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Prittyrick
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variations in Ped A&P
- Gi not fully mature until 2
- mouth: highly vascular organ, incre risk of infection (handwashing)
- esophagus: edema or narrowing, decre tone, lax/les regurgitation
- Stomach: NB capacity 10-20ml, adolescent 1,500ml 12m 200-250ml. Narrow pyloric sphincter= stenosis
- Intestines: not functionally mature at birth
- billary system: liver large= 5% infant body weight. Pancreatic enzymes at adult levels by 2 yrs.
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Variation in Pediatric A&P
fluid balance, insensible fluid loss
- fluid balance and fluid loss:
- Body fluid balance (infants and children)
- - body water incre compared to adults
- - required incre fluid intake
- - at increase risk for fluid loos with illness (fever, loss thru vapor and skin)
- Insensible fluid loss (losing water everywhere) (infant and children)
- - fever: severe fluid loss
- - skin: larger body surface area
- - basal metabolic rate: increased to support growth which incr need for water. kidneys immature (comes out more faster)
- 7ml/kg loss of water w/fever 1.8 degree above normal for 24hrs
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Nursing assessment
collect hx
Physical exam
- chief concerns- v/n/d constipation, abd pain, distention, decre weight, lethargy, paleness
- pregnancy hx- hydraminos- oligiohydraminos
- PMH hx of V/D. abd pain
- Fhx family member with a similar disorder
- stress at school and home
- how many times in the last 24 hrs for vomiting and diarrehea
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Common medical treatment
- cleansing enema- children with encoprisis (holding on to stool)
- bowel prep- surgery, c-scope, cleanse colon
- IV therapy- fluid to help with dehydration
- Ostomy- diversion of bowel to be outside
- oral rehydration therapy
- probiotics- give back normal flora
- total parenteral nutrition- IV complete nutrition. special formula that goes thru the vessels
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Common medical treatments: ostomy
- stool diversion: ileostomy or colostomy
- - portion of the small or large intestine to abdominal surface=stoma
- Ostomy care: pg 1339 ricci stoma
- - set up equipment
- - warm wash cloths or paper towels
- - clean pouch and clamp
- - skin barrier: power paste sealant
- - pencil or pen
- - scissors
- - pattern to measure stoma size
- - take of pouch, adhesive remover
- - observe the stoma and skin. clean stoma and skin as needed. allow to dry throughly
- - measure stoma, mark the new pouch backing and cut new backing to size
- apply pouch
- REMEMBER STOMA
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commons nursing dx
- imbalance nutrition, less body requirement- celiac disease malabsorption
- pain- acute, surgery
- risk for infection
- fluid volume excess
- fluid volume deficient
- constipation
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Dehydration extra Kim
- vomiting: hold PO feed for 1-2hr after vomiting. give 0.5-2oz q 15. advance as tolerated (50-100 ml/kg)
- home ORT (pedialyte):
- - oral rehydration therapy
- - mild to moderate dehydration
- - 1 quart of water
- - 8 tsp of sugar
- - 1 tsp of salt
- Nausea: ginger ale. the real ginger canada dry
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Dehydration
- occurs when water loss exceeds water intake over a period of time and the body is in a negative fluid balance
- dehydration is a common sequel of prolonged bouts of diarrhea or vomiting, profused sweating, water deprivation, hemorrhage, burns
- early signs: sticky oral mucous, thrist, dry, flushed skin, decre urine output (oliguria)
- hypovolemic shock: occurs due to incr water lost from the ECF compartment, once lost there is not enough blood volume to maintain normal circulation
- - if left uncheck
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Types of dehydration
p 1345
- mild dehydration: alert, fontanels soft and flat, eye normal pink moist mucous membrane, normal HR and BP, elastic turgor, brisk cap refill, slight decr urine output
- Moderate dehydration: alert to listless (lethargic), sunken fontanels, pale, slightly dry mucous membrane, decre turgor, HR incre, bp normal, delayed cap refill, urine output decre
