Week 10: elimination, nutrition, and dehydration

Bowel elimination

passage and dispelling of stool through the intestinal tract by means of intestinal smooth muscle contraction

Urinary elimination

passage of urine out of the urinary tract through the urinary sphincter and urethra​

Functional problems

passage of urine out of the urinary tract

through the urinary sphincter and urethra​

Clinical manifestations of constipation

**infrequent and difficult passage of stool

-Two or fewer defections per week​

-History of excessive stool retention or retentive posturing​

-History of painful or hard bowel movements​

-Presence of a large fecal mass in the rectum​

-Large diameter stools​

-At least one episode of incontinence after the acquisition of toileting skills​

-History of large diameter stools (that may obstruct the toilet)

Constipation risk factors

-Limited daily fluid intake​

-Sedentary lifestyle​

-Poor fiber intake​

-Consumption of foods known to cause hard stools​

-Excessive dairy products​

Other causes of constipation

-Lead poisoning​

-Underactive thyroid function​

-Celiac disease​

-Abnormal calcium levels

Toddler/preschool triggers for constipation

-Learning to control body function​

-Transition to cow’s milk​

-Withholding behaviors

School age triggers for constipation

-Diet​

-Toileting habits​

-Activity​

-Abuse​

-Changes to routine

Withholding/retentive behaviors

Voluntary contraction of external sphincter “holding it in”

Causes of retentive behaviors

-he or she is afraid of the toilet ​

-doesn't want to take a break from play. ​

-uncomfortable using public toilets.​

-Painful bowel movements caused by large, hard stools also may lead to withholding​

-If it hurts to poop, your child may try to avoid a repeat of the distressing experience

Identifying retentive behavior

-Crossed legs(scissoring)​

-Tiptoe with legs stiff​

-On hands and knees​

-Sitting on heel​

-Potty dance​

-Lifting off the toilet seat ​

-Stiff posture with legs locked (salute)​

-Sitting on coccyx with legs in stiff posture

Health history Qs for constipation

-When was their last bowel movement? ​

-Describe the stool? ​

-How often do they usually stool in a week? ​

-Does it hurt to defecate?​

-Is the stool large or hard?​

-Any small lose stools or stains in underpants?

Physical exam for constipation

-Ausculate hyper or hypo depending on where you listen ​

-Palpate – may feel firm fecal mass​

-Assess pain

Encopresis

-Abnormal elimination pattern characterized by the recurrent soiling or passage of stool at inappropriate times by a child who should have achieved bowel continence​

-Liquid stool leaking around a large/hard/impacted stool mass ​

-Seen in chronic constipation​

-As common as 1 in 100 kids​

1st line constipation treatment

-↑ Fluids ​

-↑ fiber​

-Age + 5 = grams of fiber needed per day​

-Many children do not even meet the minimum​

-Dietary modifications:​

→ Infants: 2 oz pear, apple, prune juice​

→ Increase physical activity and fluid intake​

→ Remove constipating foods​

Follow up treatment for constipation

-Next: Medications which increase water release into colon or soften stool​

→ Miralax, Docusate sodium, Sennakot​

-Clean out​

→ Enemas: work on lower part of colon to release hard stool​

-“jump start” – help get things moving as medications and 1st line treatments take time to work​

-Laxatives​

Laxatives

-Increase peristalsis: Bisacodyl – use short term only! ​

-Quicker effect than stool softeners ​

-Long term use can lead to dependence ​

Education for pt and family on constipation

School age kids​

-anatomy of GI tract​

-Talk with the older child about barriers to going to the bathroom​

Families: ​

-physiology of bowel movements​

-Stretching of rectum and colon

Constipation medication education

-purposes and dose adjustment

-length of treatment​

Collaboration for constipation

-School notes to ensure they have access to the bathroom or a private toilet ​

-GI psychologists

Constipation behavioral modification

-Interrupt the withholding behaviors​

-Encourage toilet sitting after meals and at scheduled times​

-Toilet sits for 5-10 minutes after all meals​

-Feet supported on step stool “squatty potty”​

-Develop potty box with toys for potty sits for younger kids​

-Age-appropriate incentives

Expected time for constipation resolution

-The longer the problem ~ the longer the treatment​

-Minimum of 2-6 months of aggressive therapy​

-If dependent on laxatives, 1-4 months to wean off​

-Poor adherence with treatment recommendations will prolong therapy​

-Even after problem is resolved there is 50% chance of reoccurrence in 1st year ​

