question

body water differences in children <2

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-total body water is increased in a newborn and decreases over time -dont have as much intracellular water, so this can easily be depleted because there is no reserve -they therefore have a greater need for fluids (but newborns get their extra fluid from breast milk) -functionally immature kidneys

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sensible fluid losses

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measurable fluid losses ( urination, vomiting, feces etc)

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insensible fluid losses

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fluid loss you can't measure (from sweat, exhalation, etc)

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health conditions that can lead to fluid loss (4)

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1. diarrhea 2. vomiting 3. fever (hyperpyrexia OR hyperthermia) 4. respiratory conditions

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the key determinant of the level of dehydration in an infant or young child...

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weight loss!

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first thing you do when a child comes in...

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WEIGH THEM! this is the priority over the IV, getting fluids started, etc

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2 of these 4 symptoms can predict at least 5% of fluid loss

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1. cap refill of <2s 2. absent tears 3. dry membranes 4. ill appearance (toxic)

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s/s of moderate dehydration (3-9% of fluid)

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1. thirsty 2. normal to increased HR and pulses 3. slightly sunken eyes 4. decreased tears 5. dry mucous membranes 6. tenting of <2s 7. prolonged cap refill 8. cool extremities 9. decreased urine output

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s/s of severe dehydration (9% of fluid)

answer

1. lethargic 2. unable to drink 3. tachycardia 4. deeply sunken eyes 5. thready or impalpable pulses 6. deep breathing7. absent tears 7. tenting of >2s 8. cold, mottled extremities 9. minimal urine output

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3 types of diarrhea

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1. acute: quick onset, a few episodes, goes away or progresses, depending 2. acute infections diarrhea: quick onset, involves a pathogen, need treatment 3. chronic diarrhea: >14 days

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gastroenteritis aka infectious diarrhea

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-defined as: 3 or more loose or watery stools for < 14 days -largely due to infectious agent -losses of 5-100ml/kg/day

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rotavirus

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-causes more severe diarrhea than any other pathogen (50% of hospitalizations!) -highly contagious-> contact precautions -starts w/ fever/vomiting-> watery diarrhea -onset 2 days after exposure, lasts 3-8 days -there IS a vaccine

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questions to ask when assessing for diarrhea (5)

answer

1. birth age and birth history 2. associated fever? 3. character of stool 4. mental status? 5. what is there response to ORT? Keep giving it as long as disease hasn't progressed to more severe

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treatment of mild/moderate dehydration

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-ORT!

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treatment of severe dehydration

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-MEDICAL EMERGENCY -requires immediate IV rehydration-> once pt. has stabilized a bit, try giving ORT too. DON'T stop IV until they are completely stable

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examples of 3 ORTs

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1. pedialyte 2. infalyte 3. hydralyte

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recipe for ORT

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1. 1 liter + 5 cups 2. 6 tsp of sugar 3. half tsp of salt 4. stir until dissolved -this is a LAST resort if they can't afford pedialyte, etc.

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WHO ORT recommendations

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1. treat at home so they don't have to come to hospital 2. recommend generics 3. two phases: rehydration and maintenance

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administering rehydration ORT (4)

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1. key is to start it early 2. try 5mL/1tsp and inc. as tolerated 3. ideal rate is to replace existing losses over 2-4 hours 4. you can freeze ORT into a popsicle

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administering maintenance ORT (2)

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1. avoid foods high in simple sugars (juices, sodas) 2. follow 7 principles for treating diarrhea and dehydration as recommended by CDC)

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7 principles for treatment for diarrhea and dehydration (CDC)

answer

1. use pediatric oral rehydration solutions 2. perform rehydration rapidly, w/in 3-4 hours 3. offer unrestricted diet as soon as dehydration is corrected 4. breastfeeding continued w/ ORS 5. don't dilute formula if formula-fed 6. additional ORS if ongoing losses through diarrhea 7. no unnecessary labs or meds

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keys of assessment for dehydrations (5)

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1. WEIGHT 2. mental status 3. fluid balance assessment 4. intake output 5. visual observation

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good places to look for skin turgor

answer

1. abdomen 2. groin

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nursing diagnosis r/t dehydration (4)

answer

1. fluid volume deficit 2. risk for infection 3. impaired skin integrity 4. parent knowledge deficit

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nursing priorities r/t fluid volume deficit (4)

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1. monitor I&O 2. rehydration (ORS or IV) 3. monitor dehydration s/s 4. monitor IV access

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nursing priorities r/t impaired skin integrity

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1. change diapers frequently 2. meticulous cleaning w/ mild soap (avoid baby wipes) 3. let air dry 4. apply protective barrier -may need treatment for yeast infection

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nursing priorities r/t parent knowledge deficit

answer

1. prevention 2. early recognition 3. rehydration

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formula for MAINTENANCE fluids

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1. 100ml/kg for first 10kg 2. 50ml/kg for second 10kg 3. 20ml/kg for additional kgs

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when do you want to see meconium?

answer

first 24 hours!

