Ch. 25 Flashcards
Infants and children have a proportionately ____ amount of body water than adults.
Infants and children have a proportionately greater amount of body water than adults.
Infants and young children require a ___ relative fluid intake than adults and excrete a _____ amount of fluid.
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
until age 2 years, what makes up half of the child’s total body water?
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.
water loss occurs more rapidly and in larger amounts in children or adults?
children
frequent introduction of bacteria from oral fixation and exploration
mouth
frequent regurgitation from underdevelopment of the lower esophageal sphincter occurs at what age?
< age 1 mo. frequent regurgitation from underdevelopment of the lower esophageal sphincter
stomach: capacity
capacity=200 ml (2 mos.); 2,000 (adult); HCL acid levels @ adult level by 6 mos.
intestines have rapid growth spurts at what age?
rapid growth spurts in toddler and teenage yrs.
biliary system
liver is down (up to 2cm below costal margin); enzyme deficiencies up to at least six mos. of age
fluid balance and loss s/sx
rapid H2O loss; large extracellular volume
insensibile loss s/sx
fever, ↑ metabolic rate, ↑ BSA contribute to this loss
GI maturity is complete by age ___
complete by around age 2 yrs.
health history
PMH, PSH, allergies, Family hx, HPI, home interventions, G & D, nutrition, parent/pt perception of problem
physical exam structure
least to most invasive
lab testing (require MD order)
lytes, O&P, stool cx, OB testing, amylase/lipase
Dx testing (require MD order)
KUB, ph probe; upper or lower GI barium testing (aka contrast studies), Manometry
GI assessment: inspection
LOC
Skin color and hydration status
Abd. Shape, size, & Symmetry
- ask patient to bend knees (relaxes abd muscles)
Abdominal movements
Ecchymosis
Hernias
GI assessment: percussion
All 4 quad
Hyper, Hypo, Regular or Absent (5 min).
Vascular sounds (Renal HTN)
Irritable vs. calm with exam
Use pacifier if needed
GI assessment: auscultation
Dullness vs tympany
Liver dullness=2 cm down in babies/toddlers
Dullness with bladder distention
GI assessment: palpation
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
where would you find an olive?
RUQ
concerned about pyloric stenosis
where would you find a sausage-like mass?
RLQ
concerned with intussusception
where would you find the liver border?
the costal margin
where would you find McBurney’s point?
2/3 of the way from the umbilicus to ASIS (anterior superior iliac spine)
this is where appendicitis is felt (pain)
where would you find laparoscopic appendectomy markings?
abdominal quadrants
RUQ
for treatment of appendicitis
where would you find herniations?
inguinal
umbilical
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
chronic diarrhea
> 14 days of diarrhea
dehydration
*IBS
*celiac disease
intractable diarrhea
brand new babies have diarrhea for 2 weeks of life due to carbohydrate imbalance (not agreeing with mom’s breastmilk or formula)
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
diagnostic evaluation (labs) of diarrhea
CBC
electrolytes
stool culture, viral culture, guiac the stool
what are the (3) consequences of FEN loss?
- metabolic acidosis
- dehydration
3.
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
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
s/sx of mild dehydration
increased thirst
slightly dry buccal mucous membranes
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
s/sx of severe dehydration
signs of moderate dehydration plus 1 of following rapid thready pulse, cyanosis, rapid breathing, lethargy, coma, no urine output
(mild) rehydration
ORS, 50 mL/kg within 4 hours
(moderate) rehydration
ORS, 100mL/kg within 4 hours
(severe) rehydration
IV RL 40mL/kg until pulse and state of consciousness return to normal, then 50-100mL/kg or ORS
replacement of stool losses
1:1 replacement; 1gram lost in stool to 1 mL replaced
determining the degree of dehydration
((former weight - current weight) divided by former weight) x 100%
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
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
encopresis therapeutic management
Determine cause
- constipation
- dehydration
- stress
Dietary intervention, management of constipation
Psychotherapeutic interventions
encopresis nursing care management
History
Education
Routine with reinforcements
Counseling
how would you obtain a stool sample from an infant?
collection bag
how would you obtain a stool sample from a preschooler?
pee in a urinal hat
seran wrap in the toilet at home
how would you obtain a stool sample from an adolescent?
use a hat or go in a cup
FMR is important because
it determines the amount of fluid an individual needs to take in per their weight (kg) to remain hydrated
FMR
0-10kg: 100mL/kg
11-20kg: 1000 + 50mL/kg
>20kg: 1500 + 20mL/kg
vomiting
forceful expulsion of stomach contents
involuntary regurgitation of GI contents
vomiting etiology
> 8
ABT, anxiety (emotions), pain
daycares, germs
can be acute and chronic
vomiting pathophysiology
medulla activated
- chemoreceptor trigger zone (CTZ)
- vomiting center
- diaphragm
- vomiting
vomiting diagnostic evaluation
metabolic panel (electrolyte imbalances)
CBC
ultrasound
CT/MRI (brain tumor)
vomiting therapeutic management
oral rehydration very slowly- little bits, frequently
positioning: on side to prevent aspiration, upright
vomiting nursing care management
- assessment of hydration
- prevent complications with positioning
- support of the child and family; education
- handwashing
vomiting is commonly spread by
daycare
can medications be used to treat vomiting?