-This can become an ongoing problem & consistency is required to prevent reocurrence​

Enuresis

-Repeated involuntary voiding by a child old enough that bladder control is expected/after mastery of toilet training​

-Bedwetting!

-Night (nocturnal) vs day (diurnal)​

Primary enuresis

-Never dry​

-Related to maturational delay, small functional bladder capacity

Secondary enuresis

-Dry for 6 months then bedwetting starts​

-Related to stress, infection, sleep disorders​

-Example: 10 year old boy starts wetting the bed (was potty trained since 3)

Enuresis treatment options

-Limit fluid in evening​

-Toileting right before bed​

-Avoid caffeine​

-Avoid constipation​

-Bladder exercises​

-Timed voids​

-Enuresis alarm​

-Reward system​

-Medications

Medications for enuresis

-Desmopressin (anti-diuretic)​

-Oxybutynin (anti-spasmodic) ​

GER

-Defined as the passive backward flow of gastric contents upward into the esophagus that can occur with or without regurgitation or vomiting​

-Considered a normal, physiological process – but can become problematic​

-Effortless, painless spitting often within 40 minutes of eating​

-GERD occurs when there is tissue damage from GER

Causes of GER

-Short and narrow esophagus​

-Weak esophageal sphincter that does not close adequately​

-Delayed gastric emptying time​

-May progress to tissue damage from low pH of gastric acid

GER/GERD risk factors

-Prematurity​

-Delayed maturation of lower esophageal neuromuscular function​

Clinical GERD features for infants

-Feeding refusal​

-Recurrent vomiting​

-Poor weight gain (FTT)​

-Irritability​

-Sleep disturbances​

-Respiratory symptoms ​

Clinical GERD features for older child and adolescents

-Abdominal pain/heartburn​

-Recurrent vomiting​

-Dysphagia​

Airway irritation:​

→ Asthma​

→ Recurrent pneumonia​

→ Upper airway symptoms (chronic cough; hoarse voice)

GERD resolution

Most instances resolve on own within 1 year

Non pharm interventions for GERD

-Smaller more frequent meals ​

-Position during/post feeding ​

-Avoidance of foods that cause reflux

Surgical interventions for GERD

-If tissue damage continues in severe GERD

-Nissen Fundoplication – wraps stomach around distal esophagus, decreases reflux ​

Medication for GERD

-Antacids​

-Proton Pump Inhibitors (PPIs)​

→ Omeprazole (Prilosec)​

→ Lansoprazole (Prevacid)​

-Histamine 2 (H2) Receptor Antagonists​

→ Famotidine (Pepcid)​

→ Cimetidine (Tagamet)​

→ Ranitidine (Zantac)​

Obstructive disorders

-Pyloric Stenosis ​

-Intussusception

Pyloric stenosis

-Hypertrophic obstruction of the circular muscle of the pyloric canal​

-Blocks gastric emptying​

-Often occurs in young infants in first few weeks-months

Pyloric stenosis etiology

exact cause unknown, possibly hereditary but no known risk

factors​

Pyloric stenosis clinical manifestations

-Projectile vomiting​

→ During/after feedings​ (even up to a few hours)​

→ Not “happy spitters” ​

-Visible peristalsis​

→ Hyperactive bowel sounds​

-Hungry after eating, irritable​

-Fails to gain weight, dehydration​

-Olive shaped mass in RUQ​

Pyloric stenosis diagnosis

made w ultrasound

Pyloric stenosis surgical intervention

-Pyloromyotomy

-Usually 24 hour admit (day surgery)

