Alterations in Nutrition Lecture #15

ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULA >>>>SURGICAL REPAIR (depends on type)

*Staging repair* versus corrective repair If neonate is unstable (premi; SGA; or complications), may postpone surgery Surgery usually includes: --Thoracotomy; division and ligation of the TEF --End-to-end anastomosis of the esophagus

INTUSSUSCEPTION/ Nursing Intervention with surgery>>>PRE-OP

*Strict I&O* when *NPO pre-op* and *NG tube drainage post-op* (Risk for Fluid Volume Deficit). *Monitor serum electrolytes*, especially if significant diarrhea.

Cleft Palate is

A separation in the hard palate (roof of the mouth) or the soft palate (tissue in the back of the mouth) > in females; can include nasal distortion, midline or bilateral cleft, with extensions to the uvula or soft/hard palates.

DIABETES: NURSING TEACHING>>> Based on Development Level Mid adolescence

ALL like 10 year old + Insulin Pump Create diet plan for meals and snack Measure, may mix, and administer insulin Importance of rotating site Overall, better understanding of condition

EA and TEF looks like

C A E(H) B D

DIABETES Type I: NURSING INTERVENTION

*Goal:* Maintain stable glucose levels -Maintain regular meals, exercise and consistency in insulin administration *-Blood glucose* monitoring: Minimum 4 X / day -Meal planning a/t age, activity level, daily schedule *Snacks:* mid-morning; mid-afternoon and bedtime - to prevent hypoglycemia Exercise plan: Exercise is good, but plan for extra snack and NEVER exercise BEFORE eating. Teach according to child's developmental level: --Different types of insulin; proper administration --What to do if child becomes sick -----Always contact MD/NP for a "sick day plan

INTUSSUSCEPTION/ Nursing Intervention with surgery>>>POST-OP

*Assess for return of bowel* elimination, quality and quantity of stool passed, *guiac ALL stools*, and auscultate for bowel sounds to begin PO feedings. Observe surgical dressing for bleeding or s/s of infection Encourage participation in infant's care; encourage expression of feelings; teaching

DIABETES Type I: Treatment For Hypoglycemia

*Better to OVERTREAT than UNDERTREAT* Carry simple CHO (10-15 grams) for a "quick fix" -Sugar cube; insta-glucose; glucose tablets -Fruit juice (high fructose) -"Hard candy" (not preferred to due to slower action & potential for choking) Not long-lasting! Follow with complex CHO (bread, crackers) and a protein: milk, peanut butter, meat or cheese *If Emergency Situation, immediate treatment with:* High dextrose IV fluids. If unable to get IV access, may if IO (intraosseous) Glucagon: Injectable antihypoglycemic agent -Releases stored glycogen from the liver. -Rises serum glucose levels in 15-20 minutes. -Administer IV, IM or subcutaneously. May be repeated in 20 minutes. *Treatment by MD/NP ASAP or for emergency...CALL 911*

ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULA>>> Possible Pre-surgical interventions to maintain patent airway:

*Cervical esophagostomy:* --Stoma placed in back of the neck to allow for drainage of saliva --Used if an surgical esophageal anastamosis cannot be accomplished immediately to prevent respiratory compromise (aspiration of fluid collecting in pouch) *Endotracheal intubation:* --Only if infant develops acute respiratory failure (i.e. from aspiration

ESOPHAGEAL ATRESIA (EA) AND TRACHEOESOPHAGEAL FISTULA (TEF) >>> Assessment

*Depends on condition, but most commonly the "3 Cs":* *Coughing, Choking, Cyanosis* Coughing and choking with feedings - aspiration Frothing and bubbling at the mouth and nose Excessive oral secretions - drooling Regurgitation and vomiting Abdominal distention or scaphoid (hallow) if no fistula exist Failure to pass an OG or NG tube Nasal flaring and retractions Cyanosis

DIABETES Type I: Signs & Symptoms HYPO

*Emergency situation: Hypoglycemia ("Insulin Shock")* *May be caused by:* -Eating too little; skipping meals; waiting too long between meals -Not eating enough when engaged in physical activities -Taking too much insulin Common signs include: -Restlessness, weakness, dizziness -Cold, clammy, moist skin -Pallor, diaphoresis -Headache, confusion, change in behaviour -Tachycardia, tremors -Tiredness, lethargy, fatigue -Shallow breathing -Extreme hunger -Visual (blurred vision) and speech disturbances -Vertigo; inability to concentrate & loss of coordination -Decreased LOC, unconsciousness - seizure and then coma

