Lecture 4 exam 3
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. What would you like to do?
Family influence on obesity
- inconsistent eating patterns
- one or both parents overweight
- poor dietary choices
Who's most likely to be obese?
- Hispanic males
- Black girls
Complications of childhood obesity....describe
Metabolic syndrome-insulin resistance
- elevated lipids
- increased bp
- elevated fasting blood glucose
Which type of diabetes will an obese person get?
Pulmonary complications from being obese
- sleep apnea
- exercise intolerance
GI problems from being obese
- risk for cirrhosis of the liver
- risk for colon cancer
What is kept in a food diary?
- type and amt eaten
- why they ate
What is key for success in weight reduction?
ownership by the child to accept the plan and be on board
When do kids get type I dm?
- incidence peak 4-6 yo
- second peak at 10-14
What causes Type I DM
- viral infections
- dietary toxins
- hx of obesity
What causes Type II DM
- insulin resistance
- *maternal gestational dm
- Intrauterine growth retardation
- lack of physical activity
Patho of DM I
Inflammatory process/autoimmune causes destruction of islet cells making the pancreas unable to make and secrete adequate amounts of insulin
Patho of DM II
Pancreas makes insulin, but not enough to overcome chronic hyperglycemia
Clinical manifestations of DM I
- 3P's-polyuria, polydipsia, polyphagia
- wt. loss....despite eating
- blurred vision
Clinical Manifestations of DM II
- yest infections
- blurred vision
- frequent urination
- High triglycerides and LDL's
- Polycistic ovary syndrome
- Acanthosis Nigricans (dark skin/back/neck)
Who gets DKA?
- DM I
- urine ketones
- Fruity breath
3 tests for DM...what are the levels?
- Fasting Glucose=126
- Random serum glucose=200
- HbA1c= <7%
For Type II DM what is a pre diabetic? What is a diabetic?
- Fasting glucose test 140-199 pre diabetic
- 200+ is diabetic
How do you manage Type I DM
- continuous insulin therapy
- nutrition therapy
- physical activity
- blood glucose monitoring
How do you manage Type I DM with nutrition?
- 15g = 1 carb
- 1 unit of insulin for 5-20 carbs
How do you manage Type II DM
- regular/moderate exercise
- Insulin therapy to reverse metabolic imbalances
- blood glucose monitoring
- Metformin oral meds
- Follow up with HgA1c tests
Weird things that cause hyper and hypoglycemia
Hyperglycemia-infection, illness, stress
Behaviors when you have hypo and hyperglycemia
hypo-irritable, shaky, weak, confused
hyper-drowsy, lethargic, weak, confused
Pulse/HR for a person with hypo/hyperglycemia
hypo-full, bounding, rapid
Breathing for a person with hypo/hyperglycemia
hypo-shallow, no odor
hyper-deep, labored, rapid, fruity
Onset of hypo vs. hyperglycemia
hypo-rapid onset and progression
hyper-slow onset and progression
How do you treat hypo and hyperglycemia?
- hyper-non sugar IV fluids
- Very short acting-Lispro
- Short acting-Regular
- Long Acting-Ultra lente
- Very Long Acting-Glargine
Which type of DM is more likely to lead to PICU admission when not controlled?
Type I for hyperglycemia and ketoacidosis
Primary focus for discharge teaching/ed with parents for kids with DM
- insulin admin-draw up correct dose and admin
- how to monitor blood sugar and read results
- other areas....diet, exercise
Age related concerns for infants/toddlers with DM
- rapid growth/varying metabolic rate affects blood glucose levels and insulin needs
- picky eater
- hard to get urine samples from diapers
- can tell you how they feel-hypo/hyperglycemia
- afraid of needles
- don't understand why cant eat things and having painful procedures done
Age related concerns for pre school aged child with DM
- afraid of body mutilation associated with needles
- can now tell when they don't feel right
- have high energy which can affect blood glucose levels
- compliance and adjustments r/t special occasion with food (Halloween/birthday)
Age related considerations for the school aged kid with DM
- mastery of own glucose testing/injections
- now can discuss fears
- concerns about being different, activity limitations and dietary restrictions
- noncompliance with junk food
- anticipate needs for more glucose r/t sports
- **many get insulin pump**
Age related considerations for adolescents with DM
- activity, puberty and growth spurts affect glucose and insulin
- feel isolated from peers related to having DM
- start experimenting with alcohol/drugs
- non compliance with diet etc...to be normal
- **anorexia-purposefully withhold insulin and allow BG to increase to prevent weight gain**
Infants/kids are more vulnerable to alterations in F&E cuz
- have more water than adults
- have a higher metabolism
- greater surface area than adults
- inadequate fluid conservation with dehydration
- more vulnerable to fluid overload
- dependent on others for fluids and can be stubborn
Because infants have a higher concentration of water in their ECF, they can lose fluid equal to their ECF in how long?
