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How is the stomach lining protected from stomach acid?
What happens if this is disturbed?
stomach lining has a mucous layer that contains bicarbonate that neutralizes acid
9 known factos that can alter mucous-bicarbonate barrierin the stomach and duodenum of children?
- 1. excessive acid secretion
- 2. bile salts break down mucous structure of gastric duodenal lining
- 3. deficiendies in mucosal prostaglandins that augment mucous lining and bicarbonate secretion
- 4. genetic factors - duodenal ulcers run in families, O type has more ulcerws
- 5. H. pylori weakening the gastric mucosal barrier
- 6. physilogic stress/ serious illness
- 7. meds - NSAIDS, aspirin, indomethacin, alcohol, and tobacco
- 8. cola, tea, and chocolate may contribute but diet usually doesn't affect it
- 9. psych is not a factor but can exacerbate condition once it develops
Main cause of duodenal ulcers in children?
Causes of secondary ulcers in children?
NSAIDS, physiologic stress critical/acute illness
Manifestation of ulcer disease in children?
- 1. burning, cramping pain when stomach is empty
- 2. awakening hs or early am with abd discomfort
- 3. vomiting (< 6 years old)
- 4. hematemesis and melena (black face) in infants and young children
How are ulcers diagnosed?
fiberoptic upper endoscopy, ultrasound to rule out other conditions, occult blood test
What is endoscopy used for?
visualize the esophagus, stomach, and duodenum and obtain tissue for biopsy
Diet for ulcers?
regular diet low in caffeine and high in fiber and polyunsaturated oils
Caffeine affect on ulcers?
stimulant of acid secretion
_____ is the first line of treatment for ulcers.
Treatment for H. pylori?
4 to 6 week med combo of proton pump inhibitor, antibiotic, and bismuth salts
_____ is indicated for managemtn of ulcer complications such as hemorrhage, perforation, or obstruction.
Why may an NG tube be inserted if a child has an ulcer?
for active bleeding to remove blood, decompress stomach, and estimate blood loss
Interventions that may be used for bleeding ulcer?
IV fluids, oxygen, blood replacement, and vasoactive drugs (vasopressin)
balloon tamponade with a sengstaken - blakemaore tube
How are blood or clots removed with bleeding ulcer?
room-temp gastric lavage
What is included in the nursing history of a child with an ulcer?
family history of ulcers, pst episodes of abd pain, recent stress
What is included in assessment of ulcer pain?
description and nature of pain, location, relationship to meals, defecation, or voiding, nocturnal pain, meds that relieve pain,
If a child has an ulcer bowel sounds should be ausculatated for ____ minutes.
The major focus of nursing interventions in ulcers is ____.
What are nursing responsibilities with a child having a fiberoptic endoscopy
preparing the child for conscious sedation, NPO for at least 6 h prior, maintaining an IV line, monitoring VS during procedure
Why is education important with ulcers?
most of the care is done at home
Meds that should not be given with an ulcer?
aspirin and NSAIDS
Foods to avoid with ulcer?
acidic foods, caffeine, and carbonated beverages
When should the parent contact MD if child has ulcer/
coffee-ground vomitus, tarry stools, increased pain, diarrhea, vomiting, or unexplained weight loss
Cause of infectious gastroenteritis?
bacteria, viruses, and parasites
2 ways to get infectious gastroenteritis?
ingesting contaminated food & person to person contact
2 common causes of infectious gastroenteritis?
giardia & rotavirus
When should infants be vaccinated against rotavirus?
2, 4, & 6 months
Antacids should not be used withing ____ hour(s) of other antiulcer meds.
Manifestations of gastroenteritis?
Which are the most common 3?
most common - diarrhea, vomiting, and abd pain
tenesmus, fever, dehydration
Who is most at risk for dehydration with gastroenteritis?
children < 2 years
Pathophysiology of infectious gastroenteritis?
pathogen adheres to mucosal lining -> inflammatory response activated -> pathogen releases toxins -> excess secretions due to toxins + decreased absorption due to inflammation = excess fluid in the intestine = diarrhea
Diagnostic evaluation of gastroenteritis?
stool culture (for pathogen), WBC, unprepared sigmoidoscopy (for determining extent of mucosal involvement)
Priority intervention for gastroenteritis?
replace fluids and maintain pH and electrolytes
What 3 substances are lost in diarrhea?
K, Na, and bicarbonate
feeling of constantly needing to pass stools
Nursing history of gastroenteritis?
length of symjptoms, frquency and consistency of stools, presence of blood or mucus in stools, symptoms in family members, travel, formula and food prep
4 symptoms of neurotoxins?
HA, nucal rigidity, irritability, and seizures
What gastric bacteria releases neurotoxins?
Indications of dehydration during assessment?
low urine output, high specific gravity, mucous membranes, skin turgor, no tears, sunken fontanel
Why is metabolic acidosis a major concern with diarrhea?
lose bicarbonate in diarrhea
increased RR and effort compensating for acidosis by blowing off CO2
6 nursing diagnoses for infant or child with gastroenteritis?