FTT Medical vs Psychosocial

*Medical -* Genetic, metabolic, hormonal, neurological, oxygenation, etc - when not treated *Psychosocial -* Emotional deprivation due to parental withdrawal, rejection or hostility (i.e. institutionalized) *Economical factors* - Affects nutrition, living conditions, parental attitudes and environmental factors that expose children to infections etc. Seen as FAILURE TO GAIN HEIGHT / WEIGHT.

HYPERTROPHIC PYLORIC STENOSIS>>> Nursing Interventions PRE-OP

*Strict I&O:* -Administration of IV fluids with electrolyte corrections (i.e. NaCl & KCl supplements for alkalosis due to HCl loss in vomit) -Assess amount, frequency and characteristics of vomit -Monitor daily weights, serum electrolytes, and urine specific gravity Infant will be NPO pre-operatively with an NGT for gastric decompression: -Promote comfort while NPO: pacifier, oral care, rock and cuddle, encourage parental participation in infant's care

CONGENITAL AGANGLIONIC MEGACOLON>>> Nursing Interventions (Part 1)

*Strict I&O:* urine output; frequency and quality of stool; daily weights, monitor hydration; daily abdominal girth *Monitor electrolytes* *For "older" children (i.e. delayed surgical repair; partial obstruction) - teach parents about low residue diet (low fiber):* *Exclude: Legumes, whole grains, nuts, juices with pulp, most fruits & vegetables* *Include: Foods made with white flour, bananas, seedless grapes, lettuce, carrots, pumpkin, avocado, tomato, stewed apple (no skin or core), melons and skinned potatoes.*

Cleft Lip and palate Tx #1 Option

*Surgical repair is necessary* *Nasoalveolar molding (NAM)*, an acrylic orthopedic appliance which approximate the cleft and mold the nose, is commonly used pre-surgery in order to improve the final results of surgical repair of cleft lip and/or cleft palate. The use of NAM also reduces the amount of surgical corrections required.

Cleft Lip and palate Diagnosis

*There are no laboratory tests other than X-ray/CT/MRI to see extensiveness of cleft palate.* *Physical exam:* may be a simple notch in the upper lip or a large opening in the lip that extends into the nostril If not outwardly visible, *Gloved inserted finger* into infants mouth and test ability to suck May *Drip breast milk or formula from the nares* during feeding, especially with cleft palate

INTUSSUSCEPTION>>> Diagnosis

*Ultrasound* usually identifies intussusception *AIR ENEMA* has replaced *barium enema* to confirm a suspected diagnosis of intussusception since it decreases unnecessary exposure to radiation Sometimes the enema results in correction of the invagination since the air pushes the invaginated bowel out

Celiac Disease Diagnosis>>> Loss of absorption in the intestine results in:

-*Stool sample: Steatorrhea* (72 hour quantitative fecal level) -*Serum studies: Anemia* (low Hct, serum iron, low vitamin B12 & folic acid) -*Electrolytes:* Low Calcium and Vitamin D which results in osteomalacia (softening of bone = rickets) and *Osteoporosis* (porous, brittle bones).

Cleft lip/ Cleft palate either can

-Be found in isolation of the other, or they can occur together (cleft lip/palate) -Cleft lip can be unilateral or bilateral, with or without involvement of the palate *(>70 % cleft lip have cleft palate)* Cleft defects *frequently accompany other defects (~ 13%).*

CONGENITAL AGANGLIONIC MEGACOLON>>>> Dx

-Infant: Failure to pass meconium -*Rectal exam* reveals an *empty rectum* with a tight sphincter and there may be obvious stool leakage (seepage around impaction) - "encopresis" = voluntary or involuntary passage of stools -*Barium enema reveals megacolon.* -*Biopsy* results in an absence of ganglion cells in a segment of bowel confirming diagnosis.

