week 10: care of child and family w GI/GU Flashcards
describe pediatric smaller stomachs
- neonates have small amounts, infants have 30-300ml
- gastric acid is lower, babies have reflux not as acidic
- food remains in stomach for shorter period due to high metabolism - why they eat so much more
how to calculate daily fluid requirements
Daily:
100mL/kg for the first 10 kg
+50mL/kg for the second 10 kg
+20mL/kg for each kg >20 kg
=mL/day
OR 421 rule x24 hr
how to calculate hourly fluid requirements
Hourly:
4mL/kg x first 10 kg
+2mL/kg x second 10 kg
+1mL/kg x for each kg >20kg =mL/hr
clinical manifestations of GI dysfunction
Changes in stool
Decreased or absent bowel sounds
Abdominal pain
Decreased appetite
Distension
Regurgitation
Blood in stool
Difficulty swallowing
Abdomen might be firm on palpation
Weight loss
def of dehydration
When the total output of fluid exceeds the total intake, children are very prone to dehydration.
Occurs most commonly due to a stomach bug
s/s of dehydration
Tachycardia
Dry mucous membranes
Decreased skin tugor
Decreased urine output (less than 1ml/kg/hr) or using washroom less frequently (not using in 8 hours)
More concentrated urine
No tears with crying
Less than 6 wet diapers a day
Sunken fontanelles
Delayed cap refill
Sunken eyes
Decreased BP
Lethargy
Decreased LOC
therapeutic management of dehydration
Increased fluid intake or bolus depending on the severity. Bolus with NS based on their weight at a max of 20mls/kg.
nursing care of dehydration
Track ins and outs
Monitor for signs of dehydration
Have the symptoms resolved or worsened
Monitor safety during mobilization
what is the definition for failure to thrive
Weight less than 2nd percentile for age and sex, usually caused by a decreased velocity of weight gain disproportionate to growth in length
Very multifactoral
Done by comparing weight and length of patient and head circumference
what are the 5 reasons that cause failure to thrive
Reasons categorized
Inadequate caloric:
May not eat enough, ineffective breastfeeding, may be a picky eater, drinks milk and not enough iron.
Inadequate absorption:
Short gut syndrome (necrolizing endocolitis) therefore does not have a long enough Gi tract to absorb sufficient nutrients, celiac, CF, bowel obstruction.
Increased metabolism:
Fever, infection, children not getting needs met, hyperthyroid, severe burns, increased exercise, cardiac disease.
Defective utilization:
Abnormal genetic makeup that may affect metabolism.
Increased urinary or intestinal losses:
Diarrhea, vomiting.
evaluation of failure to thrive/GI issues
History and physical
Gathering information about the medical history such as birth proccess, gestational age at birth, allergies, chronic disease, recurrent illness, weight at birth
Age of onset
Family history
any diabetes or delays in puberty or illness that slows growth or other family members that had a history of slow weight gain
Psychosocial issues
history of eating disorders or lack of financial resources or lack of education on nutrition needs or a parent’s mental health disorder causing an inability to meet needs.
Examination
Through a GI assessment and measurements to assess development
Development and behaviour
diagnostic criteria for failure to thrive
No definitive tests
CBC for any infection indicators.
ESR (erythocyte sedementation rate) to check for inflammation in the body.
Urianlysis and culture to check for UTI, proteins or carbohydrates in the urine.
what is the management of failure to thrive
Dependent on the cause
Provide nutritional therapy (strict meals, NG feeds, TPN, etc) and observe its effectiveness. If with nutrition there is weight gain can rule out absorption issues.
Multivitamins
Strategies to improve dietary intake
Daily weights in morning at the same time of day
describe diarrhea (disorder of motility)
Diarrhea
Acute diarrhea is the leading cause of illness in children under five yrs with 20% of all deaths in developing countries being related to diarrhea and dehydration.
Acute infectious diarrhea/gastroenteritis is caused by a variety of organisms such as rotavirus, c-diff, food poisioning, salmonella (pet turtle) parasites, ecoli.
There is a sudden increase in frequency & change in consistency of stools
>3 loose or watery stools in 24h, or several watery stools that exceeds the child’s usual number by 2 or more
Caused by infectious agents in GI tract, may be associated with URI or UTI, antibiotics therapy or laxative use.