- 1. dehydration
- 2. risk for infection
- 3. acute pain
- 4. deficient knowledge
- 5. imbalanced nutrition due to malabsorption
- 6. risk for impaired skin integrity
Priority nursing intervention with gastroenteritis?
oral/parenteral rehydration with I&O and weights
How does the nurse evaluate the effectiveness of rehydration interventions?
skin turgor, urine output, and serum electrolyte
Precautions to take with infectious gastroenteritis?
contact isolation, hygiene, determining if contaminated food is indicated
oral rehydration therapy
What foods should be avoided when a child is experiencing vomiting and diarrhea?
foods high in sugar and fat
______ assists in reducing diarrhea by restoring normal bowel flora.
When may a child with gastroenteritis resume regular diet?
when fluid imbalance is corrected / after IV fluids are given
When to call MD with gastroenteritis?
- 1. child is < 6 months old
- 2. fever
- 3. diarrhea worsens
- 4. diarrhea has blood
- 5. vomiting increases or cannot keep fluid down
- 6. severe abd pain
- 7. dehydration
Most common cause of emergency surgery in children and adolescents?
4 causes of appendicitis?
lymphoid swelling r/t viral infection, impacted fecal material, foreign bodies, and parasites
midway b/t right anterior superior iliac crest and the umbilicus where appendix is
Manifestations of appendicitis?
if it perforates?
abd pain progressing in intensity and localizing to the right lower quadrant, N/V, anorexia, diarrhea or constipation, fever & chills
pain relieved initially then gets worse along with worsening of other symptoms, rigid abd, and shock symptoms
Diagnosis of appendicitis?
abd pain localizing at McBurney point, guarding, rebound tenderness, N/V, and fever, WBC, ultrasound or CT,
Pathology of appendicitis?
obstruction of appendix -> secretions accumulate-> distention occludes caps and engorges walls of appendix -> can have abscesses and fistulas -> perforation due to tissue b/d and swelling -> bowel contents contaminate mesenteric bed and peritoneum -> peritonitis and sepsis
Preop treatment of appendicitis?
fluid therapy, immobilizatrion, pain control, NPO status, antibiotics, and antipyretics
What postition may a child with appendicitis have?
supine postition with right leg flexed to decrease tension on abd wall
2 important indicators of appendicitis in infants and toddlers?
behavioral changes and refusal to eat
4 nursing diagnoses for appendicitis?
- 1. acute pain
- 2. risk for infection
- 3. deficient fluid volume
- 4. anxiety
Considerations for diagnosing appendicitis in young children?
if pain, anorexia, or N&V, and fever occur together should consider appendicitis
- if pain comes before N = appendicitis
- if N before pain = gastroenteritis
child will not want to play and cannot get comfortable or may flex right leg
Why should heat not be used with appendicitis?
causes vasodilation and can = perforation
Pre and post op considerations for appendectomy?
pre op - pain meds, IV fluids, NPO, VS & monitoring for sepsis, comfort measures
post - op- NPO until bowel functions returns
If a child has a ruptured appendix what should be done?
NG tube for decompression pre op and draining gastric contents post op, IV antibiotics, may have postop incisional drains, wound may be left open and treated with steril we-to-dry or wet - to -moist dressings & wound irrigation with antibacterial solutions
How is the presence of wound infection, abscess, or fistula evaluated in post op appendectomy?
assessment of abd pain
After appendectomy monitor VS q ____ h.
2 - 4
What position should post op appendectomy pt be in? Why?
elevate HOB or have child lie on operative side
facilitates drainage and minimizes spread of infection into the upper abd
Teach parents of appendectomy pt to watch for ___, ____, and ____ as signs of bowel obstruction or peritoneal infection.
vomiting, abd pain, or distention
Inflammatory bowel disease?
chronic inflammatory condition of the small or large intestine
2 distinct conditions that are included in IBD?
ulcerative colitis and Crohn disease
inflammatory bowel disease
Ulcerative colitis affects only the _____ involving the ____ & _____ layers of the intestine. Chron disease occurs where?
- mucosal and submucosal
anywhere in the GI tract mouth to anus and involves all layers of the intestine
Factors that affect IBD?
infection, food allergies, vasculitis, increased intestinal permeability, immunologic dysfunction, stress effects on immune response
Appearance of affected areas with Crohn's disease & ulcerative colitis?
Crohn's - cobblestone appearnace
ulcerative colitis - mucosa is gone
Does Crohn's disease or ulcerative colitis cause fistulas?
In IBD caused by ____ ______ remissions are uncommon, but IBD caused by _____ ______ will have remissions and exacerbations.
4 tests used for diagnostic evaluation of Crohn's and ulcerative colitis?
colonoscopy, rectoscopy, barium enema, biopsy
In colonoscopy of Crohn's diseae and ulcerative colitis what will be seen?
