1. Developmental and Biological Variances
    • Infants younger than 6 weeks do not produce tears.
    • In an infant a sunken fontanel may indicate dehydration- closes at 12-18 months
    • Infants are dependent on others to meet their fluid needs
    • Infants have limited ability to dilute and concentrate urine
  2. Developmental and Biological
    • The smaller the child, the greater the proportion of body water to weight and proportion of extracellular fluid to intracellular fluid.
    • Infants have a larger proportional surface area of the GI tract than adults-get dehydrated quicker
    • Infants have a greater body surface area and higher metabolic rate than adults
  3. Developmental changes
    • GI tract not mature until 4-6 months
    • Eruption of teeth (baby 6 mo, lose 6 yr.)
    • Volume of stomach(30-90ml, goes up 150 a year)
    • Changes in appetite-growth spurts
    • fluid is of great importance in children because it makes a greater portion of the child's weight
  4. When do you increase fluid needs?
    • Fever
    • Vomiting & Diarrhea
    • High-output renal failure
    • Diabetes insipidus (DI)- lots of urine
    • Burns
    • Shock
    • Tachypnea
  5. When do you decrease fluids?
    • Congestive heart failure-overload would = dec. resp.
    • Renal failure
    • Head trauma/ meningitis=inc. ICP.
  6. Maintenance Requirement of Fluid
    • First 10kg----100ml/kg/day
    • 10-20 kg------100ml+50ml/kg of body wt. more than 10kg
    • >20kg---------150 ml+ 20ml/kg of body wt.>than 20 kg
  7. What are some signs of dehydration?
    • Dry skin and mucus membranes
    • Poor skin Turgor
    • Sunken eyes (dec. IOP)
    • Depressed anterior fontanel
    • Gray or ashen in color
    • Rapid and weak pulse
    • Decreased BP (child compensates 25% body loss, bp does not drop right away)
    • Oliguria
    • Decreased tears (after 6wks)
    • Irritability
    • Delayed capillary refill
    • Inc. Hgb, Hct
  8. What is Gastroenteritis?
    • A group of clinical syndromes manifested by nausea, vomiting, and diarrhea
    • Inflammation of the stomach and intestines
    • Rotovirus is the leading cause of pediatric gastroenteritis
  9. Predisposing Factors of Gastroenteritis
    • Poor sanitation
    • Improper handling of food
    • Daycare-use spray cleaner, soap & water
    • Antibiotics
    • Previous bowel surgery
    • Hospital acquired
    • Presence of other infectious processes
    • Anxiety-inc. motility
  10. Viral Agents in Gastroenteritis
    • More common in winter
    • Rotavirus-most common in children 6-24 months
    • Norwalk-affects all ages (daycares, cruise ships)
    • adenovirus
  11. Bacterial agents and gastroenteritis
    • More common in summer
    • mild to severe symptoms
    • Most recover without treatment
    • Salmonella (turtles, baby chicks)
    • Shigella (oral/fecal, monkeys)
    • E-Coli (undercooked foods)
  12. Hypernatremia in dehydration
    • Warm, "doughy" skin texture
    • hypertonia
    • hyperreflexia
    • lethargy with irritability when touched
  13. Hypokalemia in dehydration
    • weakness
    • Illeus with abdominal distention
    • Cardiac arrhythmias
  14. Management of Gastroenterititis
    • Assessment of dehydration
    • Oral rehydration (inc. po fluids if diarrhea inc, give po fluids slowly if vomiting., resume diet slowly)
    • Avoid fluid with high carbohydrate and low electrolyte values (pop)
    • Advance to normal diet as soon as possible
    • Nursing mothers should continue to breast feed
    • Use of anti-diarrheal agents discouraged
    • Protect skin
    • IV therapy for inadequate circulating blood volume
    • Hylinex-SQ rehydration (acts quickly)
