Pediatric Nursing Module 3 Caring for Children with Alterations
in Nutrition/Elimination Caring for Children with Alterations in
Nutrition/Elimination Slide 2 Assessment of GI System History
History gathering base line data gathering base line data infant -
formula type and tolerance infant - formula type and tolerance
children - diet, appetite, preferences meal schedule children -
diet, appetite, preferences meal schedule any prior GI problems any
prior GI problems elimination patterns elimination patterns stools,
characteristic, number per day, toilet habits stools,
characteristic, number per day, toilet habits general nutritional
appearance general nutritional appearance height and weight height
and weight Slide 3 Physical Assessment Inspection Inspection oral
cavity oral cavity ability to suck, swallow, chew ability to suck,
swallow, chew any ulcers, sores, bleeding, thrush, dental
caries,congenital anomalies (cleft lip and palate) sore throat any
ulcers, sores, bleeding, thrush, dental caries,congenital anomalies
(cleft lip and palate) sore throat Abdomen Abdomen distention,
turgor, contour, pain, girth distention, turgor, contour, pain,
girth Slide 4 Physical Assessment Stool Stool number, consistency,
presence of blood number, consistency, presence of blood Vomitus
Vomitus color, amount, blood, projectile color, amount, blood,
projectile Urine Urine specific gravity, frequency amount specific
gravity, frequency amount Tears Tears Fontanels Fontanels Pf closes
at 2-3 months, Af closes 9-18 months Pf closes at 2-3 months, Af
closes 9-18 months Slide 5 Assessment - dehydration Children are
more susceptible to dehydration due to greater % or portion of
their body weight being water Children are more susceptible to
dehydration due to greater % or portion of their body weight being
water Signs and Symptoms Signs and Symptoms poor skin turgor poor
skin turgor sunken fontanel sunken fontanel decreased urine out-put
decreased urine out-put (1-2ml/uo/kg/hr) (1-2ml/uo/kg/hr) decreased
body weight decreased body weight dry mucous membranes, lips dry
mucous membranes, lips no tears no tears Slide 6 Physical
Assessment Auscultation Auscultation Abdominal Abdominal
peristalsis peristalsis presence/absent presence/absent hypo or
hyper hypo or hyper visible - possible pyloric stenosis visible -
possible pyloric stenosis Slide 7 Adjunct Assessment Weight Weight
Temperature Temperature Labs Labs stool culture, ova &
parasite, guiac, roto virus stool culture, ova & parasite,
guiac, roto virus electrolytes - Na, K, Cl, HCO3 electrolytes - Na,
K, Cl, HCO3 CBC - wbcs CBC - wbcs I & O I & O X-ray X-ray
barium swallow, barium enema barium swallow, barium enema Slide 8
What questions do you have for the parent, for the child? Slide 9
Signs and Symptoms of Dehydration Neurological Neurological Cardiac
Cardiac Respiratory Respiratory Gastrointestinal Gastrointestinal
Genitourinary Genitourinary Musculoskeletal Musculoskeletal
Integumentary Integumentary Slide 10 Disorders of Motility
Gastroenteritis Acute Diarrhea Acute Diarrhea bacterial vs viral
bacterial vs viral isolation - good handwashing isolation - good
handwashing bloody stools, mucous, cramping bloody stools, mucous,
cramping change in the number and consistency of stool, increase in
the water margin, usually green in color change in the number and
consistency of stool, increase in the water margin, usually green
in color Slide 11 Slide 12 Gastroenteritis Acute vomiting Acute
vomiting Differentiate between vomiting vs spitting up
Differentiate between vomiting vs spitting up projectile - pyloric
stenosis projectile - pyloric stenosis reflux - may lead to
respiratory problems reflux - may lead to respiratory problems
Slide 13 A 6 month old is admitted with dehydration. Effectiveness
of therapy is evaluated by which assessment measures? Choose all
that apply assess fontanel assess fontanel measure and document
abdominal girth measure and document abdominal girth document
mucous membrane moisture document mucous membrane moisture record
and analyze I & O record and analyze I & O daily wt., same
scale, time, no clothes daily wt., same scale, time, no clothes
Analysis question, first recall assessment findings for dehydrated
child Slide 14 Hirschsprungs Disease Congenital absence of the
parasympathetic nerve ganglion cells in the mesenteric plexus of
the distal bowel 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 area proximal to the aganglionic portion becomes
hypertrophied and greatly dilated Slide 15 Hirschsprungs Disease
Signs/Symptoms Signs/Symptoms abdominal distention abdominal
distention intermittent intermittent progressively increasing
progressively increasing anorexia anorexia malnutrition
malnutrition obstruction with diarrhea obstruction with diarrhea
dehydration and electrolyte imbalance dehydration and electrolyte
imbalance Slide 16 Slide 17 Hirschsprungs Disease Treatment
Treatment temporary colostomy temporary colostomy Pre-op Pre-op
clear liquids clear liquids bowel prep bowel prep enemas/laxatives
enemas/laxatives antibiotic therapy - decrease normal bowel flora
antibiotic therapy - decrease normal bowel flora Slide 18
Hirschsprungs Disease Post-op Care Post-op Care pain control pain
control hydration hydration assessing stoma assessing stoma bowel
elimination bowel elimination teaching teaching Slide 19 Gastric
Reflux Gastroesophageal Reflux (GER) Gastroesophageal Reflux (GER)
backward flowing of gastric contents into the esophagus backward
flowing of gastric contents into the esophagus incompetent lower
esophageal sphincter incompetent lower esophageal sphincter
increase intra abdominal pressure increase intra abdominal pressure
Slide 20 Gastric Reflux Signs and Symptoms Signs and Symptoms
Infant Infant spitting up, regurgitation, vomiting spitting up,
regurgitation, vomiting crying, irritable crying, irritable wt.
