Week 2 Care of pediatric clients with GI/GU dysfunction Flashcards
How do F/E imbalances differ in children?
They are more frequent
They don’t adjust as quickly
What is the total body water percent of a newborn?
75%
What is the total body water percent of an infant
65%
What is the total body water percent of a child
60%
How do infants BSA’s differ from adults?
they are 2-3 times larger than that of an adult or older child
How is an infants GI tract different?
Its longer
What are the implications of a longer GI tract in infants?
They are more prone to diarrhea and thus higher risk for FVL
What is important to consider about an infants kidney function?
Their kidneys are immature until 2 years of age. This increases the risk of drug toxicity
Infants have a higher BMR. What does this mean for fluid volume?
They run hotter and breath faster so they have larger insensible water loss from skin and lungs
When a pediatric patient is dehydrated, what happens to LOC?
They become lethargic
When a pediatric patient is dehydrated, what happens to B/P
It is low
When a pediatric patient is dehydrated, what happens to pulse
its high
When a pediatric patient is dehydrated, what happens to skin turgor. Where is it assessed?
it becomes poor. Assess on abdomen or sternum
When a pediatric patient is dehydrated, what happens to mucus membranes?
They become dry
When a pediatric patient is dehydrated, what happens to Urine output
It drops
When a pediatric patient is dehydrated, what happens to Thirst?
its high
When a pediatric patient is dehydrated, what happens to Fontanels?
They become sunken
When a pediatric patient is dehydrated, what happens to Extremities?
Cap refill becomes slow
When a pediatric patient is dehydrated, what happens to respirations?
they change
When a pediatric patient is dehydrated, what happens to weight?
drops
When a pediatric patient is dehydrated, what happens to tears?
Absent
What are the common causes of dehydration in young children/infants?
- Loss of sodium containing fluids
- Radiant heaters
- Adrenal insuff. 3rd spacing
- Diuretics
- Excessive exercise
- Burns
If a child is being given ORT and is vomiting what is to be done?
Keep up with the ORT. even if its down for a few minutes it still helps
if giving juice or soda for ORT what needs to be done?
Dilute it to half strength
Should ORT include only water?
No, some sugar is needed to absorb na
In pediatric patients, mild dehydration is characterized by what traits? How is it treated?
40-50ml/kg or 5% weight loss
Treated with ORS @50ml/kg
In pediatric patients, moderate dehydration is characterized by what traits? what is the treatment?
60-90 ml/kg loss or (6-9%)
Replace with 100ml/kg ORS
in pediatric patients, severe dehydration is characterized by what traits? How is it treated?
100ml/kg lost (10% or more)
Replace with IV and ORS
After what age is specific gravity used as an assessment in children
2 years old
What are the three most common pediatric GI motility disorders?
- Diarrhea/Gastroenteritis
- Hirschsprung’s disease
- Gastroesophageal Reflux
Describe acute Diarrhea/Gastroenteritis
It has a sudden onset. Often caused by infections both viral or bacterial. It’s normally self-limiting if it’s not causing dehydration
What is a common viral cause of acute Diarrhea/Gastroenteritis in infants? How is it prevented?
Rotavirus
there is a vaccine
What is the common cause of acute viral Diarrhea/Gastroenteritis in children over 2?
the norwalk virus
Diarrhea/Gastroenteritis is considered chronic after how many days?
14
with chronic Diarrhea/Gastroenteritis, there is a very high risk of
Malabsorption
One condition that can cause malabsorption r/t the food we eat is ____
Lactose intolerance
Chronic Diarrhea/Gastroenteritis can be caused by poor management of ___
Acute Diarrhea/Gastroenteritis
When a child presents with chronic Diarrhea/Gastroenteritis what are some questions to ask?
Do they have allergies, IBS, or are they lactose intolerant?
How is Diarrhea/Gastroenteritis diagnosed?
Based off of history and severity.
- If other diseases are present
- Other symptoms present
- Hx of ABO use
How is Diarrhea/Gastroenteritis treated?
For acute, it’s often watchful waiting
The key is to assess and treat fluid imbalances using ORT/ORS
What are not to be given to children with Diarrhea/Gastroenteritis
Antidiarrheals, clear liquids, or the BRAT diet
What kind of diet should a child with Diarrhea/Gastroenteritis have?
whatever they can tolerate
How do you prevent Diarrhea/Gastroenteritis?
