Transcript Peds GI, Altered Fluid

Variations from the Adult
• Mechanical functions immature
– No voluntary control over swallowing until 6
weeks
– Stomach capacity decreased
– Peristalsis increased, faster emptying time
– Relaxed cardiac sphincter
• Liver functions immature
• Decreased production of antibodies lining mucosa
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Variations from the Adult (cont)
• Digestive processes not mature until
toddlerhood
– Gastric acidity low until school age
– Decreased saliva & ability to digest
starches
• No voluntary control of elimination until
myelinization of spinal cord.
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Categorization of Conditions
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Developmental (congenital)
Problems w/motility
Inflammation or infections
Obstructive disorders
Malabsorption conditions
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Fluid & Electrolyte Differences
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Percent body water /total body weight
Infant higher percentage fluid ECF
Greater insensible loss
Renal function immature
Infants unable to communicate thirst
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Maintenance Fluid
Requirements per 24 hours
• ≤ 10 Kg: 100 ml/kg/day
• 11-20 kg: 1,000 ml + 50 ml/kg/day
• >20 kg: 1500 ml + 20 ml/kg/day
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Minimum Urine Output
• Infants, toddlers
– >2-3 ml/kg/hr
• Preschool, young school-age
– >1-2 ml/kg/hr
• Older school-age & Adolescent
– 0.5-1 ml/kg/hr
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Etiology of Fluid Imbalances
(the “related to”)
• Imbalance of intake vs output
• Result: fluid volume deficit or fluid volume
excess
• Secondary to therapy or disease process
– All organ systems can be cause
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Types of Dehydration
• Isonatremic
• Hyponatremic
• Hypernatremic
• Normal serum Na = 135-145 mEq/L
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Key Factors
in Diagnosing Dehydration
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History of acute or chronic fluid loss
Serum electrolyte values
Clinical manifestations
Weight of the child
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Clinical Manifestations
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Level of consciousness
Urine output
Weight
Pulse
Cap refill
Respirations
Skin turgor
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Clinical Manifestations (cont)
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Mucous membrane
Blood pressure
Fontanel
Thirst
Sunken eyes
No tears
“toxic looking”
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Cleft Lip and Palate
• CL: the lip does not completely form
during fetal development
• CP: Nonunion of the tissue & bone
hard/soft palate during embryologic
development.
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Problems: cleft lip/palate
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Feeding difficulties
Speech & language difficulties
Ear infection and hearing loss
Dental problems
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Surgical Management
• Cheiloplasty: correction of cleft lip
– Functional & cosmetic
– age 3-6 mo (McKinney)
– “rule of 10s”: 10 weeks, 10 lbs, Hgb of 10
g/dL
• Palatoplasty: cleft palate repair
– 6 mo to 2 yrs (most: 1 year)
– Before speech
– Able to take liquids from cup
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Nursing management: preop
• Feed in upright position
• Burp frequently, w/ periods of rest
• Large-holed nipple or rubber-tipped
syringe
• Finish feeding w/H2O
• Small, frequent feedings
• Emotional support
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Nursing Diagnoses – Pre-op
Post-op cleft lip
• Patent airway
• Assess for hemorrhage
• Protect the operative site !!!
– No pressure on cheeks
– No prone position
– Elbow restraints
• Pain relief
• Feed when awake
• Keep site clean – prevent infection
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Post-op cleft palate
Immediate post-op goals
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Airway
– OK to be on side or abdomen – drain secretions
• Pain
• Prevent injury to suture site
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Instructions to Mother
Risk for injury to surgical site
• Progress diet
• Only cups for liquids
• Provide soft toys
• Elbow restraints
• Cleanse mouth after eating
• No rough play
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Long-term care CP
Team approach
• Hearing evaluation
• Speech & language therapy
• Dentist, orthodontist
• Plastic & maxilofacial surgeon
• Social worker
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Other Developmental
Gastrointestinal Defects
• Esophageal atresia with tracheoesophageal
fistula
• Imperforate anus
• Gastroschisis
• Omphalocele
• Umbilical or diaphragmatic hernia
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GER
• Physiologic
• Functional
– Painless, frequent emesis after meals
– No failure to thrive
– 40% asymptomatic by 3 months
– 70% asymptomatic by 18 months
– Medical management very effective
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Therapy for
Gastroesophageal Reflux Disease
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Diet
Positioning
Lifestyle change
Acid-suppressant therapy
Prokinetic therapy
G-tube
Surgery – Nissen Fundiplication
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Constipation and Encopresis
[information only]
• Definitions
• Common causes of constipation
– dietary transition
– voluntary withholding
• Emotional issue
• Treatment
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Inflammatory or Infectious
Conditions
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Necrotizing Enterocolitis (NEC)
Appendicitis
Inflammatory bowel disease
Viral gastroenteritis
Hepatitis
Parasites
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Appendicitis - diagnosing
• History
– Pain, then vomiting
• Ultrasound
• CT
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Treatment
• Uncomplicated: may watch
– Rehydration, Antibiotics prior to surgery
• Complicated
– Surgery
– Non-operative: fluid replacement, IV
antibiotics, analgesics
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Interventions
Uncomplicated Appendicitis
Pre-op
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VS
Comfort measures
No enemas, laxatives
No heat to abdomen
IV fluids, abx
Monitor for
perforation
Post-0p
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Laparoscopic
Pain control
C & DB
Early ambulation
NPO until bowel
function returns
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CMs of perforation:
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Sudden relief from pain, then increased pain
Rigid abdomen
Early shock
Infants: refusal to eat, behavior changes
Danger: peritonitis
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Appendicitis: perforation &/or abscess
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Surgical or medical management
Percutaneous drainage of abscess
NG tube
IV fluids and Antibiotics
Drains
Pain med: ATC
Routine post-op: C&DB, move
Monitor for sepsis, abscess
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Obstructive Disorders
• Hypertrophic Pyloric Stenosis
• Hirschprung’s Disease
• Intussusception
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Hypertrophic Pyloric Stenosis
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Post-op Pyloromyotomy
• Nursing priorities
–Hydration status
–Pain
–Infection
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Hirshprung’s Disease
Typical Presentation
• 2 1/2 week old child
• Poor weight gain
• 38 weeks gestation
• Easily takes 2-3 oz of formula
• Has frequent vomiting after feeds, some
bile-stained
• Constipation
• Dx: rectal biopsy
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Celiac disease: definition
• Immune-mediated disease induced by
ingestion of defined proteins in subjects who
are genetically predisposed
• EBP: exclusive 6 month breast feeding delays
onset of sx.
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Patho: Celiac Disease
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Celiac Disease – Assessment “classic”
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Symptoms 3-6 mo after gluten introduced
Steatorrhea
Abdominal distention, vomiting, anorexia
Growth retardation, muscle wasting
Anemia
During crisis: severe dehydration
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