · Inflammatory Bowel Disease (IBD): this term describes two chronic forms of intestinal inflammation (Chron Disease and Ulcerative colitis) · ____________________: intestinal inflammation is throughout any part of the GI tract and involves all layers of the bowel wall. It involves skip lesions, and inflammation can cause fistulas, adhesions, strictures, ulcerations, and fibrosis. § S/S: · Rectal bleeding: uncommon · Diarrhea: moderate to severe · Pain: common · Anorexia: may be severe · Weight loss: may be severe · Growth delay: may be severe · Anal/perianal lesions: common · Fistulas/strictures: common · Rashes: mild · Joint pain: mild to moderate
(BROW) barely, rye, oats, grains of wheat ; they need a high-carb; low-fat diet
Malabsorption Syndromes · Celiac Disease (Gluten-sensitive enteropathy): Permanent intestinal intolerance to dietary gluten (protein) present in wheat, barley, rye, and oats § Causes damage to villi in small intestine § More common in Europeans in US § Celiac Disease (Gluten-sensitive enteropathy) S/S: large, pale, oily, frothy, foul-smelling stools (steatorrhea), with malnutrition, muscle wasting, anemia, anorexia, ABD distention, irritability, uncooperativeness, apathy · Celiac Crisis: acute episodes of profuse, watery diarrhea, vomiting, often precipitated by infections, fluid/electrolyte depletion, emotional disturbance · Blood tests positive for transglutaminase and antiendomysial antibodies and UGI biopsy § Treatment is "gluten-free" diet (actually low gluten); no __________________________________ § Dietary consult to assist parent and child to meal plan at home and school
enzyme lactase added to foods, and eating yogurt (contains natural lactase), supplements of vitamin D and calcium
Malabsorption Syndromes · Lactose Intolerance: Inability to digest lactose, a sugar found in milk and dairy products. It involves a deficiency of lactase, which is needed for digestion of lactose § Congenital: occurs soon after birth after exposure to milk-containing formula § Developmental: occurs in preterm infants <34 weeks and is reversible over time § Primary: most common manifested by age 2; common in Asians, American Indians, and African-Americans § Secondary: can occur after damage to intestinal lumen due to cystic fibrosis, celiac disease, kwashiorkor, giardiasis or rotavirus § Manifested by pain, bloating, flatulence, diarrhea, nausea within 30 minutes of exposure to lactose § Treated with ___________________________________
Bed Rest
Meckles' Diverticulum · Meckel Diverticulum: a remnant of the fetal omphalomesenteric duct, which connects the yolk sac with the primitive midgut during fetal life. Failure of obliteration results in fistula. It arises from the small intestine and includes all layers of the intestinal wall. § Most common congenital malformation of GI tract usually found within 16-20" of ileocecal valve § Twice as common in males · Pathophysiology: Ulceration, bleeding, intestinal obstruction causes symptomatic complications · Clinical Manifestations of Meckel Diverticulum § Rectal bleeding (usually painless) § Abdominal pain (similar to appendicitis, and may be vague or recurrent) signs of GI obstruction § Bright red or dark bloody, mucus stools ("currant-jelly") that can be severe enough to cause hypotension, anemia, or shock · Diagnostic Evaluation of Meckel Diverticulum § Radionucleotide scan § Meckel scan: technetium-99 pertechnetate scan § CT or MRI · Management of Meckel Diverticulum § Surgical removal of diverticulum § Pre-op Care: · With severe bleeding: IV fluids, blood transfusions, O2 therapy · Antibiotics to prevent infection · Provide O2, maintain bed rest, monitor blood loss in stools § post-op care: · _______________ initially · pain management; monitor respiratory status/O2 · IV fluids/antibiotics; assess surgical site for bleeding · Monitor bowel sounds and bowel function · NG tube to low suction, NPO · psychologic support · Nursing Care for Meckel Diverticulum § IVF and blood transfusions for hypovolemia § Bed rest; oxygen; IV antibiotics § Postop Care: airway, vitals, pain, bleeding, bowel function, NPO, NG tube to low suction
Bright red or dark bloody, mucus stools ("currant-jelly")
Meckles' Diverticulum · Meckel Diverticulum: a remnant of the fetal omphalomesenteric duct, which connects the yolk sac with the primitive midgut during fetal life. Failure of obliteration results in fistula. It arises from the small intestine and includes all layers of the intestinal wall. § Most common congenital malformation of GI tract usually found within 16-20" of ileocecal valve § Twice as common in males · Pathophysiology: Ulceration, bleeding, intestinal obstruction causes symptomatic complications · Clinical Manifestations of Meckel Diverticulum § Rectal bleeding (usually painless) § Abdominal pain (similar to appendicitis, and may be vague or recurrent) signs of GI obstruction § ____________________________ that can be severe enough to cause hypotension, anemia, or shock · Diagnostic Evaluation of Meckel Diverticulum § Radionucleotide scan § Meckel scan: technetium-99 pertechnetate scan § CT or MRI
