Gastrointestinal Blueprint Flashcards
How should we be able to tx mild and moderate dehydration?
orally
in mild/moderate dehydration, nausea and vomiting can make it very difficult to tx pt orally. What is the priority?
priority is to keep these from progressing to severe dehydration (explain to parents)
If they have N/V, try to give them even as little as 1 tsp of fluid at a time, or have them suck on popsicle anything to prevent severe
Normally, how many wet diapers should a child have in 24 hours when they have dehydration?
3 wet diapers in a 24 hr period so roughly every 8 hours
If you have a child who is already slowing down urine production and refusing to drink, now it will get to the point of what? what should parents do?
severe dehydration
parents need to make a plan to go to hospital or doctors office
What is severe dehydration?
Occurs when the loss of water exceeds the loss of electrolytes → leads to an imbalance where the ECF has a higher concentration of solutes (like sodium) than normal.
Na+ > 150mEq/L
This results in a higher osmolarity in the blood, causing fluid to shift from the intracellular space to the extracellular space in an attempt to balance the osmotic pressure.
What causes severe dehydration?
(not on blueprint but she said in her announcement)
This can happen due to excessive fluid loss (through vomiting, diarrhea, or inadequate fluid intake) or due to high intake of salt or other solutes without enough water.
What are the signs and sx of severe dehydration?
(not on blueprint but she said in her announcement)
The child might show signs like increased thirst, dry mucous membranes, sunken eyes, lethargy, and irritability.
Can lead to neurological changes → confusion or seizures because of the altered osmolarity affecting brain function.
What do we not want to do when managing severe dehydration with IV fluids?
Why?
Do not want to rehydrate too quickly!!
Bc there’s a risk of causing cerebral edema (swelling of the brain). This happens because the sudden influx of water into the bloodstream could cause water to shift back into the cells too quickly, particularly in the brain, where cells are sensitive to osmotic changes.
What should be avoided when initially giving IV fluids for severe dehydration?
Initially avoid potassium replacement!!
what fluid is used to tx severe dehydration? why?
Normal saline (0.9% sodium chloride)
It is isotonic, meaning it has a similar concentration of sodium and water to that of normal blood plasma (which means it will not drastically alter the balance of sodium in the blood.)
It is used to gradually expand the extracellular fluid volume without introducing significant shifts in osmolarity.
What is the goal in treating severe dehydration?
slowly rehydrate the child without making their sodium levels drop too quickly
what could happen if we used hypotonic fluids to tx hypertonic severe dehydration?
If hypotonic fluids (like water or 0.45% saline) were used too early, they could cause the cells to absorb too much water, increasing the risk of cerebral edema.
What should the fluid replacement rate be when treating severe dehydration?
replace the fluid over 48 hours or longer, depending on the severity.
What is intussusception?
Telescoping or invagination of one portion of intestine into another
Portion of the intestine folds like a telescope
intussusception is the most common cause of what?
intestinal obstruction in children 3 mos to 3 y/o
What is the cause of intussusception?
unknown
what gender experiences intussusception more?
Boys
The diagnosis of intussusception is based on what? (hint: 3)
Subjective findings
Ultrasound
Enema
List the common S&S of intussusception (hint: 11)
- Severe abdominal pain: sudden onset → have periods of relief
- Loud crying episodes
- Bilious Vomitus
- Drawing knees to chest
- Abdominal Mass: palpable sausage- shaped mass in RUQ
- Stools mixed with blood & mucus: Jelly-like stool; “Red currant jelly”
- Lethargy
- Not feeding well
- May show signs of dehydration
- Intermittent change in mental status
- Pain is so bad they nearly pass out
What is included in the therapeutic procedures for intussusception? (hint: 4)
- IV bolus
- Pain medications: Analgesics to manage the pain temporarily
- Enema
- NGT
What is the purpose of enemas in intussusception?
Manage pain first esp. In older child
Air or contrast to allow telescoping to move back into the right place
When is surgery required for intussusception? What are the two types called?
Required for recurrent intussusception (complication) → that is not reduced through enema
Types:
- Laparotomy
- Laparoscopy
What is the main concern in a child with cleft lip?
