NSG-434 Exam 2
Dehydration - answer-A common body disturbance in infants and children - total output
of fluid exceeds total intake
-Degrees of dehydration related to percentage of body weight:
•Mild dehydration: loss of less than 5% in infants and 3% in children
•Moderate: loss of 5%-10% in infants and 3%-6% in children
•Severe: loss of more than 10% in infants and 6% in older children
-Other predictors of fluid loss:
•Change in level of consciousness: irritable with moderate dehydration; lethargic with
severe dehydration
•Altered response to stimuli
•Decreased skin elasticity and turgor
•Prolonged cap refill
•Increased heart rate (usually earliest sign)
•Sunken eyes and fontanels
•Mottling
-Lab tests:
•Serum bicarbonate
•Urine specific gravity and BUN are unreliable assessments
Therapeutic Management:
-Mild - moderate:
•Oral rehydration over 4 to 6 hours
-Severe:
•IV fluids to expand fluid volume and replace deficits
diarrhea - answer-Diarrhea involves:
•The stomach (gastroenteritis)
•The small intestines (enteritis)
•The colon (colitis)
•The colon and intestines (enterocolitis)
-Acute diarrhea:
a sudden increase in frequency and a change in consistency of stools, often caused by
an infectious agent in the GI tract
-Chronic diarrhea: an increase in stool frequency and increased water content with a
duration of more than 14 days
-Most pathogens that cause diarrhea are spread by the fecal-oral route from person to
person
•Close contact (day care centers)
-Rotavirus is the most important cause of serious gastroenteritis among children
,-Most children are infected with rotavirus at least once by 5 years of age
Therapeutic Management:
-Oral rehydration therapy
-Early reintroduction to a normal diet is recommended
Care Management:
-Education regarding s/s of dehydration
-Skin care to prevent excoriation
-Education regarding prevention measures
-Give kids a BRAT diet (bland, rice, applesauce, toast), scrambled eggs, jello, pudding,
soup, etc.
constipation - answer-An alteration in the frequency, consistency, or ease of passing
stool
-Often associated with:
•Painful bowel movements
•Blood-streaked or retained stool
•Abdominal pain
•Lack of appetite
•Stool incontinence
Causes:
-Structural disorders: Hirschsprung's disease, strictures
-Systemic disorders: hypothyroidism, hypercalcemia
-Medications: antacids, diuretics, antiepileptics, antihistamines, opioids, iron
supplements
-Spinal cord lesions
-Management: high fiber diet, exercise, regular toileting habits after meals, stool
softeners, emotional support - helping child to feel in control
encopresis - answer-Repeated and involuntary defecation in a child older than 4, may
be the result of constipation
-Frustrating for parents and child
-Can lead to social withdrawal
Hirschsprung disease - answer-Lack of innervation often in lower portion of bowel, no
peristaltic waves causing chronic constipation above this area, megacolon
-Rectal sphincter fails to relax: ribbon-like stool from passing through the narrow
segment
-Etiology: both genetic and environmental factors, but the exact etiology is unknown
-Most commonly observed in neonates - 4x more common in males
-Absence of ganglion cells in the rectum or in the colon
-Abnormal or absent peristalsis
-Total absence of spontaneous bowel evacuation
,Clinical Manifestations:
-Neonate: failure to pass meconium within 24-48 hours of birth, bilious vomiting
-Infancy & childhood: constipation, recurrent diarrhea, ribbon-like, flat, foul-smelling
stool, failure to thrive
-Rectal biopsy to detect absence of ganglion cells is definitive diagnosis
Treatment:
-One-stage surgical treatment: transanal pull-through
-Colostomy (temporary) and then removal of aganlionic section
-If the proximal bowel is not extremely distended (possible with early diagnosis), when
the infant is between 6 to 12 months (or 8 to 10 kg) the surgeon will perform a rectal
pull-thru procedure in which all the aganglionic bowel is removed and the normal bowel
is reconnected to the anus.
-If a transanal pull-thru is not possible, then the surgeon will perform a removal of the
defective bowel and colostomy to decompress the bowel and divert the fecal contents.
-The colostomy allows the dilated and hypertrophied portion of the bowel to regain
normal tone and size (takes approximately 3 to 4 months)
-Post‐op: assess site, NPO until bowel sounds return, IV fluids, may require daily anal
dilations
gastroesophageal reflux - answer-The presence of abnormal amounts of gastric
contents in the esophagus, upper airways, and tracheobronchial area.