primary ulcers, increased chance of recurrence, H. Pylori, epigastric pain, vague ABD pain, nighttime waking, hematemesis, melena, anemia
Peptic Ulcer Disease (PUD) · Peptic Ulcer Disease (PUD): a chronic condition that affects the stomach and duodenum, characterized by ulcers. § Gastric ulcers: ulcers that involve the stomach § Duodenal ulcers: ulcers involving the pylorus or duodenum § HELICOBACTER PYLORI, alcohol, smoking, ulcerogenic drugs are common causes of infection and primary ulcers § Secondary ulcers result from stress of disease/injury (burns, sepsis, ICP) · Manifestations of Peptic Ulcer Disease (PUD): § Neonates: gastric ulcers, secondary ulcers; history of preterm birth, respiratory distress, sepsis, hypoglycemia, intraventricular hemorrhage; perforation can cause bleeding § Infants to 2 year old: secondary ulcers; occurs in relation to illness, surgery, or trauma; s/s of hematemesis, melena, or perforation § Children 2-6 years old: primary/secondary ulcers; perforation, periumbilical pain, poor eating, vomiting, irritability, nighttime waking, hematemesis, melena § Children older than 6: _____________________________
do not rapidly administer carbs
Severe Malnutrition · Marasmic Kwashiorkor is a form of severe malnutrition in which the clinical findings of both marasmus and kwashiorkor are evident. · Treatment of Marasmus, Kwashiorkor, and severe malnutrition: § Rehydration with ORS and electrolytes § Administration of antibiotics to prevent infection § Provision of adequate nutrition § Prevent refeeding syndrome:_________________________________ § Vitamin A, zinc, and copper supplements § Avoid iron supplementation until the child can tolerate a steady food source § Monitor for skin breakdown § Encourage breastfeeding § Prevent infection
Kwashiorkor
Severe Malnutrition · __________________________: Deficiency of protein and inadequate calories usually in children age 1-4 § __________________________ may result from interplay of nutrient deprivation (Vitamin A, zinc, Ca+, Fe+), infections, or environmental stress § Signs/Symptoms of __________________________: Thin, wasted extremities, prominent abdomen (from edema and ascites), dry scaly skin that may be depigmented, loss of hair, blindness (Vitamin A), poor wound healing, persistent diarrhea, and anemia § Protein deficiency increases susceptibility to infection (HIV), which may lead to death, or death from diarrhea and circulatory failure
Marasmus
Severe Malnutrition · ___________________________: General malnutrition of calories and protein in infants as young as 3 months § It is a syndrome of emotional and physical deprivation often associated with TB, HIV, parasitosis, and dysentery § Signs/Symptoms of ___________________________: General wasting and atrophy of body tissues (especially Sub-Q fat), lethargy, apathy, withdrawal and irritable, wrinkled/loose skin (old appearance); fluid/electrolyte imbalances, hyponatremia, hypoglycemia § Treatment with ORS, antibiotics for infection, breastfeeding for a minimum of six months, or proper weaning diet; may require tube feedings; ready-to-use therapeutic food (RUTF)
Inspection, Auscultation, Percussion, Palpation
Taking A History · Growth patterns · Food allergies · Genetic disorders · Intestinal infections · Dietary issues Physical Exam · Order of Gastrointestinal Exam: ________________________________ · Least invasive first · Skin Color - pallor, icteric (yellow), bruising · Hydration - sunken fontanels, oral mucosa, tear absence, urine output · Abdomen - mass, obstruction, ascites, gas distention · Mental Status - dehydration, anaphylactic reactions, metabolic disorders, irritability, restlessness, lethargy, listlessness
b. Administration of analgesics for pain d. Intravenous (IV) fluids continued until tolerating fluids by mouth e. Clear liquids as the first feeding
The nurse is preparing to care for an infant returning from pyloromyotomy surgery. Which prescribed orders should the nurse anticipate implementing? (Select all that apply.) a. Nothing by mouth for 24 hours b. Administration of analgesics for pain c. Ice bag to the incisional area d. Intravenous (IV) fluids continued until tolerating fluids by mouth e. Clear liquids as the first feeding
