UNIT 2 GI PEDI Flashcards
True or false: The distribution of water does not change with growth?
False
What % water makes up a term newborn and decreases to ___% in late adolescents?
- 75%
- 45%
Premature babies require even more water
Under normal conditions the amount of water we ingest should relate to….
How much urine we excrete in a 24 hour period
Water & electrolyte imblanaces occur more frequently & more rapidly in what age population?
Infants
children adjust less quickly to these changes
What are sensible water loss?
Losses that can be measued and we are more aware of… like urine, vomiting… measurable fluid loss
What is insensible water loss?
Fluid loss that cannot be measured… perspirations, fluid loss through lungs, fluid in poop…
What are important factors in fluid loss?
- Insensible fluid loss
- 2/3 of insensible water loss occurs thorugh the skin, 1/3 happens through the resp. tract.
- example of insensible water loss… since childrens immune system is not as mature infants and children are more prone to infections… with infections your chances to sweat increases… and even your respirations may increase…
- Body surface area
- infants and children have an increased body surface area… the smaller the patient the larger body surface area…
- Basal metabolic rate
- Higher in children…because of there larger body surface area… any condition that increases there BMR causes greater heat production which leads to insensible fluid loss… higher to support tissue and cellular growth.
- Kidney function
- Not fully developed so they are functionally immature at birth… they are **inefficient in excreting waste products of metabolism so infants kidney have a harder time being able to concentrate and dilute urine. **
- Fluid requirements
- Have higher fluid requirements… maintance fluid have to include both water and electroloytes
What are different types of distubances of fluid and electorlyte imbalances?
- Water intoxication
- Causes: too much water, electrolyte free water can lead to water intoxication, consistent tap water enemias, incorrectly mixed formula, hypotonic fluid admin.
- What happens when you drink to much water is that it decreases your serum sodium which can actually worsen dehydration
- Dehydrations
Causes: Incorrectly mixed formula… too much formula not enough,
What are different types of dehydration?
- Isotonic
- Water and electrolytes are decreased in balanced proportions
- Sodium level normal
- Hypotonic
- Electrolyte deficit exceeds the water deficit
- More water less electrolytes so sodium is decreased.
- Hypertonic
- Water loss in excess of electorlyte loss
- More electrolytes less water… increased sodium
**- slowly hydrate this patient. **
What is the most important determinant of total body fluid loss in infants & young children?
- Weight.
What are clinical manifestations of dehydration?
- Depends on the degree of dehydration
- Dry mucous membrane
- Decreased skin turgor
- Dark Urine
- Sunken fontenales
- Lethargic
- Extremities will be cool to the touch
- No tears
- Dry mucous membrane
- **Earliest detectable sign is usually tachycardia **
- Compensatory mechanisms
What is a very late sign of dehydration?
Drop in blood pressure
What is the treatment for isotonic and hypotonic dehydration?
- Inital phase of IV therapy is rapid fluid replacement
- May need a bolus or two
What is the treatment of hypertonic dehydration?
Rapid infusion of IV fluid may lead to cerebral edema (central pointine myelinoysis)
How much weight loss is cause for concern in a pedi patient?
1-2 weight loss within 24 hours but mostly dependant on situation and trend
True or false: Pulse ox may not work well if dehydrated?
True
If a child is in mild or moderate dehydration what should we do?
- Enteral (PO) rehydration
- Oral replacement therapy (ORT) over 4-6 hours
- Goal is to keep fluids in them and down.
- Provide at least minimum fluid requirements
How are we going to know that our ORT is working?
Urine output increases
If a child is in severe dehydration what should we do?
Parenteral (IV) rehydration
1. Severe- child is unable to keep enough fluids and electrolytes down to:
- Meet daily physiological needs
- to replace previous deficits
- To replace ongoing abonormal losses
What is considered acute diarrhea?
<14 days
self-limiting
often seen in viral infections
What is considered chronic diarrhea?
> 14 days
related usually to chronic conditions…
lactose intolerant, IBD
What do we need to do for exterme amounts of diarrhea?
We want to replinish loss to avoid dehydration and get back to normal urine output. Once we achieve that we want to restore childs diet to a normal diet
What is rotavirus?
Viral infection and the most common cause of acute diarrhea in children less than 5 years.
When is rotavirus more severe age wise
Infants 6-12 months… remember the smaller the patient the more they will be affected by the fluid loss
What route is the immuization of the rotavirus given?
Oral
How is rotavirus spread?
- Fecal-oral route
- Person-to-person
What symptoms does rotavirus produce?