Hand hygiene especially after diaper changes
What is some good anticipatory guidance for parents with young children prone to Diarrhea/Gastroenteritis
Keep ORS on hand so you don’t have to go to the store later
What does a CBC test?
Blood counts. Specifically Hemoglobin, Hematocrit, WBC’s and platelets
What does a BMP test?
Sodium, Chloride, BUN, Potassium, HCO3, creatinine, and glucose
What does the CMP test?
Everything in the BMP plus Calcium, albumin, total protein, ALP, ALT, AST, and Bilirubin tests. (these are liver tests)
What is in the electrolyte panel?
CMP plus Blood gasses and osmolality
What is Hirschsprung’s disease?
Congenital aganglionic megacolon
Basically, a large colon with portions of it that have no innervation (no motility)
Hirschsprung’s disease occurs in _____ births
1/5000
Hirschsprung’s disease accounts for ____ of all neonatal colon obstructions
33%
Hirschsprung’s disease is ____ more times common in males
3-4
75% of Hirschsprung’s disease is limited to the ____ area
Rectosigmoid area
What are the six assessments for Hirschsprung’s disease. Which one is key?
- Bilious vomiting
- Chronic constipation/ab. distention
- FTT
- Ribbon-like, foul-smelling stools and a palpable fecal mass this is key
- Enterocolitis
- Hx, x-ray, rectal biopsy
What are some characteristics of enterocolitis?
Fever, Watery diarrhea, toxic appearance
What is the treatment for Hirschsprung’s disease?
Resection
Childen with Hirschsprung’s disease have less fecal matter contact on their bottom and therefore ______
Their bottoms are more sensitive and require more skin care
After an infant has a bowel resection, they usually receive a temporary_____
colostomy depending on the location
What is Gastroesophageal reflux (GER)?
The return of gastric contents in the lower esophagus through the lower esophageal sphincter caused by TRLES
What is TRLES
Transient relaxations of the lower esophageal sphincter
What is the most common esophageal disorder in infants?
GER
When does GER usually begin to improve?
around 6-12 months when the esophagus begins to elongate and the LES moves below the diaphragm
What are the main manifestations of GER
- Resp. disorders (aspiration)
- Esophagitis
- Strictures (narrowing of the esophagus)
- Malnutrition
- FTT
- Bleeding (with GERD)
How often does GER occur in infants?
5/1000 or 1/200live births. Males 3x’s
How often does GERD occur in infants
1/300
What four conditions cause an infant to be at higher risk for GER?
Premature birth, Cystic Fibrosis, Cerebral palsy, asthma
What are the main assessments for GER
- Vomiting and regurgitation of formula and mucus
- Crying are irritable
- FTT
- Aspiration
- Apnea
What are the interventions for GER?
- Thickened foods
- Position upright for 20-30 min after feeding
- Give H2 antagonists, proton pump inhibitors
- Avoid citrus
- Nissen Fundoplication
How can GER affect development?
It can cause issues in bonding with the parent during feeding. The infant may lose trust
What are the two main inflammatory disorders of the GI system in pediatrics
- Acute appendicitis
- Inflammatory Bowel disease
What is the most common reason for abdominal surgery in children?
Acute appendicitis
How many cases of Acute appendicitis happen a year?
60-80k
The average for Acute appendicitis is?
10 years
Acute appendicitis occurs in _______ of kids under 14
4/1000 or 1/250
What ratio of inflamed appendices rupture?
1:3
What is the most frequent subject of malpractice suits and 5th most expensive source of claims for ED MD’s
Failure to Dx Acute appendicitis
What is the pathophysiology of Acute appendicitis
An obstruction of the vermiform appendix or inflammation caused by bacteria, virus, trauma, or parasites
Where does Acute appendicitis pain begin?
The periumbilical region
What are the assessment signs of early Acute appendicitis
Periumbilical pain, Fever, vomiting, dec appetite
What are the assessment signs of Acute appendicitis after the early phase
Pain moves to McBurney’s point, WBC begin to elevate with a left shift in Neutrophils
What are the signs of fully developed Acute appendicitis
Muscle rigidity, guarding, rebound tenderness
If a patient presenting with signs of Acute appendicitis suddenly reports the pain has stopped what does this indicate.
That the appendix has likely ruptured and is now a medical emergency
How can you palpate the abdomen in a case of suspected appendicitis in a way that reduces trauma?
With the stethoscope
Should you use heat packs or enemas if you suspect appendicitis?