a. Elevating the head to facilitate secrete drainage. d. Strangulated hernia c. Visible peristalsis and weight loss
The nurse, caring for a neonate with a suspected tracheoesophageal fistula, should include what intervention into the plan of care? a. Elevating the head to facilitate secrete drainage. b. Elevating the head for feedings only. c. Feeding glucose water only. d. Avoiding suctioning unless the infant is cyanotic. Which type of hernia has an impaired blood supply to the herniated organ? a. Hiatal hernia b. Incarcerated hernia c. Omphalocele d. Strangulated hernia The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis? a. Abdominal rigidity and pain on palpation b. Rounded abdomen and hypoactive bowel sounds c. Visible peristalsis and weight loss d. Distention of lower abdomen and constipation
vomit that is mostly bile (green in color) and usually associated with obstruction
Vomiting · Vomiting: the forceful ejection of gastric contents through the mouth, often accompanied by nausea and retching. It is commonly caused by infectious diseases, ICP, toxic poisons, food intolerances/allergies, mechanical obstructions, or metabolic disorders. · Nonbilious Vomiting: vomit that is mostly stomach content without bile · Bilious Vomiting: ___________________________ · Forceful Vomiting: vomit that is usually due to pyloric stenosis · Cyclic Vomiting: rare with bouts of vomiting lasting hours to days and child appears otherwise healthy · Nursing Care Management for Vomiting: § Detection and treatment of cause § Prevention of complications (dehydration and malnutrition) § ORS preferred or IVF is severe dehydration § Antiemetics: · ondansetron has fewer side effects in children · dimenhydrinate for motion sickness § Position vomiting child/infant on side or up to prevent aspiration § Small, frequent fluids and feedings preferred increasing to liberal fluid amounts after vomiting stops § Brush teeth after vomiting
a. Oatmeal c. "Currant jelly" stools d. Coping with stress and avoiding triggers
What food choice by the parent of a 2-year-old child with celiac disease indicates a need for further teaching? a. Oatmeal b. Rice cake c. Corn muffin d. Meat patty Which description of a stool is characteristic of intussusception? a. Ribbon-like stools b. Hard stools positive for guaiac c. "Currant jelly" stools d. Loose, foul-smelling stools What should the nurse stress in a teaching plan for the mother of an 11-year-old diagnosed with ulcerative colitis? a. Preventing the spread of illness to others b. Nutritional guidance and preventing constipation c. Teaching daily use of enemas d. Coping with stress and avoiding triggers
a. Notify the practitioner a. Refer to a nutritionist for detailed dietary instructions and education. c. Teaching dietary modifications
What is the most appropriate nursing action when a child with a probable intussusception has a normal, brown stool? a. Notify the practitioner b. Measure abdominal girth c. Auscultate for bowel sounds d. Take vital signs, including blood pressure An important nursing consideration in the care of a child with celiac disease is to facilitate which intervention? a. Refer to a nutritionist for detailed dietary instructions and education. b. Help the child and family understand that diet restrictions are usually only temporary. c. Teach proper hand washing and Standard Precautions to prevent disease transmission. d. Suggest ways to cope more effectively with stress to minimize symptoms. What is the major focus of the therapeutic management for a child with lactose intolerance? a. Compliance with the medication regimen b. Providing emotional support to family members c. Teaching dietary modifications d. Administration of daily normal saline enemas
c. Reduce gastric acid production. d. Abdominal pain that is most intense at McBurney point c. Sudden relief from pain
What is the primary purpose of prescribing a histamine receptor antagonist for an infant diagnosed with gastroesophageal reflux? a. Prevent reflux b. Prevent hematemesis. c. Reduce gastric acid production. d. Increase gastric acid production. Which clinical manifestation would most suggest acute appendicitis? a. Rebound tenderness b. Bright red or dark red rectal bleeding c. Abdominal pain that is relieved by eating d. Abdominal pain that is most intense at McBurney point When caring for a child with probable appendicitis, the nurse should be alert to recognize what sign of perforation? a. Bradycardia b. Anorexia c. Sudden relief from pain d. Decreased abdominal distention
a. Provide a well-balanced, low-fat diet. c. Teach parents not to administer any over-the-counter medications. e. Instruct parents on the importance of good hand washing.
