Pediatric Nursing Exam 3
“The Child with Gastrointestinal Dysfunction / Transfer of Nutrients”
Infant’s Nutrition
The parental dilemma between breast milk or formula feedings is dictated by
o Nutritional
o Economical
o Psychosocial Factors
Breast Milk Positives
o Promotes immunity – AAP 2005; studies reveal increased infant immunity toward meningitis, bacteremia, otitis media, respiratory
infections, UTI
o Lipids are 50% of Human milk
Breast milk contains lipids, triglycerides, and cholesterol.
All essential element for brain growth and proper growth and development.
o Analgesic effect (2002 study)
o Carbohydrates: lactulose: 6.8mg/dl, (Vit B) galactose, glucose, & glycosamine are essential for lactobacillus production in gut
o Adequate protein not excessive
o Growth modulators
o Lower amount but more efficient ratios of essential elements and minerals
o Promotes Bonding
o Economical (less expensive than formula)
Breast Milk Negatives
o Human milk may not have enough Vitamin D/iron
o Without appropriate teaching for the mother it can be painful and the infant may not latch on easily
o Requires more frequent feedings to stimulate milk production
o Time consuming
o To achieve lasting benefits studies have shown it takes at least 6 months of consistent breast feeding to achieve successful outcomes
o Concerns over low weight gain initially; averages out by 12 months of age.
o Culturally or socially unacceptable, case dependent
Health Newborn – 108 kcal/kg/day
Caloric requirements increase according to disease state
Nursing Calculations
cal/oz X 6oz/feeding X number of feedings/day = calories/day
Breast-feed every 2 to 3 hours for 10-15 minutes on each breast within each 24 hour period.
Parent Teaching
Check for wet diapers to ensure proper hydration/ Monitor growth and development
Pediatrician assessment 1st 3-5 days of breast feeding and 2-3 wks to ensure appropriate nutrition
Toddlers 1-2 Years Old – 102 kcal/kg/day
Nutritional Changes
o Slight decrease in nutritional needs
o Protein requirements change from 2.2 to 1.5g/kg
o Change in body fluid balance
Developmental Behaviors and Milestones
o 18 mos. Physiological Anorexia
o Active Exploration (often do not want to sit still to eat)
Nursing Interventions
o Promote healthy finger foods for child to eat on the run
o Present with healthy snack and meal choices
o Stress quality of food over quantity
o Requires whole milk until at least 2 y.o. (fat for myelination)
o Teach parents to role model good eating habits.
o How do we ensure adequate nutrition? Especially in children with special needs? Or Chronic Illness?
Pre-School – 90kcal/kg averages to about 1800 kcal/day
Nutritional Changes
o Fluid requirements decrease slightly as well to 100ml/kg/day
o 90kcal/kg averages to about 1800 kcal/day
o Fat > 20%<30% daily intake
o Calcium requirements increase from ages 2 to 4 y.o. (500-800mg/day)
, Developmental Behaviors and Milestones
o Established independence
o Reaching pre operational cognitive
Teaching pre K children the names of fruits and vegetables and other healthy foods gives them the language to understand when they are
cognitively ready.
School-Age – 1200-1800 cal/day
Caloric requirements – r/t reduced rate of growth
Nutritional Foundation – rapid growth of adolescence
Good Eating Habits – Optimal time for children to learn good eating habits
Avoiding obesity
o Childhood obesity has been found increasingly over the passed decade in this age group.
o Thought to be r/t sedentary lifestyle: computer games, TV, decreasing prevalence of “safe places” to play out of doors
o Recent research suggests that increased scheduled snacking has influenced obesity
o Importance of role modeling good eating habits in the home, the school and the community
Adolescence – 1800-2200 cal/day
Developing Healthy Eating Habits in the Presence of Peer Pressure
Primary Psychosocial Developmental Stage = Identity vs Role Confusion
o Developing a sense of identity
o Cognitive ability is reaching formal operationalà ability to think abstractly
o Both effect decision making
o Teenage girl expectation of self in this society?
o Teenage boy’s expectation of self in this society?