CONGENITAL AGANGLIONIC MEGACOLON>>> Assessments S/s

1.Failure to pass meconimum (within 48 hours of life) 2.Poor feeding / Failure to thrive 3.Chronic constipation / failure to pass stool / explosive bowel movement 4.Vomiting & diarrhea (encopresis)

Cleft Lip and palate/ Nursing intervention POST-Surgery///>>>Cleft palate repair

More complex *(staging surgery)* Infant feeding is still time consuming - impaired sucking ability Utilize special feeding devices such as *"Breck Feeder"* Can be made using asepto syringes with rubber extension tubing at the tip long enough to extend back into mouth) or *Haberman Feeder:* Rubber bottles with special long, thin rubber nipples, and rubber-tipped droppers.

DIABETES Type I: 24-HOUR INSULIN PUMP

Very popular with teen-agers (more discrete) Use Regular or lispro insulin Battery driven; Set pump for entire day/night Computer chip controls how much insulin is delivered Convenient: less interference with activities. Sometimes need to monitor dosage and may readjust a/t food intake and activities. However, newer pumps (i.e. MiniMed Paradigm) will have a separate continuous BGM

INTUSSUSCEPTION Description

With this condition, intestinal edema and obstruction occur as a result of an *Invagination of a portion of intestine into itself (telescoping)* Usually from hyperactive peristaltic activity mostly near the ileocecal valve. It is a very common obstruction in infancy.

HYPERTROPHIC PYLORIC STENOSIS>>> Lab TeSt

^ Hct and Hgb shows concentration and dehydration ^ pH and bicarbonate show *metabolic alkalosis* ↓serum Na, Cl and K levels due to fluid imbalance

Breck Feeder

a syringe with a soft feeding tube extension.

Haberman Feeder

Activated by tongue and gum pressure, imitating mechanics in breastfeeding, rather than sucking. A one-way valve separates the nipple from the bottle. Milk cannot flow back into bottle and is replenished continuously .

HYPERTROPHIC PYLORIC STENOSIS>>> Tx

Administer *Antacids if prescribed to neutralize acidity of refluxed contents to prevent damage to the esophagus.* *Alleviate obstruction* utilizing a surgical incision to split the pylorus muscle (pyloromyotomy).

DIABETES: Unique to Pediatrics>>> SOMOGYI PHENOMENON

Affects children with DM) A rapid "rebound" effect from prolonged, untreated hypoglycemia Children with DM Type I may experience hypoglycemia overnight due to the excess insulin in the evening or not eating proper dinner, snacks, etc. Result: *hypoglycemia* Additionally, stress on the body (release of counter-regulatory hormones: glucagon, cortisol, and norepinephrine = anti-insulin reaction; insulin antagonists) and the Dawn Phenomena will "kick in" causing morning hyperglycemia *This REBBOUND HYPERGLYCEMIA* (rapid increase in serum glucose after hypoglycemia) *is unique to pediatrics and makes it more difficult to manage* For example, be careful when correcting a child waking up with hypoglycemia in the middle of the night! If Somogyi occurs, treat the hyperglycemia carefully, using a sliding scale to administer regular insulin

Celiac Disease or "Celiac Sprue"

An *error in metabolism* or an abnormal response in the immunologic system *Celiac Disease : intolerance to gluten food products (malabsorption of gliadin fraction).* *Gliadin factor*: water insoluable protein in gluten of wheat It causes *villi to atrophy & reduces absorptive surface of the small intestine* Results in *accumulation of glutamine* This effects absorption of all nutrients ingested and diarrhea (loss of bicarbonate) can result in electrolyte imbalance, dehydration & acidosis. Often *accompanied by lactose intolerance* (gliadin & villi atrophy makes lactose absorption difficult). Even after withholding gliadin and normalization of villi, lactose intolerance takes longer to reverse. Precipitation factors that lead to *CELIAC CRISIS* include *infections,* exposure to *anticholinergic drugs, prolonged fasting and ingestion of gluten products.*

Cleft Lip is

An opening in the upper lip alone > in males; can range from a slight notch to a complete separation from the floor of the nose

Cleft lip and palate >>>NURSING INTERVENTIONS: Post-treatment FEEDINGS

Assess ability to handle secretions; suck, swallow, and breath without distress *Teach ESSR method* of feeding (Enlarge the nipple, Stimulate, Swallow, Rest) Hold child in an upright position and direct expressed breast milk or formula to the side and back of mouth to prevent aspiration; burp frequently Encourage breast feeding if appropriate

