TLO 2.3 Nutrition and Fluid Balance - Child Flashcards
Cleft Lip/Cleft Palate
Structural defect?
Causes?
Structure:
Facial malformations that occur during embryonic development
Most common of congenital deformities of the head and neck
Most often have both deformities
Causes:
Interaction of multiple genetic and environment factors
-exposure to alcohol, smoking, anticonvulsants, steroids (10x increase with phenytoin)
Cleft Lip/Cleft Palate
First sign?
Occurs during 7-12th week of embryonic development
US during pregnancy can reveal deformity
Cleft lip obvious at birth
Cleft palate is discovered with exam
Cleft Lip/Cleft Palate
Problems?
Inability to suck -imbalance nutrition -imbalanced fluid/electrolytes -breast/bottle feeding difficulties -growth and development -liquids escape through nose Risk for aspiration Risk for chronic otitis media and hearing loss Parental anxiety and fears Maternal-child bonding -emphasize positive physical features -emphasize post op outcomes -do not focus on defect
Cleft Lip/Cleft Palate
Feeding
ESSR method of feeding: enlarged, stimulate, swallow, rest feeding
- special bottle systems with enlarged nipples
- hold infant in semi upright seated position
- try to limit feeding to 30 min
Cleft Lip Palate
Post op care
Cleft lip repair: 3-6 mo old, revision by 5 yr Focus on protecting operative site -prevent crying -elbow restraints -keep on back/side position or infant seat Analgesia for pain Clear liquids when awake Suture line meticulously cleaned Antibiotic ointment Gentle aspiration of mouth/nose prn
Cleft palate repair
Post op care
Cleft palate repair: 6-24 mo, <1 yr recommended 4-6 weeks healing May position on abdomen No suction or other objects in mouth No hard foods Parental support access information
Esophageal atresia
Suspected?
Any infant with unexplained frothy saliva in the mouth and unexplained episodes of cyanosis should be suspected in having esophageal atresia
Esophageal atresia with a tracheoesophageal fistula
what is it?
Esophagus terminated before it reaches the stomach and a fistula occurs that represents an unnatural connection with the trachea
Results in aspiration, respiratory distress and dehydration
Surgical repair needed
Esophageal atresia with a tracheoesophageal fistula
clinical signs and diagnosis
Clinical signs: 3 "C's" chocking, coughing, cyanosis with feeding Excessive oral secretions Vomiting Unable to pass an NG tube at birth Abdominal distention
Diagnosis:
X-ray, proximal esophagus dilated with air (atresia) or abdominal distention (fistula)
Bronchoscopy and endoscopy to assess fistulas
Esophageal atresia with a tracheoesophageal fistula
Surgical emergency
Repair to ligate fistula and anastomose esophagus Priority: prevent aspiration -NPO until repaired -frequent suctioning oral -NG w/ aspiration q 5-10 min (pouch empty) -infant in warmer/humidified O2 -IV fluids -HOB elevated to 30 -monitor VS, pulse ox, I/O
Esophageal atresia with a tracheoesophageal fistula
Post op nursing
Monitor respiratory status Support fluid balance and nutrition Maintain temperature, pain relief monitor for infection Promote bonding with parents chest tube patency maintained Assess lung sounds, suction prn Accurate I/O, gastric tubes for feeding
Esophageal atresia with a tracheoesophageal fistula
Evaluation
Infant tolerating oral feedings with 3 “C’s”?
Infant gaining weight?
Surgical site without signs of infection?
Skin intact around G tube, chest tube, incision?
Esophageal atresia with a tracheoesophageal fistula
Parent care
Parents anxiety levels with care responsibilities
Demonstrate G tube feeding and care (tube bath in 1-2 wks)
Report drainage, leakage of formula, s/s of infection
Demonstrate skin care of wounds
CPR trained
Home care resources
Gastroesophageal Reflux and Disease: GER and GERD
What is it?