Foundation for Healthy Growth and Development
Nursing interventions
o Educationà The first step in change is realization and awareness
o Consider peer group education
o Positive reinforcement
Childhood Obesity – What are 3 pediatric nursing interventions that could help prevent or ameliorate childhood obesity?
Knowing and sharing community resources
Teaching value of healthy age appropriate diet
Promoting breast feeding
What would be some barriers to healthy nutrition for the school-aged child?
Children do not do the grocery shopping or prepare the food generally
Subject to family and cultural environment(s)
Knowledge deficit r/t: What contains adequate protein etc…Food guide pyramid/ My plate.gov
Think of capitalizing on the tasks of the developmental age: Industry vs. Inferiority
o Teach parents to include children in meal planning and food preparation
o Education programs in the public and private schools
o Empower them with knowledge of healthy growth related to nutrition
Translation of Proper Nutrition in the Presence of Various Disease States
Starvation
o PEM (protein energy malnutrition)
o Marasmus = non edematous protein energy malnutrition
o Kwashiorkor = edematous protein energy malnutrition
o Common in third world countries r/t poverty in the US r/t chronic illness
Diagnostics
o CMP, CBC, Albumin level, lipids, Triglyceride levels
o Albumin is the most abundant protein in the fluid portion of the blood, the plasma.
It keeps fluid from leaking out of blood vessels: nourishes tissues; and transports hormones, vitamins, drugs, and ions like
calcium throughout the body. Albumin is made in the liver and is extremely sensitive to liver damage.
Drops when the liver is damaged, when a person has a kidney disease that causes nephrotic syndrome, when a person is
malnourished, has inflammation, or is in shock.
Levels can rise when a person is dehydrated. This is a relative increase that occurs as the volume of plasma decreases.
Methods of Delivering Nutrition – Parenteral vs. Enteral
Parenteral – IV nutrition
Enteral – routed through the digestive tract (oral, NG, NJ, GT)
o NGT – stomach
o NJ Tube – crosses pylorus into duodenum
NGT/NJT – Placement
Equipment
, o Gloves
o Empty clean 3-5 ml syringe
o KY jelly
o Appropriate size tube
o Stethoscope
o Tape and/or occlusive dressing
Measurement – Ear to nose to…xyphoid process (NGT), umbilicus (NJT)
Procedure
o Wash hands – Explain procedure – Open packages – Measure length and mark tube
o Prepare tape and/or tegaderm dressing
o Don gloves and place cath-tip in KY – Insert cath tip into patient’s nare (leaning toward right) until mark
o Encourage patient to swallow
o NJT remove insertion guide (never replace while in patient)
o Hold firm and auscultate 1-3 ml air into LUQ (NGT) or RLQ (NJT)
o Secure to patient
o NJT get order for KUB and lie patient on left side
NGT – Confirm placement after taping via: auscultation and/or pH test
Gastric position pH <5.5
Bronchial position and small bowel position – pH 6-8
Check Placement
Prior to initiating feeds or medication administration
If there is potential for tube is displacement
Continuous feeds in progress check placement at least q shift
Parenteral vs. Enteral Pros and Cons
Parenteral
Pros Nursing Interventions
For use when the GI tract is inaccessible
Volume, absorption, first pass
Provides nutrition when no other means are available
Cons
Liver Damage from long term use
Routinely monitor liver enzymes, NH4, jaundice, stools, urine,
Toll on veins & risk for severe infiltrate burns and LOC
C-line for Dextrose > 12.5%; continuous IV monitoring
GI tract attrition from not being used Trophic Feedings
Minimized bonding opportunities Provide opportunities for the parents to have eye to eye contact
Enteral
Pros Nursing Interventions
Tube feedings provide a mechanism to get nutrition into the
gut
Minimizes chances of aspiration (especially when paired with
Nissan Fundal Plication)
Keeps gut stimulated and working
Cons
Loss of suck and swallow mechanism in infants Enforce pacifier use to stimulate suck and swallow in infants
Provide opportunities to have eye to eye contact
Minimized bonding opportunities