CONGENITAL AGANGLIONIC MEGACOLON>>> Nursing Interventions (Part 2)

Assess for respiratory distress secondary to abdominal distention *Administer medications:* Systemic antibiotics to decrease intestinal flora and prevent infection *Stool softeners and/or enemas* to relieve constipation *-Monitor for enterocolitis = infection of small intestine & colon: Fever, prostration (exhausted; depleted of strength) and explosive, watery diarrhea* *** EMERGENCY SITUATION! ***

Cleft Lip and palate / Nursing interventions PRE-Surgery

Assess the ability to suck, swallow and breathe without distress Feeding is difficult & time consuming: *Should never take more than 20-30 minutes or will utilize too many calories* Keep infants *Head Upright* May use *"Premie nipple"* with *larger opening* which make sucking easier Cleft palate requires special nipples to cover the opening *-Flange nipple* *-Lambs nipple* *Hagerty nipple (Haberman feeder)* Plastic bottles can be compressed by the feeder to control flow and decease the amount of ingested air Feed slowly and burp frequently: Greater tendency to swallow air than infant with normal cavity In some cases with cleft palate, *Spoon feeding* works well *before surgery*. Cleft palate foundation (feeding issues)

DIABETES: NURSING TEACHING>>> Based on Development Level 4-5 yr old

Assist in picking preferred foods Pick injection sites; wipe skin with ETOH Assist to collect blood (fingerstick)

FAILURE TO THRIVE is

Associated with developmental delays (physical & psychosocial) in infants, toddler, pre-school, school-age or adolescence. Results from genetic, physical, psychological and/or social factors.

NURSING INTERVENTIONS: Post-treatment

Avoid objects placed in mouth i.e. spoons, forks or straws --Do not use tongue blade to examine inside the mouth Maintain elbow restraints to prevent damage to suture line; remove at intervals a/t hospital policy (i.e. Q4H) Only use soft, flexible suction catheter if child is in respiratory distress Maintain regularly scheduled follow-up exams, especially hearing evaluations due to increased risk of middle ear infections. Encourage parents to describe feelings related to deformity Information about resources: American Cleft Palate Association, Cleft Palate Foundation and March of Dimes.

ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULA>>> Post OP PO FEEDs

Begin PO feedings10 -14 days post-op following Barium swallow to ensure that the esophagus is healed. Begin with small amounts of water and advance. Observe for any s/s of choking. When PO feedings are tolerated, D/C home

Cleft Lip and palate Etiology

Both occur because of *Incomplete development of the lip &/or palate in the early fetal development* --Lip and primary palate begin to develop between 4 to 6 weeks gestation, with the hard palate completed at 9 -10 weeks gestation

CONGENITAL AGANGLIONIC MEGACOLON (Hirschsprung's Disease) description

Congenital absence of Meissner's and Auerbach's autonomic plexus in the bowel wall *(absence of parasympathetic ganglionic cells)*I Results in lack of nervous system stimulation to the bowel portion affected (distal bowel / colon), which leads *lack of motility and intestinal obstruction (complete or partial)* Accumulation of stool and distention of bowel = *megacolon*

ESOPHAGEAL ATRESIA (EA) AND TRACHEOESOPHAGEAL FISTULA (TEF) >>> Is

Congenital anomaly: 2/3,000 live births *Polyhydramnios* in utero is frequently associated with EA (swallowed amniotic fluid doesn't reach GI tract due to obstruction) Associated with other anomalies: Trisomy 13 (Turners), 18 (Edwards), 21 (Downs); Cardiac anomalies (VSD, PDA, TOF), & other disorders Esophagus terminates before it reaches the stomach and/or a fistula is present that forms an unnatural connection with trachea The condition causes oral intake to enter the *lungs or a large amount of air to enter the stomach, and choking, coughing, and severe abdominal distention can occur *

DIABETES: NURSING TEACHING>>> Based on Development Level 10 years

Create diet plan for meals and snack Measure, may mix, and administer insulin Importance of rotating site Overall, better understanding of condition

Celiac Disease S/S

Diarrhea Abdominal distention Bloating Steatorrhea Constipation Abdominal pain Vomiting Anorexia