Self limited <14 days & subsides without specific treatment if dehydration dosent occur. If pt is dehydrated, they need to get rehydrated.
nursing considerations for diarrhea
Provide emotional support.
Promote rest and comfort by darkening the room, having a quiet environment, encouraging parents to room in, keeping favourite toys and pics.
Ensuring adequate nutrition by providing liquids and diet based on tolerance.
Discharge planning, education on prevention and teaching about symptoms of dehydration.
prevention of diarrhea
Most is spread by the fecal-oral route, teaching hand hygiene.
Teach personal hygiene.
Clean water supply/protect from contamination/
Careful food preparation.
Handwashing.
describe constipation
An alteration in frequency, consistency, or ease of passage of stool.
May be secondary to other disorders, idiopathic, or chronic (environmental or psychosocial factors).
In the newborn period, need to check that there is a patient anus. The first meconium should be within the first 24-36 hrs of life. If not assess for Hirschsprung disease, hypothyroidsm, meconium plug, meconium ileus (CF)
In infancy, often it is related to diet. Formula fed infants and infants transitioning to a solid diet are at higher risk. Constipation in exclusively breastfed infants is rare, infrequent stools may be due to minimal residue of digested breastmilk. Interventions include increasing fluids, mobilizing, decreasing iron in formula.
In childhood often due to environmental changes or control over bodily functions. Painful defecation may cause children to hold in stool, causing constipation, toilet training may put too much pressure on the child, may result from stresses such as starting school, encopresis. Management involves providing PEG, making going to the bathroom fun.
encopresis (for constipation)
-The involuntary passage of stool in underwear after acquisition of toilet training.
-Give impression they dont sense the need to defecate
-Stool appears soft, parents think the child has diarrhea
-Treament depends on age, focus on psychological health, provide laxatives, high doses of PEGlyte, anema, look for structural/organic causes in the GI tract.
-Categorized as:
Retentive-fecal incontinence with underlying constipation (80%)
Non-retenive-fecal incontinence without underlying constipation (strong association with psychological triggers)
what is hirschsprungs disease
Absence of ganglion cells in colon, causing inadequate motility in that area leading to mechanical obstruction as stool/gas/liquid cannot pass. Also called congenital aganglionic megacolon
Lack of enervation produces functional defect (no peristalsis)
75% of disease is limited to rectosigmoid area
Enterocolitis (inflammation of small bowel & colon) develops, leading cause of death in this disease due to sepsis
Treat through a bowel resection by removing the part of the bowel that is affected, may have complications based on how much of the bowel was taken out.
Incidence is 1 in 5000 live births, more common in males and in down syndrome
describe gastroesophageal reflux
The transfer of gastric contents into the esophagus typically resolves within the first year of life. Due to the lower esophageal sphincter relaxing allowing for passive regurgitation of stomach contents into the esophagus or even airway. May occur without GERD.
GERD is a serious manifestation of GER that is characterized by poor weight gain, esophagitis and persistent resp symptoms, and requires treatment using PPI to inhibit secretions.
Need to ask what the reflux looks like (projectile). Becomes an issue if it persisnts past the first year especially with the introduction of solid foods, if its affecting growth, if there is alot of irritation and risk for aspiration
diagnostics for gastroesophageal reflux
History and physical asking questions about weight
Endoscopy for esophagitis (looking for ulcers)
therapeutic management for gastroesophageal reflux
No interventions for children that are growing
Avoid tobacco smoke
Watch feeding positions ensuring there is upright sitting during and after feedings
Provide medications depending on the severity (PPI, pantoprazole, lansoprazole)
Perform surgery- nissen fundoplication in severe cases by taking the top of the stomach and wrapping it around the esophagus to create a sphincter that closes the stomach up.
nursing considerations for gastroesophageal reflux
Dehydration
Emotional support
describe vomiting and some concerning signs
Many different causes, the immediate goal is to recognize serious conditions for which immediate intervention is required and identification of the cause of the symptoms.
Concerning signs include
>12 in neonate, biliemesis is not a normal finding
>24h in children <2 years
>48 in older children