Which interventions should a nurse implement when caring for a child with hepatitis? (Select all that apply.) a. Provide a well-balanced, low-fat diet. b. Schedule playtime in the playroom with other children. c. Teach parents not to administer any over-the-counter medications. d. Arrange for home schooling because the child will not be able to return to school. e. Instruct parents on the importance of good hand washing.
c. Intestinal bleeding may be mild or profuse. a. Crohn's disease c. Corticosteroids
Which statement is most descriptive of Meckel's diverticulum? a. It is more common in females than in males. b. It is acquired during childhood. c. Intestinal bleeding may be mild or profuse. d. Medical interventions are usually sufficient to treat the problem. What condition is characterized by a chronic inflammatory process that may involve any part of the gastrointestinal (GI) tract from mouth to anus? a. Crohn's disease b. Ulcerative colitis c. Meckel's diverticulum d. Irritable bowel syndrome What is used to treat moderate-to-severe inflammatory bowel disease? a. Antacids b. Antibiotics c. Corticosteroids d. Antidiarrheal medications
Rotavirus
· Acute Diarrhea: increase in frequency and consistency of stool; usually due to infectious agent spread via fecal-oral route, but may be caused by URI, UTI, antibiotic therapy, or laxative use. § ________________: mild-moderate fever, vomiting (2 days) followed by watery stools, diarrhea lasts 5-7 days · Most common cause of diarrhea in children younger than 5 · Fecal-oral transmission § Norovirus: Abd cramps, nausea, vomiting, malaise, low fever, water diarrhea (no blood) § Yersinia enterocolitis: mucoid, possibly blood diarrhea, ABD pain, fever, vomiting; transmitted from pets and food § E. Coli: watery diarrhea 1-2 days, then severe ABD cramping and bloody diarrhea, can progress to hemolytic uremic syndrome § Salmonella: n/v, colicky ABD pain, bloody diarrhea, fever, headache, cerebral symptoms (drowsiness, confusion, seizures), meningitis, septicemia; transmitted from person-person, undercooked meats, poultry § Clostridium Difficile: mild, water diarrhea for a few days, possible leukocytosis, hypoalbuminemia, and high fever, possible pseudomembranous colitis; associated with overgrowth from antibiotic therapy or contact with colonized spores § Clostridium botulinum: ABD pain, cramping, diarrhea, respiratory/CNS problems; transmitted from contaminated food products; incubation 12-26hr § Shigellosis: sick appearance, fever, fatigue, anorexia, cramping ABD followed by water/bloody diarrhea for 5-10 days; transmitted from contaminated food/water § Caliciviruses: ABD cramps, nausea, vomiting, malaise, water diarrhea for 2-3 days; transmitted from contaminated water § Staphylococcus: diarrhea, nausea, vomiting; transmitted from inadequate cooked or refrigerated foods § Enterobius vermicularis (pinworm): perianal itching, enuresis, sleeplessness, restlessness, irritability; transmitted from fecal-oral route. Eggs inhaled/ingested hatch in upper intestine and mature, then they migrate out of the intestine to lay eggs and can survive on surfaces for 2-3 weeks. § Giardia lamblia (parasite): children 5 year or younger have diarrhea, vomiting, and anorexia; older children have ABD cramps, intermittent loose, malodorous, pale, greasy stools; transmitted from person-person, food, or animals
constipation, abdominal distention, foul-smelling, Ribbon-like stools, visible peristalsis, and palpable fecal mass; undernourished, anemic appearance
· Hirschsprung Disease: a congenital anomaly that causes constipation due toinadequate motility and absence of ganglion cells in affected area. The absence of ganglion cells causes loss of recto-sphincteric reflex and lack of the internal sphincter to relax and normal peristalsis. § 4X more common in males and 25% of all neonatal intestinal obstructions · Manifestations of HiRschspRung Disease: § Newborn: newborn does NOT pass meconium stool in first 24 - 48 hours of life; bilious vomit, distention, refusal to feed § Infancy: FTT, chronic constipation, ABD distention, diarrhea/vomiting, or enterocolitis (explosive, watery diarrhea, fever, ill-appearance); § Children: _________________________________