Parenteral
Total Parenteral Nutrition – TPN – Care & Considerations
Before
o Check MD order and bag of TPN with 2nd RN
o Requires 2 RN signatures after check
During & After
o Dextrose content and IV access – If: Dextrose 12.5% and greater – Central Venous Line (CVL) required
o Requirements for care of CVL
o Assessment and teaching of s/s for infection*
o Dextrose concentration and blood glucose management especially in neonates (even in non diabetic pt)
o Labs to be monitored
o Possible Long Term consequences
, Cleft Lip & Cleft Palate
Epidemiology
Occurs in every 1 of every 500-550 births
The lowest rate is for blacks. A high prevalence of cleft lip with or without cleft palate was found for the Japanese population, and the
highest prevalence was found for the North American Indian populations
Etiologies
Syndromes
Genetic and teratogenic variables interplay
Genetic predispositions (certain genes identified)
Preventable environmental triggers (lack of folic acid in maternal diet)
Unidentified teratogens
Cleft Lip –1st 5 weeks gestation; Unilateral or Bilateral; Complete or Incomplete
Cleft Palate – Primary palate (lip and gum) – 1st 5 weeks gestation; Secondary palate (hard and soft palate) – 8-12 weeks gestation
Initial Management
Importance of Diagnostic Clarification
It is critical to understand the depth of the underlying condition before taking a patient to surgery to repair a cleft lip and or palate.
o Other associated syndromes
o VeloCardial Facial Syndrome (VCFS) 75% also have cardiac anomalies
o DiGeorge Syndrome (sometimes synonymous with VCFS but is different) Cardiac anomalies, thyroid issues
o Van der Woude Syndrome (VWS) Most common associated syndromeàis involved in about 2 percent of all cases (hypodontia and
prominent cleft indentions in lower lip, autosomal dominant BUT individuals with the genetic karyotype have varying phenotypes)
Psychosocial support
• Determine the degree of anxiety of the parents. You can ask them mild? Mod? Severe.
• Allow verbalization of feelings
• Monitor your own handling of the child; are you being gentle and caring?
• Communicate in a calm, honest way; allow them to view children with successful repairs. Suggest they speak with other parents who have
children with similar disorder
• Inform the parents of usual ages of repairs.
Surgical Repair
Surgical Repair is done when the patient weighs enough and is stable with all co morbidities (cardiac, thyroid etc…)
Cleft Lip – repair between 3-5 mos.
Cleft Palate – 9 – 18 mos. although some surgeons are repairing in the neonatal period
Balance between having enough palate to work with to allow for physiological growth and development and having the palate available
early enough to have optimal language development
Surgical Repair Frequently Includes Eustachian Tubes Placement to prevent otitis media
The Eustachian tube, the communication link between the middle ear and the throat, is controlled by the palatal musculature. CP have
abnormal placement and underdevelopment of palatal musculature and the Eustachian tube performs poorly.
Feeding Issues
Goal -- to maintain optimum nutrition using a technique that is as normal as possible
Cleft lip – not much problemà repositioning
Cleft palate – have difficulty achieving intraoral negative pressure – this affects suction ability but not swallowing adaptability of infant to
adjust
Bottle Feeding
The important thing is to allow baby to suck as much as possibleà
Muscle development is especially important for later development of speech.
Position baby upright to help keep milk out of nasal cavity
Position nipple so that it is compressed between the infant’s tongue and existing palate
Makes noisy feeding sounds BUT does not lead to aspiration
Physical anatomy and poor positioning of patient places them at risk for aspiration
Breast Feeding Considerations
• Determination
• Coping Mechanisms
• First Child and or Social support (IF she has other children and little help, she may not have the time required)
• Consider pumping and then using a special feeder
• If mom was planning on breast feeding, should be encouraged to still try . MUST be VERY motivated!!!