Feeding is the main concern → need to make sure the baby gas a good seal so they can suck and take in enough volume
What is the surgical tx for cleft lip?
cheiloplasty performed at 2-3 months of age
list the postoperative considerations for cheiloplasty (hint: 5)
- May need larger nipple to still allow for good seal
- Stimulate sucking reflex
- Give frequent rest periods
- Swallow assessment
- Hold bottle at 180 degrees
why do bottle fed babies with a cleft lip have problems feeding?
They often struggle to create enough suction to draw milk from a standard bottle nipple bc of the gap in their palate.
How exactly does an enlarged nipple help a baby with a cleft lip?
It helps the baby get enough milk by providing a more controlled flow, making it easier for the baby to feed without having to generate as much suction.
The nipple will have to help fill in the opening so that the infant can get a good seal to be able to feed.
In a baby with a cleft lip, how can nurses help stimulate sucking reflex and why is this important?
Nurses can gently stroke the baby’s lips or encourage sucking by positioning the baby to bring the nipple into contact with the mouth.
This tactile stimulation can help encourage the baby to suck more effectively, and it may assist in initiating and maintaining the sucking action
In a baby with a cleft lip, what must be done to prevent aspiration?
assess the infant’s swallowing
Monitoring swallowing helps ensure the baby is safely swallowing milk and not aspirating it into the lungs, which could lead to choking or respiratory issues.
Why are babies with a cleft lip at higher risk for aspiration?
the gap in the palate can interfere with the proper closure of the oral cavity, making it easier for milk to enter the airway.
Why is it important to maintain periodic rest periods for an infant with cleft lip during feedings?
Feeding a baby with a cleft palate can be tiring because it often requires more effort to suck and swallow.
Rest periods during the feedings allow the baby to recover from fatigue, reducing the risk of them becoming overly tired, which can interfere with proper feeding and increase the chance of aspiration.
How does holding the bottle at 180 degrees (parallel to the floor) assist in feeding a baby with a cleft palate?
helps control the flow of milk and reduces the risk of milk flowing too quickly or too slowly, which can be difficult for an infant with a cleft palate to manage.
helps prevent aspiration bc the milk doesn’t flow directly into the baby’s mouth without control
What is encopresis?
The medical term for when children poop in their pants
Stool/fluid leakage around stool blockage
What causes encopresis?
Extreme stool holding (severe constipation)
How does encopresis start off?
It starts off as constipation → usually when they are initially potty training
What happens if a child is holding their stool for a prolonged amount of time?
How does this cause encopresis?
it builds up and their body turns off the signal and they stop feeling like they have to go
Stool continues to build up, and when the whole colon is filled, the stool that is made is liquid. The liquid has no where to go so it leaks out into the child’s pants
When encopresis occurs, does the child do it on purpose?
No, they are NOT doing it on purpose → it is bc they cannot feel it
List the strategies for managing encopresis (hint: 3)
Will not resolve on its own
Needs bowel clean out
Retraining
How do you recognize failure to thrive on a growth chart?
Typically when the child falls below the 5th percentile for the child’s age
If the child is not gaining weight or falling 2 percentiles below where they were before it lets us know something is going array
All babies have some degree of what?
Gastroesophageal reflux Disease (GERD)
What are the expected findings for GERD in infants? (hint: 7)
FTT
Spitting up
forceful vomiting
irritability
excessive crying
blood in emesis
stiffening/arching
What are the expected findings for GERD in children? (hint: 4)
Abdominal & Chest Pain
Heartburn
Chronic Cough
Difficulty Swallowing
What are the tx options for GERD? (hint: 4)
- Diet (first line)
- H2 Receptor-Antagonist Blockers
- Proton Pump Inhibitors
- Surgery → Nissen Fundoplication
How is diet used as a tx for GERD? (hint: 4)
- Encourage smaller more frequent feedings
- Make sure kids do not eat right before laying flat
- Older children → not having carbonation or fried foods; keep diary of what they are eating to see what makes it worse
- Some kids tolerate dairy fine but others find that it makes GERD worse
What are examples of H2 Receptor-Antagonist Blockers used for GERD?
Zantac & Pepsid
How do H2 Receptor-Antagonist Blockers work to tx GERD?
Reduce the amount of acid produced by cells in the lining of the stomach
Blocks the histamine receptors
Reduction of gastric acid and pepsin production
What are examples of Proton Pump Inhibitors used for GERD?
