GI Dysfunctions in Newborn Flashcards
Distribution of ______ changes with growth
water
Water and electrolyte imbalances occur more frequently and more rapidly at what age?
infants and through early children
Do children adjust to these water distribution changes quick or slow?
less quickly
Total Water in the body
75% in term newborn
decrease to 45% in adolescents
Premature more than 75%
The amount of water ingested approximates what
urine to be excreted in 24 hours
I&O balance
Factors of fluid loss
Insensible fluid loss (perspirations, sweating, respirations, fluid in feces)
Increased Body surface area (
Basal metabolic rate
Kidney function
Fluid requirements
With body surface area, what do you need to remember with size of the patient?
The smaller the patient the greater the BSA
- the baby has more skin than body weight and dehydration can come on more quickly
Basal Metabolic Rate in children
higher to support cellular and tissue growth
** Any condition with the metabolism causes increased heat production and insensible water loss to increase in relation**
- rapid growth
The kidney function of a newborn
functionally immature at birth
inefficient in excreting waste products of metabolism
harder time to concentrate and dilute urine
- higher fluid requirements
Maintenance fluid requirements in a newborn have to include
water and electrolytes (balanced)
2/3 of insensible fluid loss is through
the skin (sweating)
1/3 of insensible fluid loss is through
respirations
Infants are more prone to
infections due to weakened immune system
What condition causes a large amount of insensible water loss to occur? and Why?
infection
fever and sweating (2/3 of insensible)
fever causes tachypnea (1/3 of insensible from respiration)
Isotonic Dehydration
water and electrolytes are decreased in balanced proportions
Isotonic dehydration sodium level
stays the same
Hypotonic dehydration sodium level
decrease of Na
Hypertonic dehydration sodium level
increase of Na
Water Intoxication Causes
water without electrolytes
increase serum sodium
worsen dehydration
consistent tap water enemas (GI is longer)
- absorb more water
Incorrect formula balance
- little powder and more water
Hypotonic IVF admin - less solute and more water
Dehydration Causes
the infection affects the water loss
incorrect mixing formula (too much powder and little water)
Hypotonic Dehydration
electrolyte deficit exceeds the water deficit
Hypertonic Dehydration
water loss in excess of electrolyte loss
What is the most important determinant of total body fluid loss in infants & young children?
Daily weights
- goes up = retaining
- goes down = dehydration
same scale, time, and nude
What is the earliest detectable sign of dehydration?
tachycardia
Compensatory mechanisms
heart is bounding
overtime till it stops
pulse ox low (blood towards vital organs)
S/S of dehydration
lethargic
dark urine
dry mucous membranes
skin turgor slow
no tears
reduce cap
fast hr
decrease sunken fontanels
cool extremities
low pulse Ox
When should you be concerned about a pedi pt changing weight
day or 2 different
trends
A very late sign of dehydration is
drop in BP (heart is overworked)
Tx for severe isotonic and hypotonic dehydration
initial IV therapy of rapid fluid replacement
Bolus or 2
Tx of hypertonic dehydration
slow infusion of IV fluids
Why do you not do a rapid infusion of IVF on a hypertonic dehydration patient?
rapid may lead to cerebral edema (central pontine myelinolysis)
Mild to Moderate Dehydration starts with rehydration methods
Enteral (PO) - pedilyte
Oral replacement therapy over 4-6 hours
= replacement of continuing losses
= Provide least minimum fluid replacements
Severe Dehydration starts with rehydration methods
Parenteral (IV)
unable to keep fluid and electrolytes down
- meet daily physiological needs
- replace previous deficits
- replace ongoing abnormal losses
How do we know if rehydration methods are working on a pedi pt?
urine output is meeting the minimum acceptable urine output
Acute diarrhea
self-limiting
less than 14 days
viral infections
Chronic diarrhea
more than 14 days
cause is usually chronic (IBD; lactose intolerance)
If children are having intense and long periods of diarrhea, what should the main interventions be?
dehydration - replenish fluids
return to normal diet (better nutrients regardless of increase stool output)
Rotavirus is known as the
c.diff of the infant
What is the most common cause of acute diarrhea in children less than 5 y/o?
