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Diarrhea
- Significant World Problem
- 10% of all hospitalization in US
- 20% of death for children in developing countries
- Children most at risk
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Children More at Risk for Problems Due to...
- Intestinal mucosa more permeable to water
- Deceased ability to absorb with inflammation
- Lack of enzymes which icrease gas
- Mobility faster, effect absorption
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Acute Diarrhea
- <14 days
- Infection: rotavirus #1 cause in US
- Secondary to UTI or URI
- Parasites: Jigardia
- Diet: apple juice, high sugar/fructose content
- Medication/Antibiotics
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Chronic Diarrhea
- Metabolic/Absorption/Genetic Disorders: Celiac Disease; Cystic Fibrosis
- Inflammatory Disorders: Crohn's vs Ulcerative Colitis
- Bowel Damage/Short Gut
- Diet: Lactose Intolerance
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Celiac Disease
- Do not have the enzyme to digest gluten
- Can impair growth in children
- Foods high in gluten: white flour, wheat, barley, rye (pasta, bread, cakes, cookies)
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Cystic Fibrosis
- Learn to immediately hide feces
- Do not absorb well so they have greasy smelly stools
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Crohn's Disease
Continuous bleeding in the stool (mouth to anus)
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Ulcerative Colitis
- Bleeding from the colon
- Cure by removing colon
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Questions to ask diarrhea pt's
- How long
- How often
- Things that make worse/better
- Color, smell, etc
- Meds
- Pain or discomfort
- Traveling
- Fluids
- Fever?
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Clinical Manifestations Diarrhea
- Malabsorption: foul smelling and greasy appearance
- Bacterial gastroenteritis: (+) for neutrophils and RBC
- Parasitic infection or Protein intolerance: (+) for eosinophils
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Treatment for Diarrhea
- Fluids: oral rehydration or IV fluid
- Early reintroduction of food: BRAT diet
- Medication: Antimicrobial therapy for (+) culture or febrile infant; Avoid antidiarrheal agents
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Newborn (stomach capacity)
10-20 ml
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One Week (stomach capacity)
30-90 ml
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2-3 weeks (stomach capacity)
75-100 ml
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1 month (stomach capacity)
90-150 ml
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3 month (stomach capacity)
150-200 ml
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1 year (stomach capacity)
210-360 ml
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2 year (stomach capacity)
500 ml
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Vomiting and Retching
- Green, bilious
- Curdled stomach contents
- Fever+Diarrhea+Vomiting
- Change with Level of Conscience (LOC)/with or without headache
- Localized pain with vomiting
- Forceful, projectile (infants)
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Emesis Treatment
- Fluids: Oral rehydration and/or IV (continue fluids in small frequent amounts)
- Treating the source
- Positioning and burping
- Pain/anti-nausea meds
- Cleaning of the mouth
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Gastroesophageal Reflux (GER)
- Regurgitation of gastric contents into the esophagus due to a lax cardiac sphincter
- Symptoms: heartburn, bad breath, very irritable (babies), not want to eat, may be connected with respiratory infections, may cause apnea spells, may have diarrhea/blood stools (irritated esophagus)
- Risk Groups: preemies, cystic fibrosis, short gut, neurological disorders, vents
- Testing/Diagnosis: Upper GI (barium swallow), esophageal pH study (24hr), endoscopy, MRI, Ultrasound
- Treatment: Positioning (slightly uprights), Nissen Fundoplication (wrap stomach around esophagus to make a valve; cannot get rid of gases as easily so distention occurs), Tube Feedings (run feedings over a longer period of time), Medications (protonix-decreases secretions, xantac, reglan-increasing mobility)
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Constipation
- Infants: congenital, diet (esp. formulas with iron-slows down)
- Early Childhood: diet (too much milk, too little fiber), developmental (fear of toilet, ignoring urge)
- School Age: environment (diet and lack of exercise), behavioral (stress)
Cure: Fiber, Fluid, and Movement
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Congenital Aganglionic Megacolon Hirshsprungs
- Absence of ganglionic innervation of lower bowel
- External sphincter normal but internal sphincter fails to relax
- 4x more males (1:5,000 occurrence)
- Symptoms: no meconium w/i the 1st 24 hours, hx of constipation alternating with ribbon like foul stools, fussiness and irritability, failure to thrive, distended abdomen
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Hirshsprungs Clinical Manifestations
- Absence of meconium in first 36 hours
- Alternating constipation with ribbon like stools
- Fussiness and irritability
- Failure to thrive
- Distended abdomen, constipation
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Hirshsprungs
- Diagnosis: Rectal Biopsy (take little pieces to see if there is nerve conduction)
- Treatment: Soave endorectal pull-through (sometimes colostomy); Bowel program (encourage breastfeeding to avoid constipation
- NOTHING PER RECTUM!