Crohn's - "skip" lesions with deep fissures and granulomas (collection of macrophages)
ulcerative colitis - inflammation and superficial ulceration demarcation b/t areas of inflamed and normal colon
Biopsy showing nonspecific chronic inflammation may indicate _____ _____ IBD?
Differences between the manifestations of Crohn's and ulcerative colitis?
- 1. Crohn's = abd pain
- 2. diarrhea in ulcerative colitis may have blood
- 3. Cronhn's has fever
- 4. Crohn's has abd masses
- 5. Chron's has anorexia and more weight loss than ass. with ulcerative colitis
- 6. more growth impairment in Chron's
- 7. perianal and anal lesions usually not present in UC
- 8. fistualas and obstructions rare in UC
- 9. Crohn's has extraintestinal symptoms (arthralgia, arthritis) and UC has risk of toxic megacolon
- 10. surgery does not cure Crohn's
Meds used to treat IBD?
antiinflammatory, antibiotic, immunosuppresants, steroids
total parenteral nutrition
_____ ____ ____ my be necessary during flare-ups of Crohn's
_____ or ____ promotes healing of the mucosa and can control Crohn's disease in some children as effectively as prednisone.
NG tube nutrition and gastrostomy
Diet for UC?
no milk, hypoallergenic, low-fiber, lowfat, low-residue- high-protein diet
Surgery for UC?
total or partial colectomy with colostomy or ileostomy
Primary finding in history of child with IBD?
Symptoms of IBD?
weight loss, dehydration, anorexia, growth failure, vitamin deficiencies, and anemia
How does IBD affect CH growth rate?
malabsorption and steroid use
Which form of IBD has remissions & exacerbations?
Which form of IBD has intermittent cramping exacerbated by eaTing?
2 skin issues with Crohn's disease?
oral lesions & perianal skin b/d
Psych issues with IBD?
depression, anxiety, fears about social interactions, and low self-esteem
Nursing diagnoses with IBD? (4)
- 1. malnutrition/malabsorption
- 2. low self-esteem
- 3. disturbed body image
- 4. anxiety
Focus of nursing interventions for IBD? (3)
drug interventions, nutrition, and emotional support
Steroids should be given with ____ or ____ to prevent GI distress.
food or antacids
Supplements for IBD?
vitamin, Fe, folate,
What must be continually assessed in CH with IBD?
How are they assessed?
G&D & nutritional status
# of stools, nutritional status, weight, developmental milestones, pain
Camp for kids with IBD?
Important education for home care of a child with IBD?
steroid use, side effects, and not stopping abruptly
When to seek med help with IBD?
sudden exacerbations of symptoms, weight loss, blood loss, and severe abd pain
Hypertrophic pyloric stenosis?
When is it common in CH?
circular area of muscle surrounding the pylorus hypertrophies and obstructs gastric emptying
hypertrophic pyloric stenosis
Main factor that affects incidence of HPS?
genetics - parent who has it
Highest risk for HPS?
white, full term, male infant
Major manifestation of HPS?
projectile, nonbilious vomiting in a previously healthy infant that may be blood -tinged if esophageal irritation occurs
firm, olive-shaped mass in RUQ, visible peristalsis before vomiting, irritable/hungry right after feeding, dehydration, met. alkalosis
3 factors for diagnosis of HPS?
history of vomiting, visible peristalsis, and palpable pyloric mass
If HPS is suspected but mass cannot be felt what is done?
ultrasound / radiography
Possible lab findings for HPS?
metabolic alkalossis, decreased serum K & Na, increased bicarbonate, decreased CL, elevated bilirubin level
Patho of HPS?
pyloric spasms = milk curds propelled against a narrowed pyloric channel -> irritation of mucosal lining -> edema of pyloric mucosa -> reduces size of pyloric canal & creates resistance to flow of milk -> to promote gastric emptying & compensate for resistance pylorus contracts with more force & gradually enlarges -> begins to constrict pyloric channel (when mucosal edema subsides the muscle is still causing resistance) -> cycle is created -> obstruction of pyloric canal
incision of the pyloric muscle to release the obstruction
What is included in nursing history of child with HPS?
feeding schedule & relation to vomiting,
Assessment exam data for HPS?
dehydration, K / Na,/ CL depletion, abd distention / tenderness, bowel sounds, presence of pyloric mass, and peristalsis
Nursing diagnoses r/t HPS?
- 1. dehydration
- 2. imbalanced nutrition
- 3. impaired skin integrity r/t surgical incision
- 4. deficient knowledge
- 5. acute pain r/t surgery
- 6. anxiety of parents
Preop interventions with HPS?
NPO, IV fluids, VS, daily weight, monitoring labs, I&O, oral care (dehydration = increased risk for mucosal b/d), elevated HOB with towels or blankets rolled up to keep position, resp assessment, explain procedure to parents
When will NG tube be removed and feedings be resumed after a pyloromyotomy?