loss, FTT wt. loss, FTT Children Children heartburn, chest pain,
abd. pain heartburn, chest pain, abd. pain dysphasia, burping,
dysphasia, burping, regurgitation, cough, pneumonia regurgitation,
cough, pneumonia Slide 21 Gastric Reflux Treatment Treatment small
frequent thicken feedings small frequent thicken feedings
hypoallergenic formula hypoallergenic formula positioning
positioning medications medications H 2 antagonist H 2 antagonist
pepcid, tagament, zantac pepcid, tagament, zantac surgical surgical
Nissen fundoplication Nissen fundoplication Slide 22 Inflammatory
Disorders Appendicitis Inflammation of the appendix resulting from
bacterial infection or obstruction Inflammation of the appendix
resulting from bacterial infection or obstruction Rupture =
peritonitis abscess Rupture = peritonitis abscess Slide 23
Appendicitis Signs and Symptoms Signs and Symptoms G.I. G.I. n/v/a
and d/c, rigid abdomen n/v/a and d/c, rigid abdomen Pain Pain
peri-umbilical - localizing RLQ peri-umbilical - localizing RLQ
re-bound tenderness re-bound tenderness progressive progressive
Other Other fever, stooped posture, lethargy fever, stooped
posture, lethargy Treatment Treatment appendectomy appendectomy
Slide 24 Structural Defects Craniofacial Abnormalities Cleft Lip
& Palate May occur separately or together May occur separately
or together Unilateral or bilateral Unilateral or bilateral
Associated problems Associated problems feeding difficulties
feeding difficulties URTI URTI otitis media otitis media speech
speech dental formation dental formation self-image self-image
Slide 25 Cleft Lip Interference with bonding Interference with
bonding Disfigurement Disfigurement Feeding Techniques Feeding
Techniques more upright to avoid aspiration more upright to avoid
aspiration frequent burping frequent burping lambs nipple lambs
nipple asepto syringe with tubing if infant unable to create
closure and suction asepto syringe with tubing if infant unable to
create closure and suction Slide 26 Cleft Lip Surgical repair
Surgical repair 2-4 months old 2-4 months old Post-op care Post-op
care prevent strain on suture line prevent strain on suture line
keep infant off their stomach keep infant off their stomach keep
suture line clean keep suture line clean Q-tip, NS, antibiotic
oint. Q-tip, NS, antibiotic oint. Slide 27 Cleft Palate Feeding
Feeding same as cleft lip same as cleft lip solids as soon as
possible solids as soon as possible thicken liquids thicken liquids
aspiration may be a problem aspiration may be a problem frequent
URTI and ear problems frequent URTI and ear problems Slide 28 Cleft
Palate Surgical Repair Surgical Repair usually 9 - 18 months
usually 9 - 18 months perform closure prior to speech perform
closure prior to speech after weaned to cup after weaned to cup
Post-op Care Post-op Care keep on abdomen till fully awake keep on
abdomen till fully awake semi-liquid, puree diet semi-liquid, puree
diet no sucking no sucking elbow restraints elbow restraints keep
suture line clean after feeding with water keep suture line clean
after feeding with water Slide 29 Cleft Palate Long term care Long
term care speech speech socialization socialization dental problems
dental problems psychosocial psychosocial Slide 30 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 HR for impaired parent/infant attachment R/T
newborn structural defect Ineffective feeding pattern R/T newborn
structural defect Ineffective feeding pattern R/T newborn
structural defect HR for aspiration 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. HR for imbalanced nutrition less than body
requirements R/T abnormal feeding patterns and structural defect.