- Very watery diarrhea which can be severly dehydrating
- fever
- vomiting
- Very distint foul smell
How long does the diarrhea from rotavirus last?
2-7 days
Does infection mean immunity for Rotavirus?
No- so if they have the oral vaccine it doesnt mean they wont get it. It will just be a less severe case
What are some interventions and education for Rotavirus?
- Hand washing
- Change diapers frequently and dispose of properly
- Anti diahhrea meds prolong the shedding of the virus so it is not recommended
- Avoid fruit juices and carbonated drinks since they are high carb, low electorlyte, and high in sugar. Could increase diarrhea
- Chicken soup avoid high in sodium… futher dehydrates patient
- Fluid replacemtn thearpy- pedialyte
What is constipation?
A decrease in bowel movement frequency or trouble defecating for more than 2 week
What are some causes of constipation?
- Failure to pass 1st stool after birth
- Low thyroidism: alot of the bodys functions tend to slow down
- Imperforated anus
- Strictures and/or anal fissures
Between formula fed and breast fed infants who is going to have the most stool output?
Breastfed
True or false: If at any time mom switches from breastfed to formula we do not need to inform mom that babies poop and frequency will change?
False– we need to tell mom
Can stress cause constipation
Yes
What is a common cause of constipation in school aged children?
Fear of going at school
What can we do to help prevent constipation?
- Dietary restirctions- as they get older and begin to eat we can increase the amount of fruits, cerals, fiber and fluid intake… we can educate to avoid cheese
If the problem continues we can recommeded OTC stool softners
What is Hirschsprung disease
AKA congenital ananglionic megacolon
Congenital anomoly that results from a mechanical obstruction from inadequate motility of part of the bowel caused by a absence of ganglion cells
What are ganglion cells?
Nerve cells that coordinate perstalisis
What is the patho of Hirschsprung diesase?
- Absences of ganglion cells
- Absence of peristalisis
- Loss of retrosphincteric reflex
- Sool accumulation
- Megacolon
- Intestinal ischemia may devlope
- Enterocolitis may develop
- damage to the mucosal cells linging the bowel wall. Which decreases blood supply and lead to cell death.
What are the clincal manifestations of hirschsprung in infants?
- Failure to pass meconium
- Abdominal distention
- Feeding intolerance/vomiting
What are clincal manifestations of hirschsprung in older children?
- Constipation
- Diarrhea and/or ribbon-like, foul smelling stools
- Easily palpable stool mass.
How is Hirschsprung diagnosed?
Rectal biopsy… looking for ganglion cells
How is Hirschsprungs treated?
Surgery- Hirschsprung’s endorectal pull-through.
What are some pre/post op considerations?
- Nothing per rectum
- Monitor stool output
- Monitor abdominal circumferences
- Prep Iv and do prophylactic antibiotics
- Post IV used for pain meds but with caution due to pain medications affect on GI issues
What is gastroesophageal Reflux?
The transfer of gastric contents into the esophagus
How is Gastroesophageal reflux diagnosed?
- Hx & physical assessment
- Upper GI series
- For anatomical abnormalities related to refulx.
- 24-hour intraesophageal monitoring
- Endoscopy w/ biopsy
- Helps detect the seveirty of the esophagitis
- Scintigraphy
- Detects radioactive substances after feeding can also assess gastric emptying.
At what age do we start seeing issues with Gastroesophageal reflux
In infants aroud 4 months of age but usually out grow it by 1 year…
GERD is seen in what age population?
Adults
Reasons for reflux include?
- All liquid diet
- Infants are born with a more relaxed esophegeal sphincter
- Delayed gastric emptying
How long should you have a baby sit up after feeding to help prevent reflux?
30 mins
What are some clinical manifestations of reflux in infants?
- Spitting up/vomiting (passive regurgitation)
- Irritabily
- Arching of back
- Poor weight gain (need smaller more frequent meals)
- Chocking with feedings
- Respiratory issues
What are some clinical manifestations of reflux in children/adolecents?
- Heartburn
- Abdominal pain
- Chronic pain (after eating)
- Dysphagia
- Recurrent vomiting
- Horse voice
- Hx of asthma
What should we avoid with reflux
- Avoid foods that are acidic
- Avoid caffine
- Avoid citrus food
- Avoid spicy food
- Avoid peperment
What are some interventions/treatments for reflux
- Thicken milk… keep in mind this can make it more difficult to puke.. also adding calories… keep in mind the size of the nipple hole
- Poisiton bed 30 degrees or sit up.