apple, bananas, beans, beets, blackberries, blueberries, bread, broccoli, Brussel sprouts, carrots, cereals, collards, dates, lentils, oat bran, lima beans, pears, raisins, spinach
· Interventions for Constipation: § Increase fluid intake § Promote regular BMs § Increased fiber (age + 5gm) daily: ______________________________________ § Stool-softening agents: Docusate, lactulose, polyethylene glycol § Further investigation
Air Enema
· Intussusception: Telescoping Bowel into a more distal segment, pulling the mesentery with it, and resulting in lymphatic and venous obstruction. As edema fron obstruction increase, pressure in the area increases, resulting in ischemia and pouring of mucus into the intestine § * Edema § * Vascular Compromise § * Total Bowel Obstruction § * Necrosis (if uncorrected) · Manifestations of Intussusception: 1. ABD pain, 2. ABD mass, 3. Bloody stools § Sudden episodic pain, child screaming, but appearance comfortable during intervals between episodes of pain § Draws knees to chest § Sausage shaped mass in URQ, with empty lower right quadrant (dance sign) § Red currant jelly stools § Tender, distended ABD § Vomiting § Fever · Nursing Care of Intussusception § Prepare parents for immediate hospitalization and possible surgery § * __________________________- with or without water-soluble contrast or ultrasound guided saline enema § * Surgery for Recurrent cases § NPO, NG tube to suction, IV fluids, antibiotic therapy § Passage of a normal brown stool usually indicates that the Intussusception has reduced itself. Report to provider immediately due to possible change of therapeutic care plan
Sausage shaped mass in URQ
· Intussusception: Telescoping Bowel into a more distal segment, pulling the mesentery with it, and resulting in lymphatic and venous obstruction. As edema fron obstruction increase, pressure in the area increases, resulting in ischemia and pouring of mucus into the intestine § * Edema § * Vascular Compromise § * Total Bowel Obstruction § * Necrosis (if uncorrected) · Manifestations of Intussusception: 1. ABD pain, 2. ABD mass, 3. Bloody stools § Sudden episodic pain, child screaming, but appearance comfortable during intervals between episodes of pain § Draws knees to chest § ___________________________, with empty lower right quadrant (dance sign) § Red currant jelly stools § Tender, distended ABD § Vomiting § Fever
E. coli, salmonella, shigella
· Nursing Care for Diarrhea · GOAL: asses fluid/electrolyte imbalance, rehydration, fluid therapy, reintroduction of adequate diet · Careful History: causes of diarrhea, severity of symptoms, current symptoms, recent travel, drinking and H2O sources, contact with animals/birds, if attending daycare, recent antibiotics or recent food intake · Appearance and odor of stool can give clues to glucose intolerance, fat malabsorption, enzyme deficiency, protein intolerance, IBD, parasites § Watery, explosive stools suggest glucose intolerance § Foul-smelling, greasy, bulky stools suggest fat malabsorption § Diarrhea after ingesting milk, fruits, or cereal can suggest protein intolerance § Neutrophils or RBCs in stool suggest bacterial gastroenteritis or IBD · Stool C&S (viral and bacterial) · CBC, electrolytes, and renal function · Maintain hydration and nutrition: oral rehydration therapy, oral rehydration solutions § Start ORS therapy of 75-90mEq of sodium/L at 40-50mL/kg over 4 hr § Initiate maintenance therapy with ORS of 40-60 mEq of sodium/L and limit to 150mL/kg/day · Give ORS alternately with intake of other liquids, breast milk, formula, water § 10mL/kg of ORS for each diarrheal stool § For vomiting children, give 5-10mL or ORS every 1-5 minutes § **Diarrhea is not managed by encouraging intake of clear liquids by mouth like fruit juices, soft drinks, and gelatin. These have a high carb content, low electrolyte content, and high osmolality. Avoid caffeine, chicken broth, and BRAT diet (for children and infants) § IV therapy of Lactated Ringers 40mL/kg is given with severe dehydration until pulse and POL return to normal · Early re-introduction of diet after rehydration with breast milk, lactose-free formula, or regular diet · Monitor I/O to determine if renal blood flow is sufficient to permit the addition of potassium into IV fluids · Monitor weights and vitals (avoid taking rectal temperature) · Teach parents to monitor for signs of dehydration. Teach parents that children should stay home during incubation period. PREVENT: hand washing · Skin care for diaper area, avoid taking rectal temperatures · Antibiotics for Shigella and G. lamblia: metronidazole and tinidazole · Antibiotics for C. Diff: Mebendazole, albendazole, pyrantel pamoate · AVOID antibiotics and antimotility drugs for __________________________________
