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NCM 102

Pediatric Nursing

Prepared by: Adahlia T. Basco RN, MAN

RESPIRATORY TRACT DISORDER

(Laryngotracheobronchitis)
Inflammation of the larynx, trachea and major bronchi One of the most frightening diseases of early childhood for both parents and children

Croup

Signs and symptoms


Fever (low grade to high) Irritability and restlessness Hoarse voice Seal bark and brassy cough Inspiratory stridor and suprasternal retractions Use of accessory muscle for breathing

Management
Maintain patent airway Assess respiratory status, monitor for nasal flaring, sternal retraction and inspiratory stridor Monitor for pallor or cyanosis Elevate the head of the bed and provide bed rest Provide humidified oxygen via cool mist tent for the hospitalized child

Management
Run the hot water on the shower or hot water tap in the bathroom until filled w/ steam, then keep the child in warm moist environment If steam doesnt relieve the symptoms, bring the child to ER Mist tent administer at 10 LPM Nebulize w/ Corticosteroids and Epinephrine Fluids

Instruct the parent to use a cool air vaporizer or humidifier at home Other measure includes having the child breath in the cool night air or the air from an open freezer or taking the child to a cool basement or garage Provide and encourage fluid intake (IV may be
prescribed to maintain hydration status if the child is unable to take oral fluids).

Administer acetaminophen Avoid cough syrups and cold medicines which may dry the throat.

Epiglottitis
Inflammation of the epiglottis caused by Haemophilus influenzae bacteria. Creates an emergency because swollen epiglottis is unable to rise and allow the airway to open Common in children 2-7 years old

Clinical Manifestations
Sudden onset, anxious muffled voice Difficulty swallowing Drooling, tripod position Very soar throat Retractions, fever, irritability Cherry red epiglottis leukocytosis

Management
Do not agitate the child Never leave the child unattended Do not inspect throat Position: High Fowlers Administer O2, moist air ET at bedside, tracheostomy at OR Antibiotics

Tonsillitis
Infection and inflammation of palatine tonsils All of the tonsils are easily infected because of the bacteria that pass through or are screened through the lymph nodes

Clinical Manifestations
Sore throat High fever Tonsillar tissues appear bright red Pus can be detected

Tonsilitis

Tonsillectomy
Removal of tonsils and adenoids is performed for chronic enlargement that interferes with breathing (sleep apnea), chronic otitis media or recurrent tonsillitis

Pre operative Interventions


Prepare child according developmental stage Demonstrate use of collar, tell child of sore throat after surgery Check for loose teeth

Post operative Interventions


Assess airway, prone position w/ head to side Observe for bleeding Give pain relievers Cool clear non-red fluids Apply ice collar 20min on, 20 min off

LOWER RESPIRATORY TRACT DISORDERS

Asthma
A chronic condition of the hyper responsiveness of the airway, causing edema, increased mucous production and broncho spasm Maybe exacerbated by various triggers Occur initially before 5 y/o

asthma

asthma

asthma

Asthma
Chronic inflammatory disease of the airway Cause by physical and chemical irritant
Food Fallen Cockroaches Activity stress dust mites smokes animal dander Temperature changes respiratory infection

Allergic reaction in the airways can cause an immediate reaction like obstruction that can precipitate a late bronchial obstructive reaction

Irritants

Common symptoms is coughing in the absence of respiratory infection specially at night Also known as status asthmaticus
Child display respiratory distress despite a vigorous treatment measure A medical emergency that can result in respiratory failure and death if left untreated.

Risk factors for developing asthma


hay fever (allergic rhinitis) and other allergies -- this is the single biggest risk factor;

eczema: another type of allergy affecting the skin; and genetic predisposition: a parent, brother, or sister also has asthma.

Management
Nebulized with bronchodilators O2 to maintain O2 sat >95% Corticosteroid Elevate head on bed, fluids Teach home management: trigger identification, s/s of distress, meds and side effects

Measurements of how well you are breathing include the following: Spirometer: This device measures how much air you can exhale and how forcefully you can breathe out. The test may be done before and after you take inhaled medication. Spirometry is a good way to see how much your breathing is impaired during an attack. Peak flow meter: This is another way of measuring how forcefully you can breathe out during an attack.

Spirometer and Peak Flow Meter

Asthma
Oximetry: A painless probe, called a pulse oximeter, will be placed on your fingertip to measure the amount of oxygen in your bloodstream. There is no blood test than can pinpoint the cause of asthma. Your blood may be checked for signs of an infection that might be contributing to this attack. In severe attacks, it may be necessary to sample blood from an artery to determine exactly how much oxygen and carbon dioxide are present in your body.