rotavirus
Rotavirus is more severe in infants less than
6 months
Immunization of Rotavirus is taken by
mouth
Transmission of Rotavirus
fecal-oral route
person-to-person
S/S of Rotavirus
Fever
Vomiting
Watery diarrhea (severely dehydrating)
distinct foul smell
2-7 days of diarrhea
Infection of the rotavirus does not mean
immunity just less severe
Nursing Teachings of Severe Diarrhea
handwashing
diapers need to be changed more frequently and disposed of properly
Do not give antidiarrheal medications because the virus is expelled through the diarrhea and just keeping it inside them prolongs the virus
no fruit juices, no sugar or carbonation
no Na
Good forms of fluid replacement for diarrhea
Pedialyte
no fruit juices, no sugar or carbonation
no Na
Constipation
decrease in bowel movement frequency or trouble defecating for more than 2 weeks
Reasons of constipation
failing to pass meconium
hypothyroidism
Hirshsprung Disease
imperforated anus
stricture or anal fissures
stress and school
Strictures
the small opening of the rectum in which the bowel mvmt can not pass
Anal fissures
tears in the rectum
Who has a higher stool output (frequency) breastfeed or formula feed
Breastfed
- educate if a change in food to formula and whole milk
The majority of constipation issues can be addressed with
dietary modifications
- Cereals, veggies, and fruits increase fiber
- increase fluid intake
- no cheese
If constipation continues even with dietary modifications, then the pediatrician usually recommends
stool softeners
Hirschsprung aka
Congenital Aganglionic Megacolon
Hirschsprung is usually misdiagnosed
chronic constipation
What is Hirschsprung Disease?
- anomaly results from mechanic obstruction from inadequate motility of the bowels caused by the absence of ganglion cells (nerve cells coordinate peristalsis)
Pathology of Hirschsprung
absence of ganglion cells
no peristalsis
loss of rectosphicteric reflex
stool accumulation
Megacolon
Intestinal ischemia may develop
Enterocolitis (damage to the mucosal cells lining the intestinal walls)
- decreases blood supply and leads to cell death
Enterocolitis
damage to the mucosal cells lining the intestinal walls
= decreases blood supply and leads to cell death
Diagnose Hirschsprung
Xray assists distended colon
Rectal Bx - looking for ganglion cells
Infants S/S of Hirschsprung
Failure to pass meconium
Abdominal distension
Feeding intolerance/Vomiting
Older children s/s of Hirschsprung
Constipation, diarrhea, and/or watery or ribbon-like
foul-smelling stools
Easily palpable stool mass
Tx of Hirschsprung
Hirschsprung’s Endorectal Pull-through
https://www.youtube.com/watch?v=9QjZe6zZpRA
Pre-Op Considerations for Endorectal Pull-Through
Nothing per Rectum
monitor stool output and abd girth,
IV and prophylactic antibiotics
Post-Op Considerations for Endorectal Pull-Through
IV and prophylactic antibiotics
Pain meds and activity
Gastroesophageal Reflux defincition
transfer of gastric contents into the esophagus
usually outgrow after 1 year
Reason for Gastroesophageal Reflux
diet is liquid as an infant but start eating solids at 4-6 months it decreases and usually outgrows after 1 year
- relaxed esophageal sphincter
- delayed gastric emptying
Diagnosis for Gastroesophageal Reflux
H&P mainly
Upper GI series (anatomic abnormalities)
24-hr intraesophageal monitoring
Endoscopy with biopsy (presence and severity of esophagitis)
Scintigraphy - gold standard (detect radioactive substances in the esophagus after feedings)
Difference between Gastroesophageal Reflux and GERD
GERD is environmental overtime and chnage the cell lining
If only reflux as an infant = spit up and regurgitate much more
Infants s/s of Gastroesophageal Reflux
Spitting up/vomiting
Irritability
Arching of back
Poor weight gain
Choking with feedings
Respiratory (aspirations)
Child/Adolescent s/s of Gastroesophageal Reflux
Heartburn
Abdominal pain
Chronic cough/clearing
Dysphagia
Recurrent vomiting
trouble eating
Hx asthma - respiratory with aspiration pneumonia
Tx for Gastroesophageal Reflux
H2 Antagonist (Ranitidine and famotidine)
Proton Pump Inhibitors (Esomeprazole (Nexium); lansoprazole (Prevacid); omepraxole (Prilosec); pantoprazole (Protonix))
Nissen Fundoplication surgery
Foods to avoid with Gastroesophageal Reflux
citrus fruits
tomatoes
alcohol
peppermint
fried
spicy
Infants with Gastroesophageal Reflux need
smaller but more frequent feedings
give iron-fortified cereal in formula
= makes it more difficult to suck through the nipple to get nutrients
breastfed - pump and give smaller and more frequent
special formulas
Positioning - elevate HOB, sit up in chair
if after all interventions for Gastroesophageal Reflux the kid is still going down on wt and falling off track, then the doctor will Rx?