Causes?
Gastroesophageal Reflux: GER
Regurgitation of gastric contents back into the esophagus: 50% of infants <2 mo have GER, physiologic usually resolves by 1 yr
Gastroesophageal Reflux Disease: GERD (pathologic)
Represents resulting symptoms or tissue damage
Becomes a disease when complication occur
-growth failure
-bleeding
-dysphagia develops
-GERD is associated with: apnea, bronchospasm, laryngospasm and pneumonia
Causes: inappropriate transient relaxation of the lower esophageal sphincter (LES)
GERD s/s
Symptoms: vomiting or spitting up after meals hiccupping apnea, coughing, choking recurrent otitis media weight loss/failure to thrive irritable, discomfort, ad pain severe cases: hematemesis or melena and anemia
GERD diagnosis
H/P
UGI series/barium swallow study
24 hr intraesophageal pH monitoring study- gold standard
endoscopy with biopsy, US, CT
GERD nursing interventions
Monitor airway CPR education Provide education on nutrition/fluids Position upright after feeding, 1hr Small frequent feeding (rice cereal) Teach signs of dehydration and when to seek help Observe for GI bleeding
GERD evaluation
Patent airway Swallowing without respiratory distress Retaining feeding with regurgitation of <10ml Gaining weight Balanced I/O
GER/GERD colaborative care and medications
Care:
No therapy if thriving and no resp complications
15% require surgery
Medications:
H2-receptor antagonists: Pepcid (famotidine), Zantac (ranitidine)
Proton pump inhibitors: Prilosec (omeprazole), Protonix (pantoprazole)
Gastroenteritis causes
Infectious agent in GI tract
Viral, bacterial and parasitic pathogens
Spread by fecal-oral route
-contaminated food or water
-spread person to person in close contact
**Giardia is the most common pathogen in daycare
**Rotavirus is the most common viral cause of diarrhea (29% of deaths <5 yr)
Most severe in 3 mo to 24 mo
Gastroenteritis NI
Obtain accurate history, length of symptoms, frequency and consistency of stools blood/mucus
Assess for poor hydration
Maintain fluid balance: I/O, weight, electrolytes, K+, NA+
Maintain isolation: teach prevention of spread
No antidiarrheal
Report worsening symptoms: bloody stool, ab distention/pain, persistent elevated temp
Pyloric Stenosis
what is it?
Circular area of muscle around pylorus hypertrophies and obstructs gastric emptying
Most common symptom is progressive projectile vomiting (no bile)
Dehydration is most serious outcome
NI aimed at preventing dehydration
Hypertrophic Pyloric Stenosis
what is it?
Pyloric sphincter is thickened causing narrowing
-outlet obstruction and dilation, hypertrophy and hyperperistalsis of the stomach
Develops at 2-5 wk
Hypertrophic Pyloric Stenosis clinical findings
Projectile vomiting Vomiting after feeding Emesis is nonbilious Dehydration Metabolic alkalosis Growth failure Olivelike mass palpated when the stomach is empty Lethargic Eventually malnourished
Pyloric Stenosis diagnostic tools
History Clinical findings US of pyloric channel Upper GI if US negative Laboratory findings reflect fluid and electrolyte depletion
Pyloric Stenosis nursing assessment
Weight on admission
H and P
Observe for signs of dehydration
Signs of electrolyte imbalance
Ab assessment for distention, tenderness, bowel sounds, presence of pyloric mass
Assess family for knowledge deficit regarding diagnosis, treatment, support, ability to participate in care
Pyloric Stenosis preoperative
NPO Weight, daily IV fluids VS I/O Labs Elevate HOB NG tube: amount, color, type of drainage Skin/mouth care Respiratory distress
Pyloric Stenosis therapeutic management and post op care
Pyloromyotomy: incision of pyloric muscle to release obstruction
Laparoscopy: shorter surgical time, rapid postop feeding, quicker d/c
Post-op: feeding 4-6 hr post op small amounts of clear fluid breast/formula as tolerated monitor I/O daily weight
Celiac disease
what is it?