- Special formulas
What are some medications to treat GER
1.H2 antagonists
- Supresses the secreation of gastric acid by selectively blocking h2 receptors
- Ranitidine (zantac) and famotidine (pepcid)
2. Proton pump inhibitors (PPI)
- Reduce gastric acid secretions
- Esomeprazole (nexium); lansoprazole (prevacid); Omepraxole (prilosec); Pantoprazole (protonix)
What is the surgical treatment for GER and what should we know about it?
- Reserved for pts with severe complications
- Nissen Fundoplication
- Fundus of the stomach is placed behind the esophagus; encircles the distal esophagus which helps stregnthens the esophageal spinchter
- Post op care
- NG tube (do not replace) goal is to decompress the stomach is the primary goal.
- Monitor for gastric distention
What is an imperforated anus?
- Absence of anal opening
- Inability to visualize rectal opening
- No meconium is passed
- Gradual abdominal distention
- May have a fistula (If they do they are more prone to UTIs)
How is an imperforated anus fixed?
Analplasty which will make an opening for stool to pass…
If fistula is involved they may make an osteum 1st so they can get everything reconnected appropriate and once urine and stool output is seperated then they can reverse the ostomy
What is an appendicitis?
Inflammation of the vermiform appendix caused from an ostruction of the lumen of the appendix
What is the avg. age of an appendicitis?
12-18 years
What are some clinical manifestations of appendicitis?
- Abdominal pain that shifts into RIGHT lower quadrant (mcburneys point)
- Rigid abdomen
- Decreased absent BS
- Fever
- Possible vomitting
What is Mcburneys point?
It is the midway point between the anterior superior ililac creast and the umbilicas… where appendicits pain can occur
A child comes in c/o of n/v and abdominal pain (periumbilical pain) that shifts to the right… what could the possible dx be?
Appendicits r/o with ct
What are diagnostic procedures to diagnose appendixitis?
CT or ultrasound
What are some nursing interventions for appendicitis?
- Labs to r/o possible perforated appendix… will monitor labs for s/o sepsis
- Ultrasound/CT– looking for increased size or missing appendix
How is appendicitis treated?
Surgically- laparoscopically and remove appendix
Will be on prophylactic antibiotics prior to surgery and post op
If you have a child who is suspected of having appendicitis, and is presenting with pain, n/v and then all of a sudden has relief of symptoms what does this indicate??
Appendix has ruptured
True or false: A patient with a ruptured appendix may not need surgery?
True– Moving toward not opening up patients. We will instead will place a central vein to give our “big gun” antibiotics for two weeks
Some docs. still prefer opening up
What is biliary atresia?
A progressive inflammatory process that results in intrahepatic and extrahepatic bile duct fibrosis, resulting in ductal obstruction
Simply put this is when bile is trapped in the liver which causes damage and scarring to the hepatic cells in the liver. Overtime if left untreated will lead to liver failure and death within the 1st 3 years of life
What is the function of the bile ducts?
Helps remove waste from the liver and carry salts that can help small intestine breakdown and digest fat
If bile’s are blocked, we are not removing waste or carrying salts to help break down fat.
What are the clinical manifestations of biliary atresia?
- Jaundice persisting beyond 2 weeks of age
- Most common early sx
- Putty-like white or gray stools
- Due to bile duct being blocked.. absence of bile pigment
- Tea colored urine
- Due to the excretion of bilirubin and bile salts by the kidneys
- Intense itching & irritability
- Hart to feed, arching of back, skin becomes super itchy because bile salts and cholesterol deposits are in the skin and malabsorption of fats.
- Malnutrition leading to severe growth failure
How is biliary artesia diagnosed?
- Ultrasound & percutaneous liver biopsy
- Biopsy is the emits useful method. Ultrasound allows dr. to see and inspect the liver and biliary system.
- Exploratory laparotomy or intraoperative cholangiogram
What are red flags for biliary atresia baby?
Might be completely normal at birth but then when they come in for a well check they have developed mild jaundice that persists thorugh the 2 week time frame… they will start falling off the growth chart.
What happens if biliary atresia is left untreated?
Left untreated can lead to progressive cirrhosis of the liver and death of hepatic cells by 3 years of age.
How is biliary atresia treated?
- Hepatoportoenterostomy (Kasai procedure)
- connect the liver to the small intestine. It improves the condition but DOES NOT cure. it ONLY buys time
- How much time it buys depends on the severity of the case.
- Most children will need to liver transplant
- Nutritional support
- Formula v. TPN
- Because they have poor fat metabolism they will have TPN through a central line because they will need the nutritional support.
What are some nursing considerations for biliary atresia?
- Emotional psychosocial support
- Good education on growth and development
- Education on signs to watch for indicating infection or liver failure
- Education on how to administer TPN
What is EA?