Pyloromyotomy pre op goals

correct fluid deficits and any electrolyte imbalances

Pyloromyotomy post op considerations

-Focus on comfort after surgery​

-Anxiety for the parents​

-Monitor incision site for infection and healing​

-Keep diaper away from incision​

-Advance feedings as tolerated per provider orders

Pyloromyotomy post op education

-Call provider for fever/infection signs​

-Keep area clean ​

-Instructions for feeding at home ​

→ baby should be eating at regular intervals to maintain hydration + meet nutritional needs

→ If not tolerating feedings, contact provider ​

→ Do not hold feedings, infant is at risk for dehydration!​

Intussusception

-Form of intestinal obstruction ​

-A segment of bowel telescopes or invaginates into another segment​

-Often the cause is unknown​ (Could be due to lymphatic tissue)​

-Most common site is at ileocecal valve ​

-Usually occurs between 5 months & 3 years

Intussusception manifestations

-Sudden onset of cramping abdominal pain​

-Vomiting​

-Inconsolable crying​

-Drawing up the knees to the chest​

-Hyperactive peristalsis – proximal bowel​

-Hypoactive/overly inactive peristalsis – distal bowel

-Classic triad

Classic triad

-Abdominal pain​

-Abdominal mass (sausage shaped) ​

-Bloody-like, mucousy stools (currant jelly-like stools)

Intussusception management

-May resolve spontaneously​

-May resolve with contrast enema​ (Air or barium) ​

-May need surgical intervention: ​

→ reduce the invagination (telescoping)​

→ possibly resect any areas of ischemia/necrosis

Intussusception nursing considerations

-Watch stools closely​

→ If a normal stool occurs before the surgery the intussusception may have reduced itself. ​

-Watch for sepsis, dehydration​

-Treat pain ​

-NPO, IV Fluids

Inflammatory and infectious conditions

-Appendicitis

-Celiac disease

-UTI

Acute appendictis

**similar to adult, but some differences in pediatrics

-Obstruction of the lumen of the appendix by hardened fecal material (usually), foreign bodies, microorganisms, or parasites resulting in inflammation/infection​

-Obstruction blocks outflow of mucus, pressure builds within lumen causing compression of the blood vessels, venous engorgement, eventual necrosis and rupture

Appendicitis diagnostic assessment

-Largely based on history and exam​

-R/O other causes such as: 

→ Other infection (UTI or STI)

→ Pregnancy​

→ Constipation or Gastroenteritis

→ Testicular torsion or ovarian cyst

Appendicitis diagnostics

-CBC​

→ Elevated WBC​

→ Increased neutrophil count​

-Elevated C-reactive protein​

-Abdominal ultrasound or CT Scan

Appendicitis therapeutic management

• Antibiotics with/without surgery​

• Remove appendix (appendectomy) ​

• Ruptured appendix​

  • Requires IV antibiotics post op ​

  • Monitor for peritonitis ​

  • Usually has a peritoneal drain ​

• Prognosis – overall good with early recognition​

  • Be aware of possible complications: peritonitis or perforation

Pediatric Appendicitis Score (PAS)

Tool for clinical decision making: ​

Treat w/ abx and surgery ​

-Or-​

Give antibiotics and observe​

Post op care for appendectomy (same as adult care)