  15. Nursing Rehydration interventions
    • Assess child's hydration status
    • Strickt intake and output
    • Daily weights
    • Hourly monitoring of IV rate and site of infusion
    • *increase fluids if increase in vomiting or diarrhea
    • *decrease fluids when taking po fluids or signs of edema
  16. What is constipation?
    • Difficulty passing hardend stool
    • May be due to underlying disease
    • May occur when trasitioning from formula/breast milk to cow's milk
    • More common in toddler years
    • management-diet, exercise, behavior modifications
    • Encorpresis-retention of stool with recurrent soiling
  17. What is Hirschsprung's disease?
    • Congenital Aganglionic Megacolon
    • Absence of autonomic parasympatheic ganglion cells in the mucosal and muscular layers of the colon
    • Peristalsis normal
    • results in obstruction and dilation of the proximal bowel
  18. clinical findings of Hirschsprung's disease
    • failure to pass meconium
    • enlarged, distended abdomen
    • vomiting
    • fecal mass palpable
    • rectum is empty of stool
    • anorectal manometry (test the sphincter's reaction to rectal distention)
    • Biopsy to confirm diagnosis
  19. Management of Hirschsprung's disease
    • Medical management-monitor F&E balance, May need regular rectal irrigation
    • Surgical removal of the agangliionic portion of the bowel
    • May need temporary ostomy proximal to the aganglionic segment
    • complete correction- pull-through procedure
  20. Special considerations in Hirschsprung's disease
    • May be too malnourised to withstand immediate surgery (High calorie, high protein, low fiber diet OR TPN)
    • Enterocolitis
    • *Inflammation of the small bowel and colon
    • *Leads to ischemia and ulceration of bowel wall
    • * surgical emergency if bowel perforation occurs
  21. What is Gastroesophageal Reflux?
    • Retrograde flow of gastric contents into the esophagus
    • Effortless vomiting-not having sufficient intraluminar pressure to prevent spitting up
    • Failure of the sphincter mechanism at the junction of the esophagus and the stomach
    • May see spontaneous improvement by 6-9 months
    • GERD-GER with complications (aspiration, apnea)
  22. Manifestations of GI reflux
    • spitting up
    • vomiting
    • weight loss
    • gagging, chocking at the end of feedings
    • respiratory problems
    • heartburn/irritability
  23. Diagnostic testing for GI reflux
    • pH probe- Probe is placed in the distal esophagus to detect pH changes below 4.0pH is measured and recorded q 4-8 sec.
    • UGI-fluroscopic and radiographic examinations of the esophagus, stomach, and small intestine.
    • Swallow study-Oral barium or water soluble contrast agent is swallowed. The barium or contrast is observed as it passes through the digestive tract and films are taken.
    • Scintiscan -gastric emptying study
    • Flexible endoscopy-visualize the internal structures of the esophagus, stomach, and duodenum.
  24. Management of GI reflux
    • Change to soy formula
    • Frequent burping
    • Small feedings-not over 30 minutes
    • Elevate the HOB
    • Lay on right side after feeding
    • Thicken feeding with rice cereal
    • Weight monitoring
    • Nissen Fundoplication-Wrapping the gastric cardia with adjacent portions of the gastric fundus around esophagus (cannot vomit)
    • G-Tube-decreases the incidence and discomfort of gas (vents stomach)
  25. Histamine H-2 receptor antagonist-Medications
    • Zantac (Rantidine)
    • Pepcid (Famotidine)
    • Tagament (Cimetidine)
  26. H-2 receptor anatongist-Action/Indication
    Zanatc, Pepcid, Tagament
    Inhibition of the histamine-2 receptor on the gastric parietal cell, thus blocking gastric acid secretion
  27. Histamine H-2 Receptor antagaonist-Nursing implications
    Zantac, Pepcid, Tagment
    • May be administered with/out food
    • If antacids are perscribed, administer 2 hours before or after H2 antagoinist
    • Teach parents to avoid OTC medications without check with healthcare provider