Management acute episode


Assess airway Administer oxygen Administered quick relief medication as prescribed Continuously monitor respiratory status, pulse oximetry and color, be alert to decrease wheezing and silent chest which may signal inability to move air

Asthma

Initiate an IV line and prepare to correct dehydration, acidosis and electrolytes imbalance. Prepare the child for x-ray Prepare to obtain ABG and serum electrolytes

medication
Quick relief ( rescue medication)
To treat symptoms and exacerbation Short acting B2 agonist for acute exacerbation ( alupent, albuterol Anti-cholinergic for relief of acute bronchospasm (atropine sulfate) Systemic corticosteroid anti inflammatory action to treat reversible airflow obstruction

Long term control (preventer, medication)


Achieve and maintain control of inflammation Corticosteroids NSAID inhibit acute airway narrowing(cromolyn sodium,ibuprofen) Nedocromil Sodium- an antiallergic and anti inflammatory used for maintenance therapy Long acting B2 agonist-for the prevention of EIB (bricanyl, terbutaline, ventolin, alupent)

Long acting bronchodilator-used for long term prevention of symptoms (serevent) Peak expiratory flow meters(PEFMs)-way of measuring how forcefully you can breathe out during an attack. MDI metered dose inhaler-method of providing beta agonist

Classification of Severity of asthma


Mild intermittent: This includes attacks no more than twice a week and nighttime attacks no more than twice a month. Attacks last no more than a few hours to days. Severity of attacks varies, but there are no symptoms between attacks. Mild persistent: This includes attacks more than twice a week, but not every day, and nighttime symptoms more than twice a month. Attacks are sometimes severe enough to interrupt regular activities.

Moderate persistent: This includes daily attacks and nighttime symptoms more than once a week. More severe attacks occur at least twice a week and may last for days. Attacks require daily use of quick-relief (rescue) medication and changes in daily activities. Severe persistent: This includes frequent severe attacks, continual daytime symptoms, and frequent nighttime symptoms. Symptoms require limits on daily activities.

Allergic control
Prevent and reduce exposure to airborne allergens Skin testing to identify allergens Dust mites- maintain the humidity in the house under 50% Cockroaches- cleaning kitchen floors and cabinet, taking the trash out in the evening

Allergic control

Home Care Measures


Instruct measures to eliminate allergens Avoid extremes environmental temperature Avoid exposure to individual with viral respiratory infection Instruct the child how to recognize early symptoms of an attack Instruct the child in the administration of medication as prescribed

Instruct the child in the use of nebulizer, MDI, or PEFM. Instruct the cleaning of devices used for inhaled medication( oral candidiasis may occur with the use of aerosolized steroid) Encourage adequate rest and sleep and well balanced diet Adequate fluid intake to liquefy secretions Assist in developing an exercise program

MDI & PEFM

Medication

Instruct the child the procedure for respiratory treatment and exercise as prescribed Encourage the child to cough effectively Encourage the parent to keep immunization up to date; annual flu vaccine are recommended Inform other health care providers and school personnel of the asthma condition Allow the child to take control of self care measure on the basis of age appropriateness

How do I use a meter-dose correctly?


Remove the cap and hold the inhaler upright. Shake the inhaler. Tilt your head back slightly and breathe out. Hold the inhaler A or B are the most effective, but C is okay for people who are unable to use A or B. Spacers are useful for all patients, especially young children and older adults (see picture B). Press down on the inhaler to release the medicine as you start to breathe in slowly. Breathe in slowly for 3 to 5 seconds. Hold your breath for 10 seconds to allow medicine to go deeply into your lungs. Repeat puffs as directed. Wait 1 minute between puffs to allow the second puff to get into the lungs better.

How do I use a meter-dose inhaler

How do I use a meter-dose inhaler

Bronchitis
Inflammation of the major bronchi and trachea One or more common illnesses that affect pre-school and school age children

Bronchitis

bronchitis
chronic bronchitis is a serious long-term disorder that often requires regular medical treatment. inflammation and swelling of the lining of the airways that lead to narrowing and obstruction of the airways. inflammation stimulates production of mucus, which can cause further obstruction of the airways and increase the likelihood of bacterial lung infections.

Clinical Manifestations
Nasal stuffiness Fever and dry hacking cough, usually in conjunction with nasal congestion On auscultation: Rhonchi and coarse crackles (the sound of rales) can be heard

Management
Monitor for respiratory distress Provide cool humidified air Monitor for signs of dehydration
Sunken fontanel Poor skin turgor Decreased and concentrated urinary output

Increase fluid intake Administer acetaminophen

Bronchiolitis
Respiratory Syncytial Virus (RSV) Causes inflammation of bronchioles and increased mucous production of lower airway in infants under 1 year old

Bronchiolitis

Signs and Symptoms


URI symptoms
Rhinorrhea Low grade fever

Lethargy, poor feeding and irritability in infant Tachypnea Increased difficulty in breathing Nasal flaring and retractions Expiratory wheezing and grunts Diminished breath sounds