• Maintain fluid balance​

  • IV fluids until bowel function returns​

  • Monitor for nausea​

  • Advance diet as tolerated​

• Antibiotics & monitor for infection (especially if perforated)​

• Maintain skin integrity / incision site​

• Maintain airway clearance (incentive spirometer)​

• Assess for Bowel function (bowel sounds, flatus, stool) ​

• Pain management​

Pain management post appendectomy

• Position: semi-Fowler or side-lying position on the right side 

• Medication​ 

• Splinting

Celiac disease

• Autoimmune disorder​

  • Not an allergy or an intolerance​

  • A gluten-sensitive enteropathy​

• Immune-mediated inflammatory disease of the small intestine

  • ​caused by sensitivity to dietary gluten and related proteins ​

  • Intestinal lining is damaged ​

  • Cannot absorb nutrient as well ​

Complications: Leads to malabsorption and effects of being malnourished

Celiac risk factors

• Genetic predisposition​

• First- and second-degree relatives of patients with celiac disease ​

• People with… ​

  • Down Syndrome ​

  • Type 1 diabetes ​

  • Selective immunoglobulin A (IgA) deficiency ​

  • Autoimmune thyroiditis ​

  • Juvenile chronic arthritis

Classic manifestations of celiac

• Chronic diarrhea​

• Steatorrhea (greasy/fatty, yellowish stool)​

• Abdominal distention ​

• Bloating​

• Pain​

• Anemia​

  • Growth delay

Atypical manifestations of celiac

• tooth enamel defects

• aphthous ulcers

Celiac crisis

• Acute exacerbation due to exposure to gluten ​

  • Severe diarrhea​

  • Dehydration​

  • Metabolic acidosis​

  • Electrolyte disturbances

Celiac diagnosis

• 72-hour fecal fat collection​

• Total IgA levels​

  • commonly found in mucous membranes in respiratory & GI systems​

• Biopsy of mucosal tissue

Celiac treatment

• Gluten Free Diet – life long​

  • Referral to dietician​

  • Financial burden​

  • Adherence concerns​

    • Cross contamination ​

    • ‘cheating’

• May need vitamin supplementation: ​

  • Fat soluble vitamins (A, D, E, & K)​

  • Iron & folic acid

Examples of gluten

• Wheat (and derivates)​

• Rye​

• Barley​

• Malt​

• Brewer’s yeast

Adult UTI review

• Urine output: 30ml/hr MINIMUM ​

• Normal Urinalysis Results: ​

  • pH 5 to 9

  • Specific gravity 1.005 to 1.030 (1.010-1.020)​

  • Protein 0-8 mg/dl ​

  • Urobilinogen up to 1 mg/dl​

  • Color: clear to pale yellow ​

  • Appearance: clear/translucent​

  • NONE OF THE FOLLOWING Present:​

    • Glucose RBC’s​

    • Ketones Casts​

    • Nitrates​

    • WBC’s

Pediatric urine output differences

• Determined by weight! ​

• Newborn 2 ml/kg/hr​

• Child 0.5 to 1 ml/kg/hr​

• Adolescents 40-80 ml/hour

Pediatric bladder capacity differences

• Average is 30 ml at birth​

• Grows until reaching adult capacity of 300-500mL​

• Bladder capacity (in Oz) = child’s age in years + 2 ​

• 1 year old = 1 + 2 = 3oz (90mL)

Pediatric urethra differences

• Shorter​

• risk for bacteria entering bladder

Pediatric renal function differences

• Immature, infants do not concentrate urine ​

• Glomerular filtration rate is slower in infant​

• Higher risk for dehydration

Risk factors for UTI

• Urinary stasis​

• Poor hygiene​

• Irritated perineum​

• Uncircumcised penis (if not cleaned properly) ​

• Constipation (prevents bladder from fully emptying) ​

• Urinary tract anomalies​

• Urinary reflux (back flow, risk for upper UTI and renal damage) ​

• Females (or person with vagina) ​

Female risk factors for UTI

• Shorter urethra compared to males​

• Soaking in tub (bubble baths) ​

• Staying in wet diapers, swimwear for a long time​

• sexually active adolescent females ​

  • provide education r/e urinating after sex, personal hygiene

Upper tract s/s of UTI

• Fever

• nausea/vomiting

• flank pain (CVA tenderness)

