Pediatric Nursing Module 3 Caring for Children with

Pediatric Nursing Module 3 Caring for Children with Alterations in Nutrition/Elimination

Assessment of GI System n History n gathering base line data infant - formula type and tolerance n children - diet, appetite, preferences meal schedule n any prior GI problems n elimination patterns n n stools, characteristic, number per day, toilet habits general nutritional appearance n height and weight n

Physical Assessment n Inspection n oral cavity ability to suck, swallow, chew n any ulcers, sores, bleeding, thrush, dental caries, congenital anomalies (cleft lip and palate) sore throat n n Abdomen n distention, turgor, contour, pain, girth

Physical Assessment n n n Stool n number, consistency, presence of blood Vomitus n color, amount, blood, projectile Urine n specific gravity, frequency amount Tears Fontanels n Pf closes at 2 -3 months, Af closes 9 -18 months

Assessment - dehydration n n Children are more susceptible to dehydration due to greater % or portion of their body weight being water Signs and Symptoms n poor skin turgor n sunken fontanel n decreased urine out-put (1 -2 ml/uo/kg/hr) n decreased body weight n dry mucous membranes, lips n no tears

Physical Assessment n Auscultation n Abdominal n peristalsis n presence/absent n hypo or hyper n visible - possible pyloric stenosis

Adjunct Assessment n n n Weight Temperature Labs n stool culture, ova & parasite, guiac, roto virus n electrolytes - Na, K, Cl, HCO 3 n CBC - wbc’s I&O X-ray n barium swallow, barium enema

What questions do you have for the parent, for the child?

Signs and Symptoms of Dehydration n n n Neurological Cardiac Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary

Disorders of Motility Gastroenteritis n Acute Diarrhea bacterial vs viral n isolation - good handwashing n bloody stools, mucous, cramping n change in the number and consistency of stool, increase in the water margin, usually green in color n

Gastroenteritis n Acute vomiting n n n Differentiate between vomiting vs spitting up projectile - pyloric stenosis reflux - may lead to respiratory problems

A 6 month old is admitted with dehydration. Effectiveness of therapy is evaluated by which assessment measures? Choose all that apply Analysis question, first recall assessment findings for dehydrated child n n n assess fontanel measure and document abdominal girth document mucous membrane moisture record analyze I & O daily wt. , same scale, time, no clothes

Hirschsprung’s Disease n n Congenital absence of the parasympathetic nerve ganglion cells in the mesenteric plexus of the distal bowel area proximal to the aganglionic portion becomes hypertrophied and greatly dilated

Hirschsprung’s Disease n Signs/Symptoms n abdominal distention intermittent n progressively increasing n anorexia n malnutrition n obstruction with diarrhea n dehydration and electrolyte imbalance n

Hirschsprung’s Disease n Treatment n n temporary colostomy Pre-op clear liquids n bowel prep n enemas/laxatives n antibiotic therapy - decrease normal bowel flora n

Hirschsprung’s Disease n Post-op Care pain control n hydration n assessing stoma n bowel elimination n teaching n

Gastric Reflux n Gastroesophageal Reflux (GER) backward flowing of gastric contents into the esophagus n incompetent lower esophageal sphincter n increase intra abdominal pressure n

Gastric Reflux n Signs and Symptoms n Infant spitting up, regurgitation, vomiting n crying, irritable n wt. loss, FTT n n Children heartburn, chest pain, abd. pain n dysphasia, burping, n regurgitation, cough, pneumonia n

Gastric Reflux n Treatment n small frequent thicken feedings n hypoallergenic formula positioning n medications n n H 2 antagonist n n pepcid, tagament, zantac surgical n Nissen fundoplication

Inflammatory Disorders Appendicitis n n Inflammation of the appendix resulting from bacterial infection or obstruction Rupture = peritonitis abscess

Appendicitis n Signs and Symptoms n G. I. n n/v/a and d/c, rigid abdomen n Pain n peri-umbilical - localizing RLQ n re-bound tenderness n progressive n Other n fever, stooped posture, lethargy n Treatment n appendectomy

n n n Structural Defects Craniofacial Abnormalities Cleft or. Lip & Palate May occur separately together Unilateral or bilateral Associated problems n feeding difficulties n URTI n otitis media n speech n dental formation n self-image

Cleft Lip n Interference with bonding n n Disfigurement Feeding Techniques more upright to avoid aspiration n frequent burping n lamb’s nipple n asepto syringe with tubing if infant unable to create closure and suction n

Cleft Lip n Surgical repair n n 2 -4 months old Post-op care prevent strain on suture line n keep infant off their stomach n keep suture line clean n n Q-tip, NS, antibiotic oint.