H2 Antagonist
Proton Pump Inhibitors
H2 Antagonist
Suppresses the secretion of gastric acid by selectively blocking H2 receptors
H2 Antagonist meds
Ranitidine (Zantac) and famotidine (Pepcid)
Proton Pump Inhibitors (PPI)
Reduce gastric acid secretion
Proton Pump Inhibitors (PPI) meds
Esomeprazole (Nexium); lansoprazole (Prevacid); omepraxole (Prilosec); pantoprazole (Protonix)
Nissen Fundoplication is for what pts
severe complication of Reflux
Nissen Fundoplication process
fundus of the stomach is placed behind the esophagus; encircles the distal esophagus
strengths the sphincter and prevent regurgitation
Post-Op for Nissen Fundoplication
NG Tube (do not replace if pulled out)
- decompress stomach
Monitor for gastric distension
Imperforate Anus
Absence of analopening
occurs during the development
fistula connection - stool passes through increases UTIs
With an imperforated anus, what would happen
Inability to visualizerectal opening
No meconium is passed
Gradual abdominaldistention
May have fistula
Imperforated anus is fixed with
surgery (Analplasty)
with Colostomy afterwards
Appendicitis
Inflammation of the vermiform appendix caused by an obstruction of the lumen of the appendix or viral
Appendicitis average age
12-18 y/o
S/S of appendicitis
Pain starts in the middle of the abdomen and moves to RLQ (Mcburney’s point)
Rigid abdomen
Decreased/absent BS
Fever
Possible vomiting
Where is McBurnery’s Point?
Midway point between the superior anterior iliac crest and ileus
Dx of appendicitis
Ultrasound
CT scan
basic labs
Tx of appendicitis
appendectomy
prophylactic antibiotics
If the patient is suspected of having appendicitis and is in the pain stage, BUT now has no pain at all, what happened?
ruptured
then the pain gradually starts up again
start the central line and start strong antibiotics
nursing care for appendicitis
child life
post-op: pain control and activity
Biliary Atresia
progressive inflammatory process that results in intrahepatic & extrahepatic bile duct fibrosis, resulting in ductal obstruction
- bile trapped in liver
- causes damage and starring to cells in the liver
- untreated leads to liver failure and death within 1st 3 years of life
S/S of biliary atresia
Jaundice persisting beyond 2 weeks of age
most common early sx
Putty-like white or gray stools
-the absence of fat
Tea colored urine - bilirubin and bile salts
Intense itching & irritability - cholesterol deposits and malabsorption of fat
Malnutrition leads to severe growth failure
- fall off growth chart
The Bile duct of the Liver does what
bile ducts remove waste from the liver
carries salts to help the small intestine break down fat
Dx of Biliary atresia
Abd Ultrasound - look at it
percutaneous liver biopsy (most useful) in true dx
Exploratory laparotomy or intraoperative cholangiogram
Biliary atresia results if untreated
excessive cirrhosis of the liver
death of the hepatic cells by 3
Tx of Biliary Atresia
Hepatoportoenterostomy (Kasai procedure)
- connect the liver to s. intestine goal to drain bile
- improves condition BUT not a cure
Liver Transplant
- Most still need
Nutitional support (formula vs. TPN)
- nutritional support with fat-soluble vitamins
What is the only cure for Biliary atresia?
liver transplant
Nursing Considerations of Biliary Atresia
emotional support - child life and religious
education with G and D
s/s of infection or liver failure
Esophageal Atresia
failure of the esophagus from developing as a continuous passage
TEF
Tracheoesophageal fistula
- failure of the trachea and esophagus to separate into 2 district structures
T/F: EA can occur separately or with TEF.