NG may be removed immediately with feeding starting 4 - 6 h post op if bowel sounds present or may leave NG for 24 hours
How is feeding resumed post op pyloromyotomy?
start with oral electrolye solution -> 1/2 strength formula that is progressed to full strength in 48 hours - breast milk does not need diluting
progress to next strength when previous can be taken without vomiting
Postop assessment HPS?
same as preop except must assess surgical incision
What to report to MD with HPS?
vomiting, abd tenderness, fever and incisional redness and drainage
_____ is a pediatric emergency in which enfolding of a section of the intestine into the distal bowel causes bowel obstruction.
How does intussusception usually occur in children?
section of the terminal ileum telescopes in to the ascending colon through the ileocecal valve
Most common cause of intestinal obstruction in children b/t ages 3 months and 6 years?
Cause of intussusception?
Contributing factors to intussusception?
preexisting upper resp tract infection or other viral infection
Most likely cause of intussusception in children > 6 years?
pathologic condition within the colon - mass or anatomic defect
Who is usually affected by intussusception?
infants and young children <2 years old
Children with _____ ______ are more at risk for intussusception.
What is the pain like with intussusception?
Is there vomiting?
comes and goes then becomes more constant and severe
Classic symptoms of intussusception?
- 1. bloody mucus stool & diarrhea - may not appear until post op period
- 2. sausage-shaped abd mass
When will symptoms of shock and sepsis be present in intussusception?
obstruction present longer than 12 to 24 h
When assessing GI pain what aspects are important?
location, frequency, relationship to meals, nocturnal pain, what releves the pain
In intussusception what may abd radiographs show?
What is ultrasound used for?
abnormal gas patterns r/t bowel obstruction of a soft tissue mass
ID location of intususception and amnt of edema in area
How can a definitive diagnosis & treatment be provided at the same time with intussusception?
barium enema or air enema exam
How is intussusception treated with if no sepsis/shock?
If this fails?
hydrostatic reduction with barium, air, saline enema
Typical njursing history of child with intussusception?
previously healthy infant who suddenly began crying and flexing the legs in severe pain
What should a CH presenting with symptoms of intussusception be asessed for?
S/S of bowel obstruction?
N/V, abd distention, & hypoactive or hyperactive bowel sounds
What S/S with intussusception are emergency?
fever, increased heart rate, changes in LOC or BP, & resp. distress
may be sepsis or peritonitis
3 assessments essential before pt has hydrostatic reduction with intussusception?
What should be documented?
hydration, sepsis, shock
mental status, cap perfusion, urine output
Post hydrostatic reduction care?
observe stools, S/S bowel obstruction, intermittent NG suction, IV, pain meds, maintenance of resp function, frequent assessment, meet dev needs
bowel obstruction that is caused by a malrotation or twisting of the bowel
Cause of Volvulus?
congenital defect where mid-gut that normally rotates 270 degrees around superior mesenteric artery, fails to rotate and fixes itself to the abd wall
Manifestations of volvulus?
pain, bilious vomiting, S/S of bowel obstruction
Tx for volvulus? Why?
surgery to prevent ischemia
results from absence of ganglion cells in rectum and to varying degrees upward in the colon
AKA congenital aganglionosis or megacolon
Major cause of lower bowel obstruction in newborns?
Males: female ration for Hirschsprung?
2 risk factors for Hirschsprugn?
- 1. hereditary
- 2. down syndrome present
Cardinal sign of Hirschsprung disease?
delayed/absence of meconium
Any child who does no pass meconium in first 24 hours or is prone to constipation in first month after birth is suspected of having _____.
Stool of child in first moth of Hirschsprung?
pellet-like or ribbon-like & foul smelling
Definitive diagnosis of Hirschsprung is made by ___ ____ ____.
What will the results be?
suction rectal biopsy
ganglionic cells will be absent
anal rectal manometry
ARM procedure and pupose?
Results in Hirschsprug/
catheter with a balloon is inserted into the rectum to test nerves and sphincter peressure of the anus
diagnose ultrashort-segment Hirschsprung AKA anal achalasia
nonrelaxing internal anal sphincter
What area of the colon is affected by Hirschsprung?
any and all
Tx of Hirschsprung?
removing aganglionic portion of colon
Medical interventions for Hirschsprung?
botox injections to decrease internal anal sphincter pressure
rectal irrigations to remove air and stool
Life-threatening complication of Hirschsprung?
When should it be suspected?
if a child suspected of having Hirschsprung presents severely ill
Route of temp in Hirschsprung or suspected Hirschsprung?
monitor bowel elimination, isotonic saline enemas or GoLYTELY in NG tube in CH > 5 or NA phosphate, NPO, IV fluids, I&O
NG tube post op Hirschsprung?
intermittent suction until bowel sounds return
3 things to tell parents about post op Hirschsprung?
