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Pediatric Nursing

Pediatric Nursing. Module 3 Caring for Children with Alterations in Nutrition/Elimination. Assessment of GI System. History gathering base line data infant - formula type and tolerance children - diet, appetite, preferences meal schedule any prior GI problems elimination patterns

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Pediatric Nursing

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  1. Pediatric Nursing Module 3 Caring for Children with Alterations in Nutrition/Elimination

  2. Assessment of GI System • History • gathering base line data • infant - formula type and tolerance • children - diet, appetite, preferences meal schedule • any prior GI problems • elimination patterns • stools, characteristic, number per day, toilet habits • general nutritional appearance • height and weight

  3. Physical Assessment • Inspection • oral cavity • ability to suck, swallow, chew • any ulcers, sores, bleeding, thrush, dental caries,congenital anomalies (cleft lip and palate) sore throat • Abdomen • distention, turgor, contour, pain, girth

  4. Physical Assessment • Stool • number, consistency, presence of blood • Vomitus • color, amount, blood, projectile • Urine • specific gravity, frequency amount • Tears • Fontanels • Pf closes at 2-3 months, Af closes 9-18 months

  5. Assessment - dehydration • Children are more susceptible to dehydration due to greater % or portion of their body weight being water • Signs and Symptoms • poor skin turgor • sunken fontanel • decreased urine out-put (1-2ml/uo/kg/hr) • decreased body weight • dry mucous membranes, lips • no tears

  6. Physical Assessment • Auscultation • Abdominal • peristalsis • presence/absent • hypo or hyper • visible - possible pyloric stenosis

  7. Adjunct Assessment • Weight • Temperature • Labs • stool culture, ova & parasite, guiac, roto virus • electrolytes - Na, K, Cl, HCO3 • CBC - wbc’s • I & O • X-ray • barium swallow, barium enema

  8. What questions do you have for the parent, for the child?

  9. Signs and Symptoms of Dehydration • Neurological • Cardiac • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary

  10. Disorders of Motility Gastroenteritis • Acute Diarrhea • bacterial vs viral • isolation - good handwashing • bloody stools, mucous, cramping • change in the number and consistency of stool, increase in the water margin, usually green in color

  11. Gastroenteritis • Acute vomiting • Differentiate between vomiting vs spitting up • projectile - pyloric stenosis • reflux - may lead to respiratory problems

  12. A 6 month old is admitted with dehydration. Effectiveness of therapy is evaluated by which assessment measures? Choose all that apply • assess fontanel • measure and document abdominal girth • document mucous membrane moisture • record and analyze I & O • daily wt., same scale, time, no clothes Analysis question, first recall assessment findings for dehydrated child

  13. Hirschsprung’s Disease • Congenital absence of the parasympathetic nerve ganglion cells in the mesenteric plexus of the distal bowel • area proximal to the aganglionic portion becomes hypertrophied and greatly dilated

  14. Hirschsprung’s Disease • Signs/Symptoms • abdominal distention • intermittent • progressively increasing • anorexia • malnutrition • obstruction with diarrhea • dehydration and electrolyte imbalance

  15. Hirschsprung’s Disease • Treatment • temporary colostomy • Pre-op • clear liquids • bowel prep • enemas/laxatives • antibiotic therapy - decrease normal bowel flora

  16. Hirschsprung’s Disease • Post-op Care • pain control • hydration • assessing stoma • bowel elimination • teaching

  17. Gastric Reflux • Gastroesophageal Reflux (GER) • backward flowing of gastric contents into the esophagus • incompetent lower esophageal sphincter • increase intra abdominal pressure

  18. Gastric Reflux • Signs and Symptoms • Infant • spitting up, regurgitation, vomiting • crying, irritable • wt. loss, FTT • Children • heartburn, chest pain, abd. pain • dysphasia, burping, • regurgitation, cough, pneumonia

  19. Gastric Reflux • Treatment • small frequent thicken feedings • hypoallergenic formula • positioning • medications • H 2 antagonist • pepcid, tagament, zantac • surgical • Nissen fundoplication

  20. Inflammatory Disorders Appendicitis • Inflammation of the appendix resulting from bacterial infection or obstruction • Rupture = peritonitis abscess

  21. Appendicitis • Signs and Symptoms • G.I. • n/v/a and d/c, rigid abdomen • Pain • peri-umbilical - localizing RLQ • re-bound tenderness • progressive • Other • fever, stooped posture, lethargy • Treatment • appendectomy

  22. Structural DefectsCraniofacial AbnormalitiesCleft Lip & Palate • May occur separately or together • Unilateral or bilateral • Associated problems • feeding difficulties • URTI • otitis media • speech • dental formation • self-image

  23. Cleft Lip • Interference with bonding • Disfigurement • Feeding Techniques • more upright to avoid aspiration • frequent burping • lamb’s nipple • asepto syringe with tubing if infant unable to create closure and suction

  24. Cleft Lip • Surgical repair • 2-4 months old • Post-op care • prevent strain on suture line • keep infant off their stomach • keep suture line clean • Q-tip, NS, antibiotic oint.

