Ch. 25 Flashcards
1
Q
Infants and children have a proportionately ____ amount of body water than adults.
A
Infants and children have a proportionately greater amount of body water than adults.
2
Q
Infants and young children require a ___ relative fluid intake than adults and excrete a _____ amount of fluid.
A
Infants and young children require a larger relative fluid intake than adults and excrete a greater amount of fluid.
*This places them at increased risk for fluid loss with illness compared to adults
3
Q
until age 2 years, what makes up half of the child’s total body water?
A
Until age 2 years, the extracellular fluid, with its larger proportion of sodium and chloride, makes up about half of the child’s total body water.
4
Q
water loss occurs more rapidly and in larger amounts in children or adults?
A
children
5
Q
frequent introduction of bacteria from oral fixation and exploration
A
mouth
6
Q
frequent regurgitation from underdevelopment of the lower esophageal sphincter occurs at what age?
A
< age 1 mo. frequent regurgitation from underdevelopment of the lower esophageal sphincter
7
Q
stomach: capacity
A
capacity=200 ml (2 mos.); 2,000 (adult); HCL acid levels @ adult level by 6 mos.
8
Q
intestines have rapid growth spurts at what age?
A
rapid growth spurts in toddler and teenage yrs.
9
Q
biliary system
A
liver is down (up to 2cm below costal margin); enzyme deficiencies up to at least six mos. of age
10
Q
fluid balance and loss s/sx
A
rapid H2O loss; large extracellular volume
11
Q
insensibile loss s/sx
A
fever, ↑ metabolic rate, ↑ BSA contribute to this loss
12
Q
GI maturity is complete by age ___
A
complete by around age 2 yrs.
13
Q
health history
A
PMH, PSH, allergies, Family hx, HPI, home interventions, G & D, nutrition, parent/pt perception of problem
14
Q
physical exam structure
A
least to most invasive
15
Q
lab testing (require MD order)
A
lytes, O&P, stool cx, OB testing, amylase/lipase
16
Q
Dx testing (require MD order)
A
KUB, ph probe; upper or lower GI barium testing (aka contrast studies), Manometry
17
Q
GI assessment: inspection
A
LOC
Skin color and hydration status
Abd. Shape, size, & Symmetry
- ask patient to bend knees (relaxes abd muscles)
Abdominal movements
Ecchymosis
Hernias
18
Q
GI assessment: percussion
A
All 4 quad
Hyper, Hypo, Regular or Absent (5 min).
Vascular sounds (Renal HTN)
Irritable vs. calm with exam
Use pacifier if needed
19
Q
GI assessment: auscultation
A
Dullness vs tympany
Liver dullness=2 cm down in babies/toddlers
Dullness with bladder distention
20
Q
GI assessment: palpation
A
Light followed by deep
Parent lap/distraction/knees
Warm hands, avoid tickling
Note any tender areas
Attempt to reduce hernias
only palpate liver in a newborn or if there is an issue
21
Q
where would you find an olive?
A
RUQ
concerned about pyloric stenosis
22
Q
where would you find a sausage-like mass?
A
RLQ
concerned with intussusception
23
Q
where would you find the liver border?
A
the costal margin
24
Q
where would you find McBurney’s point?
A
2/3 of the way from the umbilicus to ASIS (anterior superior iliac spine)
this is where appendicitis is felt (pain)
25
where would you find laparoscopic appendectomy markings?
abdominal quadrants
RUQ
for treatment of appendicitis
26
where would you find herniations?
inguinal
umbilical
27
acute diarrhea
Often Infectious (rotavirus, salmonella)
Related to another illness: lactose/gluten intolerance
Related to ABX usage: ABT kills the gut
<14 days of diarrhea
28
chronic diarrhea
>14 days of diarrhea
dehydration
*IBS
*celiac disease
29
intractable diarrhea
brand new babies have diarrhea for 2 weeks of life due to carbohydrate imbalance (not agreeing with mom's breastmilk or formula)
30
chronic nonspecific (irritable colon)
common cause of chronic diarrhea in children ages 6-54 months
- loose stools, with undigested food particles, and diarrhea lasting longer than 2 weeks
- poor diet habits and food sensitivities have been linked to chronic diarrhea
- normal growth, no blood in stool, no evidence of malnutrition, no enteric infection
31
diagnostic evaluation (labs) of diarrhea
CBC
electrolytes
stool culture, viral culture, guiac the stool
32
what are the (3) consequences of FEN loss?
1. metabolic acidosis
2. dehydration
3.
