Pediatric
Nursing
Module 3
Caring for Children with
Alterations in
Nutrition/Elimination
Assessment of GI System

History

gathering base line data
infant - formula type and tolerance
 children - diet, appetite, preferences meal
schedule
 any prior GI problems
 elimination patterns


stools, characteristic, number per day, toilet habits
general nutritional appearance
 height and weight

Physical Assessment

Inspection

oral cavity
ability to suck, swallow, chew
 any ulcers, sores, bleeding, thrush, dental
caries,congenital anomalies (cleft lip and palate)
sore throat


Abdomen

distention, turgor, contour, pain, girth
Physical Assessment





Stool
 number, consistency, presence of blood
Vomitus
 color, amount, blood, projectile
Urine
 specific gravity, frequency amount
Tears
Fontanels
 Pf closes at 2-3 months, Af closes 9-18 months
Assessment - dehydration


Children are more susceptible
to dehydration due to greater
% or portion of their body
weight being water
Signs and Symptoms
 poor skin turgor
 sunken fontanel
 decreased urine out-put
(1-2ml/uo/kg/hr)
 decreased body weight
 dry mucous membranes, lips
 no tears
Physical Assessment

Auscultation
 Abdominal
 peristalsis
 presence/absent
 hypo or hyper
 visible - possible pyloric stenosis
Adjunct Assessment





Weight
Temperature
Labs
 stool culture, ova & parasite, guiac, roto virus
 electrolytes - Na, K, Cl, HCO3
 CBC - wbc’s
I&O
X-ray
 barium swallow, barium enema
What questions do you have for
the parent, for the child?
Signs and Symptoms of
Dehydration

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
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
Neurological
Cardiac
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Disorders of Motility
Gastroenteritis

Acute Diarrhea




bacterial vs viral
isolation - good handwashing
bloody stools, mucous, cramping
change in the number and consistency of
stool, increase in the water margin, usually
green in color
Gastroenteritis

Acute vomiting



Differentiate between
vomiting vs spitting up
projectile - pyloric stenosis
reflux - may lead to
respiratory problems
A 6 month old is admitted with
dehydration. Effectiveness of therapy
is evaluated by which assessment
measures? Choose all that apply
Analysis question, first
recall assessment
findings for dehydrated
child





assess fontanel
measure and document abdominal girth
document mucous membrane moisture
record and analyze I & O
daily wt., same scale, time, no clothes
Hirschsprung’s Disease


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
Hirschsprung’s Disease

Signs/Symptoms

abdominal distention
intermittent
 progressively increasing



anorexia
malnutrition
obstruction with diarrhea
 dehydration and electrolyte imbalance

Hirschsprung’s Disease

Treatment


temporary colostomy
Pre-op


clear liquids
bowel prep
enemas/laxatives
 antibiotic therapy - decrease normal bowel flora

Hirschsprung’s Disease

Post-op Care





pain control
hydration
assessing stoma
bowel elimination
teaching
Gastric Reflux

Gastroesophageal Reflux
(GER)



backward flowing of
gastric contents into the
esophagus
incompetent lower
esophageal sphincter
increase intra abdominal
pressure
Gastric Reflux

Signs and Symptoms

Infant
spitting up, regurgitation, vomiting
 crying, irritable
 wt. loss, FTT


Children
heartburn, chest pain, abd. pain
 dysphasia, burping,
 regurgitation, cough, pneumonia

Gastric Reflux

Treatment

small frequent thicken feedings



hypoallergenic formula
positioning
medications

H 2 antagonist


pepcid, tagament, zantac
surgical

Nissen fundoplication
Inflammatory Disorders
Appendicitis


Inflammation of the
appendix resulting from
bacterial infection or
obstruction
Rupture = peritonitis
abscess
Appendicitis

Signs and Symptoms
 G.I.
 n/v/a and d/c, rigid abdomen
 Pain
 peri-umbilical - localizing RLQ
 re-bound tenderness
 progressive
 Other
 fever, stooped posture, lethargy

Treatment

appendectomy



Structural Defects
Craniofacial Abnormalities
Cleft orLip
& Palate
May occur separately
together
Unilateral or bilateral
Associated problems
 feeding difficulties
 URTI
 otitis media
 speech
 dental formation
 self-image
Cleft Lip