Chromosomal variation that result in child’s inability to digest gluten (gliadin)
Immune mediated enteropathy of proximal small intestine
Resulting in severe GI mucosal changes that continue on exposure
Teach about diet (no wheat, rye, barley, oats)
Replace with corn or rice
Vitamin supplements may be needed, especially fat soluble and folate
Celiac disease causes
Unknown
Inherited predisposition with environmental factors
Genetic markers is almost 100% of cases
Celiac disease pathophysiology
Inflammatory reaction is activated by gluten
Cytokines released contribute to intestinal damage
Fat, calorie, carb and vitamin deficiencies
Celiac disease diagnosis
Immunoglobulin A (IgA) deficiency, IgG is used
Jejunal biopsy for ulceration in GI
Monitoring reaction to a gluten free diet
Symptoms often relieved in 1 wk after gluten free diet
Celiac disease clinical findings
3-6 mo after introduction of grains to diet Diarrhea: steatorrhea (greater amounts of fat in feces, characterized by frothy foul smelling fecal that floats) Growth failure Ab distention Vomiting Anemia Irritability Anorexia Muscle wasting Edema Folate deficiency **Crisis: profuse watery diarrhea and vomiting
Celiac disease NI
Teach diet restriction (no wheat, barley, rye, oats)
Monitoring of all food labels
-gluten and lactose free diet
-diet high in calories and protein with simple carbs
-avoid high fat, high fiber foods
Monitor weight, growth
Physician monitoring: anemia, osteomalacia (softening of bones, def in Vit D and calcium)
Teach disease process, life long condition
Refer to support group
Minimum Urine Output
Infants/toddlers: >2-3 ml/kg/hr
Preschoolers/young school age: >1-2 ml/kg/hr
School age/adolescents: 0.5-1 ml/kg/hr
Infant nutrition
Breast feeding benefits
Bacterially safe
Always fresh
Correct temperature
Maturation of the GI tract, immune factors lower gastroenteritis, neonatal necrotizing enterocolitis, celiac disease
Antibodies against otitis media, resp illness: RSV, pneumonia, UTI, bacteremia and bacterial meningitis
Decrease allergies
Decreased incidence of SIDS
Protective affect against childhood lymphoma/diabetes
Enhanced cognitive development
Analgesic effect for painful procedures (heel stick)
Infant nutrition
Formula kcals
Formula: 85-100 kcal/kg/day
- birth to 6 mo: weight doubles between 4-7 mo
- 6-12 mo: weight triples
Infant nutrition
Breastfeeding consideration
Vitamin D deficiency (risk for rickets)
400 IU of vit D: shortly after birth until taking 1 L/day of fortified formula
Cobalamin (vit B12) deficiency
Contributes to infant neurologic impairment
Caused by inadequate maternal ingestion
Do not feed infants?