Cleft lip – minor positioning changes
“The Child with Gastrointestinal Dysfunction / Transfer of Nutrients”
Infant’s Nutrition
The parental dilemma between breast milk or formula feedings is dictated by
o Nutritional
o Economical
o Psychosocial Factors
Breast Milk Positives
o Promotes immunity – AAP 2005; studies reveal increased infant immunity toward meningitis, bacteremia, otitis media, respiratory
infections, UTI
o Lipids are 50% of Human milk
Breast milk contains lipids, triglycerides, and cholesterol.
All essential element for brain growth and proper growth and development.
o Analgesic effect (2002 study)
o Carbohydrates: lactulose: 6.8mg/dl, (Vit B) galactose, glucose, & glycosamine are essential for lactobacillus production in gut
o Adequate protein not excessive
o Growth modulators
o Lower amount but more efficient ratios of essential elements and minerals
o Promotes Bonding
o Economical (less expensive than formula)
Breast Milk Negatives
o Human milk may not have enough Vitamin D/iron
o Without appropriate teaching for the mother it can be painful and the infant may not latch on easily
o Requires more frequent feedings to stimulate milk production
o Time consuming
o To achieve lasting benefits studies have shown it takes at least 6 months of consistent breast feeding to achieve successful outcomes
o Concerns over low weight gain initially; averages out by 12 months of age.
o Culturally or socially unacceptable, case dependent
Health Newborn – 108 kcal/kg/day
Caloric requirements increase according to disease state
Nursing Calculations
cal/oz X 6oz/feeding X number of feedings/day = calories/day
Breast-feed every 2 to 3 hours for 10-15 minutes on each breast within each 24 hour period.
Parent Teaching
Check for wet diapers to ensure proper hydration/ Monitor growth and development
Pediatrician assessment 1st 3-5 days of breast feeding and 2-3 wks to ensure appropriate nutrition
Toddlers 1-2 Years Old – 102 kcal/kg/day
Nutritional Changes
o Slight decrease in nutritional needs
o Protein requirements change from 2.2 to 1.5g/kg
o Change in body fluid balance
Developmental Behaviors and Milestones
o 18 mos. Physiological Anorexia
o Active Exploration (often do not want to sit still to eat)
Nursing Interventions
o Promote healthy finger foods for child to eat on the run
o Present with healthy snack and meal choices
o Stress quality of food over quantity
o Requires whole milk until at least 2 y.o. (fat for myelination)
o Teach parents to role model good eating habits.
o How do we ensure adequate nutrition? Especially in children with special needs? Or Chronic Illness?
Pre-School – 90kcal/kg averages to about 1800 kcal/day
Nutritional Changes
o Fluid requirements decrease slightly as well to 100ml/kg/day
o 90kcal/kg averages to about 1800 kcal/day
o Fat > 20%<30% daily intake
o Calcium requirements increase from ages 2 to 4 y.o. (500-800mg/day)
, Developmental Behaviors and Milestones
o Established independence
o Reaching pre operational cognitive
Teaching pre K children the names of fruits and vegetables and other healthy foods gives them the language to understand when they are
cognitively ready.
School-Age – 1200-1800 cal/day
Caloric requirements – r/t reduced rate of growth
Nutritional Foundation – rapid growth of adolescence
Good Eating Habits – Optimal time for children to learn good eating habits
Avoiding obesity
o Childhood obesity has been found increasingly over the passed decade in this age group.
o Thought to be r/t sedentary lifestyle: computer games, TV, decreasing prevalence of “safe places” to play out of doors
o Recent research suggests that increased scheduled snacking has influenced obesity
o Importance of role modeling good eating habits in the home, the school and the community
Adolescence – 1800-2200 cal/day
Developing Healthy Eating Habits in the Presence of Peer Pressure
Primary Psychosocial Developmental Stage = Identity vs Role Confusion
o Developing a sense of identity
o Cognitive ability is reaching formal operationalà ability to think abstractly
o Both effect decision making
o Teenage girl expectation of self in this society?
o Teenage boy’s expectation of self in this society?