  25. Cleft Palate • Feeding • same as cleft lip • solids as soon as possible • thicken liquids • aspiration may be a problem • frequent URTI and ear problems

  26. Cleft Palate • Surgical Repair • usually 9 - 18 months • perform closure prior to speech • after weaned to cup • Post-op Care • keep on abdomen till fully awake • semi-liquid, puree diet • no sucking • elbow restraints • keep suture line clean after feeding with water

  27. Cleft Palate • Long term care • speech • socialization • dental problems • psychosocial

  28. You are caring for a newborn with a cleft lip and palate. You are aware the infant and family have multiple needs. Which is your priority nursing diagnosis? • HR for impaired parent/infant attachment R/T newborn structural defect • Ineffective feeding pattern R/T newborn structural defect • HR for aspiration R/T newborn structural defect • HR for imbalanced nutrition less than body requirements R/T abnormal feeding patterns and structural defect.

  29. Obstructive Disorders Intussusception • Telescoping or a portion of the small intestine or colon into a more distal segment • Signs/Symptoms • vomiting • pain - paroxysmal colicky abdominal • “current jelly” stools - brown, bloody, mucous mixed

  30. Intussusception • Treatment • barium enema to reduce it or surgery • Post-op • gastric decompression • IV therapy

  31. Obstructive DisordersPyloric Stenosis • Narrowing of the pyloric valve • hypertrophic muscle • Signs/Symptoms • projectile vomiting • left to right peristalsis • olive sized mass palpated in upper right quadrant • cries with hunger • readily accepts 2nd feeding after vomiting

  32. Pyloric Stenosis • Adjunct Problems • dehydration • electrolyte imbalance • alkalosis • malnutrition • Diagnosis • confirmed with barium x-ray

  33. Pyloric Stenosis • Surgery • Pyloromyotomy • Post-op Feeding • post-pyloromyotomy feeding schedule • sterile water, small amount, gradually increasing in substance and quantity

  34. Nursing Care - Nutrition and Fluid Balance Needs • Nursing Care and Concerns • Fluid Volume and Electrolyte Imbalance • daily wt. • I & O • assess for s/s of dehydration • maintain IV therapy • oral care if NPO • monitor labs - electrolytes

  35. Nursing Care • When introducing fluids • small frequent feedings • clear liquids • pedialyte • may dilute formula • monitor for • vomiting • diarrhea • abdominal distention

  36. Nursing Care/Concerns • Nutrition • check for vomiting • assess tolerance of feedings • weight and graph • thickened feedings • feed slowly • check suck • small amounts • calorie count • upright - infant seat

  37. Nursing Care/Concerns • High Risk for Infection • Cleft Lip/Palate • URTI or OM • diarrhea • spread of infection • pyloric stenosis • body may be debilitated • appendicitis • peritonitis

  38. Nursing Care/Concerns • Local infection - superficial • redness, heat, swelling • tenderness, pain • Systemic infection - internal • abdominal pain, increasing abdominal girth • guarding • temperature

  39. Nursing Care/Concerns • Knowledge Deficit • assessing parents understanding of child’s needs and the problem • assess parent’s ability to learn • teach simply, clearly, allowing time for questions and return demonstration • support group • referrals

  40. Case Study • Jesus 5-year old boy, weights 40.3Kg wakes up at 2am with a “stomach ache”, he has a fever of 100.2F and vomiting. Parents administer Tylenol 120mg which he vomits 5 minutes later. • In the morning he is still sick, so parent take him to the ER. Vital signs are Ax Temp 100.4, HR 125, RR 35, B/P 119/79. RLQ guarding, crying. IV started then MS 2mg IVP given. Abdominal US is ordered, CBC shows WBC’s are 17,500. • Discuss your impressions of the situation.

  41. Questions • The US confirms appendicitis. • Discuss the following orders. • NPO • B/R • D5 1/2 with 10 KCL at 70ml/hr • Gentamycin 45mg IV on call to OR • MS 1-2mg IVP q2hrs prn pain • K-pad to abdomen • Prepare for OR - lap appendectomy

  42. Questions • Just prior to OR, Jesus experiences a relief from his pain. What is happening now? What is your nursing action? • What are your nursing priorities in the PACU? • What are the pros and cons of letting parents into the PACU? • Post-op orders are as follows: • routine post op vitals • foley catheter to straight drainage • D5 1/2 NS with 20KCL 75ml/hr • Gentamycin 45mg IVP q8hr • Unasyn 900mg IV q 6hr • MS PCA • Tylenol 240mg q4rhs per N/G tube prn T>100.4 • NGT to continuous drainage • NPO except for meds • IS 10 times each hour while awake

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