What makes infants less able to concentrate their urine?
immature renal function...which also makes them more susceptable to acidosis
Infants have a immature lower esophageal sphincter....what's the result?
they are prone to GERD which can lead to dehydration and electrolyte imbalance
List all infection/diseases that make kids susceptible to F&E disturbances
- respiratory infection
Body weight loss for dehydration...mild, moderate, severe
- mild-4 to 5% (40-50mL/kg)
- severe 10%
With all dehydration the HR will increase....but at severe it....
increases then drops
What happens to BP during severe dehydration?
it drops significantly and collapses
How does LOC change with the different stages of dehydration?
- mild-alert, irritable, restless and THIRSTY
- moderate-alert, irritable, but lethargic
- severe-apprehensive, lethargic, COMA
What happens to the anterior fontanelle with the different stages of dehydration?
What happens to skin color with the different stages of dehydration?
- severe-gray and mottled
What happens to peripheral pulses with the different stages of dehydration?
- mild-normal to slight decrease
- severe-very weak to absent
What happens to a childs extremity temp with dehydration?
- mild-warm to cool
What happens to capillary refill when a child is severely dehydrated?
What happens to urine output when a childs dehydrated?
- mild-normal, slightly decreased
- moderate-decreased, dark and inc. USG
- severe-significantly lower UO to none
What happens to serum levels for a child with dehydration?
- mild-normal BUN And Cr
- moderate-increased BUN
- severe-increased Bun and Cr
Priorities for treating dehydration
- correct the fluid and electrolyte imbalance
- treat the cause
- keep sin intact
- get the person adequate nutrition....thru an IV if necessary
Vascular access for a dehydrated person
try peripheral then go intra-osseous
How do you replace fluids for a kid with mild dehydration?
oral rehydration with Pedialyte....1mL for 1mL replacement
How do you rehydrate a kid with moderate dehydration?
- rapid oral rehydration with pedialyte (50-100mL/kg over 3 h
- reevaluate rehydration status every 1-2 hrs
How do you rehydrate a kid with sever dehydration?
- IV bolus of fluids 20/mL kg of NS or LR
- when stable start oral rehydration 100mL/kg over 2-4 hrs
- *continuous evaluation after each bolus of IV solution
What causes diarrhea?
- intestinal infections
- food intolerances
- colon disease
- intestinal obstruction
- emotional stress
- infectious diseases
List infectious diseases that cause diarrhea
What do you assess with a person who has V/D?
What do you test on stool when a person has diarrhea?
- ova and parasite
- occult blood
- fecal fat
What do you test on a persons vomit
What do you test on a persons blood with V/D?
Dx tests done when a person has V/D to rule out other causes
- upper GI/Endoscopy
How do you treat a person with diarrhea
- oral rehydration....avoid juice, milk ok, but need electrolytes...not just water!
- BRAT diet
- NG tube
- perineal care
How do we treat a person who's vomiting?
- observe vomit
- assess for associated problems
- admin antiemetics
- sips of fluid of not NPO
If a baby is vomiting when do you admit and when do you treat and send home?
send home if >3 mo or >5kg, alert and mild dehydration
admit if <3mo or <5kg, prolonged illness and not urine output
Describe failure to thrive
- weighs <5% for age
- DD or behind in milestones
- hypotonia-decreased muscle mass
- thin hair
- brittle nails
- abdominal distention
- abnormal bowel habits
- anemia, calcium and or v. deficiencies
- self stimulating behaviors
- F&E imbalances
- decreased immune function
How can a baby be FTT due to inadequate caloric intake?