Management
Maintain patent airway Position the child at a 30-40 degree angle with the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm Provide cool, humidified oxygen Encourage fluids, IVF may be necessary until the acute stage has passed Assess for signs of dehydration

Management
Contact isolation Administer O2 to maintain O2 sat via nasal cannula <2 lpm for infants Suction PRN Elevate HOB, Small frequent feedings Fluids Nebulize w/ bronchodilators and steroids

The Child with RSV


Isolate in a single room or place in a room with another RSV child Good hand washing procedure Ensure that nurses caring for this children do not care for other high risk children Wear gowns to avoid soiling of clothing Administer Ribavirin (virasole) as prescribed
Ribavirin is administered via aerosol by hood, tent, mask or thru ventilator tubing Pregnant health care provider should not care for a child receiving ribavirin Nurse wearing contact lenses should wear goggles when coming in contact with ribavirin ( it may dissolve the lens)

RSV Mngt.

Prepare for the administration of RSV immune globulin ( Respigam)


Used prophylactically to prevent RSV in high risk infant IV preparation of immunoglobulin G and is administered before the RSV epidemic season ( November April) subsequent doses are given every month to maintain protection Not administered to infants and children with congenital heart disease or with cyanotic CHD

Risk
More severe RSV disease may be seen in: Premature infants Infants with chronic lung disease Infants whose immune system does not work well Infants with certain forms of heart disease

Bronchiectasis
Chronic dilation of the bronchi May follow pneumonia, foreign body aspiration, pertussis or asthma Often associated with Cystic Fibrosis

Clinical Manifestations
Chronic cough w/ muco purulent sputum Young infants may have wheezing and stridor Children may have cyanosis, Clubbing of fingers and easy fatigability (chronic) Enlarged lungs from over inflation of alveoli

Cystic Fibrosis
A chronic multisystem disorder characterized by exocrine gland dysfunction The mucus produced by the gland is abnormally thick, causing obstruction of the small passageway of the affected organs Common symptoms: Pancreatic enzymes deficiency Progressive chronic lung disease associated with infection Sweat gland dysfunction- increased sodium and chloride sweat concentration
Diagnostic test: sweat chloride test

Cystic fibrosis

Cystic fibrosis

Respiratory system
Stagnation of mucus in the airway-leading to bacterial colonization and destruction of lung tissue Emphysema and atelectasis due to obstruction Chronic hypoxemia causes contraction and hypertrophy of the muscle fibers in pulmonary arterioles leading to pulmonary hypertension and eventual cor pulmonale

Cystic fibrosis

Pneumothorax from ruptured bullae and hemoptysis from erosion of the bronchial wall through an artery Wheezing and dry non productive cough Dyspnea, cyanosis Clubbing of fingers and toes Repeated episode of bronchitis and pneumonia

Cystic Fibrosis

Gastrointestinal system
Meconium ileus in the neonate Intestinal obstruction Steatorrhea (frothy, foul-smelling stool) Deficiency of fat soluble vitamins A, D, E,K which causes easy bruising Malnutrition Rectal prolapse due to large bulky stool

Cystic Fibrosis Integumentary system High concentration of sodium and chloride in sweat Parents report that the infant taste salty when kissed Dehydration and electrolytes imbalances

Diagnostic test
Quantitative sweat chloride test
The production of sweat is stimulated (pilocarpine iontophoresis) the sweat is collected and the sweat electrolytes are measured Normal sweat chloride concentration is 40mEq/L Result of 60 mEq/L is positive result Result of 40-60mEq/L are highly suggestive of CF and require a repeat test

Chest x-ray
Reveals atelectasis and obstructive emphysema

Pulmonary function test


Provide evidence of abnormal small airway function

Stool/Fat and or enzymes analysis


A 72 hour stool sample is collected to check the fat and or enzyme (trypsin) content (food intake is recorded during the collection)

Management (respiratory)
Goals of treatment include preventing and treating pulmonary infection by:
Improving aeration Removing secretion Administering antimicrobial medications

Chest physiotherapy
Percussion Postural drainage Note: should not be performed before or immediately after meal

Bronchodilator- to open the bronchi

Use of flutter mucus clearance device- a small hand-held plastic pipe with a stainless steel ball on the inside that facilitates the removal of mucus Use of therapy vest device provide high frequency chest wall oscillation to help loosen secretion Administration of recombinant human deoxyribonuclease (dornase alfa)decrease viscosity of mucus

Instruct the parent not to give cough suppressant Teach the child forced expiratory technique to mobilize secretion Develop a physical exercise program Administer antibiotic Administer oxygen Monitor for hemoptysis Lung transplantation is a final therapeutic option for the end stage child