0.01mg/kg max of 0.5mg
· Nursing Care of Food Allergy § Emergency Management of Anaphylaxis: · 1. Epinephrine _______________________ · 2. EpiPen jr 0.5mg IM for children weighting 8-25kg or regular EpiPen for children weighing more than 25kg · Monitor: tachycardia, HTN, irritability, headache, nausea, tremors · Indications for epi administration: itching, tightness in throat, hoarseness, barky cough, dysphagia, dyspnea, wheezing, stridor, flushing, urticaria, angioedema, anxiety, confusion, sense of impending doom, syncope, bradycardia, dysrhythmias, hypotension § Children can outgrow food allergies, but nut allergies usually persist § Education for parent, child, and school personnel: WEAR ID BRACELET and CARRY EPI PEN § Avoid unfamiliar foods and restaurants, and read food labels carefully § Pregestimil, Nutramigen, Alimentum, Neocate or EleCare for cow's milk allergy (all very expensive) § May tolerate soy formulas or have cross-sensitivity
thickened (1 tsp/tbs of rice cereal per ounce of formula) for infants PRN (need to widen bottle nipple).
· Nursing Care of Gastroesophageal Reflex (GER): § Avoidance of foods known to cause discomfort: caffeine, citrus, tomatoes, alcohol, peppermint, spicy/fried foods § Feedings or formula ______________________________ § Elevate HOB or place infant in upright seat for 1hr after/during feedings. Do not place infants to sleep in prone or side-lying position. § Reassure parents that it is often a benign, temporary condition § NG or gastrostomy feedings if severe for FTT § Smaller portions, more frequent feedings, and frequent burping. Avoid vigorous play after feedings § Elevate HOB after feeding for one hour § Restrict meals before bed § Weight loss for obese children § Coping strategies: use bibs for frequent vomiting § Medications (30 Minutes Before Feeding): · PPIs: esomeprazole, lansoprazole, omeprazole, pantoprazole · H2-receptor Antagonist: cimetidine, ranitidine, famotidine § Nissen Fundoplication Repair: reserved for children with recurrent aspiration, PNA, apnea, severe esophagitis, or FTT; post-op care · Monitor for complications: obstruction, gas-bloat syndrome, infection, retching, dumping syndrome
· 5-aminosalicylates, Mesalamine, olsalazine, balsalazide · Corticosteroids: prednisone; monitor for adrenal suppression, growth suppression, weight gain, decreased bone density · Immunomodulators: azathioprine; monitor for infection, pancreatitis, hepatitis, bone marrow toxicity, arthralgia, and malignancy
· Nursing Care of Inflammatory Bowel Disease, Chron Disease, and Ulcerative Colitis: § Reduce and control symptoms § Promote normal growth and development § Allow a normal lifestyle, prevent stress § Medications: - - - § Nutritional support to prevent growth failure: enteral/parental nutrition, high-protein/calorie diet, supplements of vitamins, iron, and folic acid · Meal planning, small/frequent meals or snacks, serve meals with medications · Eggnog, milkshakes, cream soups, puddings, custard § Surgery for ulcerative colitis when medical/nutritional therapies fail to prevent complications: subtotal colectomy and ileostomy: teach stoma care and monitor for pouchitis (inflammation of surgically created pouch) § Monitor for colorectal cancer § Provide emotional support: care of ileostomy
mucosal protective agents
· Nursing Care of Peptic Ulcer Disease (PUD): § Relieve discomfort, promote healing, prevent recurrence § Medications: · Antacids · H2 receptor blockers: cimetidine, ranitidine, famotidine (monitor gastric pH value) · PPIs: omeprazole, lansoprazole, pantoprazole, esomeprazole · Sucralfate or bismuth compounds are __________________________ · Antibiotics for H. pylori · Triple drug therapy § Massive bleeding care: IV fluids, blood transfusion, surgical intervention