No, they can cause additional inflammation or trauma
_____ contributes to the 30-60% perforation rate in appendicitis
Delayed Diagnosis
What are the infant assessments for appendicitis
- Hip-flexion(eases the pain)
- Irritable
- Whimpering not crying(because crying hurts)
How is appendicitis diagnosed?
Ultrasound, CT scan
What are the two types of Inflammatory Bowel Disease?
Ulcerative Colitis and Crohns Disease
When does Ulcerative Colitis usually begin?
adolescence/young adult
Is there a cure for inflammatory bowel disease?
No
What are the signs of Ulcerative Colitis?
Chronic and recurring Bloody diarrhea, and pain/cramping relieved with BM. Along with no other systemic signs
Where is Ulcerative Colitis limited to and what does it affect?
The colon and rectum
affects the mucosa and submucosa
When does Crohns Disease usually begin?
Adolescence/ young adult
what are the signs of Crohns Disease
Cramps, diarrhea, wt loss
Where does Crohns Disease occur and what does it affect?
The entire GI tract and affects all layers of the bowel
Can cause fistulas (abnormal fibrous connection between organs)
What are the three main (general) interventions for Inflammatory Bowel diseases
- Mediation and nutritional management
- Emotional support (body image, home, and school)
- Community referrals
What are the two main pediatric Malabsorption syndromes?
Celiac Disease and Short Bowel Syndrome
Celiac Disease is often secondary to ____
Cystic Fibrosis
What is the Patho of Celiac disease?
- Unable to digest the gliadin component of gluten
- Ingestion of gluten causes damage to mucosal villi causing an immune response
- The villi flatten and atrophy, thus decreasing absorptive surface of intestines
Celiac Disease in children commonly occurs at _____ years
1-5
What are the S/S of Celiac disease?
- FTT
- Chronic Steatorrhea
- Vomiting, Irritability, Abd pain
- Muscle wasting, distended abd, delayed dentation
- Fatigue
- Abnormal coagulation (Vit K deficiency)
How do we test for celiac disease?
- Small Bowel Biopsy
- Serologic tests (IgA deficiencies)
If someone with celiac disease removes gluten from the diet, how long until villi heal and return to normal?
6 months
If someone with celiac disease removes gluten from the diet, when with Growth normalize?
1 year
What is short bowel syndrome?
Decreased ability to digest and absorb regular diet caused by shortened intestine due to extensive resection.
How severe is short bowel syndrome?
It depends on the extent and location of the resection
What are the issues that come from ileum resection?
- Diarrhea w/loss of bile salts, fluid, and electrolytes
- restricted fat absorption
What are the issues that come from colon resection?
Impaired F/E management
What are the issues that come from Jejunum resection?
The remaining bowel compensates
What are some of the interventions for severe short bowel syndrome?
- 3 stages of TPN
- Home care or prolonged hospitalization
What is an issue that arises from the home care of a child with TPN?
Catheter sepsis. (kids are dirty and central line care needs to be well done)
What are the two main obstructive GI disorders common in pediatrics
- Intussusception
- Hypertrophic pyloric stenosis
What is Intussusception?
When one segment of the bowel telescopes(prolapses) into the lumen of the adjacent segment.
What does the occurrence of Intussusception peak?
3-9 months
How common is Intussusception?
1-4/1000 births. boys 2x
What percent of Intussusception is secondary to another pathology?
10%
What are the classic 4 signs of Intussusception?
Colic, Intermittent abd pain, vomiting, current jelly stools
What are the other sigs of Intussusception beyond the classic 4?
- Sudden onset
- Lethargy
- Listlessness
- A sausage shaped mass in the RUQ or mid Upper abd
What are the interventions for Intussusception?
- Barium enema
- Correct Dehydration
What is Hypertrophic Pyloric Stenosis?
When the pyloric sphincter hypertrophies, narrowing gastric outlet
When is Hypertrophic Pyloric Stenosis normally diagnosed?
2-8 weeks old
What is normally the first sign of Hypertrophic Pyloric Stenosis?
the infant was a good eater and then suddenly began vomiting formula increasingly over time.
What kind of vomit is common with Hypertrophic Pyloric Stenosis?
Projectile
What are the symptoms of Hypertrophic Pyloric Stenosis?
Vomiting, Dehydration, Irritable, lethargic, fewer smaller stools,
-Olive-shaped mass palpable
How can you tell when the infant is about to projectile vomit?