Management (gastrointestinal)
Treatment of pancreatic insufficiency is to replace pancreatic enzymes (administer 30 minutes of eating meal and snacks)
Enteric coated pancreatic enzymes should not be crushed or chewed Should not be given if NPO

Assess weight and monitor for failure to thrive Encourage well balanced, high protein, high caloric diet Multivitamins and vitamins A,D,E and K Monitor for constipation and intestinal obstruction

Home Care
Instruct the parents about the prescribed treatment measures and their importance Up to date immunization Child should be vaccinated yearly for pneumococcus and influenza Inform the parents about the Cystic Fibrosis Foundation

prevention
Healthy infants should be placed in the supine position for sleep Infant with GERD or other airway anomalies that predispose to airway obstruction may be placed in a prone sleeping position Soft moldable mattress and bedding such as pillows or quilts should not be used under the infant for bedding Stuff animals should be removed from the crib while the infant is sleeping

Pneumonia
Inflammation of the alveoli caused by:
Virus Mycoplasmal agent Bacteria Aspiration of foreign substance

Causative agent usually introduced into the lungs through inhalation or from the blood stream

Classification
Viral pneumonia Primary atypical pneumonia (Mycoplasma) Bacterial pneumonia Aspiration pneumonia

Viral pneumonia
Occurs more frequently than bacterial Associated with upper respiratory infection

assessment
Mild fever, slight cough,malaise, to high fever, severe cough and prostration Non productive or productive cough of small amounts of whitish sputum Wheezes or fine crackles

Primary Atypical Pneumonia


Signs and Symptoms
Fever, chills, anorexia, headache, malaise, and muscle pain Rhinitis, sore throat, and dry hacking cough Cough is non productive initially then produces seromucoid sputum that becomes mucopurulent or blood streaked

Management:
symptomatic

management
Administer oxygen Increase fluid intake Administer antypyretics for fever Administer chest physiotherapy and postural drainage as prescribed Antimicrobial therapy is reversed for children in whom the presence of infection is demostrated cultured

Bacterial pneumonia
Signs and Symptoms
Acute onset, fever, toxic appearance Infant:
Irritability Poor feeding Respiratory distress lethargy abrupt fever

Older child:
Headache Abdominal pain Meningeal symptoms chills chest pain

Hacking, non productive cough

Diminished breath sound or scattered crackles As the infection resolves, coarse crackles and wheezing are heard and the cough becomes productive with purulent sputum

management
Antimicrobial therapy Administer oxygen Place the child in a mist tent as prescribed, cool humidification, moisten the airway and assist in temperature reduction Suction the infant to maintain patent airway (if unable to manage secretions) Administer chest physiotherapy and postural drainage every 4 hours as prescribed

Promote bed rest to conserve energy Encourage the child to lie on the affected side( if pneumonia is unilateral) to splint the chest and reduce the discomfort caused by pleural rubbing Provide liberal fluid intake, IV fluids may be necessary Administer antipyretics for fever ( monitor temperature due to risk of febrile seizures) Isolation precautions with pneumococcal or staphylococcal pneumonia ( according to
agency policy)

Administer antitussives as prescribed before rest time and meals if the cough is disturbing Continuous closed chest drainage if purulent fluid is present ( usually noted in staphylococcus infections) Fluid accumulation in the pleural cavity may be removed by thoracentesis( it also provides a means of obtaining fluid for culture and instilling antibiotic directly into the pleural cavity

Tuberculosis
A contagious disease caused by Mycobacterium tuberculosis ( an acid fat bacillus) Children are susceptible to the human mycobacterium tuberculosis and Mycobacterium bovis
Common in part of the world where TB is not controlled or pasteurization of milk not practiced Organism can be ingested via infected milk

Multidrug- resistant strains of Mycobacterium tuberculosis occurs because of non compliance with therapeutic regimens Route of transmission:
Inhalation of droplet from an individual with active TB

Most children are infected by family member or individual with whom they have frequent contact

assessment
May be asymptomatic or develop symptoms such as:
Malaise Cough Anorexia fever weight loss lymphadenopathy

Specific symptoms related to the site of infection such as:


Lungs brain bone

Diagnostic test
Mantoux test
Will produce a positive reaction 2-10 weeks after the initial infection Determine whether the child has been infected and has developed a sensitivity to the protein of the tubercle bacillus (a positive reaction does not
confirm the presence of active disease)

Once the child react positively, the child will always react positve. A positive reaction in a previously negative test indicates that the child has been infected since the last test.