Omeprazole (Prilosec) & Esomeprazole (Nexium)
What is the downside of proton pump inhibitors for GERD? (hint: 2)
They may cause children to almost become addicted
Oftentimes insurance does not cover for infants and children under 2 bc there is not much research to show they will be helpful
How do proton pump inhibitors work to tx GERD?
Blocks the proton pump of the stomach
Act at specific secretory surface receptors to prevent the final step of acid production and thereby decrease the level of acid in the stomach
For GERD, proton pump inhibitors are taken in conjunction with what?
monitoring sx and weight gain
What tx for GERD is not common? why?
Surgery → Nissen Fundoplication
Can cause long term complications
How to assess Tx effectiveness for babies with GERD? (hint: 7)
- Failure to gain weight resolves
- Less spitting up
- Less forceful vomiting
- Improved irritability
- Reduced excessive crying
- No blood in emesis
- No stiffening/arching
what is Hirschsprung’s disease?
congenital condition where parts of the colon are missing nerve cells (ganglion cells), leading to a lack of peristalsis (the normal wave-like movement of the intestines).
What can Hirschsprung’s disease lead to?
Bowel Obstruction!
Stool cannot pass properly; Can cause stool/gas to build up behind the affected section of the colon, leading to bowel obstruction
What are the newborn/infant findings for Hirschsprung’s disease? (hint: 5)
- NO meconium within first 24-48 hours after birth
- Bilious vomiting
- abdominal distention
- refusing to eat
- Explosive, watery stools
What are the findings for an older child with chronic Hirschsprung’s disease? (hint: 5)
- Constipation
- Ribbon, like stool/ foul smelling
- Abdominal distention/ visual peristalsis
- Palpable abdominal fecal mass
- undernourished
What are the tx options for Hirschsprung’s disease? (hint: 8)
- fluid & electrolyte replacement
- TPN
- Diet changes
- Enemas
- Surgical management: colostomy
- Temporary ostomy
- Pull-through procedure
- Nursing care & education
why is TPN given for Hirschsprung’s disease?
to stimulate intestinal adaption with enteral feedings
What diet changes are made in Hirschsprung’s disease tx?
low fiber, high protein, high calorie diet
*low fiber diet dependent on level of constipation and how their stools are
Why do people with Hirschsprung’s disease receive enemas?
often will receive them, even after surgery, to help keep everything moving
what is a colostomy?
surgical procedure that involves creating an opening (stoma) on the abdominal wall to divert stool into an external bag, bypassing the part of the colon affected by Hirschsprung’s disease.
For babies with Hirschsprung’s disease, they will often have a ________ and then eventually a ___ ______ ______
colostomy;
pull through procedure
What are the complications of colostomy? (hint: 9)
- infection
- feeding difficulties
- abnormal vital signs
- increased pain
- ileus (a temporary paralysis of the bowel)
- bowel distention
- sepsis
- perforation
- bowel obstruction
What are the signs that the colostomy is infected?
Redness, warmth, or drainage around the surgical site.
How can a baby’s feeding be impacted when theres a colostomy complication?
The infant may refuse feedings or vomit, especially if there’s a bowel obstruction.
What should be looked for when there are abnormal vital signs as a complication of colostomy? what can they indicate?
- elevated HR
- low BP
- fever
can indicate infection or sepsis, including measuring abd circumference
How might the baby show increased pain when there is a complication to the colostomy?
crying
irritability
stiffening of body
Abdominal circumference is a key indicator of what?
internal changes, especially in infants who have undergone surgery
An increase in abdominal girth could indicate the development of what complications? (hint: 3)
- intestinal obstruction
- bowel perforation
- infection
What is a concerning finding regarding the amount abdominal girth increases?
A 3 cm increase in abdominal circumference over a 2-hour period is a significant and concerning finding because it could indicate bowel obstruction, ileus, perforation or sepsis.
After surgery, it’s normal for the intestines to take some time to “wake up” and resume normal function.
However, a significant increase in abdominal girth might indicate what?
that the bowel is not functioning properly (ileus) or has become obstructed.
Another concern is that a rapid increase in abdominal size could signal a bowel perforation. What does this cause ?
a hole in the intestines
Bowel perforation allows air and waste to leak into the abdominal cavity.
This is a medical emergency that can lead to what?
peritonitis (infection of the abdominal cavity) and sepsis.