Cleft lip and palate >>>NURSING INTERVENTIONS: Post-treatment ESSR Means

Enlarge the nipple Stimulate Swallow Rest

HYPERTROPHIC PYLORIC STENOSIS>>> Etiology

Exact cause not known but appears to be familial Boys > girls; 1 in 500 live births

FTT Overall S/s

Ht. / Wt. < 3rd percentile Not a normal progression of growth: falls off the growth curve Report of feeding problems Developmental skills not progressing Social skills delayed Secondary sex characteristics delayed Child appears withdrawn May be stiff or flaccid when held (later sign) Possibly history of irritability History of sleep disorders

CONGENITAL AGANGLIONIC MEGACOLON>>> Etiology

Familial; 4x more common in males Often accompanying genitic conditions, especially Trisomy 21

HYPERTROPHIC PYLORIC STENOSIS>>> Nursing Interventions POST-OP

Feed clear fluids (Pedialyte) 4- 6 hours after surgery advancing to breast milk / or formula; *Feed infant slowly, burp frequently; place in high Fowler's towards right side after feeding* *Small amount of vomiting is to be expected the first 24-36 hours post-op*. Contact MD/NP if vomiting continues beyond this time Assess surgical wound for infection: Report any redness, edema, pus or fevers Administer antibiotics if indicated Administer pain medications as needed (usually only acetaminophen)

ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULA>>> Pre OP

Frequent suctioning: ---intermittent or continuous wall suction using NGT (for suction & decompression) - placed in "pouch" if EA Humidified oxygen to relieve respiratory distress *Position supine or prone (if occipital fistula/stoma):* Monitor serum electrolytes; maintain IV fluids as prescribed Comfort measures: crying will increase intra-abdominal pressure NPO; Maintain strict I&O

What nipple is mostly used to feed babies with Cleft Lip and palate

Hagerty nipple

ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULA>>> Pre OP>>> Positioning Type A&B 1&2

Head down to promote drainage - (NO CONNECTION!)

Cleft Lip and palate Tx cont.

Ideally, *cleft lip* is repaired as early as a *few days of age to about 3 months old* The repair of the *Palate* is most often done between *9 and 18 months* Surgical repair of *Orthodontic deformities* may be required at a later age (mostly with palate). These children have problems with feedings, ear infections and speech development, as well as dental problems. The *Multidisciplinary health team* usually includes a pediatrician, nurse, plastic surgeon, dental specialists, otolaryngologist (ENT specialist), speech-language pathologist, audiologist (hearing specialist), geneticist, psychologist and social worker.

DIABETES: NURSING TEACHING>>> Based on Development Level 6-7 years old

Identify foods with "little" or "a lot" of sugar Assist in administering the insulin Often do their own fingerstick Dip urine for ketones

FTT Tx prevention

Identify infant and parent at risk... *Psycological* Immediate intervention Teaching of expected G&D (i.e. milestones) Psychology / counselor referral

PYLORIC STENOSIS: Assessment

In the first 1-2 weeks of life, there are usually no clinical manifestations *~3 weeks old,* parent usually notes regurgitation or non-projectile vomiting The emesis is *gastric (no bile)* and might be blood tinged Vomiting will increase with time *(age 4-6 weeks)* until it becomes *projectile, the which is the sign most commonly identified with pyloric stenosis* Appetite and feeding is usually good with no apparent pain Other signs: -weight loss or failure to gain, malnutrition, dehydration, decreased stools, upper abdominal distention, and hyperperistalsis (waves across the epigastrium) usually directly following or during feeding *An olive shaped mass is usually palpable on R-side of umbilicus* as vomiting becomes projectile *Long term can lead to electrolyte imbalance and metabolic alkalosis*

ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULA>>> Post OP

Monitor respiratory status for respiratory distress Monitor amount of saliva: if increased secretions, notify MD immediately Do not offer pacifier until infant can tolerate secretions Chest tube (CT) care: --To intermittent low wall suctioning --Increased CT drainage could indicate reopening of esophageal fistula --Usually in place X 7-10 days Maintain IV fluids and/or parenteral nutrition as prescribed Antibiotics If cervical esophagostomy was performed, cover with gauze to absorb saliva PO FEEDS

