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8/4/2019 Pediatric Nursing9(Gastrointestinal Disorder)
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Pediatric NursingGastrointestinal
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Function
1. Assists in maintaining F&E and acid1. Assists in maintaining F&E and acid--base balancebase balance
2. Processes and absorbs nutrients to2. Processes and absorbs nutrients tomaintain metabolism and supportmaintain metabolism and supportgrowth and developmentgrowth and development
3.Ex
crete waste products from3.Ex
crete waste products fromdigestive processdigestive process
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Recommended DailyAllowance
Calories: 120 cal/Kbw/day; 360Calories: 120 cal/Kbw/day; 360--380 cal380 caldailydaily
ProteinProtein 2.2 g/Kbw/day2.2 g/Kbw/day FluidsFluids 1616--20 cc/kg/day20 cc/kg/day
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Supplementary Feeding
Supplementary feedingSupplementary feeding 44--6 months6 months
Never wean an infant if inNever wean an infant if in
1.Solid foods in order:1.Solid foods in order: -- cerealscereals rich in ironrich in iron
-- fruitsfruits
-- vegetablesvegetables
-- meatmeat
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2. begin in small quantities2. begin in small quantities
3.Finger foods3.Finger foods offered at 6 monthsoffered at 6 months
4.Soft table foods4.Soft table foods 1 year1 year 5. Dilute fruit juices5. Dilute fruit juices 6 months; 1 is to6 months; 1 is to
4 ounces of water4 ounces of water
6. Never give half cooked eggs6. Never give half cooked eggs salmonelliosis/gastroenteritissalmonelliosis/gastroenteritis
7. Dont give honey7. Dont give honey infant botulisminfant botulism
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8. Offer food one at a time8. Offer food one at a time interval ofinterval of44--7 days7 days
Total body fluidsTotal body fluids 6565--85% of body85% of bodyweightweight
Greater in extracellularGreater in extracellular dehydrationdehydration
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Acid-Base Balance
1.Chemical buffers1.Chemical buffers
2.Renal and respiratory system2.Renal and respiratory system
3. Dilution of strong acids and bases in blood3. Dilution of strong acids and bases in blood Respiratory acidosisRespiratory acidosis carbonic acid excesscarbonic acid excess
-- hypoventilationhypoventilation
-- RDSRDS
-- COPDCOPD
-- LaryngotracheobronchitisLaryngotracheobronchitis
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Respiratory alkalosisRespiratory alkalosis carbonic acidcarbonic aciddeficitdeficit
-- hyperventilationhyperventilation -- feverfever
-- encephalopathyencephalopathy
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etabolic acidosisMetabolic acidosis base HCO3 deficitbase HCO3 deficit
-- diarrheadiarrhea
-- severe dehydrationsevere dehydration -- malnutritionmalnutrition
-- ciliac crisisciliac crisis
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Metabolic alkalosisMetabolic alkalosis case HCO3 excesscase HCO3 excess
-- uncontrolled vomitinguncontrolled vomiting
-- NGT insertionNGT insertion -- gastric lavagegastric lavage
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Problems Leading to F&EImbalance
1. Vomiting1. Vomiting forceful expulsion offorceful expulsion ofstomach contentsstomach contents
Sx:Sx: NauseaNausea
DizzinessDizziness
Facial flushingFacial flushingAbdominal crampingAbdominal cramping
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Assess:Assess:
AmountAmount
FrequencyFrequency ForceForce projectileprojectile
Mgt:Mgt:
BRAT dietBRAT diet banana, rice, apply sauce,banana, rice, apply sauce,toasttoast
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Diarrhea
Exaggerated excretion of intestinalExaggerated excretion of intestinalcontentscontents
Types:Types: 1. Acute1. Acute related to gastroenteritis,related to gastroenteritis,
salmonellasissalmonellasis
-- dietary indescretiondietary indescretion -- antibiotic use (Ampicillin, tetracycline)antibiotic use (Ampicillin, tetracycline)
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2.Chronic non2.Chronic non--specificspecific
Cause:Cause:
1. food intolerance1. food intolerance 2.Excessive fluid intake2.Excessive fluid intake
3. carbohydrate and protein3. carbohydrate and proteinmalabsorptionmalabsorption
Assess:Assess:
Frequency, consistency, appearanceFrequency, consistency, appearance
Best criteria: consistencyBest criteria: consistency
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Complication:Complication:
DehydrationDehydration