Esophageal Atresia- It is the failure of the esophagus to develop as a continuous passage. Can occur separately or along side TEF
What is TEF?
Transesophageal fistula- Failure of the trachea and esophagus to separate into distinct structure
What should we know about EA & TEF?
- EA can occur separately or with TEF but most of the time they occur together
What causes EA & TEF?
Cause unknown, but is associated with:
1. Maternal polyhydramnios “too much amniotic fluid”
2. Midline anomalies (cardiac)
3. Vater/Vacterl syndrome (50%)
4. Low birth weight
5. Preterm birth
What are clinical manifestations of EA & TEF?
- Excessive frothy mucus nose and mouth
- The 3 C’s
- Coughing
- Choking
- Cyanosis
- Apnea
- Respiratory distress during feeds
- Abdominal distension (air trapped in abdomen)
How is EA & TEF diagnosed?
- History & physical assessment
- Radiographic studies to determine
- Esophageal patency
- Presence of blind pouch (catheter may be inserted
- Gas in small stomach or bowel
What are we going to do preop for EA & TEF babies?
- Position baby in a way that it will facilitate drainage of secretion’s
- Supine with HOB elevated around 30 degrees this is going to allow the removal of fluid and prevent aspiration of gastric content.
- May be connected to suction
What is cleft lip & Cleft palate?
- Defect in cell migration resulting in failure of maxillary & premaxillary process to merge between the 4th and 10th weeks of embryonic development
- Incomplete closure of the lip and/or palate
What causes cleft lip & cleft palate?
- Can be an isolated anomaly
- Or occur with a syndrome
- Enviromental or genetic conditions
- Excessive use of alcohol, smoking, steroids
- Deficiency in folic acid. (0.4mg is recommended)
- Can occur separately but most commonly occur together
True or false: Clift lip can happen bilaterally or unilaterally?
True
A complete cleft palate will affect what structures?
- Palate
- Gum line
- Lips
- Nose
What are our immediate problems with cleft lip/palate babies?
- Reaction of parents and family
-Esp. if they are not aware… usually detectable. - Feeding
- Fed upright with head support
- generally have no issues breast feeding because the cleft and breast will form together to fill spaces
- Special bottles for cleft lip babies
How is cleft lip treated?
- Surgical repair
- 2 to 3 months
- May require rhinoplasty (tip of nose)
How is cleft palate treated?
- Surgical repair
- Done sometime before 12 months to enhance normal speech development
- Second surgery may be needed
- Prosthetic management- fitted for prosthetic to fit in that cleft space until ready for surgery.
What would the postop care of cleft palate/lip repair consist of?
- No objects in mouth
- NPO- fed by tube.
- elbow immobilizers- “restraints”
- Resume feeding- when tolerated
- Pain control
- Upright positioning- helps with secretions
How long after a cleft palate/lip repair do they remain NPO?
Depends on healing process. 7-10 days… as suture line begins to heal theyll let them suck on paci, sugar water… half strength breast milk
What are some long-term considerations for cleft palate/lip repair babies?
- Speech therapy
- Dental- often time the dental arch is effected
- Hearing loss- Increased risk of ear infections… over time can lead to hearing loss
- Social/Academic
How long will a baby with cleft lip/palate be hospitalized?
Until they establish feeding, gain weight and no s/s of infection.. typically admitted for 2-3 weeks.
What is an umbilical hernia?
- Intestine protrudes through abdominal wall at umbilicus
What are clinical manifestations of an umbilical hernia?
1.Protrusion at umbilicus
2. Gets bigger when child crys or straines
What is the treatment of an umbilical hernia?
- No treatment for small hernia
- Surgical repair
Dont really do anything… it typically closes on its own around 3-5 years of age… only time we will intervene is if it persists around 5 years of age or if it causes strangulation of other areas.
What is omphalocele?
Abdominal contents are herniated through the umbilical cord
When is omphalocele diagnosed?
Typically prenatally
How does omphalocele present?
- Exposed abdominal contents are cowered by a translucent two-layer membrane sac.
What is the treatment for omphalcele?
- Pain and wait
- Sac itself is painted with antibiotic creme that consists of zinc which helps skin cell production. Over time the skin will grow around the defect. Can take several months
- Surgical reduction
True or false: Omphalocele babies are born via cessation if possible?
True
What does preop care for Omphalocele consist of?
- Maintain thermoregulation
- Protect defect from trauma or dying
- Warm, sterile, saline-soaked dressing
- Top dressing with layer of sterile plastic wrap
- NPO, IVF
- Antibiotics
- NGT
What does post op care for omphalocele consist of?