-The reflux of gastric contents can lead to inflammation and stricture of the esophagus
-Resulting effects:
•Aspiration of gastric contents
•Recurrent pneumonia
•Pulmonary disease
•Esophagitis
•Esophageal stricture
-Resolution of GER is often a maturational process
-Peak incidence is 4 months of age. 85% of infants outgrow by 12 months
-The child may require surgery if they do not respond to medical management
-Predisposed: preterm infants and bronchopulmonary dysplasia
-Diagnostic: weight, length, OFC, chest x-ray for respiratory symptoms, pH probe,
sometimes endoscopy
-Ranitidine, zantac, prevised, Prilosec given to kids
Conservative Treatment:
-Feeding thickened formula
-Feeding small, frequent meals
-Positioning: elevating head of the bed, hold infant in an upright position for 30 minutes
following a feeding
-Acid suppression and neutralization medications:
, •Decreases stomach acid so it will not be as irritating if the child spits up
•Administer PPIs 30 minutes before breakfast and if a second dose is prescribed, 30
minutes before the evening meal.
•Remind parents that they may not see results right away as it takes several days for a
steady state of acid suppression.
•Ranitidine - zantac, lansoprazole - prevacid, omeprazole - prilosec
Surgical Treatment:
-Nissan fundoplication
•Upper end of stomach (fundus) is wrapped around the lower portion (inferior) of the
esophagus creating a lower esophageal sphincter or cardiac sphincter
•Lower 2-3 cm of esophagus
•Laparoscopic
•This surgery is irreversible
appendicitis - answerEarly Symptoms:
-Develop slowly, over a 12 hour period
-Anorexia
-Child doesn't seem "normal"
-N&V, low grade fever
-Knees bent
-Pain is diffuse at first then gradually localizes to RLQ (rebound tenderness)
-McBurney's point: a point midway between the anterior superior iliac crest and the
umbilicus; doesn't hurt when you press there, hurts when you let go
-If pain is suddenly relieved without intervention, suspect perforation
Diagnostic Testing:
-CBC
-UA
-CT
Pre-Op:
-NPO, IV therapy (antibiotics, fluids, and electrolytes)
-Position of comfort
-Prepare for surgery (laparoscopic if non-perforated)
Post-Op:
-Monitor VS
-Maintain IV and then advance diet as tolerated
-Assess for pain
-Encourage ambulation
-Monitor incisional site(s)
-Discharge teaching
Ruptured Appendix:
-Peritonitis:
Dehydration - answer-A common body disturbance in infants and children - total output
of fluid exceeds total intake
-Degrees of dehydration related to percentage of body weight:
•Mild dehydration: loss of less than 5% in infants and 3% in children
•Moderate: loss of 5%-10% in infants and 3%-6% in children
•Severe: loss of more than 10% in infants and 6% in older children
-Other predictors of fluid loss:
•Change in level of consciousness: irritable with moderate dehydration; lethargic with
severe dehydration
•Altered response to stimuli
•Decreased skin elasticity and turgor
•Prolonged cap refill
•Increased heart rate (usually earliest sign)
•Sunken eyes and fontanels
•Mottling
-Lab tests:
•Serum bicarbonate
•Urine specific gravity and BUN are unreliable assessments
Therapeutic Management:
-Mild - moderate:
•Oral rehydration over 4 to 6 hours
-Severe:
•IV fluids to expand fluid volume and replace deficits
diarrhea - answer-Diarrhea involves:
•The stomach (gastroenteritis)
•The small intestines (enteritis)
•The colon (colitis)
•The colon and intestines (enterocolitis)
-Acute diarrhea:
a sudden increase in frequency and a change in consistency of stools, often caused by
an infectious agent in the GI tract
-Chronic diarrhea: an increase in stool frequency and increased water content with a
duration of more than 14 days
-Most pathogens that cause diarrhea are spread by the fecal-oral route from person to
person
•Close contact (day care centers)
-Rotavirus is the most important cause of serious gastroenteritis among children
,-Most children are infected with rotavirus at least once by 5 years of age
Therapeutic Management:
-Oral rehydration therapy
-Early reintroduction to a normal diet is recommended
Care Management:
-Education regarding s/s of dehydration
-Skin care to prevent excoriation
-Education regarding prevention measures
-Give kids a BRAT diet (bland, rice, applesauce, toast), scrambled eggs, jello, pudding,
soup, etc.