TB testing should not be done as the same time as measles immunization, viral interference from the measles vaccine may cause a false negative reaction Induration measuring 15 mm or greater is considered to be a positive reaction in children 4 years of age or older who do not have any risk factors Induration measuring 10 mm or greater is considered to be a positive reaction in children younger than 4 years of age and in those with chronic illness or a risk for

Induration measuring 5 mm or greater is considered to be positive for the higher risk groups, such as children with immunosuppressive condition or human immunodeficiency virus (HIV)

Sputum Culture
Diagnosis is made by demostrating the presence of mycobacteria culture Because the infant or young children often swallows sputum, gastric washing (aspiration of lavage contents from the fasting stomach) may be done to obtain specimen (early morning before breakfast)

Management Medication
Include izoniazid (INH),Rifampin and pyrazinamide. A 9 month course of INH is prescribed to prevent a latent infection from progressing to clinically active TB and to prevent initial infection in children in a high risk situation A 12 month course is prescribed for HIV infected child Recommendation for the child with clinically active TB:
INH, Rifampin and pyrazinamide daily for 2 months; then INH and Rifampin twice a week for 4 months

Place on isolation precaution until medication has been initiated, sputum cultures demostrates a diminished number of organism and cough is improving Wear a mask if the child is coughing and does not reliably cover their mouth Maintain airborne precautions with family member until they demostrated not to have infectious TB

Bacillus Calmette- Guerin vaccine (BCG)


Produce limited immunity Positive tuberculin reactions develop after inoculation Not generally recommended; but may be used for long term protection of infant and children who are at high risk for continuing exposure to persons with infectious TB

Stress the importance of adequate diet and rest Instruct the child and family measures to prevent transmission of TB

GASTRO INTESTINAL DISORDER

VOMITING
The major concern when a child is vomiting are the risk of dehydration, and the loss of fluid and electrolytes and the development of metabolic alkalosis Aspiration, atelectasis and pneumonia

Assessment
Sign of aspiration Character of vomitus Pain and abdominal cramping Dehydration Fluid and electrolytes imbalance Metabolic alkalosis

management
Maintain patent airway Position on side Monitor vital signs Monitor the character, amount and frequency of vomiting Assess the force of vomiting (projectile vomiting is indicative of pyloric stenosis or increased ICP Monitor I&O and electrolytes level and signs of dehydration

Provide oral rehydration therapy as tolerated and as prescribed (start feeding slowly, with small amount of fluid at frequent interval) Assess for diarrhea or abdominal pain Advice the parent to inform the physician when signs of dehydration, blood in vomitus, forceful vomiting or abdominal pain is present.

DIARRHEA
The major concern when a child is having diarrhea are the risk of dehydration, and the loss of fluid and electrolytes and the development of metabolic acidosis

ASSESSMENT
Character of stool Pain and abdominal cramping Dehydration Fluid and electrolytes imbalance Metabolic acidosis

management
Monitor vital signs Monitor the character, amount and frequency of diarrhea Monitor skin integrity Monitor I&O and for signs of dehydration Monitor electrolytes level

For mild to moderate dehydration, provide oral rehydration therapy Avoid carbonated beverages and those containing high amount of sugar. For severe dehydration, maintain NPO to place the bowel at rest and provide fluid and electrolytes replacement by I.V as prescribed

If potassium is prescribed by I.V ensure that the child has voided prior to administering Reintroduce a normal diet once rehydration is achieved. Provide enteric isolation as required Instruct the parents in good hand washing technique

Dehydration
Excessive loss of water from body tissue Causes are vomiting, diarrhea, poor intake, increased metabolic rate

Dehydration maybe classified by the serum Na level:


Hyponatremic Na <130 (sickest) Isonatremic Na 130-150 Hypernatremic Na > 150

Failure To Thrive
Describes infant or child whose weight falls below the 5th percentile for age. Causes maybe organic or non organic
Organic FTT - is the result of a physical cause in which the child cannot obtain or utilize adequate caloric intake necessary for growth

Non Organic FTT is caused by psychosocial factors, such as disturbance in the parent child bonding

CLEFT LIP AND CLEFT PALATE


A congenital anomaly as a result of failure of soft tissue or bony structure to fuse during embryonic development Cleft lip can range from a slight to a complete separation from the floor of the nose

Cleft palate can include nasal distortion, midline or bilateral cleft, and variable extension from the ovula and soft and hard palate Closure of cleft lip defect precedes that of the cleft palate and usually performed during the first week of life Cleft palate repair is performed between 1218 months to allow palatal changes, it is closed before the child develops faulty speech habits.