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Anorectal Malformations
- 1 in 4,000 to 5,000 live births
- Imperforated Anus: no anal opening
- Persistent Cloaca: rectum, vagina and urethra are connected
- Rectal Fistula: can connect with vaginal or urethra
- Anal Stenosis: narrow opening in rectum/anal area
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Persistent Cloaca
- Complex
- Rectum, vagina, and urinary tract all open into one common channel
- The channel opens to the outside through an orifice located in the normal urethral site
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Anorectal Malfomration Observations
- Shape of Buttocks
- Midline Groove
- Dimple
- Stool
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Anorectal Malformation Treatment
- Primarily Surgery: pull-thru, anoplasty, colostomy
- Dilations
- Bowel program
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Omphalocele (abdominal wall defect)
- Herniation of abdominal contents thru umbiliical ring
- Can include liver, bladder and kidneys
- Strongly associated with chromosomal defects and abnormalities, IUGR
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Gastroschisis (abdominal wall defect)
- Herniation of intestinal contents usually to the right of the umbilicus
- Associated with young mothers
- Occurs in many short gut
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Nursing Concerns
- Infection
- Ileus
- Heat and Fluid losses
- Growth and Development Retardation
- Oral Stimulation
- Emotional Support
- Parental Role
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Cleft Lip/Cleft Palate
- 1-700 live births (Asian 2:1000)
- Genetics, Environment (esp. smoking), Diet, Drugs (including alcohol)
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Cleft Lip
- Possibly effects seal for sucking
- Biggest problem is very visible; effects bonding and self image. Will need dental F/U
- Closure done usually 1-3 months (10 rule)
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10 Rule
- Lip @ 10 weeks
- Hb @ 10 weeks
- Weigh @ 10 lbs
- Cleft Palate @ 10 months
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Cleft Palate
- Effects feeding since unable to get negative pressure with suck and create suction
- Also effects face shape, teeth formation, speech development, and hearing
- Surgery delayed until usually until 10 months
- Do not suction or put anything in the mouth; position instead
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Cleft Palate Feeding Issues
- Positioning
- Nipples
- Face signals
- Burping
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Cleft Palate Post-Op Concerns
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Cleft Palate Long Term Concerns
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Acute Appendicitis
- Inflammatory condition
- Most common abdominal surgery
- Children more at risk for rupture
- Symptoms:
- anorexia for 12-24 hours, possible vomiting
- limited movement and rigid positioning to side, especially right hip, with knees flexed
- rebound tenderness, usually right side
- termperature
- Nursing: pain, gas, and infection control
- AMBULATE, AMBULATE, AMBULATE
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Obstructive Disorders
- Foreign bodies or substances
- Risk Groups: toddlers and adolescents
- Special concerns: agents that damage gut (batteries, lead paint, sharps)
- Nursing consideration: safety training (Ipeac syrup vs activated charcoal)
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Pyloric Stenosis
- Occurs in usually the first 6 months, more males (5x) than females
- Olive like mass felt in upper right abdomen
- Value between the stomach and the duodenum enlarges and becomes very thick-can make peristalsis visible
- Main Symptom: projectile vomiting
- At risk for: Metabolic Alkalosis
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Intussusception
- Intestines retract into themselves-most frequent intestinal obstruction
- Classic presentation of acute pain alternating with normal behavior; current jelly-like stools and/or vomiting
- Dx: barium edema, x-ray, sonogram
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Short Bowel Syndrome
- Common Causes: abdominal wall defects, necrotizing enterocolitis (1-8% of all infants in NICU)
- Treatments: ostomy, G-tube feedings and/or TPN
- Complications: fluids/electrolytes, growth retardation, infections, liver dysfunction
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NEC (Necrotizing Entrocolitis)
- Infection in the valve
- Common cause of Short Bowel Syndrome
- Abdominal Wall Defects
- Radiation Injury
- Volvulus (twisting of the bowel on itself)
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Biliary Atresia
- Liver disorder
- Intrahepatic and extrahepatic bile ducts do not function shortly after birth. Bile that normally empties into duodenum blocked and progressive damages liver
- Clinically: urine dark color and stools gray (abdomen distended, change in feeding, jaundice-increased bilirubin after 14 days)
- Treatment: Kasai procedure (reroutes bile); liver transplant
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