constipation - answer-An alteration in the frequency, consistency, or ease of passing
stool
-Often associated with:
•Painful bowel movements
•Blood-streaked or retained stool
•Abdominal pain
•Lack of appetite
•Stool incontinence
Causes:
-Structural disorders: Hirschsprung's disease, strictures
-Systemic disorders: hypothyroidism, hypercalcemia
-Medications: antacids, diuretics, antiepileptics, antihistamines, opioids, iron
supplements
-Spinal cord lesions
-Management: high fiber diet, exercise, regular toileting habits after meals, stool
softeners, emotional support - helping child to feel in control
encopresis - answer-Repeated and involuntary defecation in a child older than 4, may
be the result of constipation
-Frustrating for parents and child
-Can lead to social withdrawal
Hirschsprung disease - answer-Lack of innervation often in lower portion of bowel, no
peristaltic waves causing chronic constipation above this area, megacolon
-Rectal sphincter fails to relax: ribbon-like stool from passing through the narrow
segment
-Etiology: both genetic and environmental factors, but the exact etiology is unknown
-Most commonly observed in neonates - 4x more common in males
-Absence of ganglion cells in the rectum or in the colon
-Abnormal or absent peristalsis
-Total absence of spontaneous bowel evacuation
,Clinical Manifestations:
-Neonate: failure to pass meconium within 24-48 hours of birth, bilious vomiting
-Infancy & childhood: constipation, recurrent diarrhea, ribbon-like, flat, foul-smelling
stool, failure to thrive
-Rectal biopsy to detect absence of ganglion cells is definitive diagnosis
Treatment:
-One-stage surgical treatment: transanal pull-through
-Colostomy (temporary) and then removal of aganlionic section
-If the proximal bowel is not extremely distended (possible with early diagnosis), when
the infant is between 6 to 12 months (or 8 to 10 kg) the surgeon will perform a rectal
pull-thru procedure in which all the aganglionic bowel is removed and the normal bowel
is reconnected to the anus.
-If a transanal pull-thru is not possible, then the surgeon will perform a removal of the
defective bowel and colostomy to decompress the bowel and divert the fecal contents.
-The colostomy allows the dilated and hypertrophied portion of the bowel to regain
normal tone and size (takes approximately 3 to 4 months)
-Post‐op: assess site, NPO until bowel sounds return, IV fluids, may require daily anal
dilations
gastroesophageal reflux - answer-The presence of abnormal amounts of gastric
contents in the esophagus, upper airways, and tracheobronchial area.
-The reflux of gastric contents can lead to inflammation and stricture of the esophagus
-Resulting effects:
•Aspiration of gastric contents
•Recurrent pneumonia
•Pulmonary disease
•Esophagitis
•Esophageal stricture
-Resolution of GER is often a maturational process
-Peak incidence is 4 months of age. 85% of infants outgrow by 12 months
-The child may require surgery if they do not respond to medical management
-Predisposed: preterm infants and bronchopulmonary dysplasia
-Diagnostic: weight, length, OFC, chest x-ray for respiratory symptoms, pH probe,
sometimes endoscopy
-Ranitidine, zantac, prevised, Prilosec given to kids
Conservative Treatment:
-Feeding thickened formula
-Feeding small, frequent meals
-Positioning: elevating head of the bed, hold infant in an upright position for 30 minutes
following a feeding
-Acid suppression and neutralization medications:
, •Decreases stomach acid so it will not be as irritating if the child spits up
•Administer PPIs 30 minutes before breakfast and if a second dose is prescribed, 30
minutes before the evening meal.
•Remind parents that they may not see results right away as it takes several days for a
steady state of acid suppression.
•Ranitidine - zantac, lansoprazole - prevacid, omeprazole - prilosec
Surgical Treatment:
-Nissan fundoplication
•Upper end of stomach (fundus) is wrapped around the lower portion (inferior) of the
esophagus creating a lower esophageal sphincter or cardiac sphincter
•Lower 2-3 cm of esophagus
•Laparoscopic
•This surgery is irreversible
appendicitis - answerEarly Symptoms:
-Develop slowly, over a 12 hour period
-Anorexia
-Child doesn't seem "normal"
-N&V, low grade fever
-Knees bent
-Pain is diffuse at first then gradually localizes to RLQ (rebound tenderness)
-McBurney's point: a point midway between the anterior superior iliac crest and the
umbilicus; doesn't hurt when you press there, hurts when you let go
-If pain is suddenly relieved without intervention, suspect perforation
Diagnostic Testing:
-CBC
-UA
-CT
Pre-Op:
-NPO, IV therapy (antibiotics, fluids, and electrolytes)
-Position of comfort
-Prepare for surgery (laparoscopic if non-perforated)
Post-Op:
-Monitor VS
-Maintain IV and then advance diet as tolerated
-Assess for pain
-Encourage ambulation
-Monitor incisional site(s)
-Discharge teaching
Ruptured Appendix:
-Peritonitis:
