Gastrointestinal Dysfunction

clinical manifestations of mild dehydration

changes in behavior, dry mucous membranes, anterior fontanel pulse, normal BP, slightly thirsty

behavior in mild dehydration

changes

mucous membranes in dehydration

dry

anterior fontanel in mild dehydration

pulsating

BP in mild dehydration

normal

how do you treat mild dehydration

oral rehydration of 50 mL/kg within 4 hours

clinical manifestations of moderate dehydration

capillary refill between 2-4 seconds, thirst and irritability, slightly increased pulse, normal to slightly low BP, dry mucous membranes, decreased tears, decreased skin turgor, normal to sunken fontanels in infants

capillary refill time in moderate dehydration

between 2-4 seconds

pulse changes in moderate dehydration

slightly increased

BP changes in moderate dehydration

normal to slightly low

tear production in moderate dehydration

decreased

skin turgor changes in moderate dehydraton

decreased

HR in moderate dehydration

slight tachypnea

fontanels in infants with moderate dehydration

normal to sunken

how do you treat moderate dehydration

oral rehydration of 100 mL/kg within 4 hours

clinical manifestations of severe dehydration

greater than or equal to 10% weight loss, capillary refill > 4 seconds, increased pulse, decreased BP, extreme thirst, dry mucous membranes, tented skin, no tears with sunken eyes, sunken anterior fontanel, oliguria/anuria

weight change in severe dehydration

greater than or equal to 10% weight loss

capillary refill time in severe dehydration

greater than 4 seconds

pulse change in severe dehydration

increased

BP change in severe dehydration

decreased

thirst in severe dehydration

extreme

integumentary changes in severe dehydration

tented skin

tear production in severe dehydration

no tears with sunken eyes

fontanel changes in severe dehydration

sunken anterior fontanel

urine changes in severe dehydration

oligura/anuria

how to treat severe dehydration

IV rehydration with isotonic solution at 20 mL/kg IV bolus over 30 minutes

questions you should ask parents to check for dehydration in their child

is there pee every 8 hours, are they still making tears, are their mouths wet?

what level of dehydration indicates hospitalization?

severe dehydration

if you need to give IVF for a child, what is the rate?

maintenance rate or 1.5x maintenance rate (100 mL/kg/day)

therapeutic management goals for dehydration

correct F/E imbalance, treat underlying cause

nursing care for dehydration

closely observe because changes can occur quick

first two signs that a child is ill

loss of appetite and decreased activity

if a child is "allowing" you to complete procedures and not fighting you, what could that indicate?

they are very ill

edema in children

unique to them due to water and body tissue make-up; they can have edema but be dehydrated

what is vomiting

complex process controlled primarily by CNS where there is forceful ejection of stomach contents through mouth

what is vomiting often accompanied with

nausea and retching

causes of vomiting

acute infectious agent, increased intracranial pressure, toxic ingestions, food intolerance or allergies, GI tract mechanical obstruction, metabolic disorders, renal disease, psychogenic problems

what can help determine cause of vomiting?

color and consistency of emesis

green bilious emesis can indicate

bowel obstruction

undigested or partially digested food vomited hours after ingestion can indicate

poor gastric emptying or high obstruction

forceful vomiting can indicate

pyloric stenosis

fever with vomiting and diarrhea can indicate

infection

therapeutic management for vomiting

treat underlying cause, prevent complications such as dehydration and malnutrition

when would you use anti-emetics

if child is not bale to tolerate anything PO; last chance resort

pharmacological management for vomiting

zofran or reglan; antiemetics

nursing care management

keep NPO if surgery, keep hydrated, advance diet when emesis stops, elevate HOB after feeding, encourage brushing of teeth

diarrhea results from

disorders of digestion, absorption, and secretory functions

etiology of diarrhea

most diarrhea caused by a pathogen through the fecal oral route in food or water

common causes of diarrhea

rotavirus, salmonella, shigella, giardia, AB administraton

Rotavirus accounts for how many fatalities caused by diarrhea

28%

what is Rotavirus

viral pathogen that infects children under 5 y/o; usually through person to person contact

Salmonella, shigella, and giardia

bacterial pathogens most commonly isolated in US; transmitted through raw or undercooked food

why does AB administration cause diarrhea?