S/S of obstruction, distention, and infection
What is lactose?
sugar in dairy products
can't digest lactose b/c of absence of lactase
enzyme secreted by sm intestines that is required for the digestion of lactose
2 types of lactose intolerance?
congenital - from birth have no lactase
developmental - in early - late CH have a deficiency of lactase
What conditions exacerbate lactose intolerance?
illnesses that affect GI mucosa
GE, food poisoning, etc
Ethnicities at risk for lactose intolerance?
asian, American indian, arab, AA, jews, southern europeans
Manifestations of lactose intolerance?
frothy/not fatty diarrhea, abd distention, cramping abd pain, excessive flatus
When do lactose intolerance symptoms usually appear?
after age 3 or when other GI probs occur
Clinitest stool test positive for lactose intolerance?
1+ shows intestinal malabsorption of sugar
Lactose intolerance testing?
give oral lactose load then measure blood glucose levels and the amount of hydrogen in breath samples
low = positive
AKA breath hydrogen test
Tx of lactose intolerance?
- remove lactose form diet
- lactase supplements
Pathophysiology of lactose intolerance?
absence of deficiency of lactase -> can't digest lactose -> accumulation of lactose in lumen of sm intestines -> water is drawn into the colon and GI bacteria b/d lactose and release hydrogen -> hydrogen release =gas & water in colon = diarrhea containing undigested lactose
Assessment findings of child with lactose intolerance?
healthy, with episodes of abd pain & diarrhea w/out any other probs or nutritional deficiencies
Who is lactose intolerance serious for?
congenital - infants have more severe symptoms = diarrhea
Principle nursing intervention for child with lactose intolerance?
How should diet be adjusted?
lactose free for a time then gradually increase to see what is tolerated
Celiac Disease? (CD)
lifelong deficiency resulting from inability to digest gluten
What is gluten?
storage proteins found in wheat, barley, and rye
Cause of CD?
autoimmune disease that occurs in genetically susceptible pt due to combo of env and genetic factors
Who is at highest risk for Celiac disease?
siblings and children of ppl who have it
Manifestations of CD?
diarrhea, growth failure, abd distention, vomiting, anemia, irritability, anorexia, muscle wasting, edema, folate deficiency
When are symptoms of Celiac diseae usually seen?
9 - 12 months/3-6 mo after grains are first introduced
Tests for Celiac disease?
immunoglobulin A (IgA) antitissue transglutaminase antibody tes, IgA antiendomysial antibody test, jejuno biopsy, removing gluten from diet, breath hydrogen test (for carb malabsorption )
Mainstay of celiac treatment?
What substitues may be used for wheat, rye, barley, and ots with Celiac?
corn, rice, millet
What vitamins may be needed to correct deficiencies caused by Celiac diet
folate and fat soluble vitamins
Who is most ar risk for nutritional deficiency with Celiac disease?
manifestations of Celiac crisis?
profuse, watery diarrhea, & vomiting leading to dehydration, and metabolic acidosis, poor perfusion, edema, changes in VS due to shock or met acidosis
What usually causes Celiac crisis?
hidden source of gluten or infection
Tx for Celiac?
IV fluids, albumin for shock, and corticosteroids to decrease severe mucosal inflammation
Assessment results of infant with Celiac?
irribable, malnourished infant with failure to thrive by 9 - 12 months
abd distention & ascites with increasing girth
When should Celiac be suspected?
diarrhea (esp foul smelling), fatty stools, significant growth delays
Priority nursing intervention for child with Celiac?
teaching about diet
Short bowel syndrome
Short bowel syndrome?
congenital malfomrations of the GI tract of surgical resection that decreases the length of the sm intestines
Effects of SBS with 50% loss?
3 causes of SBS in newborns?
- 1. congenital SBS
- 2. mult GI tract atresias (areas that aren't tubular/open)
- 3. gastroschisis (abd contents protrude from abd)
Non-congenital causes of SBS?
surgery to remove part of the sm int for other GI probs
Most common cause of SBS in preterm infants is _____.
NES - necrotizing enterocolitis
Patho of SBS?
bowel is short -> decreased mucosal surface area -> inadequate absorption (deficiencies may depend on section of bowel missing b/c diff areas absorb diff things)
Manifestations of SBS?
watery diarrhea, steatorrhea, bloating, gas, foul smelling stool, poor appetite, vomiting, weight loss or inability to gain weight, fatigue
Complication of SBS?
protein - caloric malnutrition, dehydration, electrolyte imbalances, gallstones, kidney stones, and high levels of bacteria in the intestines, vitamin & mineral deficiencies
Mainstay o therapy for post op SBS?
Primary source for all nutrients post op SBS?