- fatigue/weak cuz respiratory, congenital heart, neuromuscular disease
- Nausea from chemo
- Poor suck/swallow-premie abnormal jaw shape
- Cleft/lip palate
- GI abnormalities-SBO
- Metabolic/malabsorption syndromes
Examples of ways to supplement ordinary foods with calories
- MCT oil
- corn oil
- breast milk fortifier
- carnation instant breakfast supplement to milk
- sour cream
- peanut butter
What causes GERD?
incompetent lower esophageal sphincter
Result of GERD
reflux of gastric contents in to the esophagus leading to ulceration, lung damage, apnea and pulmonary aspiration
If interventions don't happen with GERD what will the child die of?
What do 90% of babies do with GERD?
How does esophageal irritation present?
- fussy after feeds
- older kids complain of substernal burning
Complication after feeds when you have GERD?
- dx of GERD
- pH monitoring of distal esophagus
- *pH probe inserted nasoesophageally and sits above stomach
- pH of 4 or less is diagnostic-ACID
If a baby has GERD how do I burp them?
over the should and keep upright after feeds
With severe GERD how does a baby lay?
prone with head elevated....avoid infant seats cuz compresses the abdomen
What is a complication of Reglan for GERD?
Tardive Dyskinesia-involuntary repetitive body movements
Surgery for GERD
Nissen Fundoplication...stomach wrapping
When do cleft palate/lip form?
in utero at 4-9 weeks.....congenital
small or large split involving both the soft and large palate
poor sucking, choking, respiratory distress, apnea
slight indentation to complete separation that can involve the nose and or floor of nose
poor latch and sucking
How do you feed a child with a cleft palate/lip?
- feed upright
- special bottle to squeeze and nipple that has a x hole
If the cleft palate/lip is severe they may need....
GT for feeds
When do you see surgery performed on a child with a cleft palate, lip?
palate before speech of possible by 1-2 yo
lip shortly after birth
Post op considerations after a cleft lip repair
- elbow restraints
- positioning....don't lay prone
- rinse mouth after feeds
- sterile water cleaning of wounds
- antibiotic ointments
- oral feeds on side of mouth away from sutures with soft nipple
- pain man
Post cop considerations after a cleft palate repair
- elbow restraints
- rinse mouth
- soft nipple
- pain man
- *sucking restrictions-no straws, eat soft foods
- respiratory assessment looking for airway obstruction
- follow up with orthodontist, speech therapy
- possible need for myringotomy tubes
What is esophageal artesia?
pathological closure of the esophagus
What is Traheo-esophageal fistula?
abnormal formation of the trachea and esophagus....or maybe no connection at all
Kids with Esophogeal artesia and tracheoesophogeal fistula are at risk for?
- 4 c's
- copious oral secretions
How do you dx esophageal artesia and tracheosophageal fistula?
- NG tube unable to pass or comes back out
Prior to surgery of a kids with esophageal artesia and tracheosophageal fistula what are you managing?
- proper nutrition-parental/GT or JT
- keep airways clear...suction and O2 as needed
- antibiotics to prevent aspiration pneumonitis
How do you surgically repair an esophageal artesia and tracheosophageal fistula?
Ligate the fistula with an end to end anastamosis
Post op interventions for an esophageal artesia and tracheoesophageal fistula
- monitor airways
- promote nutrition slowly
- prevent infection
- pain man
hypertrophied pyloric muscle that prevents movement of stomach contents in to the jejunum
S/S of pyloric stenosis
- projectile vomiting shortly after feeds of partially digested foods and gastric contents
- always hungry even after feeds
- wt. loss
- metabolic alkalosis
What does the abdomen look like when a child has pyloric stenosis?
olive shaped mass in right epigastrium
Dx of pyloric stenosis
- X ray
- barium swallow w/ delayed gastric emptying
- string sign-threadlike pylorus
How do you manage pyloric stenosis?