  28. Histamine H-2 receptor anatgonist-side effect
    Zantact, Pepcid, Tagament
    • Bradycardia
    • Constipation
    • Nausea
    • Fatigue
    • Confusion
    • Dizziness
    • headache
    • Irritability
    • Rash
    • Thrombocytopenia
  29. Proton Pump Inhibitors-Medication
    • Pravacid (Lanzoprazole)
    • Prilosec (Omeprazole)
  30. Proton Pump Inhibitors-Action
    Prevacid, Prilosec
    • Inhibits acid secretions, alleviates symptoms and helps to heal esophagitis
    • Block the final common pathway of acid production by inhibiting activated proton pumps in the gastric parietal cell canaliculus
  31. Proton Pump Inhibitors-Nursing implications
    Prevacid, Prilosec
    • Administer in the morning on an empty stomach
    • Teach family to inform HCP if sever diarrhea occurs
    • Teach family to inform HCP if changes in urinary elimination, such as pain or discomfort associated with urination occur
  32. Proton Pump Inhibitors-Side Effects
    Prevacid, Prilosec
    • Abdominal Pain
    • Diarrhea
    • Dizziness
    • Fatigue
    • Headache
    • Hematuria
    • Nausea
    • Proteinuria
    • Rash
  33. Prokinetic Agents-Medication
    Reglan (Metoclopramide)
  34. Prokinetic Agents-Action
    • Promotes Gastric emptying
    • Improves gut motility
  35. Prokinetic Agents-Side effects
    • Mild sedation
    • Fatigue
    • Restlessness
    • Nausea
    • Rash
    • Headache
    • Insomnia
    • Diarrhea
    • Constipation
  36. Aminosalicylates-Medications
    • Sulfasalazine
    • mesalamine
  37. Aminosalicylates-Indication
    • Used for anti-inflammatory effect
    • Inhibition of prostaglandins known to cause diarrhea and affect mucosal trasport
  38. Aminosalicylates-Nursing Implication
    Sulfasalazine, meslamine
    • Administer after meals
    • Do not crush or chew sustained released tablets
    • Teach patient or parents to supplement daily intake of iron
  39. Aminosalicylates-side effects
    Sulfasalazine, meslamine
    • Nausea
    • vomiting
    • bloody diarrhea
    • anorexia
    • rash
    • headache
  40. Corticosteroids-Medications
    • Prednisone
    • Prednisolone
    • Hydrocortisone enema
  41. Corticosteroids-Indication
    Prednisone, Prednisolone,hydrocrtisone
    • Used for anti-inflammatory effect
    • **Main one used**
  42. Corticosteroids-Nursing implication
    Prednisone, Prednisolone,hydrocrtisone
    • Administer oral medications with meals to reduce gastric irritation
    • Teach family to avoid abrupt discontinuation of medication
    • Teach family to report delayed wound healing
  43. Corticosteroids-Side effects
    Prednisone, Prednisolone,hydrocrtisone
    • Nausea
    • Vomiting
    • Cushingoid appearance (moon face)
    • immunosuppression
    • growth suppression
    • hypertension
    • acne
    • altered mood
  44. Biological Therapies-Medication
    • Tumor necrosis factor-alpha (TNF-alpha)
    • Infliximab (Remicade)
    • Interleukin-10
    • Thalidomide
  45. Biological Therapies-Indication
    TNF-alpha, remicade
    Prevents TNF-alpha from binding to its receptors (TNF-alpha have been found in stools of patients with crohn's disease)
  46. Biological Therapies-Nursing implications
    TNF-alpha, remicade
    • Reconstitute IV preparation according to manufacture directions and administer according to agency protocol
    • D/C IV infusion if infusion reaction is evident (fever, chills, chest pain, hypotension, dyspnea, urticaria)
  47. Antibiotics-Medications
    • Metronidazole
    • Ciprofloxacil
  48. Antibiotics-Indication
    Metronidazole, Cipofloxacil
    Antibacterial aganst anaerobic bacteria and some gram-negative bacteria
  49. Antibiotics-Nursing implications
    Metronidazole, Cipofloxacil
    • Extended release form should not be chewed or crushed
    • Administer with food or milk to reduce gastrointestinal distress
  50. Antibiotics-Side effects
    Metronidazole, Cipofloxacil
    • Fever
    • Headache
    • Diarrhea
    • Nausea
    • Vomiting
    • Fungal overgrowth
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