33
therapeutic management of diarrhea
Assessment of fluid and electrolyte imbalance
Correction of metabolic acidosis
Rehydration
Maintenance fluid therapy
Reintroduction of adequate diet
Reinforce the Importance of oral rehydration therapy (ORT)
IV
34
nursing interventions for diarrhea
Assessment (and reassessment!
Understand and initiate appropriate treatment for mild, moderate, or severe dehydration
ORS guidelines for rehydration
Replace ongoing stool losses 1:1 with ORS
Give in small amounts frequently (teaspoon, cup, syringe or via NGT)
Continue use of breast milk (little amounts, frequent)
- don't introduce milk; no BRAT, caffeine (coffee, tea), sugar (juice), citrus)
Education (hand washing, educate where child could have picked it up; Nsg Alert p. 825)
Skin care
Support to family
35
s/sx of mild dehydration
increased thirst
slightly dry buccal mucous membranes
36
s/sx of moderate dehydration
loss of skin turgor, dry buccal mucous membranes, sunken eyes, sunken fontanel, decreased cap refill, decreased urine output, blood pressure drops and HR rises
37
s/sx of severe dehydration
signs of moderate dehydration plus 1 of following rapid thready pulse, cyanosis, rapid breathing, lethargy, coma, no urine output
38
(mild) rehydration
ORS, 50 mL/kg within 4 hours
39
(moderate) rehydration
ORS, 100mL/kg within 4 hours
40
(severe) rehydration
IV RL 40mL/kg until pulse and state of consciousness return to normal, then 50-100mL/kg or ORS
41
replacement of stool losses
1:1 replacement; 1gram lost in stool to 1 mL replaced
42
determining the degree of dehydration
((former weight - current weight) divided by former weight) x 100%
43
encopresis
Repeated voluntary or involuntary passage of feces of normal or near-normal consistency into places not appropriate for that purpose
- child looses the ability to poop
present with pain and abdominal distention with rock-hard stool
44
encopresis etiology
Primary vs. Secondary
May follow psychological stress (school, hospitalized, a change in every day living, potty training, moving, sexual abuse)
May be secondary to constipation (#1 reason) or impaction
- decreased fiber or dehydration
M > F
usually an older child >4 years
45
encopresis therapeutic management
Determine cause
- constipation
- dehydration
- stress
Dietary intervention, management of constipation
Psychotherapeutic interventions
46
encopresis nursing care management
History
Education
Routine with reinforcements
Counseling
47
how would you obtain a stool sample from an infant?
collection bag
48
how would you obtain a stool sample from a preschooler?
pee in a urinal hat
seran wrap in the toilet at home
49
how would you obtain a stool sample from an adolescent?
use a hat or go in a cup
50
FMR is important because
it determines the amount of fluid an individual needs to take in per their weight (kg) to remain hydrated
51
FMR
0-10kg: 100mL/kg
11-20kg: 1000 + 50mL/kg
>20kg: 1500 + 20mL/kg
52
vomiting
forceful expulsion of stomach contents
involuntary regurgitation of GI contents
53
vomiting etiology
> 8
ABT, anxiety (emotions), pain
daycares, germs
can be acute and chronic
54
vomiting pathophysiology
medulla activated
- chemoreceptor trigger zone (CTZ)
- vomiting center
- diaphragm
- vomiting
55
vomiting diagnostic evaluation
metabolic panel (electrolyte imbalances)
CBC
ultrasound
CT/MRI (brain tumor)
56
vomiting therapeutic management
oral rehydration very slowly- little bits, frequently
positioning: on side to prevent aspiration, upright
57
vomiting nursing care management
- assessment of hydration
- prevent complications with positioning
- support of the child and family; education
- handwashing
58
vomiting is commonly spread by
daycare
59
can medications be used to treat vomiting?
antiemetics
- zofran/ondansetron (serotonin antagonist)- watch for tachycardia
60
vomiting: what would labs look like?