You can see peristaltic waves
How is Hypertrophic Pyloric Stenosis diagnosed?
Ultrasound
How is Hypertrophic Pyloric Stenosis treated
Pyloromyotomy or Laparoscopy followed by fluids to treat dehydration
vomit may continue for a few days after
What are the 5 common GU tract disorders in pediatric clients?
- UTI/Pyelonephritis
- Glomerulonephritis
- Nephrotic Syndrome
- Polycystic Kidney disease
- Vesicoureteral Reflux
Describe the function of the kidneys of an infant (under 2)
- Cant dilute or concentrate urine well
- Cant concentrate or excrete sodium well
- Urine is less acidic
- Cant handle solute free water
- The younger the infant the higher the BMR and the more metabolic waste to filter
what percent of children get a febrile UTI before they are 2?
10%
When does the occurrence of pediatric UTI’s peak? Why?
2-6 years old.
Potty training=poor peri care = more bacteria
Also anatomy- Female urethra is 2-4cm
What organism causes 80% of UTI’s?
E. Coli
How do UTI’s Present in infants?
- Fever
- Weight loss
- N/V
- FTT
- Increased voiding lots of wet diapers that stink
- Smelly urine
- Persistant diaper rash
How do UTI’s present in older children?
- Increased frequency
- Pain
- abdominal pain
- Hematuria
- Fever
- Chills
- Flank pain
- incontinence
- Urine Odor
What are the interventions for a UTI?
- ABO
- Identification of the causative factor
- Increase fluid intake
- Prevention
What is pyelonephritis?
Inflammation of the renal parenchyma
can be caused by untreated UTI
What is Vesicoureteral Reflux?
Abnormal retrograde flow from the bladder to ureters
What is the most common post infection of strep?
Acute Glomerulonephritis
What is Acute Glomerulonephritis?
Kidney tubules get clogged by strep antigens clumped with antibodies. This results in
- Edematous Glomeruli
- Decreased Plasma Filtration
- Circulatory Congestion and edema
What is a sign of Acute Glomerulonephritis that can be seen specifically in the mornings?
Periorbital Edema
When does strep associated Acute Glomerulonephritis usually occur?
2 weeks after poor or untreated strep
What are the assessment signs for Acute Glomerulonephritis?
- Orbital edema
- Anorexia
- Hematuria
- Decreased output of dark urine
- Strep infection within the past 10-21 days
What are the interventions for Acute Glomerulonephritis
- Limit activity
- Watch Sodium and Potassium levels
- Give hypertensives/ABO’s
- Monitor for F/E especially FVE
What is Nephrotic Syndrome?
A syndrome of the kidney characterized by Edema, massive proteinuria, and hyperlipidemia
What causes Nephrotic Syndrome?
Things that affect kidney function
What are some other characteristics of Nephrotic Syndrome?
- Weight gain
- Abd pain
- Gradual onset
What are the interventions for Nephrotic Syndrome?
- Bedrest
- Corticosteroids
- Diuretics
- Albumin
What are some risks involved with Nephrotic Syndrome
- Infection
- FVE
- Skin integ if on bedrest
- Malnutrition
What is polycystic kidney disease?
It is a genetic disorder that causes the collecting ducts in the kidneys to dilate and form cysts.
The Cysts grow with the child and ultimately replace much of the functional tissue in the kidney
What syndrome is polycystic kidney disease associated with?
Autosomal recessive PDK Potter facies
If polycystic kidney disease is present in both kidneys it will cause_____
end-stage renal disease
polycystic kidney disease also affects the ___ glands. This leads to ____ and ____ issues
Adrenal
Bp regulation and Growth
What is the treatment for polycystic kidney disease?
- Support
- ABO’s
- F/E correction
- HTN meds
- Growth hormone
Many children with polycystic kidney disease develop _____ by 10 years of age
ESRD
What is Hypospadias?
When the urethra is on the bottom of the head of the penis
What is Epispadias?
When the urethra is on the top of the head of the penis
What is Chordee?
Permanent bend in the penis
What is Phimosis?
A tight constriction of the foreskin
What is Cryptorchidism? (UDT)
a condition in which one or both of the testes fail to descend from the abdomen into the scrotum.
What is hydrocele?
Fluid accumulation in the scrotum
When is the optimal time to fix external GU defects? Why
between 6-15 months
- They won’t remember
- They won’t have body image issues
- Potty training won’t be disrupted