Causes
Genetic Hereditary Chromosomal abnormalities Teratogenic factors Environmental factors:
Exposure to radiation Rubella virus

Cleft palate

Implementation
Assess the ability to suck, swallow, handle normal secretions and breath without distress Assess fluid and caloric intake Monitor weight Modify feeding technique
Use specialized feeding technique Obturators, special nipples and feeders

Hold the child in an upright position and direct the formula to the side and back of the mouth to prevent aspiration Feed small amounts gradually and burp frequently Position on side after feeding Keep suction equipment and bulb syringe at bedside

Encourage breastfeeding if appropriate Teach the parent special feeding and suctioning technique Teach the parents the ESSR Encourage the parent to describe their feelings related to deformity

ESSR Method of Feeding E-NLARGE the nipple S- TIMULATE the suck reflex S- WALLOW R-EST to allow the child to finish swallowing what has been placed in the mouth

Post op management
Cleft lip repair
Lip protector device may be taped securely to the cheek to prevent trauma to suture line Position the child on the side lateral to the repair or on the back: avoid prone After feeding cleanse the suture line of formula or sero-sanguineous drainage with a cotton tip dipped in saline Apply antibiotic ointment if prescribed

Cleft palate repair


Child is allowed to lie on the abdomen Feeding are resumed by bottle, breast, or cup Oral packing may be secured to the palate Do not allow the child to brush their teeth Avoid offering hard food items such as toast or cookies

Soft elbow or jacket restraints may be used (check agency policies and procedures) Remove restraints every 2 hours to assess skin integrity and allow for exercising the arm Avoid contact with sharp objects in the mouth such as tongue depressor, thermometer, spoon, forks or pacifier Avoid the used of oral suction

Provide analgesic for pain Instruct the parents in feeding techniques and care of surgical site Instruct the parents to monitor for signs of infection such as redness, swelling or drainage Encourage the parents to hold the child Initiate appropriate referrals for speech impairment or language based learning difficulties

Hypertrophic Pyloric Stenosis

Hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and duodenum Usually it develops in the first few weeks of life causing:
Projectile vomiting Dehydration Metabolic alkalosis Failure to thrive

Pyloric stenosis

assessment
Vomiting that progress from mild regurgitation to forceful and projectile it usually occurs after feeding Vomitus contains gastric contents (milk formula, mucus and does not usually contain bile) Hunger and irritability

Peristaltic wave visible from left to right across the epigastrium during or immediately after feeding Olive shaped mass in the epigastrium just right of the umbilicus Dehydration and malnutrition Electrolytes imbalances Metabolic alkalosis

Implementation
Monitor vital signs Monitor I&O and weight Monitor for signs of dehydration and electrolytes imbalance Prepare the child and parents for pyloromyotomy

pyloromyotomy
Incision through the muscle fibers of the pylorus may be performed by laparoscopy

Pre-op management
Monitor hydration status by daily weight, I&O and urine specific gravity. Correct fluids and electrolytes imbalance (administer IV fluids) Maintain NPO Monitor the number and character of stool Maintain the patency of NGT placed for stomach decompression

Post op management
Monitor I&O Maintain IV fluids until the infant is taking and retaining adequate amounts by mouth. Begins small frequent feedings of glucose water or electrolytes solution 46 hours post -op or as prescribed Advance the diet to formula 24 hours post -op

Gradually increased amount and interval between feedings until a full feeding schedule is reinstated usually 48 hours. Feed the infant slowly, burping frequently, handle the infant minimally after feedings Monitor for abdominal distention Monitor for signs of infection Instruct the parent about wound care and feeding

Lactose intolerance
Inability to tolerate lactose due to deficiency or absence of lactase- an enzyme found in the secretion of
small intestine that is required for the digestion of lactose.

Assessment
Symptoms occurs after the ingestion of milk products Diarrhea Abdominal distention Crampy abdominal pain Excessive flatus

Implementation
Eliminate the offending dairy product or administer enzyme replacement Provide information to parents about enzyme tablet that predigest the lactose in milk or supplement the body`s own lactase soy beans formula can be substituted for cow`s or human milk.

Provide calcium and Vitamin D supplements to prevent deficiency Limit milk consumption to 1 glass at a time If milk is consumed, drink with other food rather than alone Encourage consumption of hard cheese, cottage cheese or yogurt instead of drinking milk

Encourage consumption of small amount of dairy foods daily to help colonic bacteria adapt to ingested lactose Instruct the parents about the importance of calcium and Vitamin B supplements Instruct parents about the food that contain lactose, including hidden sources

Esophageal Atresia
The esophagus terminates before it reaches the stomach/ or a fistula is present that forms an unnatural connection with the trachea It causes oral intake to enter the lungs or large amount of air to enter the stomach resulting to:
Choking coughing Abdominal distention

Aspiration pneumonia and severe respiratory distress will develop resulting to death if no surgical intervention was done

Esophageal and Tracheoesophageal Atresia


Esophagus ends in a blind pouch Theres a communication between esophagus and trachea. May occur separately or together. Usually caused by teratogens

5 Types 1. The esophagus ends in a blind pouch; there is a tracheoesophageal fistula between the distal part of the esophagus and the trachea
2. The esophagus ends in a blind pouch. There is no connection in the trachea 3. The fistula is present between an otherwise normal esophagus and trachea.

