What are pediatric GI concerns?
1. Fluid and Electrolyte imbalances
2. Infectious Gastroenteritis
3. Cleft Lip/palate
4. Congenital GI defects
5. Intussusception
6. Celiac Disease
Why are the children at risk for F&E imbalances?
� Infant kidneys are immature (harder time to acidify urine)
� Infant=
> greater body surface area (~40% weight is extra cellular)
> metabolic needs (increased respiration rate, increased peristalsis)
> elimination needs
What is the normal pediatric urine output?
1-3 ml/kg/hour
What is the fluid requirement for children?
CHILD= 100 cc/kg
� Daily Maintenance Fluid Requirements
1. Calculate weight of child in kilograms.
2. Allow 100 ml./kg for 1st 10 kg.
3. Allow 50 ml/kg for second 10 kg.
4. Allow 20 ml/kg for remainder of weight.
5. Divide total amount by 24 hrs to obtain
Phases of fluid therapy
� Prevent or treat shock and restore circulation (must replace fluid otherwise BP will not be stable)
low BP is a late sign of shock in children
� Partial restoration of ECF volume and acid base status. (Assess
� Restoration of K (to avoid cardiac arrhyth
What kind of fluid do you give when a patient is dehydrated?
Isotonic solutions - NS
Usually NS bolus
Level of dehydration in children
- Mild dehydration is a loss of 4-5% of body weight and fluid loss of 50ml/kg or less
- Moderate : 6-10% loss of body weight and fluid loss of 50-100ml/kg
- Severe: a loss of 10% or more of body weight and fluid loss of 100ml/kg or more.
1 liter of fluid
Types of dehydration in children
Hypernatremic dehydration
Isotonic dehydration
Hyponatremic dehydration
HYPERNATREMIC DEHYDRATION
- Elevated Na+ level ? need to drop Na+ quickly
- Rehydrate over 48h
- Risk of too quick Na+ drop = cerebral edema = ? ICP (bulging fontanel, decreased LOC/lethargic, behavioral changes
ISOTONIC DEHYDRATION
- Equal levels of H2O and Na+
HYPONATREMIC DEHYDRATION
- @ risk for cerebral edema
- Rehydrate over 24h
What are major clinical manifestations of F&E problems?
Vomiting and Diarrhea
Vomiting
VOMITING maybe due to:
- improper feeding (over distended stomach)
- infections/obstructions of GI tract
- food allergies
- emotional
- F.T.T ( failure to thrive)
What metabolic state will vomiting result in?
will result in metabolic ALKALosis - d/t volume depletion
- when stomach contents are vomited, the acidic content will not go through the alkaline intestine. Because of this, the intestine will not be neutralized by the acid and will result in alkalosis
What is the difference between regurgitation and vomiting?
It depends on the timing, duration, distress, description and forcefulness.
Vomit comes from the stomach
regurgitation comes from the esophagus usually from over feeding
Diarrhea
Maybe due to:
� Infections / diseases of the GI tract
� Poor feeding technique
� Emotional
� Will result in metabolic ACIDosis
gastroenteritis
caused by a virus, bacteria or parasite
Viral gastroenteritis causes ~80% of childhood diarrhea cases
Infectious Gastroenteritis
�A group of viruses, bacteria, & parasites
- can lead to major F&E disturbances, sepsis, and even death
�Etiology: Ingestion of contaminated food or water & person to person
�Incidence: .71 million childhood deaths
Types of Infectious Gastroenteritis
1. Rotavirus- common nosocomial infection
2. Bacterial-salmonella, shigella, campylobacter
3. Parasites-Giardia, Crytosporidium, worms-pinworms/roundworms
What is sepsis?
Toxic inflammatory condition cause by spread of microbes from infection into the blood
septic shock
sepsis and uncontrollable decreased blood pressure
Common causes for gastroenteritis
� Shigella - fecal-oral (water to bloody stools / diarrhea)
� Salmonella - foodborne; rapid onset
� e. coli - green, watery stools
� Rotavirus - fecally contaminated foods ( diarrhea, low-grade fever)
� C. diff - most common hospital acquired diarrhea d/t
Assessment/interventions/evaluation for gastroenteritis
� Assessment: LOC Hydration (specific gravity)
� Interventions: Rehydration I/O's weight measurements antibiotics if needed Serum electrolytes
� Evaluation 1. Childs weight back to pre-infection 2.Hydration status 3. BM without diarrhea, blood, mucus
CLEFT LIP/PALATE
CLEFT LIP- incomplete fusion of oral cavity (indentation of lip)
CLEFT PALATE-incomplete fusion of primary and secondary palatine plates.