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nursing assessment of constipation (4)

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1. Hx of bowel habits 2. diet 3. events associated w/ onset 4. educate parents

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HIrschprung disease

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-congenital aganglionic megacolon- absence of autonomic parasympathetic ganglion cells that prevents peristalsis -sphincter is constantly contracted, and things get stuck b/c of lack of peristalsis -occurs from rectum to small intestine, but usually anus is affected

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s/s of HIrschprung disease (5)

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1. lack of stools or explosive stools 2. foul smelling and ribbon-like stools in children <1 3. abdominal distention 4. bilious vomiting 5. palpable fecal mass

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management of hirschprung disease

answer

1. staged bowel surgery 2. temporary colostomy -Important: post-op your priority nursing diagnosis may change, but nutrition and fluid volume are STILL relevant diagnoses!

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nursing diagnosis r/t hirschprung disease (2)

answer

1. Constipation related to an intestinal obstruction 2. Imbalanced Nutrition: Less than body requirements related to nausea and vomiting

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GERD (gastro-esophogeal reflux disease)

answer

-return of gastric contents into esophagus -common pediatric disorder -3x higher in males -in half of infants 1-4 months, resolves by age 1 -not just a "spitty baby"

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treatment of GERD (4)

answer

1. keep upright for 30 minutes after feeding 2. use a thickened formula 3. medication (PPI, H2 blockers) 4. it is also a possibility that baby is being overfed- frequent, smaller meals

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complications of GERD (4)

answer

1. failure to thrive 2. esophagitis 3. neurobehavioral changes 4. respiratory symptoms

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Nissen fundoplication

answer

-fundus around esophagus to create an anti-reflux valve

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bilious v. non-bilious vomit

answer

1. bilious: green 2. non-billious: creamy-> will smell like what just went down

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nursing assessment r/t GERD

answer

1. focus on observation and reporting 2. interventions depend on cause

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nursing diagnoses r/t GERD

answer

1. risk for aspiration 2. fluid volume deficit 3. risk for altered nutrition

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pyloric stenosis

answer

-hypertrophic obstruction of the circular muscle of the pyloric canal -most common in first-born males -symptoms occur 1-8 weeks after birth -PROJECTILE vomiting! -no bilious vomiting r/t location of disease

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intussusception

answer

-most frequent cause of intestinal obstruction in children <3years old -more common in boys and CF kids -usually occurs at ileocecal valve -MEDICAL EMERGENCY! tissue can become necrotic

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early s/s of intussusception (5)

answer

1. sudden, acute abdominal pain 2. inconsolible crying 3. drawing knees to chest 4. lethargy 5. bilious vomiting

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later s/s of intussusception- the classic triad

answer

1. abdominal pain 2. palpable sausage-shaped abdomen mass 3. current jelly-like stools

question

management of intussusception

answer

1. passage of brown stool indicates spontaneous reduction 2. contrast enema 3. surgery

question

contrast enema for intussusception

answer

-effective treatment 75% of time -passage of stool barium afer enema indicates non-surgical resolution

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nursing diagnoses r/t intussusception (3)

answer

1. acute pain 2. risk for fluid volume deficit 3. imbalanced nutrition: less than body requirements

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appendicitis

answer

-inflammation of vermiform appendix -peaks at ages 10-12 -most common pediatric abdominal surgery -incidence of rupture is higher in children <4

question

s/s of appendicitis (4)

answer

1. RLQ pain 2. McBurney's point pain w/ rebound tenderness 3. fever 4. N/V that usually follows onset of pain

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pre-op care for appendicitis (3)

answer

1. monitor for more or less pain (if suddenly decreases, suspect rupture) 2. IV fluids, antibiotics, NPO 3. prepare child and family for surgery and post-op experiences

question

post-op care for appendicitis (6)

answer

1. NPO until passing flatus (r/t paralytic ileus post-op) 2. pain control (teach to splint by holding a teddybear) 3. ambulation 4. advance diet to regular if possible 5. assess for constipation (look at stools!) 6. antibiotics as ordered

question

nursing diagnoses r/t appendicitis (5)

answer

1. acute pain 2. risk for fluid volume deficit 3. diarrhea 4. risk for constipation 5. imbalanced nutrition: less than body requirements

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surgery for cleft palate and cleft lip

answer

-cleft lip usually fixed first, followed by cleft palate later

question

pre-op nursing diagnoses for cleft lip/cleft palate (5)

answer

1. risk for aspiration 2. imbalanced nutrition: less than body requirements (have mom breast feed! she may have to help with the let-down) 3. risk for infection 4. risk for impaired parent/infant bonding 5. parent knowledge deficit

question

nursing interventions r/t risk for aspiration r/t cleft palate

answer

1. feeding position want cleft toward breast tissue so it can mold into it- football hold is good 2. feeding devices -Haberman -OT and speech therapy decide best type of nipple 3. s/s of feeding distress

question

Haberman feeder

answer

-used for babies with cleft lip -has a slit nipple that allows the baby to control the flow of milk

question

post-op nursing diagnosis r/t cleft palate

answer

1. acute pain 2. high risk for impaired skin integrity

question

nursing interventions r/t high risk for impaired skin integrity r/t post-op cleft lip (4)

answer

1. assess suture line 2. provide pain control -look for non-verbals and stay on top of pain 3. promote healing of incision site 4. use measures to reduce crying

question

"no-no's"

answer

wrapped around cleft palate babies' arms post-op to prevent them from putting their hands in their mouth

question

parent knowledge deficit r/t cleft palate (4)

answer

1. feeding methods 2. otitis media 3. sequential surgeries 4. dental care and speech therapy

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