MildMild 5% wt loss5% wt loss ModerateModerate 10% wt loss10% wt loss
SeverSever 15% wt loss15% wt loss
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Early signs and symptoms:Early signs and symptoms:
Tachycardia, tachypnea, hypotensionTachycardia, tachypnea, hypotension
Increase temp, sunken fontanel andIncrease temp, sunken fontanel andeyeballs, absence of tearseyeballs, absence of tears
Weight loss, scanty urine, dry skinWeight loss, scanty urine, dry skin
Severe dehydration: marked oliguria,Severe dehydration: marked oliguria,prolonged capillary refillprolonged capillary refill
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Mgt:Mgt:
Acute:Acute:
-- NPONPO -- IV therapyIV therapy
-- prone to hypokalemiaprone to hypokalemia
DrugDrug NaHCO3NaHCO3
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Chronic:Chronic:
-- thickened feeding with baby cerealsthickened feeding with baby cereals
-- feed slowly, burp often (every 1feed slowly, burp often (every 1ounce)ounce)
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Hirschprungss Disease
Congenital aganglionic megacolonCongenital aganglionic megacolon
Earliest sign:Earliest sign:
1. failure to pass meconium after 241. failure to pass meconium after 24hourshours
2. abdominal distention2. abdominal distention
3. vomitus of fecal material3. vomitus of fecal material 4. foul smelling breath4. foul smelling breath
Early childhoodEarly childhood ribbonribbon--like stoollike stool
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Diagnosis
1. Barium enema1. Barium enema reveals narrowedreveals narrowedportion of bowelportion of bowel
2.Rectal biopsy2.Rectal biopsy reveals absence ofreveals absence ofaganglionic cellsaganglionic cells
3. Abdominal X3. Abdominal X--rayray reveals dilatedreveals dilated
loops on intestineloops on intestine 4.Rectal manometry4.Rectal manometry reveals failurereveals failure
of intestine sphincter to relaxof intestine sphincter to relax
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Management
1. NGT feeding1. NGT feeding
2.Surgery2.Surgery
-- Temporary colostomyTemporary colostomy -- anastomosis and pull throughanastomosis and pull through
porcedureporcedure
DietDiet increase protein, increaseincrease protein, increasecalories, decrease residuecalories, decrease residue pastapasta
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Gastroesophageal Reflux Disease
AchalasiaAchalasia
Regurgitation of stomach contents intoRegurgitation of stomach contents into
the esophagusthe esophagus ComplicationComplication esophagitis; aspirationesophagitis; aspiration
pneumoniapneumonia
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Management
AnticholinergicAnticholinergic
1. Betanicol (Urecholine)1. Betanicol (Urecholine) increaseincrease
esophageal tone and peristaltic activityesophageal tone and peristaltic activity 2. Metachlorpromide (Reglam)2. Metachlorpromide (Reglam)
decrease esophageal pressure bydecrease esophageal pressure by
relaxing pyloric duodenal segmentsrelaxing pyloric duodenal segments
-- increase peristalsis withoutincrease peristalsis withoutstimulating secretionsstimulating secretions
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3. H2 Receptor Antagonist3. H2 Receptor Antagonist decreasedecreasegastric acidity and pepsin secretiongastric acidity and pepsin secretion
-- Ranitidine (Zantac)Ranitidine (Zantac)AntacidAntacid neutralizes gastric acidneutralizes gastric acid
between feedingsbetween feedings
-- MaaloxMaalox SurgerySurgery Nissen funduplicationNissen funduplication
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Esophageal Cancer
Assessment:Assessment:
1.Chronic vomiting1.Chronic vomiting
2.Failure to thrive syndrome2.Failure to thrive syndrome 4. Melena or hematemesis4. Melena or hematemesis
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Diagnosis
1.Esophagoscopy1.Esophagoscopy
2.Esophageal manometry2.Esophageal manometry relvealsrelveals
lower esophageal sphincter pressurelower esophageal sphincter pressure 3. Intra esophageal pH content3. Intra esophageal pH content
reveals pH of distal esophagusreveals pH of distal esophagus
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Pyloric Stenosis
Hypertrophy of muscles of pylorusHypertrophy of muscles of pyloruscausing narrowing and obstructioncausing narrowing and obstruction
Outstanding signOutstanding sign projectile vomitingprojectile vomiting -- vomitingvomiting initial sign of upper GIinitial sign of upper GI
obstructionobstruction
-- vomitus of upper GIvomitus of upper GI blood tingedblood tinged -- vomitus of lower GIvomitus of lower GI bile streaked;bile streaked;