TPN qd for 10 - 12 h or longer using a central line
Nursing implications for TPN & enteral feedings postop SBS?
infection from central catheter, proper NG tube placement, assess/document ability to tolerate enteral feedings, dehydrtion, electrolyte imbalance, and nutritional defecits
Nursing implication for infants receiving TPN or enteral feedings?
need oral stimulation
acute or chronic inflammation of the liver caused by several diff viruses, toxins, and disease states
Most common causes of hepatitis?
hepatitis A, B, C, D, and E viruses
Causes of hepatitis that occur in children?
rubella, cytomegalovirus (CMV), herpes simplex virus, and Epstein-Barr virus
Hepatitis ___ virus is highly contagious in CH and daycare centers.
Infections with hepatitis ___ can be spread perinatally.
Ways hepatitis may be spread?
body fluids, contact with objects up to 1 week after its contact with body fluids
Which hepatits viruses are vaccinated against in US?
A & B
Why is spread of hepatitis common if hand hygiene is not used?
can be excreted for 2-3 weeks before appearance of symptoms and 2 - 3 weeks after they go away
Manifestations of HAV in infants and preschool children?
What can this cause?
asymptomatic or nonspecific symptoms: anorexia, malaise, and fatigue
spread of infection before it is identified
Symptoms of HBV?
asymptomatic to fulminanty hepatitis (can be fatal)
2 stages of symptomatic acute hepatits?
- anicteric - no jaundice
- icteric - jaundiced
Manifestations of the anicteric phase of HBV infection?
anorexia, N/V, RUQ or epigastric pain, fever, malaise, fatigue, depression , & irritability
How long does the anicteric phase of HBV last?
5 to 7 days
Manifestations of the icteric phase of HBV?
jaundice, urticaria, dark urine & light-colored stools, feels better as jaundice appears,
Manifestations of acute fulminating hepatitis?
bleeding abnormalities, encephalopathy, ascites, adn acute hepatic failure
2 primary causative organisms in fulminating hepatits?
HBV & HCV
When should symptoms of hep virus go away?
What is present if they don't?
Which 3 types of hep can result in chronic hep and cirrhosis?
Which type can cause hepatic carcinoma?
HBV, HCV, HDV
What factors should cause suspicion of hep infection?
- 1. exposure to jaundiced ind
- 2. confirmed outbreaks
- 3. exposure to body fluids
Blood tests to diagnose hep?
ID of antigens & genetic material
___ ___ may be needed for hep infection to evaluate chronic forms and to det. extent of liver damage.
_____ ______ increases with the duration of HCV infection.
Tx for uncomplicated viral hepatitis?
maintaining comfort b/c self-limiting
Tx for fulminant hepatitis?
Important consideration for HAV?
hygiene to prevent the spread of infection
What should be done if person is exposed to HAV?
give immunoglobulin (Ig) ASAP
When should immunization for hep be given?
age 1 year
Most effective means of preventing HBV infection?
Ppl who need HBV vaccine?
IV drug users, health care ppl, ppl in contact with HBV carriers, inmates, travelers
What can prevent HBV infection if given within 2 weeks after exposure?
hep B immune globulin (HBIG)
How can HDV be prevented?
preventing HBV with vaccine
Where is jaudice best assessed?
sclera, nail beds and mucous membranes
_____ _____ is crucial b/c most care of children with hep is done at home.
When may a child with HAV return to school?
1 week after onset of jaundice b/c no longer contagious
Signs of worsening hep infection to teach parents?
change in LOC, bleeding, and fluid retention
How is HBV spread?
Diet for hep infection?
obstruction or absence of the extra-hepatic bile ducts
End results of biliary atresia?
cellular damage liver failure and death
Cause of biliary atresia?
When does it develop?
Number 1 indication for liver transplants in kids?
Manifestations of biliary atresia?
appears health at birth then develops acholic stools (light color b/c of absence of bile pigment), bile-stained urine, and hepatomagaly (swelling of liver)
Diagnostic testing for biliary atresia?
liver function tests, PT & PTT, metabolic screening to rule out met probs, hep test, urine and stool samples, urobilinogen levels to det degree of obstruction
What can provide definitive diagnosis of biliary atresia?
percutaneous liver biopsy that shows bile plugs, edema, and fibrosis in hepatic structure
Tx for biliary atresia?
drain bile to buy time for liver transplant
treatment of portal hypertension & ascites and variceal bleeding
Nutritional management in biliary atresia?
need extra calories, possible TPN, need vitamins
How is portal hypertension treated?
control bleeding, restrict salt, & use diuretics
6 majors areas of nursing intervetions for biliary atresia?
nutrition, skin care, developmental stimulation, continued assessment, education, and emotional support
Nutrition goals and assessments in biliary atresia.
providing adequate calories, aiding in vitamin supply and absorption, and preventing hepatic encephalopathy
calorie counting, daily weights, and abd girths
Vitamins needed for biliary atresia?
A, D, E, K, Ca, phosphate, and zinc
What should be restricted in diet of biliary atresia pt?