Goat’s milk
Skim or low fat milk
Condensed milk
Raw or pasteurized milk from any source
Infant
Solid foods
Consult with pediatrician prior to starting, usually around 4-6 mo
Infants cannot easily digest foods
Higher incidence of food allergy associated with early start
Iron fortified cereal until 18 mo
Introduce 1 food at a time
Detect allergies/intolerance
Finger food introduced 8-10 mo
Infant nutrition
Toddler considerations
Finger foods, 8-10 mo, encourage self feeding Healthy foods Nutritional snacks 2x day Growth rate slows Appetite decreases Weight quadruples by 2.5 yr Double height at age 2 Multivitamin only if poor dietary intake Nutritious foods- My Plate -fruits 100% juice, 4-6 oz/day -vegetables -whole grains -low fat dairy and nonfat dairy (milk 16-24 oz/day) -fish, beans, lean meats
Nutritional pre school considerations
Frequent small meals Healthy foods and snacks Focus on weekly food intake vs daily Increase Kcals Nutritional considerations same as toddlers Gain 2-3 kg per year Birth weight doubles by 4 yr
Nutritional adolescent considerations
Encourage food pyramid
Monitor adequate intake
Supplement as needed
Nutritional issues Milk replaced by soft drinks Fast food Body image Busy schedule Eat away from home more frequently Peer pressure
Pubertal growth spurt
Females:
10-14 yr
Weight gain 7-25 kg
95% of height by menarche
Males:
11-16 yr
Weight gain 7-30 kg
95% of height by 15 yr
Physiological principles related to fluid and electrolyte balance in children
Younger the child, higher the proportion of water content in their body to body mass
Younger the child, higher the proportion of extracellular fluid to intracellular body fluid
Extracellular body fluid is more easily depleted than intracellular body fluid. This leaves the child at higher risk for fluid depletion when they get sick
Younger children can’t tell their caregivers that they are thirsty
Dehydration
Isonatremic
Primary form in children
Electrolyte and water are lost in approx. equal amounts
Loss from extracellular compartment
-reduces the plasma volume and circulating blood volume
-affects skin, muscles and kidneys
Shock is greatest risk to life
Sodium remains 138-145 mEq/L
Dehydration
Hyponatremic
Dehydration occurs when electrolyte deficit exceeds the water deficit (sodium <135 mEq/L)
Shock if frequent finding
Dehydration
Hypernatremic
Dehydration result from water loss in excess of electrolytes loss
Most dangerous and requires specific fluid therapy (intake of large amounts of solute or high protein NG feedings)
Serum sodium >150 mEq/L
Assessment for dehydration key factors
History of acute or chronic fluid loss Clinical symptoms Weight Serum electrolyte levels -decreased bicarb, K+, glucose -sodium level may be normal in Isonatremic Urine specific gravity >1.020
Dehydration management goal
Goals:
correct fluid and electrolyte imbalance
treat underlying cause
Dehydration NI
Teach parents prevention of dehydration
-extra fluid during hot weather, avoid overdressing
-rest periods after high energy play
Treat fluid replacement (Pedialyte)
-plan water in large amounts is dangerous
Monitor weight
Monitor I/O
-stools/emesis: frequency, type, amounts, consistency
Monitor VS
Food allergens
Two catagories
Food allergy or hypersensitivity
- reactions involving immunologic mechanisms
- usually immune globulin E (IgE)
- reaction immediate or delayed
- mild to severe= anaphylactic reaction
Food intolerance
- reactions involving known or unknown nonimmunologic mechanisms
- i.e. lactose intolerance
Food allergy clinical manifestations
Systemic
- anaphylactic
- growth failure
Gastrointestinal
- ab pain
- vomiting
- cramping
- diarrhea
Respiratory
- cough
- wheezing
- rhinitis
- infiltrates
Cutaneous
- urticaria (hives)
- rash atopic dermatitis
Food allergens diagnosis
Health history Elevated IgE Skin tests Radioallergosorbent test (allergy test done on blood) Anaphylaxis occurs in 5-30 min Asthma symptoms: wheezing, dyspnea Death can occur w/o treatment
Obesity defined
Body mass index >95th percentile for youth of the same age and gender
Most common nutritional problem among US children
Obesity predisposing factors
Intake of high caloric, fatty foods
Lack of outside physical activity
Inactivity related to television, computers and video games
-63% of 8-18 yr have TV in room, watching average of 4 hours per day
-minority and low socioeconomic status populations watch over 4 hours/day
Obesity potential complications
Psychosocial Pulmonary GI Renal Musculoskeletal Neurological Cardiovascular Endocrine Diabetes HTN
Obesity NI
Parental education Do not use food as reward Scheduled meals/snacks Healthy choices Preplan meals Avoid fast food Be a role model Plan activities with children Routine pediatrician check ups