CONGENITAL AGANGLIONIC MEGACOLON>>> Tx

Initially (pre-op), NPO, NGT (decompression), IV electrolyte correction, strict I&O Surgical correction (staging) - may take up to a year in total: --*Temporary colostomy* first to allow the child to eat and gain weight. It also lets the bowel rest. --*Surgical resection* of the affected bowel (anastomosis) --*Closure of colostomy* Temporary treatment may include dietary management *(low residue)* - usually not an issue in infancy - and periodic isotonic enemas

DIABETES Type I - IDDM

Insulin-dependent- No cure! - OUR FOCUS! Also known as *childhood diabetes or insulin-dependent diabetes*, is a genetically determined autoimmune illness. Pancreas does not produce insulin Daily insulin injections (or insulin pump)

ESOPHAGEAL ATRESIA (EA) AND TRACHEOESOPHAGEAL FISTULA (TEF) >>> Surgical Repair

Ligation of the fistula with anastomosis of the atresia to decrease the severity of stricture formation

ESOPHAGEAL ATRESIA (EA) AND TRACHEOESOPHAGEAL FISTULA (TEF) >>> Overall Tx Goal

Maintain patent airway Prevent pneumonia (aspiration) Gastric or blind pouch decompression

Celiac Disease Foods Not allowed

Many processed foods (read food labels!); "commercially" prepared ice cream, malted milk, pudding, *Any product made with wheat, rye, oats, or barley* (be careful to include alcoholic beverages, i.e. beer, ale and rye whiskey). *NOTE!* Oats are safe naturally, *BUT* they are often contaminated by wheat, rye or barley when manufactured.

Celiac Disease Foods allowed

Meats such as beef, pork, and poultry, fish, eggs, milk and dairy products, vegetables, fruits, grains, rice, corn, gluten-free wheat flour, puffed rice, corn flakes, corn meal, millet, pre-cooked gluten-free cereals

DIABETES Type II NIDDM

Non-insulin dependent Body's resistance to recognize and use insulin rather than a deficiency in insulin production Frequently develops in older patientsbut childhood onset has the fastest growing numbers Treated with oral hypoglycemic drugs and diet / exercise

Cleft Lip and palate Causes

Not clearly understood, but possibly: -Some medication (sulfa drugs, anticonvulsive drugs) or maternal alcohol use: *Only associated with cleft lip* Genetic factors and environmental factors Infections; maternal illnesses deficiency of folic acid.

INTUSSUSCEPTION Assessment>>> Late S/s

Obstruction becomes worse = *"current jelly-like" stools (blood & mucus)* Infant becomes lethargic, *Vomitus becomes bile* colored and may contain feces *Condition can progress into shock with mortality*

FTT S/s Parental (especially maternal) risk factors:

Often maladaptive behavior towards baby, i.e. refuses to hold, reject infants needs and signals Parents may have been victim of maternal deprivation themselves

INTUSSUSCEPTION Assessment>>> Early S/s

Usually *Severe abdominal pain (colicky*, screaming and pulling knees up to abdomen) with tender, distended abdomen, vomiting gastric contents, possible palpable mass in abdomen May have *hypoactive or hyperactive bowel sounds*

Celiac Disease Diagnosis

Usually diagnosed after age 6 months when table foods are introduced into diet *Biopsy of small intestine* reveals *absence or atrophy of vili*, flat mucosa with deep crypts. After gluten is withheld from diet, subsequent biopsy results in normal specimen (celiac lesions return to normal) which confirms diagnosis

FTT Dx

PE: Ht. Wt. body proportion (growth chart) Medical history --Differential diagnosis to rule out other underlying causes Denver Developmental Screening X-ray for bone age Labs: Complete work-up to assess for medical conditions Identify infant and mother at risk

ESOPHAGEAL ATRESIA (EA) AND TRACHEOESOPHAGEAL FISTULA (TEF) >>> Dx

Prenatal sonogram Unable to pass NG or OG tube (radiographic) CXR shows air-filled blind or closed pouch that ends abruptly: *--Type C, D, E will show a connection between the trachea and the distal esophagus* *--Type A & B will show complete absence of air in the stomach (no communication)* *Barium should not be used - risk of aspiration*!!!!!

