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What are some developmental and biological variances seen in infants?
- Infacts younger than 6 weeks do not produce tears
- In an infant a sunken fontanel may indicate dehydration
- infants are dependen on others to meet their fluid needs
- Infants have limited ability to dilute and concentrate urine
- Infants have a greater BSA and higher metabolic rate than adults
- GI tract is not mature until 4-6 months
- volume of stomach is decreased
- Infants do not have adequate glycogen stores
What are the functions of the GI tract?
- Digestion: GI motility, enzymatic activity
- Absorption: principle site for absorption is the small intestine, Large intestine primarily absorbs Na and add'l water
What are some signs and symptoms of mild to moderate dehydration?
- dry skin and mucus membranes
- poor skin turgor
- depressed anterior fontanel
- pale in color
- increased pulse
- Oligura (kidneys try to retain body fluid)
- VS may still be normal
- decreased tears
What are some signs and symptoms of severe dehydration?
- 10% weight loss
- increased pulse
- irritiable to lethargic
- dry mucus membranes
- sunken eyes
- very delayed cap refill
- oliguria to anuria
What is the nursing management of dehydration?
- I&O: weighing diapers, at home parents can monitor # of diapers and document degree of wetness
- Vital signs
- Daily weights
- Assessment of : skin, mucous membranes, and fontanel
Gastroenteritis: what is it? Signs and symptoms? Predisposing factors? Caused by?
Inflammation of the stomach and intestines
Signs and symptoms: N&V, adb cramping, diarrhea
Predisposing factors: poor sanitation, improper handling of food, daycare, antibiotics, presence of other infectious processes.
Management of Gastroenteritis
- assessment of dehydration
- oral rehydration
- avoid fluids with high carbs and low electrolytes
- Advance to normal diet as soon as possible
- nursing mothers should continue to breast feed
- Anti-diarrheal agents are discouraged
- Protect the skin (diaper rash)
- IV therapy for inadequate circulating blood volume
Teach parent that child needs follow up if:
- Diarrhea or vomiting increases
- no improvment seen in child's hydration status
- child appears worse
- child will not take fluids
- NO URINE OUTPUT
Fluid replacement standard
- Isotonic fluids initially: IV bolus (Normal Saline 0.9%)
- followed by: Dextrose 5% in .45 NS
- Potassium is added ONLY after child has voided.
- *Never give Dextrose as a bolus*
- Chronic constipation: environmental causes/psychosocial causes, dietary causes, disease processes
- Newborn period-newborn should pass meconium 24-36 hours after birth
- Management: bowel habit training, dietary changes (increase fiber and water), enemas.
- Can be caused by pain meds or iron meds
What is Hirschsprung's Disease? And what are the clinical findings?
- Congential Aganglionic Megacolon
- Absense of ganglion cells in the mucosal and muscular layers of the colon (cannot move stools)
- Peristalsis is normal above the aganglionic area
- Results in obstruction and dilation of the proximal bowel.
Clinical findings: failure to pass meconium, enlarged, distended abdomen, vomiting, fecal mass palpable. **RECTUM IS EMPTY OF STOOL)** May see ribbon like stools with infants.
Diagnosis is done by a biopsy.
What is the medical management of Hirschsprungs Disease?
What is the nursing care for a patient with Hirschsprung's Disease?
- Surgical removal of the aganglionic portion of the bowel, usually around 12-18 months.
- A temporary ostomy is placed proximal to the aganglionic segment to allow the bowel to rest. Can do a complete correction (pull through procedure)
- Special consideration: may be too malnurished to withstand immediate surgery. Use a high calorie, high protein, low fiber diet pre op. TPN may be use BEFORE not after.
- Nursing Care: PRE OP: enema, diet, golytely, measuring abdominal circumference, education
- POST OP: NPO, NG, Strict I&O, IV fluids, abd assessment.
What is NEC? S&S and what is the treatment?
Necrotizing Enterocolitis: inflammation of the small bowel and colon. Most common in premature infants because GI tract is not yet fully developed. Usually caused by normal flora. Decrease NEC by breastfeeding.
Will see abd distension, irritable, difficulty breathing, bloody stools (may need blood products).
Bowel perforation can occur--can lead to peritonitis
Treatment: antibiotic therapy and possible surgery
What are some complications of TPN and care considerations?
- Risk for infection: Sepsis
- Liver dysfunction because the liver is not responsible for metabolizing when the GI should be doing it.