Interference with bonding


Disfigurement
Feeding Techniques




more upright to avoid aspiration
frequent burping
lamb’s nipple
asepto syringe with tubing if infant unable
to create closure and suction
Cleft Lip

Surgical repair


2-4 months old
Post-op care



prevent strain on suture line
keep infant off their stomach
keep suture line clean

Q-tip, NS, antibiotic oint.
Cleft Palate

Feeding


same as cleft lip
solids as soon as possible



thicken liquids
aspiration may be a problem
frequent URTI and ear problems
Cleft Palate


Surgical Repair
 usually 9 - 18 months
 perform closure prior to speech
 after weaned to cup
Post-op Care
 keep on abdomen till fully awake
 semi-liquid, puree diet
 no sucking
 elbow restraints
 keep suture line clean after feeding with water
Cleft Palate

Long term care

speech

socialization

dental problems

psychosocial
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
Ineffective feeding pattern 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.
Obstructive Disorders
Intussusception


Telescoping or a portion of the
small intestine or colon into a
more distal segment
Signs/Symptoms
 vomiting


pain - paroxysmal colicky
abdominal
“current jelly” stools - brown,
bloody, mucous mixed
Intussusception

Treatment


barium enema to reduce it or surgery
Post-op


gastric decompression
IV therapy
Obstructive Disorders
Pyloric Stenosis

Narrowing of the pyloric valve


hypertrophic muscle
Signs/Symptoms
 projectile vomiting
 left to right peristalsis
 olive sized mass palpated in
upper right quadrant
 cries with hunger
 readily accepts 2nd feeding
after vomiting
Pyloric Stenosis

Adjunct Problems





dehydration
electrolyte imbalance
alkalosis
malnutrition
Diagnosis

confirmed with barium x-ray
Pyloric Stenosis

Surgery


Pyloromyotomy
Post-op Feeding


post-pyloromyotomy feeding schedule
sterile water, small amount, gradually
increasing in substance and quantity
Nursing Care - Nutrition and
Fluid Balance Needs

Nursing Care and Concerns

Fluid Volume and Electrolyte Imbalance
daily wt.
 I & O
 assess for s/s of dehydration
 maintain IV therapy
 oral care if NPO
 monitor labs - electrolytes

Nursing Care

When introducing fluids
small frequent feedings
 clear liquids




pedialyte
may dilute formula
monitor for



vomiting
diarrhea
abdominal distention
Nursing Care/Concerns

Nutrition





check for vomiting
assess tolerance of feedings
weight and graph
thickened feedings
feed slowly
 check suck
 small amounts
 calorie count
 upright - infant seat
Nursing Care/Concerns

High Risk for Infection




Cleft Lip/Palate
 URTI or OM
diarrhea
 spread of infection
pyloric stenosis
 body may be debilitated
appendicitis
 peritonitis
Nursing Care/Concerns

Local infection - superficial



redness, heat, swelling
tenderness, pain
Systemic infection - internal



abdominal pain, increasing
abdominal girth
guarding
temperature
Nursing Care/Concerns

Knowledge Deficit





assessing parents understanding
of child’s needs and the problem
assess parent’s ability to learn
teach simply, clearly, allowing time
for questions and return
demonstration
support group
referrals
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.
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
WBC’s are 17,500.
Discuss your impressions of the situation.
Questions


The US confirms appendicitis.
Discuss the following orders.



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NPO
B/R
D5 1/2 with 10 KCL at 70ml/hr
Gentamycin 45mg IV on call to OR
MS 1-2mg IVP q2hrs prn pain
K-pad to abdomen
Prepare for OR - lap appendectomy
Questions



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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 the pros and cons of letting parents into the
PACU?
Post-op orders are as follows:

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

routine post op vitals
foley catheter to straight drainage
D5 1/2 NS with 20KCL 75ml/hr
Gentamycin 45mg IVP q8hr
Unasyn 900mg IV q 6hr
MS PCA
Tylenol 240mg q4rhs per N/G tube prn T>100.4
NGT to continuous drainage
NPO except for meds
IS 10 times each hour while awake