DIABETES Type I: Signs & Symptoms HYPER

Presenting symptoms are usually r/t Hyperglycemia -*Polyuria: Frequent urination (including during the night) Polydipsia: Unusual thirst Polyphagia: extreme hunger/weakness* Glucosuria Unexplained weight loss Extreme fatigue Blurred vision Dry, itchy skin Slow healing of cuts and bruises Frequent infections of skin/gums/vagina/bladder Tingling/numbing in legs, feet, hands *May lead to KETOACIDOSIS*: Emergent situation caused by excess ketone production (breakdown of protein & fat)

Celiac Disease Tx Nursing Care

Primary treatment: *Permanent dietary restrictions of gluten!* -Follow gluten-free diet with supplemental vitamins, calcium, iron and folic acid

HYPERTROPHIC PYLORIC STENOSIS >>> Description

Progressive hypertrophy and hyperplasia of the circular muscles of the pylorus causing *Narrowing of the pyloric sphincter* at the outlet of the stomach (between the stomach and the duodenum). This leads to *obstruction and distention.*

Diabetes "Sick Days" - What to do?

Reaction to illness, infection or severe stress -More energy is needed to "fight" the stressor. The body releases hormones (they're called "stress" or "gluco-counter-regulatory hormones") that tell the liver to release extra glucose to provide additional energy. They include epinephrine, cortisol and growth hormones. -These hormones also inhibit the effect of insulin --which means you become somewhat insulin resistant. Result: hyperglycemia. Depending on the extent of the infection, your blood glucose might be more difficult to control for awhile. Insulin needs increase. *Bottom line: DON'T SKIP INSULIN WHEN SICK - SEEK MEDICAL CARE!* According to the American Diabetes Association (ADA), the need for exogenous insulin may increase, even double during "sick days" or severe stress.

DIABETES: NURSING TEACHING>>> Based on Development Level 8-9 Years old

Select own foods Give their own insulin and test BG

INTUSSUSCEPTION: Tx

Usually requires some intervention and is not self limiting *Air enema* is the initial treatment as well as diagnostic tool and if it corrects the condition, then surgery is not needed Surgery can be performed to pull the bowel out *If any tissue becomes necrotic as a result of strangulation* (ischemia can occur if the patient goes more than 24 hours without seeking medical assistance), *then that part of the bowel might have to be resected* before hemorrhage, perforation and peritonitis occur Deterioration at this stage without treatment can lead to shock and mortality

Celiac Disease Tx Nursing Care >>> While in Crisis

Strict I&O, weigh daily, monitor diarrhea, quality and quantity, steatorrhea -Monitor serum electrolytes, especially if significant diarrhea. -Consult with and refer patient/family to nutritionist. -If child is malnourished, may need Transparenteral Nutrition (TPN)

INTUSSUSCEPTION Etiology

The cause of intusussception is not known, but it seems to be *Associated with viral infections (rotavirus, adenovirus)*, & intestinal polyps, swallowed foreign bodies, and lymphoma. It most commonly effects infants from 3 - 12 months (especially males), but is also seen in older children. A word on Rotavirus vaccine! - new 2013 report again with increased incidence even with new vaccine! --It is now listed as an "at risk" on the VIS (Vaccine Information Sheet) given to parents

Cleft Lip and palate/ Nursing intervention POST-Surgery///>>> Cleft lip repair

The infant usually returns from surgery with steri-strips across the upper lip

HYPERTROPHIC PYLORIC STENOSIS>>> Diagnosis

Ultrasound usually confirms diagnosis *Upper GI series* detect an elongated pyloris & delayed gastric emptying (Barium)

DIABETES Type I: Treatment considerations>> Dawn Phenomenon

affects ANYBODY with or without DM Response to hypoglycemia, which occurs due to a surge of hormones *(counter-regulatory / resistant to insulin including growth hormones and cortisol)* at around 4-5am causing individuals with or without diabetes to wake up with hyperglycemia (may be more intensified in individuals with DM Type I) The anti-insulin action raises the blood glucose causing a hyperglycemic action to occur in these early morning hours.

DIABETES Type I: Treatment considerations>> HOneymoon Effect

affects individuals diagnosed with DM The pancreas' inability to make insulin is due to the autoimmune response that destroys the insulin producing cells. However, in the early period, shortly after the patient is diagnosed (early glucotoxicity) and insulin treatment is begun, as *treatment begins to work, there may be a brief restoration of insulin production by some of the beta-cells not yet damaged or temporarily restored. * This only lasts for a short period of time known as the "honeymoon phase" until the autoimmune destruction occurs again.