Pediatric Nursing

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Pediatric Nursing

• Module 3
• Caring for Children with Alterations in
  Nutrition/Elimination

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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

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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

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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

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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

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Physical Assessment

• Auscultation
• Abdominal
• peristalsis
• presence/absent
• hypo or hyper
• visible - possible pyloric stenosis

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Adjunct Assessment

• Weight
• Temperature
• Labs
• stool culture, ova parasite, guiac, roto virus
• electrolytes - Na, K, Cl, HCO3
• CBC - wbcs
• I O
• X-ray
• barium swallow, barium enema

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What questions do you have for the parent, for
the child?
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Signs and Symptoms of Dehydration

• Neurological
• Cardiac
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary

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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

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Gastroenteritis

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

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A 6 month old is admitted with dehydration.
Effectiveness of therapy is evaluated by which
assessment measures? Choose all that apply
Analysis question, first recall assessment
findings for dehydrated child

• assess fontanel
• measure and document abdominal girth
• document mucous membrane moisture
• record and analyze I O
• daily wt., same scale, time, no clothes

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Hirschsprungs 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

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Hirschsprungs Disease

• Signs/Symptoms
• abdominal distention
• intermittent
• progressively increasing
• anorexia
• malnutrition
• obstruction with diarrhea
• dehydration and electrolyte imbalance

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Hirschsprungs Disease

• Treatment
• temporary colostomy
• Pre-op
• clear liquids
• bowel prep
• enemas/laxatives
• antibiotic therapy - decrease normal bowel flora

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Hirschsprungs Disease

• Post-op Care
• pain control
• hydration
• assessing stoma
• bowel elimination
• teaching

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Gastric Reflux

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

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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

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Gastric Reflux

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

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Inflammatory Disorders Appendicitis

• Inflammation of the appendix resulting from
  bacterial infection or obstruction
• Rupture peritonitis abscess

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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

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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

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Cleft Lip

• Interference with bonding
• Disfigurement
• Feeding Techniques
• more upright to avoid aspiration
• frequent burping
• lambs nipple
• asepto syringe with tubing if infant unable to
  create closure and suction

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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.

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Cleft Palate

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

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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

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Cleft Palate

• Long term care
• speech
• socialization
• dental problems
• psychosocial

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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.

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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

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Intussusception

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

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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

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Pyloric Stenosis

• Adjunct Problems
• dehydration
• electrolyte imbalance
• alkalosis
• malnutrition
• Diagnosis
• confirmed with barium x-ray

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Pyloric Stenosis

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

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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

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Nursing Care

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

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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

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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

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Nursing Care/Concerns

• Local infection - superficial
• redness, heat, swelling
• tenderness, pain
• Systemic infection - internal
• abdominal pain, increasing abdominal girth
• guarding
• temperature

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Nursing Care/Concerns

• Knowledge Deficit
• assessing parents understanding of childs needs
  and the problem
• assess parents ability to learn
• teach simply, clearly, allowing time for
  questions and return demonstration
• support group
• referrals

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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 WBCs are 17,500.
• Discuss your impressions of the situation.

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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

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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 Tgt100.4
• NGT to continuous drainage
• NPO except for meds
• IS 10 times each hour while awake