sodium: decrease
potassium: decrease
chloride: decrease
glucose: decrease
BUN: increase
CR: increase
Uric acid: increase
CO2: increase (HCO3 increases)
61
treatment of vomiting
antiemetics
rest
hydration
treat cause
62
normal sodium range
135-145
63
normal potassium range
3.5-5
64
normal chloride range
101-111
65
normal glucose range
64-128
66
normal CO2 range
20-29
67
normal BUN range
4-18
68
normal creatinine range
0.3-0.7
0.5-1.0
69
normal uric acid range
2.0-5.5
70
ingestion of foreign substances: pica
seen in children; children eat food or nonfood items
food picas
- uncooked cereal/oatmeal, coffee grounds
nonfood picas
- crayons, paint, hair, toys, rocks, clay, play dough
71
physiologic- (nutrition) unmet need
kids are craving zinc and iron
72
physiologic- compulsive neuroses
ADHD
OCD
autistic children
73
pica: nursing considerations
more supervision
teach parents dangers of ingestion (ie lead)
small frequent snacks
lock up whatever they are eating obsessively
lock up toxic things
74
constipation
an alteration in the frequency, consistency, or ease of passage of stool
- may be secondary to other disorders
- spinal cord injury, CF
- potty training age- hard stool scares them
*symptom not a disease
75
environmental causes of constipation
medications (example-antihistamines, opioids, and iron supplementation)
76
idiopathic or functional constipation
may be due to environmental or psychosocial factors (no organic cause)
77
nursing considerations for constipation
History of bowel patterns, medications, diet
Educate parents and child
Dietary modifications (age appropriate)
Management of impaction/chronic constipation may require 6-12 months of behavioral/dietary/pharmacologic interventions
78
diet for constipation
High-fiber diet
Milk/dairy relationship
Fluids
79
phase 1 treatment of constipation (3-5 days)
*oral clean-out method for children older than 4 years
- high-dose mineral oil
- polyethylene glycol
- magnesium hydroxide
*enema clean-out
- milk and molasses
- normal saline solution
- microlax, mineral oil, or hypertonic phosphate
*NG lavage (hospitalization)
- polyethylene glycol electrolyte solution
80
phase 2 treatment of constipation (6-12 months)
oral laxatives: polyethylene glycol, mineral oil, lactulose, magnesium hydroxide
high-fiber diet
increased fluid intake
behavioral training- exercising
81
phase 3 treatment of constipation
- gradual tapering of laxatives
- continue high-fiber diet, fluid intake, behavior modification
82
mineral oil: drug alert
must be given carefully to avoid aspiration
- not used in children under 1 year!
83
Hirschsprung's disease=
congenital aganglionic megacolon
Inadequate motility=mechanical obstruction
Absence of ganglion cells in one or more segments of colon-prevents peristalsis
Results in accumulation of stool
Occurs in conjunction with congenital diagnoses
84
prevalence of Hirschsprung's disease
Boys 4:1
family prevalence
downs syndrome patients
85
Hirschsprung's disease anatomy
distended sigmoid colon
86
Hirschsprung's disease: newborn symptoms
no mec, refusing po, bile-stained emesis, abd distention
87
Hirschsprung's disease: older children
FTT, delayed growth, distention, constipation/diarrhea (ribbon-like stools). Enterocolitis (explosive watery diarrhea, fever)
88
Hirschsprung's disease: surgery
* 9 kg (20#)-2 phase: an end-to-end anastomosis or removal with colostomy, then reversal
89
Hirschsprung's disease: diagnosis
diagnose from history, bowel pattern, contrast studies, anorectal manometry (balloon inserted into rectum to stimulate sphincter), x-ray, biopsy
90
Hirschsprung's disease: diet
Diet modification, softeners, enemas, low-fiber diet
91
Most common emergent surgery in pediatrics
appendicitis
92
appendicitis
Result of obstruction: stool, parasite infestation, stenosis, tumor
Perforation can occur=life threatening if untreated (peritonitis)
93
appendicitis is most common in
Most common: Boys school age yrs., rare before age 2
94
appendicitis nursing assessment
Gradual but persistent symptoms
starts with periumbilicus pain
Vague abdominal pain (RLQ)
- mcburney's point
- psoas sign
- oburator's sign
- rousing: ask patient to raise their leg and causes pain
Nausea and Vomiting
Loose stools or constipation
Rebound Tenderness
- murphy's sign
Fever
Posture (stooped)
Elevated WBC, C-reactive protein, ESR
95
perforation symptoms
Fever (high-grade)
Guarding persistent, intensifying pain
Sudden pain relief**
Abdominal distention
Rapid shallow breathing
Pallor
Chills
Restlessness/irritability
96
interval appendectomy
IV ABTs x 8-12 weeks
Stable appendectomy (laparoscopic)
Return to normal activities in 2-6 weeks
97
emergency appendectomy (laproscopic)