Slide 31 Obstructive Disorders Intussusception Telescoping or a
portion of the small intestine or colon into a more distal segment
Telescoping or a portion of the small intestine or colon into a
more distal segment Signs/Symptoms Signs/Symptoms vomiting vomiting
pain - paroxysmal colicky abdominal pain - paroxysmal colicky
abdominal current jelly stools - brown, bloody, mucous mixed
current jelly stools - brown, bloody, mucous mixed Slide 32
Intussusception Treatment Treatment barium enema to reduce it or
surgery barium enema to reduce it or surgery Post-op Post-op
gastric decompression gastric decompression IV therapy IV therapy
Slide 33 Obstructive Disorders Pyloric Stenosis Narrowing of the
pyloric valve Narrowing of the pyloric valve hypertrophic muscle
hypertrophic muscle Signs/Symptoms Signs/Symptoms projectile
vomiting projectile vomiting left to right peristalsis left to
right peristalsis olive sized mass palpated in upper right quadrant
olive sized mass palpated in upper right quadrant cries with hunger
cries with hunger readily accepts 2nd feeding after vomiting
readily accepts 2nd feeding after vomiting Slide 34 Pyloric
Stenosis Adjunct Problems Adjunct Problems dehydration dehydration
electrolyte imbalance electrolyte imbalance alkalosis alkalosis
malnutrition malnutrition Diagnosis Diagnosis confirmed with barium
x-ray confirmed with barium x-ray Slide 35 Pyloric Stenosis Surgery
Surgery Pyloromyotomy Pyloromyotomy Post-op Feeding Post-op Feeding
post-pyloromyotomy feeding schedule post-pyloromyotomy feeding
schedule sterile water, small amount, gradually increasing in
substance and quantity sterile water, small amount, gradually
increasing in substance and quantity Slide 36 Nursing Care -
Nutrition and Fluid Balance Needs Nursing Care and Concerns Nursing
Care and Concerns Fluid Volume and Electrolyte Imbalance Fluid
Volume and Electrolyte Imbalance daily wt. daily wt. I & O I
& O assess for s/s of dehydration assess for s/s of dehydration
maintain IV therapy maintain IV therapy oral care if NPO oral care
if NPO monitor labs - electrolytes monitor labs - electrolytes
Slide 37 Nursing Care Nursing Care When introducing fluids When
introducing fluids small frequent feedings small frequent feedings
clear liquids clear liquids pedialyte pedialyte may dilute formula
may dilute formula monitor for monitor for vomiting vomiting
diarrhea diarrhea abdominal distention abdominal distention Slide
38 Nursing Care/Concerns Nutrition Nutrition check for vomiting
check for vomiting assess tolerance of feedings assess tolerance of
feedings weight and graph weight and graph thickened feedings
thickened feedings feed slowly feed slowly check suck check suck
small amounts small amounts calorie count calorie count upright -
infant seat upright - infant seat Slide 39 Nursing Care/Concerns
High Risk for Infection High Risk for Infection Cleft Lip/Palate
Cleft Lip/Palate URTI or OM URTI or OM diarrhea diarrhea spread of
infection spread of infection pyloric stenosis pyloric stenosis
body may be debilitated body may be debilitated appendicitis
appendicitis peritonitis peritonitis Slide 40 Nursing Care/Concerns
Local infection - superficial Local infection - superficial
redness, heat, swelling redness, heat, swelling tenderness, pain
tenderness, pain Systemic infection - internal Systemic infection -
internal abdominal pain, increasing abdominal girth abdominal pain,
increasing abdominal girth guarding guarding temperature
temperature Slide 41 Nursing Care/Concerns Knowledge Deficit
Knowledge Deficit assessing parents understanding of childs needs
and the problem assessing parents understanding of childs needs and
the problem assess parents ability to learn assess parents ability
to learn teach simply, clearly, allowing time for questions and
return demonstration teach simply, clearly, allowing time for
questions and return demonstration support group support group
referrals referrals Slide 42 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. 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. 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. Discuss
your impressions of the situation. Slide 43 Questions The US
confirms appendicitis. The US confirms appendicitis. Discuss the
following orders. Discuss the following orders. NPO NPO B/R B/R D5
1/2 with 10 KCL at 70ml/hr D5 1/2 with 10 KCL at 70ml/hr Gentamycin
45mg IV on call to OR Gentamycin 45mg IV on call to OR MS 1-2mg IVP
q2hrs prn pain MS 1-2mg IVP q2hrs prn pain K-pad to abdomen K-pad
to abdomen Prepare for OR - lap appendectomy Prepare for OR - lap
appendectomy Slide 44 Questions Just prior to OR, Jesus experiences
a relief from his pain. What is happening now? What is your nursing
action? 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 your nursing priorities in
the PACU? What are the pros and cons of letting parents into the
PACU? What are the pros and cons of letting parents into the PACU?
Post-op orders are as follows: Post-op orders are as follows:
routine post op vitals routine post op vitals foley catheter to
straight drainage foley catheter to straight drainage D5 1/2 NS
with 20KCL 75ml/hr D5 1/2 NS with 20KCL 75ml/hr Gentamycin 45mg IVP
q8hr Gentamycin 45mg IVP q8hr Unasyn 900mg IV q 6hr Unasyn 900mg IV
q 6hr MS PCA MS PCA Tylenol 240mg q4rhs per N/G tube prn T>100.4
Tylenol 240mg q4rhs per N/G tube prn T>100.4 NGT to continuous
drainage NGT to continuous drainage NPO except for meds NPO except
for meds IS 10 times each hour while awake IS 10 times each hour
while awake