(From Ricci) List what should be included in the education to parents about colostomy care (hint: 6)
- Avoid tight/constricting clothing around stoma
- Store ostomy supplies in a cool, dry place.
- Teach proper ostomy care to avoid skin breakdown
- Empty the ostomy pouch & measure for stool output several times per day.
- Perform ostomy care as needed
- Pouches usually changed every 1-4 days
(From Ricci) When educating parents of a child with a colostomy about care, what should they know regarding school?
(hint: 2)
- Inform school that the child should be allowed to use the water fountain & bathroom w/o restriction
- The child’s school nurse should have extra ostomy supplies available
(From Ricci) How should the nurse educate the parents of a child with colostomy about what the stoma should look like?
The stoma should be moist and pink or red, demonstrating proper circulation to the intestine
(From Ricci) When should parents of a child with a colostomy contact surgeon?
Notify the provider if the volume of stool output is greatly increased, or if the stoma is prolapsed or retracted.
What are the common S&S of ruptured appendicitis? (hint: 9)
- Umbilical pain that moves to RLQ pain
- Nausea
- Eventually get persistent vomiting
- Fever
- Rebound tenderness
- Positive McBurney’s Point
- Positive Dunphy’s Sign
- Positive Iliopsoas Test
- Positive Obturator Test
What is positive McBurney’s point?
significant pain is elicited by palpating RLQ
What is positive dunphy’s sign?
sharp pain in RLQ with cough; pain caused by peritoneal irritation.
What is rebound tenderness?
pain is greater when deep palpation is quickly released than during palpation;
indicates peritoneal irritation
What is positive iliospsoas test?
pt is pushing their foot up towards their head while the examiner is pushing down on their thigh and pt experiences pain in their abdomen
what is positive obturator test?
pts knee is bent to 90 degree angle, examiner presses down and pt experiences pain in their abdomen
What are the lab findings for ruptured appendicitis?
Elevated WBCs >10,000 mm3
C-reactive protein (CRP) >8 mg/L
UA showing mild pyuria
What are the sx of pyloric stenosis?
Forceful vomiting
FTT
Firm round mass (olive)
When a baby has pyloric stenosis, when does forceful projectile vomiting usually occur?
within 30 mins after feeding
when is pyloric stenosis most likely to occur?
2-5 weeks of life
In a baby that is hungry, thin, pale, and failing to thrive, what happens when they have pyloric stenosis?
They will be eager to feed → screaming then projectile vomit
In a baby with pyloric stenosis, what should you examine for after a feed?
peristalsis
After a feed in a baby with pyloric stenosis, what can be felt?
Firm, round mass (like a large olive) felt in upper abdomen caused by hypertrophic muscle of pylorus
what gender is pyloric stenosis more common in?
boys
What is the first priority tx for pyloric stenosis?
IV fluids
What acid-base imbalance does pyloric stenosis cause? How can it be treated?
metabolic alkalosis → potassium can be given for correction
What surgery can be done for pyloric stenosis?
Laparoscopic pyloromyotomy
Ramstedt’s operation → make an incision to widen the canal and allow food to pass through the stomach to the duodenum so it does NOT back up into the esophagus
What are the sx of pinworms? (hint: 6)
- Enuresis (involuntary release of urine during sleep)
- perianal itching
- restlessness
- disturbed sleep (night time walking)
- irritability
- pain with urination
When someone has pinworms, when is perineal itching the worst?
night time
How is pinworms transmitted?
Transmission → fecal-oral route
Digging in dirt & getting dirt under their nails
What two testing methods are used for pinworms? Which is used now?
Scotch tape test & paddle test → paddle test used now
Explain how the scotch tape test works
Take a piece of scotch tape & after the child has been asleep for 2 hrs, the parents should enter the room (one holding flashlight & the other would look to see if they saw ay pinworms swirling)
Then use a piece of scotch tape to stick against perianal opening and collect any worms
Take piece of tape & give to pediatrician to look under microscope and look for any pinworms
Explain how the paddle test works
Test tube → with a stick that is sticky on both ends (2 parent job)
One parent holding the flashlight the other will hold the sticky test tube and go back and forth on the skin to collect any evidence of pinworms being there
Once collection is complete → the stick is put into the test tube and sent to the lab