True
mostly together
Esophageal atresia cause
unknown, but is associated with:
- maternal polyhydramnios- too much amniotic fluid
- Midline anomalies (cardiac)
- VATER/VACTERL syndrome (50%)
- higher risk: low birth weight, preterm birth
S/S of Esophageal Atresia
Excessive frothy mucus from nose and mouth
The 3 C’s:
- Coughing
- Choking
- Cyanosis
Apnea spells
Respiratory distress during feeds
Abdominal distension
Dx of Esophageal Atresia
History & physicalassessment
Radiographicstudies todetermine:
- esophageal patency
- catheter till hits the wall
X-ray = Presence ofa blind pouch with gas in the stomach orsmall bowel indicates TEF
If there is gas in the stomach this indicates a
TEF
Pre-Op for Esophageal Atresia
Position baby to facilitate drainage
- supine with HOB up at 30
- suction out secretions
Cleft Lip & Cleft Palate
Defects in cell migration failing the maxillary & premaxillary processes to merge between the 4th & 10th weeks of embryonic development
- incomplete closure of the lip and/or palate
T/F: Cleft anomalies can occur by themselves or be associated with a syndrome.
True
Cleft lip symmetry
asymmetrically
symetrically
Cleft lip dx by
prenatally in ultrasound
around 13-14 weeks
Cleft palate identified through
physical exam of the oral cavity after birth
partial or complete up the lip and to the nose
Cleft deformities are a combination of factors
genetic
environmental
- exposure to alcohol, anticonvulsants, cigarettesmoke, retinoids, or steroids is associated with a higher rate of oralclefting
- folate deficiency
Folate dose for mom
0.4 mg
Immediate problems of clefts
the reaction of parents and family if unaware
feeding and sucking (breastfeeding will conform to the cleft but if formula then get special nipples)
- if the palate more challenging
- different positioning helps - upright with supported head
Cleft Lip surgical repair
2-3 months
require rhinoplasty
Cleft Palate repair
before 12 months for speech development
- 2nd surgery possible
- prosthetic mgmt in the meantime
Post-Op of cleft repairs
No objects in mouth (protect suture site and no pressure on site)
NPO with NG tube
Elbow immobilizers
Resume feeding (7-10 days)
Pain control
Upright positioning
Long-term considerations of Cleft repairs
Speech therapy
Dental
Hearing loss (otitis media)
Social/Academic
Umbilical Hernia
Intestine protrudes through the abdominal wall at the umbilicus
S/S of Umbilical Hernia
protrusion at umbilicus
- gets bigger when they cry or force out
- can poke in and out
Tx of Umbilical Hernia
no treatment for small hernia
closes itself after 3-5 years old
surgical repair only after 5 or strangulation of tissue
Omphalocele
- Abdominal contents are herniatedthroughthe umbilicalcord
- Exposed abdominal contents are covered by atranslucent two-layer membrane sac
Dx of omphalocele and gastroschisis can often be made
prenatally at 14 weeks
delivered C section
Omphalocele is usually associated with
Trisomy 14,18,21 or cardiac defects (syndromes)
Tx of Omphalocele (small or large)
paint and wait
- sac is painted with antibiotic cream with zinc (skin cell production) and skin grows over the defect and is covered in sterile gauze
surgical reduction
- if small, put the organs back in
Zinc stimulates
skin cell production
Pre-Op of Omphalocele
Maintain thermoregulation
Protect defects from trauma or drying
warm, sterile, saline-soaked dressing
top dressing with a layer of sterile plastic wrap
NPO - NGT
IVF AND Antibiotics
Post-Op of Omphalocele
Routine postop care
Pain management
NGT
IVF
Monitor the return of bowel function
Gastroschisis
Abdominal contents herniated outside of the abdominal wall
- no covering membrane
the umbilical cord is intact
Pre-Op Gastroschisis
Maintain thermoregulation
NPO, IVF, Antibiotics, NGT
Observation of exposed bowel
- supine
Prosthetic silo