Foundation for Healthy Growth and Development
Nursing interventions
o Educationà The first step in change is realization and awareness
o Consider peer group education
o Positive reinforcement
Childhood Obesity – What are 3 pediatric nursing interventions that could help prevent or ameliorate childhood obesity?
Knowing and sharing community resources
Teaching value of healthy age appropriate diet
Promoting breast feeding
What would be some barriers to healthy nutrition for the school-aged child?
Children do not do the grocery shopping or prepare the food generally
Subject to family and cultural environment(s)
Knowledge deficit r/t: What contains adequate protein etc…Food guide pyramid/ My plate.gov
Think of capitalizing on the tasks of the developmental age: Industry vs. Inferiority
o Teach parents to include children in meal planning and food preparation
o Education programs in the public and private schools
o Empower them with knowledge of healthy growth related to nutrition
Translation of Proper Nutrition in the Presence of Various Disease States
Starvation
o PEM (protein energy malnutrition)
o Marasmus = non edematous protein energy malnutrition
o Kwashiorkor = edematous protein energy malnutrition
o Common in third world countries r/t poverty in the US r/t chronic illness
Diagnostics
o CMP, CBC, Albumin level, lipids, Triglyceride levels
o Albumin is the most abundant protein in the fluid portion of the blood, the plasma.
It keeps fluid from leaking out of blood vessels: nourishes tissues; and transports hormones, vitamins, drugs, and ions like
calcium throughout the body. Albumin is made in the liver and is extremely sensitive to liver damage.
Drops when the liver is damaged, when a person has a kidney disease that causes nephrotic syndrome, when a person is
malnourished, has inflammation, or is in shock.
Levels can rise when a person is dehydrated. This is a relative increase that occurs as the volume of plasma decreases.
Methods of Delivering Nutrition – Parenteral vs. Enteral
Parenteral – IV nutrition
Enteral – routed through the digestive tract (oral, NG, NJ, GT)
o NGT – stomach
o NJ Tube – crosses pylorus into duodenum
NGT/NJT – Placement
Equipment
, o Gloves
o Empty clean 3-5 ml syringe
o KY jelly
o Appropriate size tube
o Stethoscope
o Tape and/or occlusive dressing
Measurement – Ear to nose to…xyphoid process (NGT), umbilicus (NJT)
Procedure
o Wash hands – Explain procedure – Open packages – Measure length and mark tube
o Prepare tape and/or tegaderm dressing
o Don gloves and place cath-tip in KY – Insert cath tip into patient’s nare (leaning toward right) until mark
o Encourage patient to swallow
o NJT remove insertion guide (never replace while in patient)
o Hold firm and auscultate 1-3 ml air into LUQ (NGT) or RLQ (NJT)
o Secure to patient
o NJT get order for KUB and lie patient on left side
NGT – Confirm placement after taping via: auscultation and/or pH test
Gastric position pH <5.5
Bronchial position and small bowel position – pH 6-8
Check Placement
Prior to initiating feeds or medication administration
If there is potential for tube is displacement
Continuous feeds in progress check placement at least q shift
Parenteral vs. Enteral Pros and Cons
Parenteral
Pros Nursing Interventions
For use when the GI tract is inaccessible
Volume, absorption, first pass
Provides nutrition when no other means are available
Cons
Liver Damage from long term use
Routinely monitor liver enzymes, NH4, jaundice, stools, urine,
Toll on veins & risk for severe infiltrate burns and LOC
C-line for Dextrose > 12.5%; continuous IV monitoring
GI tract attrition from not being used Trophic Feedings
Minimized bonding opportunities Provide opportunities for the parents to have eye to eye contact
Enteral
Pros Nursing Interventions
Tube feedings provide a mechanism to get nutrition into the
gut
Minimizes chances of aspiration (especially when paired with
Nissan Fundal Plication)
Keeps gut stimulated and working
Cons
Loss of suck and swallow mechanism in infants Enforce pacifier use to stimulate suck and swallow in infants
Provide opportunities to have eye to eye contact
Minimized bonding opportunities
Parenteral