- Respiratory distress from too rapid infusion of fluids
*The TPN infusion rate should remain fairly constant to avoid glucose overload. The infusion rate should never be abruptly increased or decreased.
GERD: what, manifestations, testing, management, surgical mgmt.
- retrograde flow of gastric contents into the esophagus. Failure of the lower esophageal sphincter.
- Manifestations: spitting up, vomiting, weight loss, gagging, choking at the end of feedings(risk for aspiration), Resp problems, heartburn/irritability
Testing: Barium swallow, UGI series, Scintiscan, Flexible endoscopy
Management: change to soy formula, freq burping, small feedings (not over 30 min), elevate HOB, sleepingon left side, thicken formula with cereal, weight monitoring,Meds.
- Meds: H2 blockers-Zantac, Pepcid
- Prilosec-suppression of gastric acid
- Reglan-increase gastric emptying
Surgeries: Nissen fundoplication, G-tube
- Can be ingested or inhaled.
- Intense perianal itching
- transmitted fecal-oral route
- Scotch tape test.
Treat with Vermox, retreat in 2 week because it does not kill the eggs. Wash all bedding, treat the entire family, prevent!
- Usually present 2-4 weeks and resolves by 3-4 months
- Spells and behaviors differ indegree among infants.
- Face may be flushed, pallor. Abd may be distended, legs may be drawn up to abd. Episodes are rhythmic, usually occuring evening lasting 3-5 hours. Normal phys exam.
Management: reassure the parents. Discuss triggers, Effective soothing techniques. Telephone parents frequently. Risk for Shaken baby syndrome.
Causes: feeding to rapidly or too much. sucking in too much air, could be a cow milk allergy
When is cleft lip surgery done?
10 weeks or 10 pounds
When is Cleft palate surgery done?
9-15 months old
Cleft Lip repair: Cheiloplasty
- Clean the sutures with a cotton tip swab using NS and antibacterial ointment
- Use restraints on arms so baby does not touch sutures
- Usually home within 24 hours
What are some associated problems of a cleft palate?
- copius secretions
- otitis media
Post Op care of the child with cleft palate repair.
- watch for resp difficulties
- no sharp objects in the mouth
- monitor suture line
- earlier the repair-the better the speech dvlpmt
TEF: trachealesophagel Fistula
TE Fistula represents the failure of the esophagus to develop as a continuous passage and a failure of the trachea and esopahgus to seperate.
CHOKING, COUGHING, CYANOSIS
What is the management and post op care for TEF
Salem sump aspiration, esophagostomy, G-tube post op. Complication post op: strictures, esophageal motility issues(may need to have drink with food), reflux-commonly seen
Post op Intervention: daily weights, feedings (gtube or PO) Monitor for signs of feeding intolerance (choking, spitting up), Parent education.
- obstruction of the circular muscles of the pyloris
- 2-4 weeks after birth
- Clinical findings: vomiting, hungry infant, palpable pyloric
- Diagosis: pyloric US
- Surgery: Pyloromyotomy
Obstruction caused by invasion of segment of the bowel into the cecum
Clinical manifestation: pain, diarrhea (current jelly), sausage shaped mass, fever. Med-Surg reduction
- Risk for bowel perforation (which can lead to peritonitis)
- Use air enema
- abd pain
- McBurney point: exact location
- Rovsing sign: can palpate abd anywhere and they feel pain in lower right
- rebound tenderness
- low grade fever
Sudden pain relief may indicate rupture of appendix (leads to peritonitis)
Diagnosis: CBC, UA to R/o a UTI, Pregnancy R/O, US, CT scan
Short Bowel Syndrome
- malabsorptive disorder
- Nutritional support: TPN short term then enteral feeding long term
- low carb formulas
- STEPS procedure
treat any infections, development support, feeding support, multidisciplinary approach
- sensitivity to proteins )glutens foundin grains
- inability to absorb fats
- protrustion o intraabdominal contents through defect in abd wall
- no sac covering
- protrusion of intraabdominal viscera into base of umbilical cord.
- sac is covered with peritioneum but no skin.
Risk for thermoregulation with this and Gastroschisis
Care of the baby with an abd wall defect.
- OG tube
- thermally neutral environment(radiant warmer)
- sac covered with sterile dressing and protected from injury, IV fluids and antibiotics, surgery may be staged (if all the contents go back into the stomach at once it could cause difficulty breathing)