antiemetics
- zofran/ondansetron (serotonin antagonist)- watch for tachycardia
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)
treatment of vomiting
antiemetics
rest
hydration
treat cause
normal sodium range
135-145
normal potassium range
3.5-5
normal chloride range
101-111
normal glucose range
64-128
normal CO2 range
20-29
normal BUN range
4-18
normal creatinine range
0.3-0.7
0.5-1.0
normal uric acid range
2.0-5.5
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
physiologic- (nutrition) unmet need
kids are craving zinc and iron
physiologic- compulsive neuroses
ADHD
OCD
autistic children
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
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
environmental causes of constipation
medications (example-antihistamines, opioids, and iron supplementation)
idiopathic or functional constipation
may be due to environmental or psychosocial factors (no organic cause)
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
diet for constipation
High-fiber diet
Milk/dairy relationship
Fluids
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
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
phase 3 treatment of constipation
- gradual tapering of laxatives
- continue high-fiber diet, fluid intake, behavior modification
mineral oil: drug alert
must be given carefully to avoid aspiration
- not used in children under 1 year!
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
prevalence of Hirschsprung’s disease
Boys 4:1
family prevalence
downs syndrome patients
Hirschsprung’s disease anatomy
distended sigmoid colon
Hirschsprung’s disease: newborn symptoms
no mec, refusing po, bile-stained emesis, abd distention
Hirschsprung’s disease: older children
FTT, delayed growth, distention, constipation/diarrhea (ribbon-like stools). Enterocolitis (explosive watery diarrhea, fever)
Hirschsprung’s disease: surgery
- 9 kg (20#)-2 phase: an end-to-end anastomosis or removal with colostomy, then reversal
Hirschsprung’s disease: diagnosis
diagnose from history, bowel pattern, contrast studies, anorectal manometry (balloon inserted into rectum to stimulate sphincter), x-ray, biopsy
Hirschsprung’s disease: diet
Diet modification, softeners, enemas, low-fiber diet
Most common emergent surgery in pediatrics
appendicitis
appendicitis
Result of obstruction: stool, parasite infestation, stenosis, tumor
Perforation can occur=life threatening if untreated (peritonitis)
appendicitis is most common in
Most common: Boys school age yrs., rare before age 2
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
perforation symptoms
Fever (high-grade)
Guarding persistent, intensifying pain
Sudden pain relief**
Abdominal distention
Rapid shallow breathing
Pallor
Chills
Restlessness/irritability
interval appendectomy
IV ABTs x 8-12 weeks
Stable appendectomy (laparoscopic)
Return to normal activities in 2-6 weeks
emergency appendectomy (laproscopic)
Antibiotics are administered preoperatively. When ruptured- antibiotics continue post-op
IV fluids
Drains may be used with perforated
Pain management
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
most common condition requiring surgery before 8 weeks of age
hypertrophic pyloric stenosis
pyloric stenosis s/sx
Non-bilious projectile vomiting
Visible peristalsis
Failure to thrive in an infant who is “always hungry”
Dehydration
Metabolic alkalosis
pyloric stenosis diagnostic evaluation
Olive-shaped mass (right upper quadrant)
Ultrasound- elongated mass pyloric canal
pyloric stenosis therapeutic management
Pyloromyotomy (laparoscopic)
pyloric stenosis nursing care
Nursing process (esp. assessment)
Post-op care
Support of infant and family
prognosis of pyloric stenosis
great prognosis
treat and recover well
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
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
intussusception
Intestine prolapses and telescopes
Can result in partial or total bowel obstruction
Boys > girls; usually under age 2 (up to age 6)
intussusception: onset
Abrupt onset, crampy abdominal pain (intermittent, colicky pain)
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
intussusception diagnosis
X-ray or U/S to diagnose
Barium enema to reduce…if ineffective surgery is necessary
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
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
umbilical hernia
Common newborn finding
Typically resolves by preschool (by 5 years)
seen more in african american and hispanic children
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
how do you perform hernia reduction?
push the hernia back into the abdomen
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
incarcerated hernia
contents cannot be returned to the abdomen, with severe symptoms
red color
strangulated hernia
hernia contents are ischemic due to a compromised blood supply
no blood supply, twisted, necrotic tissue (deep red/purple)
GI dysfunction: IVs
fluids
antibiotics
GI dysfunction: NGT
nutrition
decompression
suction
GI dysfunction: Diet
NPO
ORT
nutritional modifications
GI dysfunction: enemas
air
saline
GI dysfunction: stool
collection
guaiac
therapeutic procedures for children with GI dysfunction:
- IV
- NGT
- daily weights
- I/O
- Diet
- abdominal circumference
- enemas
- surgery
- incision care
- stool
- ostomy
- indwelling catheter
gastroenteritis (organs involved)
stomach and small intestine
enteritis (organs involved)
small intestine
colitis (organs involved)
large intestine and colon
enterocolitis (organs involved)
colon and small intestine
percentages of dehydration- mild vs. moderate vs. severe
mild: 3-5%
moderate: 6-9%
severe: 10% +
GI clean out starts where?
starts at the top- orally
enterocolitis
20-60% post-op inflammation from surgery to fix Hirschsprung’s Disease
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