Total Parenteral Nutrition – TPN – Care & Considerations
Before
o Check MD order and bag of TPN with 2nd RN
o Requires 2 RN signatures after check
During & After
o Dextrose content and IV access – If: Dextrose 12.5% and greater – Central Venous Line (CVL) required
o Requirements for care of CVL
o Assessment and teaching of s/s for infection*
o Dextrose concentration and blood glucose management especially in neonates (even in non diabetic pt)
o Labs to be monitored
o Possible Long Term consequences
, Cleft Lip & Cleft Palate
Epidemiology
Occurs in every 1 of every 500-550 births
The lowest rate is for blacks. A high prevalence of cleft lip with or without cleft palate was found for the Japanese population, and the
highest prevalence was found for the North American Indian populations
Etiologies
Syndromes
Genetic and teratogenic variables interplay
Genetic predispositions (certain genes identified)
Preventable environmental triggers (lack of folic acid in maternal diet)
Unidentified teratogens
Cleft Lip –1st 5 weeks gestation; Unilateral or Bilateral; Complete or Incomplete
Cleft Palate – Primary palate (lip and gum) – 1st 5 weeks gestation; Secondary palate (hard and soft palate) – 8-12 weeks gestation
Initial Management
Importance of Diagnostic Clarification
It is critical to understand the depth of the underlying condition before taking a patient to surgery to repair a cleft lip and or palate.
o Other associated syndromes
o VeloCardial Facial Syndrome (VCFS) 75% also have cardiac anomalies
o DiGeorge Syndrome (sometimes synonymous with VCFS but is different) Cardiac anomalies, thyroid issues
o Van der Woude Syndrome (VWS) Most common associated syndromeàis involved in about 2 percent of all cases (hypodontia and
prominent cleft indentions in lower lip, autosomal dominant BUT individuals with the genetic karyotype have varying phenotypes)
Psychosocial support
• Determine the degree of anxiety of the parents. You can ask them mild? Mod? Severe.
• Allow verbalization of feelings
• Monitor your own handling of the child; are you being gentle and caring?
• Communicate in a calm, honest way; allow them to view children with successful repairs. Suggest they speak with other parents who have
children with similar disorder
• Inform the parents of usual ages of repairs.
Surgical Repair
Surgical Repair is done when the patient weighs enough and is stable with all co morbidities (cardiac, thyroid etc…)
Cleft Lip – repair between 3-5 mos.
Cleft Palate – 9 – 18 mos. although some surgeons are repairing in the neonatal period
Balance between having enough palate to work with to allow for physiological growth and development and having the palate available
early enough to have optimal language development
Surgical Repair Frequently Includes Eustachian Tubes Placement to prevent otitis media
The Eustachian tube, the communication link between the middle ear and the throat, is controlled by the palatal musculature. CP have
abnormal placement and underdevelopment of palatal musculature and the Eustachian tube performs poorly.
Feeding Issues
Goal -- to maintain optimum nutrition using a technique that is as normal as possible
Cleft lip – not much problemà repositioning
Cleft palate – have difficulty achieving intraoral negative pressure – this affects suction ability but not swallowing adaptability of infant to
adjust
Bottle Feeding
The important thing is to allow baby to suck as much as possibleà
Muscle development is especially important for later development of speech.
Position baby upright to help keep milk out of nasal cavity
Position nipple so that it is compressed between the infant’s tongue and existing palate
Makes noisy feeding sounds BUT does not lead to aspiration
Physical anatomy and poor positioning of patient places them at risk for aspiration
Breast Feeding Considerations
• Determination
• Coping Mechanisms
• First Child and or Social support (IF she has other children and little help, she may not have the time required)
• Consider pumping and then using a special feeder
• If mom was planning on breast feeding, should be encouraged to still try . MUST be VERY motivated!!!
Cleft lip – minor positioning changes