Why is skin b/d a concern in biliary atresia?
pruritis and scratching
Bile acid binders function in biliary atresia?
help excrete bile salts and decrease pruritus and development of xanthomas (fat build up under the skin)
3 things to teach parents to watch for with biliary atresia?
GI bleeding, severe edema, & ascites b/c = portal hypertension
Tx for portal vein hypertension
Na restriction, diuretics, IV albumin
When do liver transplants in biliary atresia usually occur?
before age 2
chronic, degenerative condition of the liver that results in the development of bands of fiberous tissue, firm nodules, and connections b/t central and portal areas of the liver
Patho of Cirrhosis?
stasis of bile -> inflammation and hepatomegaly -> liver destruction & attempts to heal itself -> fibrous tissue -> altered hepatic blood flow and decreased liver cell function -> scarring/collapse of hepatic vasculature, incresed vascular resistance, and portal hypertension -> liver cells die more and can't produce proteins or bile -> malabsortion and malnutrition -> more liver cells die and cycle is repeated
Most common causes of cirrhosis?
HBV infection, chronic hepatits, or biliary atresia
sickle cell, metablic errors, copper metabolism dysfunction, cystic fibrosis, and Wilson disease
Manifestations of cirrhosis result from ___ or ____.
liver cell failure or portal hypertension
Manifestations of cirrhosis?
jaundice, intense pruritus, steatorrhea, abd distention, edema, anemia, bleeding tendencies, anorexia, frequent infections, poor growth, splenomegaly, esophageal varices, GI bleeding
Tx to halt progression of cirrhosis?
Tx for cirrhosis/
management S/S & have transplant
Earliest findings of cirrhosis?
anorexia, N, indigestion, fatigue, and RUQ pain/fullness
What is reveled by palpation with cirrhosis?
splenomegaly, RUQ tenderness, & hepatomegaly
_____ can revel the extent of bile obstruction and malabsorption in cirrhosis.
The most critical cirrhosis assessment needs to be centered on detecting signs of 3 major complictions, ____, _____, & _____.
ascites, varices, and encephalopathy
Emergency symptoms in cirrhosis/
changes in LOC, increased abd girth, edema, bloody emesis,
4 areas of care for cirrhosis?
nutrition, skin care, prevention of complications, support
Diet of child with cirrhosis?
high carb and calories, normal protein, low fat
limit protein if encephalopathy develops
Cause of skin probs in cirrhosis?
scratching r/t pruritis
Tx for edematous child with cirrhosis?
diuretics and albumin
3 ways to prevent bleeding with cirrhosis/
- 1. injections avoided
- 2. child protected from injury
- 3. vitamin K given
Why does liver damage cause encephalopathy?
3 ways to prevent it?
excess ammonia in the blood due to incomplete b/d of protein by the liver
- 1. limit protein
- 2. lactulose to decrease GI bacteria that produce ammonia
- 3. admin antibiotics
Why should some drugs be avoided if liver function is impaired?
What are they?
affects metabolism of the drugs
sedatives, opioids, acetaminophen, alcohol
Upper GI system contains ___, ____, and ____ and primary function is ____.
mouth, esophagus, stomach
take in food and start digestion
upper esophageal sphincter
prevents food/etc from going into the airway
lower esophageal sphincter
keeps stomach contents from entering lower esophagus
Lower GI system organs?
liver, gallbladder, sm & lg intestine, appendix, rectum, and anus
Primary functions of the lower GI tract?
digest and absorb nutrients, detoxify, and excrete unwated waste, and aid fluid/electrolyte balance
2 functions of the pancreas?
- 1. secretes enzymes to digest food
- 2. secretes glucagon and insulin to control motility and absorption
sources of blood for the liver?
- 1. hepatic artery -O2 blood
- 2. hepatic portal vein - de-O2 blood from with absorbed nutrients from the GI tract
5 functions of the liver?
- 1. phagocytosis
- 2. bile production
- 3. detox
- 4. glycogen storage and b/d
- 5. vitamin storage
What is bile used for?
absorption of fat and excretion of end products of blood cell b/d
Primary function of the gallbladder?
store bile for secretion into the duodenum when stim by presence of fat
Where does absorption of all nutrients and vitamins occur?
in the jejunum and ileum of the sm int
Major functions of the large intestine?
- 1. water reabsorption
- 2. synth of vit B & K
- 3. b/d of bile
- 4. mucus secretion & peristalsis
6 categories of GI conditions?
- 1. developmental
- 2. probs affecting motility
- 3. inlammatory or infectious
- 4. obstructive disorders
- 5. malabsorption conditions
- 6. hepatic disorders
3 Gi disorders of prenatal development?
cleft palate, esophageal atresia with tracheoesophageal fistula, upper GI hernias
Cause of cleft palate?
environmental and genetic factors: smoking of mother, family risk
First intervention for cleft lip and palate?
modifying feeding to allow adequate growth
What may be the first sign of cleft palate?
milk coming from the nose
When is cleft lip repair usually done?
by age 3 to 6 months
When is cleft palate repair don?
based on degree of deformity and size of the child - usually completed between 6 & 24 MONTHS
Concern of cleft palate if not repaired before age 1?
