week 10: care of child and family w GI/GU

Question 1

describe pediatric smaller stomachs

Answer 1

• 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

Question 2

how to calculate daily fluid requirements

Answer 2

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

Question 3

how to calculate hourly fluid requirements

Answer 3

Hourly:
4mL/kg x first 10 kg
+2mL/kg x second 10 kg
+1mL/kg x for each kg >20kg =mL/hr

Question 4

clinical manifestations of GI dysfunction

Answer 4

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

Question 5

def of dehydration

Answer 5

When the total output of fluid exceeds the total intake, children are very prone to dehydration.
Occurs most commonly due to a stomach bug

Question 6

s/s of dehydration

Answer 6

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

Question 7

therapeutic management of dehydration

Answer 7

Increased fluid intake or bolus depending on the severity. Bolus with NS based on their weight at a max of 20mls/kg.

Question 8

nursing care of dehydration

Answer 8

Track ins and outs
Monitor for signs of dehydration
Have the symptoms resolved or worsened
Monitor safety during mobilization

Question 9

what is the definition for failure to thrive

Answer 9

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

Question 10

what are the 5 reasons that cause failure to thrive

Answer 10

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.

Question 11

evaluation of failure to thrive/GI issues

Answer 11

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

Question 12

diagnostic criteria for failure to thrive

Answer 12

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.

Question 13

what is the management of failure to thrive

Answer 13

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

Question 14

describe diarrhea (disorder of motility)

Answer 14

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.

Question 15

nursing considerations for diarrhea

Answer 15

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.

Question 16

prevention of diarrhea

Answer 16

Most is spread by the fecal-oral route, teaching hand hygiene.
Teach personal hygiene.
Clean water supply/protect from contamination/
Careful food preparation.
Handwashing.

Question 17

describe constipation

Answer 17

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.

Question 18

encopresis (for constipation)

Answer 18

-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)

Question 19

what is hirschsprungs disease

Answer 19

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

Question 20

describe gastroesophageal reflux

Answer 20

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

Question 21

diagnostics for gastroesophageal reflux

Answer 21

History and physical asking questions about weight
Endoscopy for esophagitis (looking for ulcers)

Question 22

therapeutic management for gastroesophageal reflux

Answer 22

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.

Question 23

nursing considerations for gastroesophageal reflux

Answer 23

Dehydration
Emotional support

Question 24

describe vomiting and some concerning signs

Answer 24

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

Question 25

therapeutic management of vomiting

Answer 25

Fluids Ondasertron (not gravol makes them sleepy)

Question 26

describe nursing considerations for vomiting

Answer 26

Monitor for other worrisome symptoms like diarrhea, bloody emesis, bile, severe abdominal pain, neuro symptoms like increased intracranial pressure, changes in LOC or neuro status, nausea.

Question 27

def of appendicitis

Answer 27

Acute appendix is the most common cause of emergency abdominal surgery in children with a peak age of 10-16 Etiology is the obstruction of the lumen of the appendix usually by a fecalith

Question 28

s/s of appendicitis

Answer 28

Abdominal pain in RLQ McBurneys point is where it will hurt the most Nausea and vomiting Fever Distension Painful with palpation

Question 29

complications of appendicitis

Answer 29

Appendix perforation and bursting leading to leakage of its substances into the peritoneal cavity, may cause sepsis. Does not fit classic RLQ so more likely to be missed

Question 30

diagnosis of appendicitis

Answer 30

History and physical Blood work (blood culture CBC, ESR for inflammation) Imaging

Question 31

treatment of appendicitis

Answer 31

Rehydration Antibiotics May need surgical intervention - at times antibiotics are given first to treat infection, and then parts of the appendix are removed. Sometimes the appendix/perforated appendix will simply be removed)

Question 32

non-perforated appendicitis post-op care

Answer 32

Same for other abdominal surgeries Interventions such as oral pain meds, mobilization, bowel movements, GI assessment

Question 33

perforated post-op care for appendicitis

Answer 33

IV antibiotics Bowel rest (NG to suction with bowel decompression as bowel will not be working, feed with TPN, will be ordered sham clear fluids for comfort to keep mouth moist) Drains (to drain the abscess)

Question 34

Describe the 2 types of inflammatory bowel disease

Answer 34

Two forms of chronic intestinal inflammation -etiology is not well known Ulcerative colitis Inflammation is limited to colon and rectum Crohn's disease Chronic inflammation involves any part of the GI tract from the mouth to the anus, most often affecting the terminal ileum

Question 35

s/s inflammatory bowel disease

Answer 35

Both have similar presentations of diarrhea, anorexia, bloody stools, weight loss and joint pain.

Question 36

inflammatory bowel disease diagnosis

Answer 36

History and physical, questions about stool and frequency Lab tests (CBC, ESR, CRP) looking for inflammation Endoscopy & colonoscopy -biopsies looking for ulcers to confirm diagnosis CT & Ultrasound

Question 37

management of inflammatory bowel disease

Answer 37

Depends on severity Surgical intervention can be used in US as it is isolated to one point, but with chrons this is not possible Medical -variety of medications to control symptoms and induce remission (5-ASAs, corticosteroids, immunomodulators, antibodies, biological therapies) Nutritional support - enteral, parental, TPN, NG

Question 38

nursing care priorities for inflammatory bowel disease

Answer 38

Goals of therapy include the control of symptoms and add to long term remission. Use nutritional support Provide education Stool charting Support with adolescents

Question 39

wilm's tumour

Answer 39

most common presentation - detection of abdominal mass - hematuria - hypertension diagnosed w US and surgical biopsy unilateral treated w surgery and chemo bilateral treated w pre-op chemo, renal-parenchymal-sparing resection

Question 40

describe cleft lip or palate

Answer 40

Facial malformation that occurs during embryonic development that may appear together or separately, may be caused by other syndromes or tetragones during pregnancy.

