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- 1-10 kg: 100cc/kg/day
- 10-20 kg: 50cc/kg/day
- > 20 kg : 20 cc/kg/day
-figure out minimum fluids for a pediatric patient??
- Children are at greater risk of fluid imbalances
- Newborn 70-83% body wt is H2O
Adults are 65% and the child doesn’t reach this level till 2 yrs
arge body surface compared with wt; either too much or two little fluid.
Vomitting/diahrrhea-Losing fluid risks.
**Types of Dehydration
children when they get sick, know if they've been drinking
Same loss of solvent and solute, major loss sustained from the ECF comparment which significantly reduces plasma volume and the circulating blood which affects skin, muscles and kidneys, shock is the greatest threat to life. Symptoms of hypovolemic shock. Plasma sodium remains within normal limits b/w 130 and 140 mEq/L
-primary form of dehydration in children
- => Hypertonic: Looses more solvent than solute
- - more water loss than electrolytes, most dangerous and requires more specific fluid therapy. Hypertonic diarrhea may occur in infants who are given fluids by mouth athat contain large amounts of solute or in children who receive high protin NG tube feedings..
-Plasma sodium Greater than 150 mEq, shock is less apparent altho much more water loss
- =>Hypotonic: Looses more solute than solvent
- -electrolyte deficit exceeds the water deficit leaving serum hyptolinc, ICF is more concentrated, Shock is frequent b/c movment of water to ICF which increases ECF volume loss. Physical signs tend to be more severe with small fluid loses. Serumm sodium concentration is less than 130 mEq.
- Water is the solvent & Electrolytes are the solute
**Symptoms of Dehydration
- =>5% Mild
- Loose 5% of BW
- still have tearsmay have sunken fontanel
- =>10% Moderate (kids that get admitted)
- Loose 10% of BW
- no tears, mucous membranes dry
- little urine output
- -count the diapers becuase you know they're taking something
- =>20% Fatal
- 20% loss of BW
- no tears
- parched mucous membranes
- no urine output
- fontanel sunken
- shrill cry
- alteration in loc
- Viral Causes
- Pyloric Stenosis is another cause: Pyloric sphincter is very tight so Food can’t pass. Child vomits PC (after meal)
- Vomiting progresses to projectile; shoots out of mouth
- Electrolyte imbalances: Metabolic alkalosis because stomach is acidic and they're getting rid of all those acids
- Surgical repair: reintroduce fluids in small amounts after repair (pediolyte, half strength to full strength formula)
- -Correct electrolyte balance first before surgery
- => Interventions: monitor electrolytes, I/O, sunken fontanel, nonelsatic skin turgor, dry mucous membranes, oliguria,provide antiemeitcs as prescribed
**Diarrhea in Children
Most common agent Rotavirus; there's an immunization vaccine to prevent this.
cause of serious gastroenteritis and is a nonsomcomial (hospital acquired) pathogen that is most seveer in children 3-24 months
Leading cause of mortality and morbidity is dehydration.
Older children replace with dehydration agents (gatorade, powerade)
Infants with large body surface area more at risk
- Fluid replacement with IV fluids
- After initial fluid replacement; Bland foods (skim milk, not reg milk)
- Brat Diet is now NOT RECOMMENDED b/c non nutritiveBland Diet,
stool, pain/cramping, metabllic acidosis and signs of dehydration
- => interventions:
- -for mild to moderate: provide oral rehydration with pedialyte, avoid sodas (gas producing) and sugary fluids
- -For Severe: maintain NPO status to place bowel at rest and provide IV fluid/electrolyte replacement, make sure child voids before giving potassium.
**Case Study DiarrheaAn 8 month old infant is evaluated in the primary care clinic because of fever, vomiting, and diarrhea of 12 hours’ duration.. The caregivers report that the infant has had three times as many stools as usual, and the stools are watery in consistency. After the initial examination of the infant, it is apparent that the child is mildly dehydrated because of stool losses secondary to acute infectious diarrhea. Which of the following interventions would be indicated?
1.Recommend that the caregivers offer fruit juice only and delay reintroduction of food x 48 hr
2. Administer antidiarrheal medications
3. Educate the caregivers regarding administration of oral rehydration fluids
4.IV fluids and provide nothing by mouth for several hours (THIS IS THE ANSWER!!)
**Constipation & abdominal pain
-Leading cause of people sent to gastroenterologist
-increase fiber diet: fiber one bars; prune juice everyday
- -Increase water
- -children at risk because kids hold they're stool
Congenital diaphragmatic hernia
-Diaphragm isn't developed and abdominal contents will move up into the chest and lungs. For child, surgery and fix diaphragm and excubate them
-qualify for synergist vacccine
-The esophagus terminates before it reaches the stomach ending in a blind pouch, forming an unnatural connection with trachea, causes oral intake to endter the lunch or a large amount of air to enter stomach, presenting a choking risk/sever abdominal distension, aspiration pneumonia may occur
frothy saliva in mouth/nose, Coughing, choking during feeding and unexplained cyanoiss, regurgitation
administer humidiefied o2, maintain npo, maintain IV fluids, maintain supine upright position (30 degs at least)
-espophagus isn't well formed so food can't pass through so these kids require G-Tube for feeds
- surgical repair:Colon upswing repair, take segment of colon, clean it, ligate colon but problem with this surgery is to repair, there's edema and swelling and upper airway needs blood, swelling blocks blood supply.
- -no nerve innervatiion, risk for reflux
-Tracheal Esophageal Fistula: hole between trachea and esophagus so food goes into lungs
At risk for aspiration
Gastronomy tube for nutrition until surgical repair
- close opening between esophagus and trachea
- -taken off oral, started on IV fluids,
- -surgical correction:ligation, gastrostomy,
anus doesn't go all the way to the rectum temporary colostomy until defect can be repaired
-postop interventions: monitor skin for signs of infections, side lying prone position with hips elevated, NPO status , IV flluids until GI motility returns, provide care for colostomy if present
aganglionic section of the Bowel so no nerve innervation, food goes to it, and from it, but not THROUGH it.
-we do a temporary colostomy (until they're two)and whn child gets bigger, we remove that section of the bowel and eventually take down the colostomy
-Stool softening agents
-Most serious complication is enterocolitis; signs include fever, severe prostration, gastrointestinal bleeding and explosive water diasrrhea
-treatment involves two step surgial procedures: temp colostomy is created to relieve obstructiion and allow the normally innervated, dilated bowel to return to it's normal size, when the bowel returns to its normal size, a complete surgical repair is performed via a pull through procedure to excise portions of the bowel and the colostomy is closed
-assessment: failure to pass meconium stool, refusal to suckl, abdominal distensiton
-INTERVENTIONS: maintain lowe fiber, high calorie, high protein diet, administer stool softeneres, daily rectal irrigations wiwth nnormal asaline to promote adequate elimination and prevent obstruction
- Position on abdomen pc
- thicken foods
- feed upright-problem with preemies b/c they're lying flat when they're getting fed.
abdominal contents are outside the body and so they pediatric surgery, basically take them to surgery, the contents must be kept sterile and moist, b/c abdomen wasn't born wilth the contents in it, the contents must be tented that will gradually go down into the duct by gravity.
-High risk for infection.
- If baby is born vaginally, there is less fluid in lungs because they get squeezed out.
=>Cleft Lip and Palate
cleft lip or cleft palate (can be fixed at 9 months) or both
-causes: rubella virus, exposure to radiation, chromosome abnormalities, and hereditary
-close the cleft lip before closing cleft palate
-get many ear infections due to defective eustachian tubes (frequent otitis media can result in hearing loss.)
Multilevel intervention: speech pathologists, orthodontists, plastic surgeons, ent doc
lip repaired at about 2 months
palate at about 2 years
-no crud, wash suture lines, want to heal perfectly and beautifully.
- elbow restraints
- speech defects
- faulty dentition
- Emphasize normalcy to parents of the infants, that this can be fixed
Feed upright, and direct the formula to the side and back of the mouth to prevent aspiration, feed small amounts gradually and burp, keep suction equipment ready
May require special nipples
Mothers can breast feed, but will require assistance from lactation spec; used to feed with syringe, but now can feed with nipple
=> Post op:
Keep sutures clean with NS, apply antibiotic, use elbow restrains, no lying on on prone! Don't place objects in mouth
Includes massive proteinuria, hypoalbuminemia, hyperlipidemia and edema and hypercholesterolemia
- -kidneys hyperpermeable to protein,
- -no albumin in in vascular system (protein) hence hypoalbuminemia
Secondary disorder after in association with glomerular damage
- Congenital form inherited as autosomal recessive disorder
- -primary objective: to reduce the excretion of urinary protien, maintain protein free urine, reduce edema and prevent infection while avoiding complications
- Ages 2-7 y
- Pathogenesis unknown
- Glomerular membrane becomes highly permeable to protein; This reduces serum albumin decreasing colloidal osmotic pressure which results with edema
child gains weight, facial edema inmorning, urine output decrease, hematuria, Lethargy/pallor, massive proteinuria and dcreased serum protien (hypoprotinemia)
- Goals reduce excretion of urinary protein, reduce fluid retention, prevent infection, minimizing complications
- Diet: Low salt
- Corticosteroids first line therapy: 2mg/kg/day Most children respond 7-21 days
- 80% of children have positive prognosis
- =>Nursing Care
- Regular monitoring of vital signs
- Monitor volume and character of urine
- Daily weights
- Monitor urine for albumin
- Measure abdominal girth
- Monitor for infection
- Encourage eating with no added salt, minimal appetite
- -end up on renal dialysis
- Most cases post infection with pneumococcal, streptococcal, and can be viral
- Most common post infection in children
- - charcterized by inflammatory injury in the glomerulus, results in proliferative and inflammatory changes within glomerular structure, inflammation of the glomeruliresutls from an antigen-antibody reaction produced by an infection elsewhere in the body and loss of kidney function develops.