• general malaise

Lower tract s/s of UTI

• Dysuria

• frequency/urgency

• incontinence

• suprapubic pain

• change in urine odor/color

Neonates s/s UTI

• Fever

• irritability

• poor feeding

• vomiting

• diarrhea

• FTT

• jaundice

• sepsis

UTI diagnostics

• same as adult

• Microscopic urinalysis / dipstick​

• Culture and sensitivity to determine best antibiotic treatment

• Additional testing

  • Renal Ultrasound​

    • After first febrile UTI

    • Assess for any damage

  • VCUG (voiding cystourethrogram)​

    • If US abnormal Or reoccurrence of febrile UTI

    • Detect anatomical differences or retrograde flow

Pediatric urine collection

• Clean Catch Urine preferred for older child​

• Catheterization or suprapubic needle aspiration for children <2 years old​

  • Less risk of contamination from diaper contents​

  • Different catheter sizes based on age/size ​

• U-bag for collection from infant – child​

  • Not recommended, error prone​

  • Use of a bag for a sterile specimen has potential to yield a contaminated specimen.

UTI treatment

• Anti-infective agents after urine culture and sensitivity​

• Screen for cause: ​

  • diagnostic tests​

  • Treat underlying cause in addition to giving abx​

• Ensure Adequate fluid intake for age and weight​

  • Flush the system.

UTI prevention and education

• Wipe from front to back​

• No tight-fitting underwear​

• Cotton underwear​

• No bubble baths, bath oils, hot tubs, etc.​

• Encourage abstinence (-or- If sexually active female void before and after sex​

• Adequate hydration is key to prevention​

• Encourage frequent voiding, avoid holding it in ​

• Probiotics: ​

  • some evidence may offer protection against recurring UTIs​

• Cranberry juice and supplement: ​

  • May help prevent UTI

Fluid imbalances

• Extracellular fluid volume deficit (dehydration)​

• Extracellular fluid intravascular volume excess (fluid overload)​

• Interstitial fluid volume excess (edema)

Water toxicity

• due to fluid shifts caused by electrolyte imbalance (namely hyponatremia) ​

• causes intracellular edema & Cerebral edema = life threatening ​

• Infants under 1 are at high risk for water toxicity due to their immature kidneys ​

Fluid status assessment Qs for caregivers

• What intake has child taken?​

• Infants: crying tears, wet diapers (how many)​

• Behavior: tired versus listless​

• Breathing: faster? Working hard (retractions)?​

• Any Vomitting of Diarrhea? Are they able to keep fluids/food down? ​

• How many wet diapers ( an infant should have 6-8 per day, fewer indicates dehydration)

Causes of dehydration

• Vomiting and diarrhea

• Fever​

• Wounds/Burns (insensible losses) ​

• Tachypnea from respiratory distress can contribute

Dehydration r/t vomiting and diarrhea

• most common viral causes: Rotavirus, Norovirus​

• Bacterial: Salmonella, Ecoli, Cdiff​

• Parasite: Giardia, Cryptosporidium​

• other: increased intracranial pressure, Toxins/Poisons, neuro and endocrine disorders​

• Infants: milk protein allergy, infections​

• Toddlers: infection, tumors, UC, celiac disease​

• School age: IBD, Appendix, Lactose intolerance, constipation, celiac disease

Dehydration assessment

• Physical Exam: ​

  • Fontanel sunken​

  • skin-dry, poor turgor, dry mucous membranes​

  • fever, tachycardia, ​

  • low BP is a later and more severe sign

  • less active (lethargic) ​

  • more ill appearing​

• Labs: electrolytes, CBC-WBC, Stool Cx, ​

Treatment for moderate to severe dehydration

• IVF- NS or LR bolus 20mg/kg then add K+ when voiding​

• Teaching points: hand washing, skin care and protection, prevention

Severity of clinical dehydration

Moderate dehydration treatment

• If unable to orally rehydrate after giving antiemetics, IVF will be needed

• Antidiarrheals are not recommended – especially if it is due to an infectious cause! ​