4. The esophagus ends in a blind pouch. A fistula connects the blind pouch of the proximal esophagus to the trachea. 5. There is a blind end portion of the esophagus. Fistulas are present between both widely spaced segments of the esophagus and the trachea

Esophageal and Tracheoesophageal Atresia

assessment
Frothy saliva in the mouth Coughing and choking during feedings Unexplained cyanosis Regurgitation and vomiting Abdominal distention Inability to pass a small gauge (#5 F) orogastric feeding tube via the mouth into the stomach

Pre -op management


Infant may be placed in an incubator or radiant warmer and humidified oxygen is administered If respiratory distress occurs intubation may be done NPO maintain IVF Suction accumulated secretion from the mouth and pharynx

A double lumen catheter is placed into the upper esophageal pouch and attached to intermittent or continuous low suction
To keep the pouch empty of secretion it is irrigated with normal saline to prevent clogging

Maintain in upright position to facilitate drainage and to prevent aspiration of secretions

Gastrostomy tube may be placed and is left open so that air entering the stomach through the fistula can escape minimizing the danger of regurgitation Administer antibiotic as prescribed, because of high risk of aspiration pneumonia

Post op Care
Monitor respiratory status Monitor IV fluids, antibiotics and parenteral nutrition as prescribed Monitor I&O and weight daily Inspect surgical site Provide care to the chest tube in place Assess for sign of pain Assess for dehydration and possible fluid overload

Monitor for anastomotic leaks as evidenced by:


Purulent chest drainage Increased temperature Increased WBC

If gastrostomy tube is present it is attached to gravity drainage until the infant can tolerate feedings (usually 5th to 7th day post op)

A barium swallow is performed before oral feedings and removal of test tube to verify the integrity of esophageal anastomosis Prior to feeding, the gastrostomy tube is elevated and secured above the level of stomach to allow gastric secretion to pass to the duodenum and swallowed air to escape through open gastrostomy tube

Feeding thhrough the tube until anastomosis is healed Oral feedings are begun with sterile water, followed by frequent small feeding of formula If infant is awaiting esophageal replacement, cervical esophagostomy may be performed

Assess site of redness, breakdown or exudate If the infant is awaiting esophageal replacement, nonnutritive sucking is provided by a pacifier; infant who remain NPO for extended periods and have not received oral stimulation frequently may have difficulty eating by mouth after surgery, develop oral hypersensitivity and food aversion

Instruct the parents the techniques of suctioning, gastrostomy tube care and feeding and skin site care Instruct the parents identify behaviors that indicate the need for suctioning, signs of respiratory distress and signs of constricted esophagus:
Poor feeding dysphagia Drooling regurgitated undigested food

Tracheoesophageal Repair

Gastrostomy tube

Gastro-esophageal Reflux Disease


Backflow of gastric contents into the esophagus due to relaxation or incompetence of the lower esophageal or cardiac sphincter Most infant with GERD have a mild problem that improves in about a year and requires only medical therapy

Gastroesophageal reflux

Complications
Esophagitis Esophageal strictures Aspiration of gastric contents Aspiration pneumonia

Treatment
Diet Positioning Medications Surgery- performed only if with severe complications

assessment
Passive regurgitation or emesis Poor weight gain Hematemesis and melena Irritability Heartburn (in older children) Anemia from blood loss

Implementation
Assess amount and chracteristic of emesis Assess the relation of vomiting to the times of feedings and infant activity Monitor breath sounds before and after feeding

Place suction equipment at the bedside Monitor I&O Monitor for signs and symptoms of dehydration Maintain IV fluids as prescribed Position either flat prone or head elevated prone position following feeding at night

Diet
Provide small frequent feedings to decrease the amount of regurgitation NGT feedings are indicated if severe regurgitation and poor growth are present For infant- thickens the formula by adding 1 tablespoon of rice cereal per 6 ounces of formula and crosscut the nipple Monitor for coughing during feeding

Breastfeeding may continue, and the mother may provide more frequent feeding time or express milk for thickening with rice cereal Burp the infant frequently when feeding and handle the infant minimally after feedings For toddlers- feed solid first followed by liquids

Avoid vigorous play after feeding Avoid feeding before bedtime Parents are instructed to avoid:
feeding the child fatty foods Chocolates Tomato products Carbonated liquids Fruit juices Citrus products Spicy food

medications
Administer antacids and histamine receptor antagonist-to reduce the amount of
acid present in gastric secretions and to prevent esophagitis

Administer prokinetic agents to accelerate gastric emptying and decrease reflux reflex. Administer acetaminophen as prescribed to relieve the reflux pain

Surgery
Fundoplication- a wrap to the stomach fundus is made around the distal esophagus (restores the competence of the
lower esophageal sphincter)