Antibiotics are administered preoperatively. When ruptured- antibiotics continue post-op
IV fluids
Drains may be used with perforated
Pain management
98
hypertrophic pyloric stenosis
Constriction of the pyloric sphincter
Obstruction of the gastric outlet
Hypertrophy of circular and longitudinal muscles of the pylorus
Unknown cause
seen frequently in full-term first males
can be hereditary- seen in siblings
confused with overfeeding
vomit comes shooting out of the mouth (projectile) and gets worse with each feeding
99
most common condition requiring surgery before 8 weeks of age
hypertrophic pyloric stenosis
100
pyloric stenosis s/sx
Non-bilious projectile vomiting
Visible peristalsis
Failure to thrive in an infant who is “always hungry”
Dehydration
Metabolic alkalosis
101
pyloric stenosis diagnostic evaluation
Olive-shaped mass (right upper quadrant)
Ultrasound- elongated mass pyloric canal
102
pyloric stenosis therapeutic management
Pyloromyotomy (laparoscopic)
103
pyloric stenosis nursing care
Nursing process (esp. assessment)
Post-op care
Support of infant and family
104
prognosis of pyloric stenosis
great prognosis
treat and recover well
105
pyloromyotomy: pre-op
NGT ( to make sure that nothing is in the stomach)
IVF
NPO
I/O-strict
Daily weights
VS-routine
Hydration status
Pre/post op teaching
106
pyloromyotomy: post-op
Feeding within a few hours post op
Clear liquids (12-24 hr post-op) then formula (1/2 strength) or breastmilk
Pain meds
Comfort measures
Po feeds-small, clear, advance
Incision check q 4 hrs
VS q 2-4 hrs
Teaching!!!!
Back to baseline feeds in 48 hours
d/c within a few days usually
107
intussusception
Intestine prolapses and telescopes
Can result in partial or total bowel obstruction
Boys > girls; usually under age 2 (up to age 6)
108
intussusception: onset
Abrupt onset, crampy abdominal pain (intermittent, colicky pain)
109
intussusception s/sx
- Sudden vomiting
- brown stool f/b red current jelly stools ** + OB
- knee to chest position for comfort
- Palpable sausage shaped mass RLQ
110
intussusception diagnosis
X-ray or U/S to diagnose
Barium enema to reduce…if ineffective surgery is necessary
111
intussusception therapeutic management
*Least to most invasive*
Air enema (radiologist guided)
With or without contrast
Hydrostatic (saline) enema (ultrasound guided)
Surgical reduction and fixation, or
Excision of a nonviable segment of colon
112
intussusception nursing care
Fluid/electrolyte balance
Pain management
VS
check for abdominal distention
NGT prn
BS q 4 hrs.
Clears, advance as tolerated
Assess and educate reoccurrence
Seen in CF or celiac kids
initially hypoactive bowel sounds, then active bowel sounds after normal diet is reinstated
113
umbilical hernia
Common newborn finding
Typically resolves by preschool (by 5 years)
seen more in african american and hispanic children
114
umbilical hernia nursing care management
assessment: color matches the skin tone, goes back in when pushed
wait and see
anticipatory guidance and education to family: going to enlarge when crying, upset
115
how do you perform hernia reduction?
push the hernia back into the abdomen
116
reducible hernia
hernia with a bulge that flattens out (goes back into the abdomen) when you lie down or push against it gently
same color as skin
117
incarcerated hernia
contents cannot be returned to the abdomen, with severe symptoms
red color
118
strangulated hernia
hernia contents are ischemic due to a compromised blood supply
no blood supply, twisted, necrotic tissue (deep red/purple)
119
GI dysfunction: IVs
fluids
antibiotics
120
GI dysfunction: NGT
nutrition
decompression
suction
121
GI dysfunction: Diet
NPO
ORT
nutritional modifications
122
GI dysfunction: enemas
air
saline
123
GI dysfunction: stool
collection
guaiac
124
therapeutic procedures for children with GI dysfunction:
- IV
- NGT
- daily weights
- I/O
- Diet
- abdominal circumference
- enemas
- surgery
- incision care
- stool
- ostomy
- indwelling catheter
125
gastroenteritis (organs involved)
stomach and small intestine
126
enteritis (organs involved)
small intestine
127
colitis (organs involved)
large intestine and colon
128
enterocolitis (organs involved)
colon and small intestine
129
percentages of dehydration- mild vs. moderate vs. severe
mild: 3-5%
moderate: 6-9%
severe: 10% +
130
GI clean out starts where?
starts at the top- orally
131
enterocolitis
20-60% post-op inflammation from surgery to fix Hirschsprung's Disease
132
appendectomy (laproscopic) patient education
- use incentive spirometry
- keep incisions clean and dry
- no signs of infection: redness, drainage, fever
- have the patient splint their abdomen with stuffed animal/pillow