INCIDENCE OF CL / CP
Developmental Variable � Cleft lip - due to incomplete embryonic development (6-8 weeks) / CP (7-12 wks) � CL: > male CP: > female
Sociocultural Variable � CL = rare in African Americans � > in Asians & Native Americans
Cleft Lip: INTERVENTIONS
� Depends on severity of defect
� 1st intervention: modify feeding technique
� CHEILOPLASTY - cleft surgery after birth or until 3-6 months (need revision @ 4-5 years d/t growth) Multicollaborative: - surgeon, psychologist, speech therapist, ENT
Cleft Lip: DX / INTERVENTIONS/ PC's
NURSING DX - Post-Op 1) Ineffective airway - Position: Semi-Fowler's (infant seat) - Gentle suction (red robin) 2) Impaired skin integrity - Logan bar - Elbow restraints - Feeding - no straw or nipples INTERVENTIONS - Abx - Suture care Collaborative Probl
Cleft Palate: INTERVENTIONS
� PALATOPLASTY - cleft palate surgery (6-24 months)
� Early closure: speech development (better)
� Complication: chronic otitis media (PC)
POST-OP � Position: supine / side-lying � Feeding: liquids for 1st 3-4 days - Avoid tongue depressor, spoon, straw -
Congenital Gastrointestinal Defects
� ATRESIA- congenital absence or closure of an opening
� STENOSIS- narrowing of a body passage or opening
� FISTULA- abnormal tubular passage
Types of Atresia
1.Atresia w/ DISTAL FISTULA Stomach attached to trachea - Food will come back up; air in stomach - Constant saliva, drooling
2.Atresia w/ DOUBLE FISTULA Esophagus & stomach each attached to trachea separately - Possible aspiration; stomach w/air - Respira
TRACHEO-ESOPHAGEAL FISTULA (TEF)
� TRACHEO-ESOPHAGEAL FISTULA
failure occurs during the 4-5 th week of pregnancy no difference in sex
� Premature w/ mother who has Polyhydramnios
Dx- 1. Clinical signs and symptoms 2. Radiographic studies
NURSING MANAGEMENT of TEF
1. Assessment- signs and symptoms a. excessive salivation and drooling b. 3 C's- coughing, choking, cyanosis c. apnea d. > resp. distress esp. during/after feeding e. Abdominal distention
2. Interventions- - Resp assessment - NPO - IV fluids - VS - I&Os -
Medical interventions
Emergency surgery - Gastrostomy - Abx prophylaxis Surgery - done in stages to close the fistula & anastomose of the esophageal segments (pull together)
Pyloric Stenosis
Pyloric Stenosis (hypertrophic) - Narrowing of the pyloric orifice due to hypertrophy / hyperplasia of the pyloric valve muscle making it difficult for the stomach to empty
Cause: unknown
Surgery: Pyloromyotomy (widen pyloris)
Pyloric Stenosis incidence
Developmental
- 4-6 weeks
- Less in breastfed infants, ? in full-term infant
Sociocultural
- Males > females
- ? in white infants
Heredity
- First-born & offspring of affected parent ? risk
DIAGNOSIS & ASSESSMENT Pyloric Stenosis
DIAGNOSIS
- Objective: U/S, endoscopy
ASSESSMENT
- Projectile vomiting after feeding
- Weight loss
- Signs of dehydration (metabolic alkalosis)
- Distended upper abd
- Visible peristaltic waves - observe while drinking
- Palpable olive size mass (RUQ)
PYLOROMYTOMY pre & post op
PRE-OP
- NPO
- NG to gravity
- IV fluids
- Consent / pre-op teaching (diet)
POST-OP
- Feeding regimen 1) Start with Pedialyte 5cc ? wait 2h 2) then Pedialyte 10cc 3) then Pedialyte + milk - � strength formula / breast milk 4) then full-strength formula /
ANORECTAL MALFORMATIONS
� (IMPERFORATE ANUS)
ANAL AGENESIS Rectum ends in a blind pouch above anus (at various distances)
RECTAL ATRESIA - Rectum ends in a pouch - Anal opening is normal but rectal canal not continuous Ensure meconium coming out of anus
Newborn Assessment ANORECTAL MALFORMATIONS
- check for anal patency
- Visualize
- Passage of meconium
S/S
� Failure to pass meconium � Absence of anorectal canal � Presence of anal membrane � External fistula to the perineum
Treatment, post op and teaching re anorectal malformations
SURGERY � Colostomy � Anorectoplasty (pull through procedure)
POST-OP INTERVENTIONS � Scrupulous perineal care - dressing & drain � Position: Side-lying - Prone - w/ hips elevated - Supine - w/legs suspended at 90 degree angle to the trunk
Teaching parent
INTUSSUSCEPTION
Intussusception is an invagination of a section of the intestine into the bowel that causes an obstruction
- Most cases before 2 years of age
- Incidence 1-4 in 1000 births -
Common with children with Celiacs dz and Cystic Fibrosis
INTUSSUSCEPTION assessment, diagnosis, treatment
ASSESSMENT � Severe pain � S/S of bowel obstruction � Palpable abdominal mass � S/S of dehydration
Diagnostics: � Abdominal radiographs �Ultrasound � Barium enema � Air enema
Therapeutic management: � The goal of treatment is to restore bowel to its norma
Celiac Disease
� Celiac dz: also known as gluten enteropathy
� 80-90% of children have a genetic marker HLA-B8: leukocyte antigen complex located on chromosome 6. this chromosome variation results in the inability to digest gliadin causing severe GI mucosal changes that
Assessment and diagnosis for celiac disease
� Major manifestations: Growth failure(FTT below 25%), Diarrhea (foul smelling,fatty stool)
� Other manifestations: abdominal distention, vomiting, anemia, irritability, anorexia, and folate deficiency
�Diagnostics: Immunoglobulin A (IgA) and antitissue t
treatment of celiac disease
- Dietary supplements - A, D, E, K (fat-soluble vitamins) + folate
- Gluten-free diet (no wheat, barley, oat, rye)
Adolescence are difficult to treat because they do not like to adhere to the diet