- Routine post op care
- Pain management
- NGT
- IVF
- Monitor return of bowel function
What is gastroschisis?
Abdominal contents herniated outside of abdominal wall
NO COVERING MEMBRANE
Umbilical cord is INTACT
What does preoperative care of gastroschisis consist of?
- Maintain thermoregulation
- NPO, IVF
- Antibiotics
- NGT
- Observation of exposed bowel
- Prosthetic silo
-allows gradual return of intestine to abdominal cavity over 5-10 days, then closure of abdomen
What does post op care of gastroschisis consist of?
- Routine post op care
- NGT
- Pain management
- Lower extremity pulse
- Return of bowel function
What is hypertrophic pyloric stenosis?
Narrowing of the pyloric canal producing outlet obstruction
What is the patho of pyloric stenosis?
- Thickening of the pylorus muscle
- Elongation & narrowing of pyloric channel
- Partial obsturction of lumen
- Edema and inflammation eventually leading to complete obstruction
What are clincial manifestations of pyloric stenosis?
- Olive-like mass in upper abdomen
- Vomiting after feedings
- Eventually projectile vomiting
- Dehydration
- Metabolic Alkalosis
- Growth failure
- Ultrasound
How is pyloric stenosis diagnosed?
- Often made by H&P
- May perform ultrasound to confirm
What is the treatment of pyloric stenosis?
- Pyloromyotomy
- Longitudinal incision through the circular pylours muscle
What is intussusception?
- Occurs when one segment of bowel telescopes into another segment
What is the most common age for intussusception?
3M to 6year
What is the patho for intussusception?
- Segment of bowel telescopes into another bowel segment
- Bowel mesentery is compressed & angled
- Lymphatic & venous obsturction
- Edema increases
- Pressure within the area of intussusception increases
- When the pressure equals the arterial pressure, arterial blood flow ceases
- Ischemia
- Pouring of mucous into intestine
What are clinical manifestations of intussusception?
- Acute, severe, intermittent abdominal pain
- Tender, distended abdomen
- Palpable mass in RUQ
- Empty RLQ
- Vomiting
- Lethargy
- Red, currant jelly-like stool
What is the therapeutic management of intussusception?
- Water soluble contrast enema & air pressure
or
- Water-soluable contrast enema and cabron dioxide
or
Barium enema
What surgical interventions are available for intussusception?
- Manual reduction
- Removal of dead tissue if needed.
Why is it important to check peripheral pulses in a gastroschisis babies?
They have an increased risk of vena cava compression.. so its important check circulatory status.
What is Giardiasis?
It is a diarrheal disease by a parasite called Giardiasis.
Cysts are ingested & eventually excreted in stool
How is giardiasis transmitted?
- Person to person
- Improperly prepared infected food
- Contaminated water
- Animals
How long can giardiasis leave outside of the intestines?
weeks to months
Where does the parasite giardiasis live?
intestines
What are s/s of giardiasis?
Infants
1. N/V/D
2. No appetite
Older children
1. Abdominal gramps
2. Greasy stool foul smelling
What is the dx technique for giardiasis?
Stool sample
How do we treat Giardiasis?
Metronidazole (flagal)
Tinidazole (Tendamax)
Both medication can cause metallic taste in mouth and GI side effects
What do we need to know about Enterobiasos (pinworms)
- It is the most common worm infection in the US
How is Enterobiasos spread?
- Hand to mouth inhalation of eggs
- Eggs hatch in upper intestine
- Larvae migrate to cecum
- Pregnant female migrates out of anus to lay eggs
What age group is most affected by enterobiasos?
School aged children… day care age children..
What are s/s of Enterobiasos?
Itching
How is enterobiasos dx?
Tape test
What education should we provide a family whose children are diagnosed with enterobiasos?
- Will need repeated dose of medication 2 weeks after initial dose
- pyranta is what is used to treat.
- family will need to be treated
What do we need to know about Ascariasis (round worms)
- Primarily affects 1-4 years old
- Prevalent in warm climates
- Transmission is hand-to-mouth
What is the patho of ascariasis (round worms)?
- Eggs in stool
- Hatch in small intestines
- May move to lungs
- Ascent to pharynx
- Swallow
How is Ascariasis round worms spread?
Hand to mouth
What do we need know about Ascariasis?
- Mild infection may be asymptomatic
- Severe infection may lead to intestinal obstruction, peritonitis, pneumonitis
- Examine stools 2 weeks after treatment & monthly for 3 months
- Treat family members as needed