allows a gradual return of intestines to the abdominal cavity over 5 – 10days, then closure of the abdomen
Prosthetic Silo
allows a gradual return of intestines to the abdominal cavity over 5 – 10days, then closure of the abdomen
- squeeze the contents into the body slowly and then close up
Post-Op of Prosthetic Silo
Routine postop care
NGT
Pain management
Lower extremity pulses 0 vena cava compression
Return of bowel function
https://youtu.be/Zo3cZH_7BRs
Hypertrophic Pylori Stenosis
Narrowing of the pyloric canal producing outlet obstruction
Hypertrophic Pylori Stenosis pathology
- thickening of the pylorus muscle
- elongation and narrowing of the pyloric channel
- partial obstruction of the lumen
- edema and inflammation eventually lead to complete obstruction
S/S of Hypertrophic Pylori Stenosis
Olive-like mass in the upper abdomen
Vomiting after feedings
eventually projectile vomiting
Dehydration
Metabolic alkalosis
Growth failure
Dx of Hypertrophic Pylori Stenosis
H&P - Ultrasound to confirm
Tx of Hypertrophic Pylori Stenosis
Transpyloric tube
Pyloromyotomy
- longitudinal incision through the circular pylorus muscle to widen the opening to pressure let off
Intussusception
Occurs when one segment of bowel telescopes into another segment
Intussusception PATHO
segment of bowel telescopes into another
mesentery compressed and angled
lymphatic and venous obstruction
edema increase
Pressure within the area of intussusception increases
When the pressure equals the arterial pressure, arterial blood flow ceases
ischemia
pouring of mucous into the intestines
Intussusception ages
3 months to 6 years
Intussusception s/s
Acute, severe, intermittent abdominal pain
Tender, distended abdomen
Palpable mass in RUQ
Empty RLQ
Vomiting
Lethargy
Red, currant jelly-like stool
Intussusception MGMT
Water-soluble contrast enema
air pressure
and carbon dioxide
Barium enema
Surgical Interventions of Intussusception
Manual reduction
removal of dead tissue if needed
Pre-Op and Post-Op
IV access and antibiotics
Pain control
abd distension
active bowel sounds
bowel mvmts
Giardiasis is a
protozoa
Giardiasis is ingested in how
cysts are ingested & eventually excreted in stool
- lives in the intestines and excreted out in feces
Mode of transmission of giardiasis
person-to-person
improperly prepared infected food
contaminated water
animals
Giardiasis can survive outside the body for how long
weeks or months
Giardiasis s/s
Infants:
diarrhea
vomiting
not wanting to eat
Older:
abdominal cramps
foul-smelling greasy stools
How to Dx parasites in stool
stool sample
Tx Giardiasis
Flagyl
Metronidazole (Flagyl)
Tinidazole (Tindamax)
Enterobiasis is also known as
Pinworms (small white roundworm)
most common in the US
Enterobiasis transmission
hand-to-mouth inhalation of eggs
eggs hatch in the upper intestines
larvae migrate to the cecum
pregnant females migrate out to the anus to lay eggs at night
in daycares, schools
S/S of Pinworms
intense itching
scratch butts
Dx of pinworms
Tape Test
- before getting out of bed parent places tape on anus
- 2-3 days for collection and place in jar
Tx of Pinworms
Pyrantel pamoate (Pinrid)
albendazole
all members of the household need 2 doses
initial dose and dx
2nd at 2 weeks
deep clean house
Ascariasis
Round Worms
Ascariasis in children ages
1-4 years old
Ascariasis transmission
eggs in stool
hatch in small intestines
may move to the lungs
ascend to pharynx
swallow repeat
Ascariasis transmission simplified
hand to mouth
Ascariasis prevalent in
warm climates and developing countries
Ascariasis mild s/s
asymptomatic
- cramping
Ascariasis severe leads to
intestinal obstruction, peritonitis, pneumonitis
Education of Ascariasis
Examine stools 2 weeks after treatment & monthly for 3 months
Treat family members as needed
clean fingernails and handwashing and clean house
Tx of Ascariasis
albendazole
mebendazole
regardless of symptoms