Children with cleft palate at risk for developing ___ ____ ___ which can lead to ____.
chronic ottitis media
long-term hearing loss
EA & TEF?
Esophagel atresia and tracheoesophageal fistula
congenital malformations in which the esophagus terminates before it reaches the stomach and/or a fistula is present that forms an an unnatural connection b/t esophagus and trachea
Nearly half of all infants born with EA have other ass. anomalies of the ____, ____, & ____ systems.
cardia, GI, and CNS
Manifestations of EA with TEF?
failure to pass suction catheter, NG tube at birth, excessive oral secretions, coughing, choking, vomiting, abd distention,
manifestation of EA without TEF?
airless, scaphoid abd
History of maternal ____ can be risk for EA & TEF.
Testing for EA & TEF?
try to put in NG tube, radiography will show defects, endoscopy/bronchoscopy to assess fistula, testing for ass. congenital anomalies
What type of restraints should be used for babies with cleft repair?
When should they be removed?
6 to 8 days
q 2 h for 10 to 15 minutes
What position should child with cleft repair be in?
supine or infant seat
How to clean cleft repair site after feeding?
rinse with water
Position of infant with EA/TEF?
supine with HOB elevated
How is the proximal pouch kept clear of secretions with EA/TEF?
NG tube in place and aspirated q 5 to 10 minutes
Tx for EA/TEF?
surgery - repair fistula first then anastomosis of atresia to decrease severity of stricture formation
Patho of EA & TEF?
TEF occurs b/c embryo fails to differentiate foregut into trachea and esophagus & they are fused -> oral intake enters lungs/air enters stomach -> coughing, choking, severe abd distention -> aspiration pneumonia and severe resp distress -> death
EA -> resp distress due to aspiration of saliva and oral fluids
Priority diagnosis for infant with TEF?
risk for aspiration
Assessment of infant with TEF/EA?
excesive secretions, choking, cyanosis, dysphagia, regurgitation, vomiting,
How is resp distress relieved immediately after the birth of a child with EA or TEF?
placed in radiant warmer and admin humidified O2
IV fluids, NPO, monitoring VS
Any child exhibiting ____ should be suspected of having a TEF.
three C's - coughing, choking, and cyanosis
Interventions to minimize aspiration risk in EA and TEF?
- 1. chalasia board = 30 degree angle
- 2. suction catheter in proximal pouch and mouth
- 3. constant assessment of resp
Priority interventions if cervical esophagostomy is performed for EA/TEF?
cover incision with gauze to absorb saliva and keep clean
is wet and will easily b/d
In immediate postop for anastomosis why is G-tube left open?
to dran gastric contents and air for comfort and decreases pressure at the anastomosis
How are ostomies cleaned?
half strength peroxide
Upper GI hernias?
abnormal protrusion of part of an organ or tissue through the structures that normally contain it
2 types of hernias
congenital or aquired
Medical emergency associated with hernias?
strangulated and blood supply is cut off
protrusion of portion of the stomach through the esophageal hiatus of the diaphragm
Congenital Diaphragmatic hernia?
opening in the diaphragm thru which abd contents herniate into the thoracic cavity during prenatal development
Symptoms of upper GI hernias?
resp problems, coughing, wheezing, apnea, failure to thrive, vomiting, scaphoid abd, bowel sounds over chest
Gastroesophageal reflux - regurgitation of gastric contents ack into the esophagus
Causes of GER?
- 1. neurologic - affects signal to LES
- 2. delayed gastric emptying of liquid meal
- 3. partial or incomplete swallowing dysfunction
- 4. drugs -theophyllline or caffeiene trigger LES relaxation
When will reflux from developmental causes likely resolve?
1 to 2 years
Manifesations of GERD in babies?
vomiting/spitting up after a meal, hiccupping, recurrent otitis media r/t pooled secretions, weight loss, failure to thrive, irritability, discomfort, abd pain, hematemesis, melena, anemia, resp symptoms - coughing, choking, asthma, wheezing, pneumonia, apnea, or bradycardia
What is frequently ass. with GERD?
resp illness and asthma
4 Tx for GERD?
diet, positional changes, meds, and surgery
Early treatment of GERD may prevent or leson complcations such as ___, ____, and _____.
failure to thrive, esophagitis, and strictures
breastfed w/d from milk protein and eggs, thickened feedings with rice cereal,
Foods that lower LES pressure?
cffeine, carbonation, acidic, spicy, and fatty foods
Position of infants with GERD?
prone reduces reflux
to sleep should be supine to prevent SIDS
Posistion of older children with GERD?
___is a complication of long-standing GERD and esophagitis?
How are blood and blood clots eliminated from upper GI with GI bleeds?
stomach lavage with an NG tube
Patho of gastroesophagel reflux?