bilousbilous
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-- abdominal distentionabdominal distention major sign ofmajor sign oflower GI obstructionlower GI obstruction
Metabolic alkalosisMetabolic alkalosis Failure to gain weightFailure to gain weight
Olive shaped massOlive shaped mass
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Diagnosis
Increase Na and K, decrease ClIncrease Na and K, decrease Cl
UltrasoundUltrasound
XX--ray with barium swallowray with barium swallowABGABG
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Management
1. Pyloromyotomy1. Pyloromyotomy incision of pyloricincision of pyloricmusclemuscle
2.Fredt2.Fredt--Ramstedt procedureRamstedt procedure separation of hyperthrophied muscleseparation of hyperthrophied musclewithout incisionwithout incision
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Intussusception
Invagination or telescoping of positionInvagination or telescoping of positionof bowel to anotherof bowel to another
Common site: distal ileum and proximalCommon site: distal ileum and proximalcoloncolon
Prone: eats fastProne: eats fast
ComplicationComplication -- peritonitisperitonitis
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Sn/Sx:Sn/Sx:
1. persistent paroxysmal abdominal1. persistent paroxysmal abdominal
painpain severesevere FrequencyFrequency 1515--20 minutes20 minutes
2. vomiting2. vomiting contains bilecontains bile
3. currant jelly stool3. currant jelly stool after 12 hoursafter 12 hours 4. sausage4. sausage--shaped massshaped mass
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Management
Hydrostatic reduction with bariumHydrostatic reduction with bariumenemaenema
Pneumatic insufflationPneumatic insufflation airair SurgerySurgery anastomosis and pull throughanastomosis and pull through
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Inborn Errors of Metabolism
Phenylketonuria (PKU)Phenylketonuria (PKU)
Deficiency of liver enzymeDeficiency of liver enzyme
phenylalanine hydroxylasephenylalanine hydroxylase Prevents conversion of phenylalanine toPrevents conversion of phenylalanine to
tyrosinetyrosine
TyrosineTyrosine epinephrine, thyroxine,epinephrine, thyroxine,melaninmelanin
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Signs and Symptoms
1. Urine has musty or mousy odor1. Urine has musty or mousy odor phenylpyruvic acidphenylpyruvic acid
2. Atopic dermatitis2. Atopic dermatitis 3.Seizures3.Seizures
4. Growth retardation4. Growth retardation -- thyroxinethyroxine
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Diagnosis
Guthrie testGuthrie test bacterial inhibitionbacterial inhibition
Pheric chloridePheric chloride green spots in thegreen spots in the
diaper as sign of PKUdiaper as sign of PKU
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Diet
Low phenylalanine dietLow phenylalanine diet contraindicatecontraindicatehigh protein foodshigh protein foods
LofenalacLofenalac extremelyextremely--lowlowphenylalanine formulaphenylalanine formula
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Galactosemia
Carbohydrate metabolism disorderCarbohydrate metabolism disorder
Deficient: galactose 1Deficient: galactose 1--phosphatephosphate
uridyltransferaseuridyltransferase May die at 3 days of ageMay die at 3 days of age
Symptoms:Symptoms:
GalactosemiaGalactosemia GalactosuriaGalactosuria
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Diagnosis
Beutler testBeutler test screening test; uses cordscreening test; uses cordbloodblood
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Management
DietDiet galactosegalactose--freefree
NutramigenNutramigen milk substitute formulamilk substitute formula
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Celiac Disease
GlutenGluten--induced Enteropathyinduced Enteropathy
Intolerance to:Intolerance to:
BB barleybarley RR ryerye
OO oatoat
WW wheatwheat Inability to absorb fatInability to absorb fat
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Early sign:Early sign:
1. Diarrhea1. Diarrhea
2.Constipation2.Constipation 3. Vomiting3. Vomiting
Late sign:Late sign:
1. Abdominal pain1. Abdominal pain protuberantprotuberantabdomenabdomen
2.Steatorrhea2.Steatorrhea
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Diagnosis
1. history and clinical symptoms1. history and clinical symptoms
2.Serum analysis2.Serum analysis IgA antigliadinIgA antigliadin
antibodiesantibodies
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Management
GlutenGluten--free dietfree diet lifetimelifetime
Rice and cornRice and corn OKOK
Vitamin supplementsVitamin supplements Mineral supplementsMineral supplements