Question 41

nursing considerations for cleft lip or palate

Answer 41

Pre & post-op care: This is usually surgically corrected, post-op is about refeeding, pain management. Avoid the use of suction, or objects such as tongue depressors, spoons or straws. NPO due to incision for the first while, restrain the arms to prevent infants touching their face. Pain management: Pharmacological & non-pharmacological methods. Long term care: Depending on the severity, may need speech therapy.

Question 42

feeding considerations for cleft lip or palate

Answer 42

May need assistance with feeding as there are often difficulties here. Place the child in an upright position, head cradled in one hand, use the CL/CP nipple or the haberman nipple. Can still usually breastfeed.

Question 43

describe hernias

Answer 43

A protrusion of a portion of an organ or organs through an abdominal opening. In less severe cases you can push the hernia back through the opening, but the issue arises when it gets stuck and blood supply is cut off.

Question 44

types of hernias

Answer 44

1. umbilical hernia 2. inguinal hernia 3. omphalocele 4. gastroschisis

Question 45

describe umbilical hernia

Answer 45

write something here bruh

Question 46

inguinal hernia

Answer 46

*These first two are very common and usually resolve as the bowel grows, therefore does not always need surgical interventions.

Question 47

omphalocele

Answer 47

A hole/hernia into the umbilicus with the peritoneal sac surrounding it. This is often associated with other conditions

Question 48

gastroschisis

Answer 48

Opening in the abdominal wall with no perineal sac surrounding it. Individuals become prone to constipation later on and bowel obstructions.

Question 49

describe pyloric stenosis

Answer 49

A hypertrophic obstruction of the pyloric sphincter (sphincter at the bottom of the stomach)

Question 50

s/s of pyloric stenosis

Answer 50

Begin around 3-5 weeks of age Non-bilious vomiting that is forceful and occurs immediately after feeding Infant remains hungry

Question 51

pyloric stenosis complications

Answer 51

Obstruction of the sphincter Inability to move food from stomach to duodenum Vomiting, dehydration, weight loss

Question 52

pyloric stenosis nursing considerations

Answer 52

Meet fluid and electrolyte needs by fixing any imbalance that may have occurred Minimize weight loss Promote rest and comfort Prevent infections Provide supportive care Post-op priorities would be following the diet regime and managing pain

Question 53

define intussusception

Answer 53

Proximal segment of the bowel telescopes into more distal segment, pulling mesentry with it Subjective findings such as pain and cramping that is on and off, cocliky abdominal pain, red jelly stool.

Question 53

nursing considerations for intussusception

Answer 53

Establish dx by listening to parents description of child’s physical and behavioural symptoms, as well as description of colicky abd pain, vomiting and red jelly stools. Education Pneumatic or hydrostatic reduction Passage of normal brown stool indicated resolution Issues develop when the bowel goes in, stays in and then becomes incarcerated stopping blood flow to the area. Liquid air or barrium anema may resolve it, if not may need surgery

Question 54

renal sys assessment

Answer 54

Physical examination History taking Observation of symptoms Electrolyte imbalances, very dilute/concentrated urine, decreased/increased frequency, pain. Labratory, radiology, or other evaluations methods Urine analysis, urine culture, imaging of renal system

Question 55

describe a UTI

Answer 55

Very common in childhood due to many factors that contribute to its development Anatomical and physical factors such as hydronephrosis (inability to empty) or vesicoureteral reflux (VUR causing reflux back into kidneys) Escherichia coli is responsible for 80% of UTIs May be symptomatic

Question 56

antibiotics for individuals with high risk of UTIs

Answer 56

Antibiotics can be used to prevent UTIs Especially for those who have risk factors, low doses can be used.

Question 57

s/s of UTI

Answer 57

Incontinence in a toilet trained child Pain Strong or foul smelling urine Frequency or urgency Urine culture and sensitivity

Question 58

UTI management

Answer 58

Eliminate current infection with penicillin, sulfonamide, cephalosporins, nitrofurantoin. Identify contributing factors to reduce the risk of reoccurance Prevent the systemic spread of infection (kidneys exposed to bacteria may bring infection to blood and then to brain)

Question 59

wilm's tumor

Answer 59

Malignant renal and intraabdominal tumor of childhood that is more frequent in males and african american children, also called nephroblastoma.

Question 60

wilm's tumor presentations

Answer 60

Peak age of diagnosis is 3 years Detection of abdominal mass Hematuria Hypertension Pain Urinary frequency/stasis

Question 61

wilm's tumor treatment

Answer 61

Diagnosed with UC and surgical biopsy (no CT no radiation for children) Unilaterally treated with surgery & chemo Bilaterally treated with preop chemo, renal-parenchymal-sparing resection.