- - complications: kidney failure, Hyperensive encephalopathy, pulm edema and heart failure
Immune complexes deposited in the glomerular basement membrane
Glomeruli become edematous and infiltrated with polymorphonuclear leukocytes which occlude capillary lumen
Decrease in in plasma filtration results in excessive accumulation of water and retention of sodium expands plasma and interstitial fluids, leading to circulatory congestion and edema
- Child in good health until streptococcal infection
- Onset of nephritis takes 10 days before edema starts
- Urine with hematuria and proteinuria
- Azotemia results from impaired glomerular filtration
- Elevated BUN and CR
- -anorexia, cloudy/smokey brown colored urine (hematuria, pallor, HTN, proteinuria (and excessive foam in urine), increased anti-stretolysin O titer
- Supportive measures
- Moderate sodium restriction
- Regular measurement VS, Wt, I&O
- Acute HTN
- weigh renal kids everyday
- Almost all children will recover completely with specific immunity conferred (meaning immune to streptococcus)
- =>Nursing Care
- Monitor Vital signs, fluid balance, blood pressure, behavior
- Daily weight, intake and output
- Observe for signs of cerebral complications
- Regular diet no added salt
- During acute phase content to be in bed
- Health supervision with weekly follow-up and evaluation of urine
**Urinary Congenital Defects:Hypospadias and Epispadias
: Penile opening on ventral (on the top -epispadias) and dorsal side if penis, require multi-stage repair, body image issue
- Post-op required to lay on back for up to 7-10 days.
- -suprapubic cathethers
- -done when they'r'e todlers
Dorsal placement of urethal opening (top)
Ventral placement of urethral opening (bottom/back)
crooked erection -ligate the curviture
**Failure to Thrive
- =>Organic: Physical causes
- Cystic Fibrosis
- Malabsorption syndromes
- =>Inorganic: no physical reason why they're not thriving..
- Alteration between mother and infant.
- Higher incidence high-risk mothers: teens, drug users, psychiatric pts.
- akaBedwetting: No fluids after dinner
- Toilet HS
- wake prior to parents going to bed go toilet
- Bed Alarms
Passing Stool involuntarily in Pants
Encourage regular use of BR
Treat if constipated or loose stools
DO NOT PUNISH
=> evidence of soiling of clothing, scarching or rubbing of the anal area
-> interventions: maintain high fiber diet and high fluids, decrease sugar and milk intake
Constipation Case Study Question: An 8 month old is seen by the pediatric nurse practitioner. The infant’s mother states that the infant usually has one hard stool every 4-5 days, which cause discomfort when passed. The infant has had one episode of diarrhea and two episodes of ribbon like stools. Abdominal distention and vomiting have not accompanied the constipation. And the infants growth has been normal. The infant’s diet consists of cow’s milk formula only. The infant's mother reports that the infrequent passage of hard stools began approximately 6 weeks ago when she stopped breastfeeding.
-higher level of constipation when going from breastmilk to cowsmilk.
Which of the following interventions should the nurse practitioner include in the initial management of this infant’s problem?
1. Prescribe several medicatins to be given daily to maintain a loose consistency of stools
2. Tell the infant’s mother that she stopped breast feeding too soon and if she resumes breastfeeding, the constipation will resolve
3. Reassure the mother that constipation may occur with a change of diet and recommend that the mother slowly introduce cereal ad prune juice into the infant’s diet (THIS IS THE ANSWER)
4. Refer the mother to a pediatric gastroenterologist for further evaluation