- Severe dehydration: alert to comatose, sunken fontanels, deeply sunken eye, dry oral mucosa and tenting, HR incre to bradycardia, BP normal to hypotension, cool mottle skin, delayed cap refill, urine decre to < 1ml/kg/hr
- normal urine 1ml/kg/hr for children (up to 6-8)
- adults 30 ml/hr
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Nursing management dehydration
- Goal is to restore fluid volume and prevent hypovolemia
- provide oral rehydration therapy
- mild to moderate dehydration
- - give 50-100 ml/kg of ors over 4 hrs
- severe dehydration:
- - IV fluids, Initially 20ml/kg of NS or LR bolus
- ex: child weigh 20kg you would give 400ml
- - once balance restored we use a maintenance rate
- -- 100ml/kg for the first 10 kg
- -- 50ml/kg for the next 10kg
- -- 20ml/kg for remaining kg
- ex: child weighs 12kg how much 1040ml (remember 2kg remaining so use the 20 to calculate then divide by 24 hrs) 43.3ml/hr
- ex
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Vomiting
- def: also called emesis, forceful emptying of the stomach contents thru the mouth
- cause: mild gastroenteritis (infection) either viral and bacteria (e.coli, shigella), head injury, pnemonia
- pathophysiology: areas in the medulla control vomiting reflex, chemoreceptors in the 4th ventricle stimulate vomiting. maybe a learned behavior in response to stress, wet burp, spitting up fyi
- complications: metabolic alkalnosis, stomach acid loss, dehydration malnutrition, apiration, mallory weiss syndrome (tear in the mucosa in lower esophagus)
- billous bc of bile obstruction yellow/green color (not normal)
- bloody vomiting not good
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vomiting assessment, dx
- assessment:
- non or projectile vomiting
- asso symptoms- fever, nausea, HA, abd pain, constipation or diarrhea, blood in vomit, bile, undigested or digested food, determine amt and force of vomit
- dx:
- UA for blood or protein
- basic metabolic panel for lytes
- abd x-ray or u/s for abd abnormalities
- endoscopy]CBC
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Vomiting management and intervention
- Medical management goal: prevent further episode:
- zofran (not for babies) ondansetron antiemetic
- drugs to stimulate upper GI peristalsis metoclopromide (reglan), Phergan (promethezine)
- Nursing intervention:
- evaluate feeding methods, position side lying, maintain patent airway, suction as needed, hold foods/fluids to rest stomach for 4-6 hr
- for severe vomiting : IVF, PO clear liquids (pedialyte, popsicle)
- for older children: antiemetic, hemoccult emesis, describe type and amount, HOB up, skin and mouth care, monitor hydration, monitor bowel sounds
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diarrhea and gastroenteritis
- def: diarrhea: increase frequency, amount, and decr consistency of stool
- def: gastro: inflammation of the lining of the stomach and intestines. classified as mild to severe
- Causes:
- - virus (rotavirus and adenovirus, norovirus)
- - bacteria (c. diff, staph, samanella, shigella, e.coli)
- - other: amoebea, parasites, ingestion of toxins, drug reactions, enzymes deficiencies, food allergens
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Diarrhea and Gastroen (path, complication, assessments, dx)
- Path:
- virus cause injury to the intestinal mucosa. water in bowel incr from the osomotic pull w/electrolytes imbalance. peristalsis incre
- complication: metabolic acidosis, dehydration (serious in infants bc they need water)
- assessment finding: loose, watery stools, abd discomfort, nausea, vomiting, fever
- dx: stool culture and sentivity, blood cultures (identify causative pathogen)
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diarrhea/gastro management/intervention
- medical management: bedrest, nutritional support, incre fluid intake PO or IVF, electrolyte replacement
- Nursing intervention:
- depends on severity
- mild diarrhea care for child at hoe. hold foods and fluid to rest abdomen for a short time 1 hr. then offer ORS ie pedialyte in small amounts. avoid high sodium food
- correct dehydration
- begin fluid with ORT
- skin care with protective ointments
- monitor i&o and v/s axillary temp
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