Severe dehydration treatment

• Admission to Hospital or Treatment in ED ​

• Laboratory analysis to monitor electrolytes​

• Treatment for Moderate to severe Dehydration:​

  • IVF- NS or LR bolus 20mg/kg then add K+ when voiding

  • 1.5x Maintenance fluids​

  • In addition to oral rehydration​

• Daily weights: accurate indicator of fluid status if you have a trend to follow​

• Careful I&O​

• Monitor vital signs ​(Pulse, Rate/quality of respirations,​blood pressure (including orthostatic))

Nutrition health Hx

• Current nutritional intake​

  • Any recent changes?​

• Elimination​

• Physical Activity

• Specifically for infants…

  • Gestational age/birth weight​

    • Prematurity and LBW are risk factors for inadequate nutrition​

  • Passage of first meconium stool within the first 24 hours?​

  • Jaundice?​

Nutrition red flags

• Nausea, vomiting, diarrhea​

• Spitting up ​

• Fussy with feeds​

• Encopresis​

• Abdominal pain​

• Abdominal distention​

• GI Bleeding​

Monitoring growth

• Growth charts ​

  • Provide visual trend of growth over time​

  • Track Height, Weight, Head circumference​, BMI or Percentile for Weight to determine if over/under-nourished

Newborns diet patterns

• Rapid physical, functional changes from growth & development ​

• In first year, body weight triples​

• Full term, healthy baby should gain 25-35 gms/day during first months of life ​

• Each baby’s feedings needs are unique​

  • 100cc/kg/day to be adequately hydrated

  • 150cc/kg/day to grow (minimum 120)

Infants formula feeding

• First few weeks: 2-3 oz every 3-4 hours​

• By 1 month: up to 4 oz, predictable schedule​

• By 6 months: 6-8 oz at each of 4 or 5 feedings per day​

• Max 32 oz of formula/24 hours​

• Different formulations to accommodate special dietary needs, and allergies

Infants breastfeedings

• Smaller, more frequent feeds​

• 8-12 times per day (Q3-4 hours) ​

• Cluster feeding early in life​

• Will start to sleep through night and take larger PO intake during the day ​

• Variance in length of feedings​

• Both AAP and WHO recommend exclusive breastfeeding for 6 months, followed by solid foods + complimentary BF through 2 years​

Introduction of solids

• introduce complementary foods at around 6 months of age​

• Assess an infant’s readiness to start foods​

  • Good head control​

  • Show eagerness to eat​

  • Effectively move food from the spoon to the back of the mouth​

• No specific food order​

  • Usually start with iron-fortified single grain cereal​

  • No honey or cow’s milk until >12 months of age​

  • Introduce new food every 2-3 days​

• Around 12 months, diet should be mostly solid food​

• About 1,000 calories/day​ (3meals + 2snacks per day)​

Calorie needs

Based on age, gender, activity

Toddlers and young children eating patterns

• Picky eating very common​

  • Continue to offer a variety of healthy foods​

  • May have to offer a new food more than 10 times​

• May not finish every meal or recommended portions in a single sitting​

  • Small portions, offer snacks

• Avoid a “liquid diet”​​

  • Limit juice intake or dilute​

  • Recommended amounts of daily juice​

    • Under 12 months – none

    • 1-3 years – maximum 4 oz ​

    • 4-6 – limit to 4-6oz​

    • 7 and up – limit to 8oz​

  • Limit cow’s milk (based on age)​

    • Whole milk until age 2 years​

School aged child eating patterns

• Encourage balanced diet with variety!​

• Teach healthy eating habits ​

• Can assist with with meals ​

  • Shopping, Making simple dishes, preparing ingredients ​

• Picky eating can persist ​

  • Very common with neurodivergence and sensory processing differences​

• Meal time is also about connection & is social in nature