- IV F&E replacement
- NG for decompression
- **surgery only after stabilization of F&E
Surgical repair of pyloric stenosis
Post op care after a pyloromyotomy for pyloric stenosis
- NG tube with decompression
- slow and gradual resumption of feeds
- vomiting can occur....so position upright and on right side
- pain man
colon is not innervated by ganglion cells resulting in a lack of peristalsis of food causing a dilation of the colon and an alteration in F&E
S/S of Hirschsprungs
- ribbon like stool
- abdominal distention
- bile stained emesis
- Englarged colon
Cardinal sign of Hischsprungs in a neonte
failure to pass the first meconium
Pre op management for Hirschprungs
- NGT for decompression and decrease abd. distention
- sline enemas to empty bowel
- measure abdominal girths
How do you support the parents of a baby with Hirschsprungs?
prep for colostomy and surgeries....probably exhausted from this disorder
an invagination of a section of the intestine in to the distal bowel that causes an obstruction
S/S of baby/child with Intussusception
- healthy child with sudden, sever abdominal pain
- blood diarrhea
- drawing up knees
- guarding abdomen
- *currant jelly stools
Intussusception shows up as what in abdomen
sausage shaped mass in the RUQ or epigastrium
Goal for treatment of Intussusception?
How do it?
restore bowel to normal position and function ASAP
admit to hospital to admin IV fluids, NG tubes and pain man.
Post reduction-observe for passage of barium, note stools and keep NPO till normal bowel function is achieved
What does the bowel do?
- absorption of nutrients, vitamins, minerals, electrolytes, iron, bile acids
- bacterial barrier and controls production of lactic acid
What can cause a loss of a portion of the bowel?
- necrotizing enterocolitis
- Crohns disease
How much bowel do you need to lose of the bowel to have malabsorption issues
- this causes a decreased mucosal surface area leading to inadequate absorption of fluids, electrolytes and nutrients
Nursing assessments for a person with SBS
- Alteration in F&E and acid base balance
- Malabsorption from diarrhea
- Feeding intolerance-gas, abd dist, vomit, gas
- osmotic diarrhea
- skin break down from diarrhea and acidic stools
- Liver disease
- *bacterial overgrowth, translocation of bacteria from the intestine to the blood stream
How will you see bacterial overgrowth, translocation of bacteria from intestines in to the blood stream in a child with SBS?
- foul smelling stool
- lactic acidosis
Most common symptom of SBS
**also see steatorrhea, bloating, excessive gas, foul smelling stool, poor appetite, vomiting, wt loss, fatigue
Complications of SBS
- Protein-caloric malnutrition
- Electrolyte imbalance
- Gallstones/kidney stones
- High levels of bacterial in the intestines
- vitamin/mineral deficiencies
Nursing considerations for a child with SBS
- Provide IV nutrition-TPN
- Careful intro of enteral nutrition...but advancement is from IV-NG/Gt-PO SLOWLY
- Monitor wt gain
- Monitor F&E
- Strict I&O
- Promote normal G&D
Meds for child with SBS
- H2R blockers
- antimobility agents
Vitamins for child with SBS
What is given to a child with SBS to stimulate intestinal mucosal growth?
glutamine and growth horomones
What is Celiacs disease?
when a person eats wheat, rye, oats and barley and the small intestine breaks it down in to gliadin, but this cant be digested. An accumulation of glutamine occurs which has a toxic effect on the mucosal cells.
What is the result of the toxic accumulation of glutamine with celiacs disease
villi atrophy causing malabsorption of fat, calories, carbs and vitamins.
S/S of celiacs crisis
- severe diarrhea--foul smelling
- poor perfusion
- change in VS
Dx of celiacs
IgA anti tissue transglutaminase antibody test
Nursing assessment of a child with celiacs disease
- can see as early as 4-6 mo...upon addition of gluten in to diet
- Muscle wasting
- Abdominal distention
- Chronic Diarrhea
- Apathy, irritability, fatigue, weakness, depression
What causes bruising
inability to absorb v. K
How do you manage celiacs disease?
- gluten free diet....feel better in 1 week!
- eat a high calorie, high protein, low fat diet
- vitamin supplements
Patho of Biliary Artesia?
begins prenatally, but appears healthy at birth
it is an obstruction of the extrahepatic bile ducts causing an obstruction of the normal flow of bile out of the liver and in to the gallbladder and small intestine
Result of biliary artesia.....leading to....
obstruction causes bile to form plugs and a back up of bile in to the liver causing inflammation, edema and hepatic degeneration
liver will become fibrotic and cirrhosis and portal hypertension develops leading to liver failure
How do you dx biliary artesia?