disrupts normal intestinal flora that allows overgrowth of other bacteria; most common is C. DIFF

what to recommend to parents if their child is on antibiotics

probiotic supplement or yogurt every day they're on ABs

how to diagnose diarrhea

Hx, physical exam, recent travel, stool testing, appearance of stool

watery, explosive stools indicate

too much glucose

foul smelling, greasy, bulky stools indicate

malabsorption

when should you do stool testing

if they had diarrhea over 1 to two weeks, worried about bacterial infection, constant blood in stool

why do we not recommend pedialyte to rehydrate for diarrhea in children?

may cause too much glucose

what can we give to children to help treat diarrhea

usually water, something lower in sodium due to risk of hypertonic dehydration in infants

for diarrhea do we limit fluid intake?

no

if diarrhea continues but the child is not dehydrated, what should we do

alternate ORS with another low sodium fluid (water, breast milk, formula)

what diet should we start with for patients with diarrhea

BRAT or blan diet and gradually advance

replacing stool loss ratio

1:1 with hydration fluids

if you have a diaper weighing 50 grams, how much liquids should you give them

50 mL over 4 hours to replace that loss

education for diarrhea management

causes and preventions, ORS and advancing diet

diaper rash interventions for diarrhea

apply protective ointments when diarrhea starts (very acidic)

what is constipation

decreased stool frequency and increased hardness of stool with difficulty passing

constipation stool qualities

painful or blood streaked (anal fissure) and can cause abdominal pain, lack of appetite, may lead to incontinence of stool

what is encopresis

Fecal soiling of clothing; fecal deposition in inappropriate places

causes of constipation

structural disorders, systemic disorders, medicatons, spinal cord lesions, idiopathic

structural disorders that cause constipation

strictures, ectopic anus, Hirschsprung disease

systemic disorders that cause constipation

hypothyroidism, hypercalcemia, vitamin D excess, lead poisoning

medications that cause constipation

narcotics, diuretics, antacids, antihistamines, iron supplements

why do spinal cord lesions cause constipation

loss of rectal tone and sensation

most common cause of constipation

idiopathic (no underlying cause); often as a result of illness, withholding, psychosocial factors, dietary habits

#1 cause of constipation in children

iron supplements

how to diagnose constipation

history and physical

therapeutic management of constipation

#1 modify diet (water and fiber)

#2 behavior modification (scheduled 30 min potty time after meal)

#3 stool softeners (miralax)

nursing management of constipation

education; how to help and stop recurrence

Hirschsprung Disease (Congenital Aganglionic Megacolon)

congenital anomaly resulting in mechanical obstruction due to lack of motility of a portion of the intestine

The absence of ganglion cells due to Hirschsprung Disease can cause

loss of rectosphinceteric reflexes and an abnormal microenvironment of the cells of the intestine

what body parts are affected by Hirschsprung Disease

internal sphincter, rectum and a few cm of the sigmoid colon;

what happens to areas affected by Hirschsprung Disease

cannot relax and stool cannot pass

newborn clinical manifestations of Hirschsprung Disease

failure to pass meconium in the first 24-48 hours (#1 sign), refusal to feed, bilious vomiting, abdominal distension

infant clinical manifestations of Hirschsprung Disease

failure to thrive, constipation, abdominal distension, episodes of vomiting and diarrhea

how to diagnose a child with Hirschsprung disease

99% of infants will pass first meconium in the first 24-48 hrs of life; rectal biopsy will show absence of ganglion cells

therapeutic management of Hirschsprung Disease

surgical removal of dysfunctional bowel (need), temporary colostomy

nursing care for Hirschsprung Disease

encourage parent-child bonding, educate on pre/post op care, manage pain, monitor abdominal circumference, educate about complications

Gastroesophageal reflux (GER)

transfer of gastric contents into the esophagus (NOT GERD)

GERD

symptoms or tissue damage that results from having GER

When does GER occur

throughout the day but more common after meals and at night when laying down

How to treat GER

sit up for 30-60 minutes after eating

Peak incidence of GER

children that are at 4 months of age but most instances resolve by 12 months of age

complications from GER

FTT, respiratory problems, dysphagia

Incidence and prevalence of GER

impaired neuro status, hiatal hernia, morbid obesity, premature, tracheoesophageal/esophageal atresia, scoliosis, CF, cerebral palsy

clinical manifestations of GER in infants

recurrent spitting up, excessive crying, poor weight gain, respiratory problems, refusal to feed

clinical manifestations of GER in children

heartburn, abdominal pain, chronic cough/hoarse voice, dysphagia, asthma, recurrent vomiting

how to diagnose GER

H & P, Upper GI series (look for abd. abnormalities), intraesophageal pH monitoring (gold standard)

if a child with GER is thriving, what interventions are done

no interventions are neccessary