Cleft Palate n Feeding same as cleft lip n solids as soon as possible n n thicken liquids aspiration may be a problem n frequent URTI and ear problems n

Cleft Palate n n Surgical Repair n usually 9 - 18 months n perform closure prior to speech n after weaned to cup Post-op Care n keep on abdomen till fully awake n semi-liquid, puree diet n no sucking n elbow restraints n keep suture line clean after feeding with water

Cleft Palate n Long term care n speech n socialization n dental problems n psychosocial

n n You are caring for a newborn with a cleft lip and palate. You are aware the infant and family have multiple needs. Which is your priority nursing diagnosis? HR for impaired parent/infant attachment R/T newborn structural defect Ineffective feeding pattern R/T newborn structural defect HR for aspiration R/T newborn structural defect HR for imbalanced nutrition less than body requirements R/T abnormal feeding patterns and structural defect.

Obstructive Disorders Intussusception n n Telescoping or a portion of the small intestine or colon into a more distal segment Signs/Symptoms n vomiting n pain - paroxysmal colicky abdominal n “current jelly” stools - brown, bloody, mucous mixed

Intussusception n Treatment n n barium enema to reduce it or surgery Post-op gastric decompression n IV therapy n

Obstructive Disorders Pyloric Stenosis n Narrowing of the pyloric valve n n hypertrophic muscle Signs/Symptoms n projectile vomiting n left to right peristalsis n olive sized mass palpated in upper right quadrant n cries with hunger n readily accepts 2 nd feeding after vomiting

Pyloric Stenosis n Adjunct Problems dehydration n electrolyte imbalance n alkalosis n malnutrition n n Diagnosis n confirmed with barium x-ray

Pyloric Stenosis n Surgery n n Pyloromyotomy Post-op Feeding post-pyloromyotomy feeding schedule n sterile water, small amount, gradually increasing in substance and quantity n

Nursing Care - Nutrition and Fluid Balance Needs n Nursing Care and Concerns n Fluid Volume and Electrolyte Imbalance daily wt. n. I & O n assess for s/s of dehydration n maintain IV therapy n oral care if NPO n monitor labs - electrolytes n

Nursing Care n When introducing fluids small frequent feedings n clear liquids n n pedialyte may dilute formula monitor for n n n vomiting diarrhea abdominal distention

Nursing Care/Concerns n Nutrition n n check for vomiting assess tolerance of feedings weight and graph thickened feedings feed slowly n check suck n small amounts n calorie count n upright - infant seat

Nursing Care/Concerns n High Risk for Infection n n Cleft Lip/Palate n URTI or OM diarrhea n spread of infection pyloric stenosis n body may be debilitated appendicitis n peritonitis

Nursing Care/Concerns n Local infection - superficial redness, heat, swelling n tenderness, pain n n Systemic infection - internal abdominal pain, increasing abdominal girth n guarding n temperature n

Nursing Care/Concerns n Knowledge Deficit assessing parents understanding of child’s needs and the problem n assess parent’s ability to learn n teach simply, clearly, allowing time for questions and return demonstration n support group n referrals n

Case Study n n n Jesus 5 -year old boy, weights 40. 3 Kg wakes up at 2 am with a “stomach ache”, he has a fever of 100. 2 F and vomiting. Parents administer Tylenol 120 mg which he vomits 5 minutes later. In the morning he is still sick, so parent take him to the ER. Vital signs are Ax Temp 100. 4, HR 125, RR 35, B/P 119/79. RLQ guarding, crying. IV started then MS 2 mg IVP given. Abdominal US is ordered, CBC shows WBC’s are 17, 500. Discuss your impressions of the situation.

Questions n n The US confirms appendicitis. Discuss the following orders. n n n n NPO B/R D 5 1/2 with 10 KCL at 70 ml/hr Gentamycin 45 mg IV on call to OR MS 1 -2 mg IVP q 2 hrs prn pain K-pad to abdomen Prepare for OR - lap appendectomy

Questions n n Just prior to OR, Jesus experiences a relief from his pain. What is happening now? What is your nursing action? What are your nursing priorities in the PACU? What are the pros and cons of letting parents into the PACU? Post-op orders are as follows: n n n n n routine post op vitals foley catheter to straight drainage D 5 1/2 NS with 20 KCL 75 ml/hr Gentamycin 45 mg IVP q 8 hr Unasyn 900 mg IV q 6 hr MS PCA Tylenol 240 mg q 4 rhs per N/G tube prn T>100. 4 NGT to continuous drainage NPO except for meds IS 10 times each hour while awake