- Liver biopsy....but it can cause hemorrhage
S/S of a child with biliary artesia
- clay colored stools
- dark urine stained diapers
What causes FTT in a child with biliary artesia?
bile isn't present in the intestines so fat and fat soluble vitamins cant be absorbed which will cause malnutrition, and deficiencies in fat soluble vitamins
Describe Kasai procedure for Biliary Artesia
a portion of the jejunum is used to reestablish bile flow, this allows the bile to drain from the liver directly in to the intestines.
should do at 2 mo. old
Treatment options for a child with Biliary Artesia
- Liver transplant
- treat malnutrition and sumptoms.
After a child has had Kasai procedure for Biliary Artesia, what do I monitor them for?
What do I teach the parents of a child after Kasai procedure
- monitor BP always
- watch for GI bleeding
- severe edema
- ascites....may need diuretics, low sodium diet and IV albumin
What will a child take to assist with the secretion of bile salts and decrease pruritis?
Inborn Error of Metabolism
child eats carbs, proteins, fats and they cant be broken down in to energy due to a defect in specific enzymes (proteins) that help break down food parts
What is the result of inborn error of metabolism?
build up of toxic chemicals in the body
Dx of Inborn Error of Metabolism
heel stick done at 12 hours old.. and before the 6th day of life on all newborns. Tests for 45 metabolic disorders
S/S of Inborn Error of Metabolism?
- poor feeding
- altered LOC
- developmental regression
- seizures, coma death
Why is inborn error of metabolism hard to dx?
they cant talk and it they sleep a lot when normal
A toxic amount of this causes irritability
Clinical Management of inborn error of metabolism
protein restrictions + medications
Fatty acid oxidation defect
- fat restricted diet
- no fasting greater than 4 hours
- avoid fasting
- low protein and high carb foods
- supplement with Carnitine
Amino Acid disorders
Most common is PKU
- low protein foods
- amino acid replacement-sodium benzoate
most common is Galactosemmia
- eliminate galactose and lactose from the diet
- have patient drink Duart Galactosemia soy for the first year, check blood and then introduce dairy as tolerable
Nursing considerations for patient with Inborn Error of Metabolism
- med admin
- formula admin
- daily/hourly lab draws....reporting all abnormal labs to Dr. on call
- excellent assessment skills looking for decompensation
When do you discontinue NG tube feeds
- signs of respiratory distress
- abdominal distention
While kids are on tube feedings what is important to give them....
paci to associate sucking with feedings
or if older have child sit at table to promote socialization during feedings
When do you do gavage feeds?
in pre term infants prior to starting oral feeds....
small catheter is inserted through the nose or mouth to provide intermittent/continuous feeds
Describe bolus feeds
given over 30-60 min
Who should get Continuous feeds?
- infants with SBS
- congenital heart disease
- intolerance of bolus feeds
Position child is placed in to receive continuous or bolus feeds
on back or right side with HOB elevated
Which kind of feeding is at greater risk for aspiration?
After a bolus feed what do I do?
flush the tube with sterile water and clear it by injecting 1-5 mL of air
place child on right side with HOB elevated for 30-60 min and watch for signs of nausea, emesis and respiratory difficulties
IV infusion of solutions containing the major nutrients needed for metabolism and growth...it provides calories, amino acids, fatty acids and minerals specific to that child
Munchausen by Proxy definition
injury falsified or inflicted by caretaker and they bring them to hospital/doctor for attention/care
- decreased LOC
Shaken baby syndrome
vigorous shaking causing severe whiplash type of injury and leding to intracranial damage and intraocular damage
brain injury and brain death
Families at risk for abuse
- competitive environment for emotions
- altered family roles
- lack of trust
- drug abuse
- aggression used for conflict resolution
- altered communication patterns-threats
- dominant/controlling family member
- family hx of abuse
Children at risk for abuse
- premies-altered bonding
- chronic illnesses
- frustrating behavior-irritable baby, cant feed, cries a lot, ADHD, DD
- emotional disturbances
- birth order/gender
- passive child
- family scapegoat
What do adolescents who are abused need?
- Encouragement to.....
- stay in school
- have dreams
- want to live
someone will listen and can be trusted
What would you like to do?
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