Gastrostomy may be performed at the same time as fundoplication (for


decompression of the stomach post -op)

Fundoplication may be combined with pyloroplasty in children with GER who also have delayed gastric emptying Post -op care is similar to that of other types of abdominal surgery Instruct the parents in the potential postoperative problems such as:
Bloating syndrome or discomfort after consuming large solid meals.

fundoplication

fundoplication

Intussusception
Telescoping of one portion of the bowel into another portion Result in an obstruction to the passage of intestinal content

intussusception

intussusception

assessment
Colicky abdominal pain that causes the child to scream and draw the knees to the abdomen Vomiting of gastric contents Bile stained fecal emesis Currant jelly like stools containing blood and mucus Hypoactive or hyperactive bowel sound Tender distended abdomen, with palpable sausage- shaped mass in the upper right quadrant

management
Monitor for signs of perforation and shock as evidenced by :
Fever -increased heart rate Changes in LOC or blood pressure Respiratory distress

Prepare for hydrostatic reduction


Antibiotics, IV fluids Monitor for the passage of the normal, brown stool (which indicates that the
intussusception has reduced itself

After hydrostatic reduction


Monitor for return of normal bowel signs, passage of barium and characteristic of stool Administer clear fluids and advance the diet gradually as prescribed If surgery is required, post- op care is similar to any abdominal surgery

Hirschprung`s disease
A congenital anomaly also known as aganglionosis or megacolon It occurs as a result of an absence of ganglion cells in the rectum and upward in the colon Result in mechanical obstruction from inadequate motility in an intestinal segment

May be familial congenital defect or may be associated with other anomalies like Down`s syndrome and genital urinary anomalies A rectal biopsy demostrates histologic evidence of the absence of ganglionic cells The most serious complication is enterocolitis with sign of:
Fever GI bleeding severe prostration explosive watery diarrhea

Treatment for mild or moderate disease is based on relieving the chronic constipation with stool softeners and rectal irrigations Most children require surgery Treatment for moderate to severe disease involves a two step surgical procedure Initially in neonatal period the obstruction is relieved by a temporary colostomy to relieve obstruction and allow the normally innervated, dilated bowel to return to its normal size

A complete surgical repair is performed when the child weighs approximately 9 kg, via a pull-through procedure to excise portion of the bowel at this time colostomy is closed

Hirschprung`s disease

colostomy

assessment
Newborn
Failure to pass miconium Refusal to suck Abdominal distention Bile stained vomitus Failure to gain weight and delayed growth Abdominal distention Vomiting Constipation alternating with diarrhea Ribbon like foul smelling stools

Children

Management
Dietary management Stool softeners Daily rectal irrigations with normal saline- to promote adequate elimination and prevent obstruction

Pre op management
Assess bowel function and administer bowel preparation as prescribed Maintain NPO Monitor hydration and fluid and electrolytes status; provide IV fluids Administer antibiotics to clear the bowel of bacteria Monitor I&O, measure abdominal girth Avoid rectal temperatures Monitor for respiratory distress associated with abdominal distention

Post op management
Monitor vital sign, avoiding rectal temperature Measure abdominal girth Assess surgical site for redness, swelling and drainage Assess the stoma for bleeding or skin breakdown Assess anal area for the presence of stool, redness or discharge

Maintain NPO status until bowel sounds return or flatus is passed: bowel sound usually return within 48 to 72 hours Maintain NGT to allow intermittent suction until peristalsis returns Maintain IV until the child tolerates appropriate oral intake Begin the diet with clear liquids, advancing to regular as tolerated and as prescribed Assess for dehydration and fluid overload

Monitor I&O and weight Assess pain and provide comfort measures as required Provide parents with instructions regarding colostomy care and skin care Teach the parent about the appropriate diet and the need for adequate fluid intake

Colostomy with infections

Phenylketonuria
Is an inborn error of metabolism inherited as an Autosomal recessive trait. The child is missing a liver enzyme called: phenylalanine hydroxylase and cannot convert phenylalanine into tyrosine. A build up of phenylalanine in the blood will cause brain damage. Normal phenylalanine: 3-7mg/100ml

Signs and Symptoms


Newborns don`t have any symptoms signs may develop with in few months Mental retardation Behavioral or social problem Seizures, tremors or jerking movements of arms and legs Rocking Hyperactivity Stunted growth Eczema (skin rashes) Microcephaly Vomiting Musty odor in the child breath, skin or urine Fair skin and blue eyes because phenylalanine cannot tranform into melenin

Complications
Irreversible brain damage Mental retardation Behavioral problems in older children Seizures Damage to central nervous system( child may become irritable, restless and destructive

Treatment
Strict diet with limited intake of phenylalanine (mostly found in protein rich
food) Food to Avoid Milk Ice cream Eggs Steak

nuts beans chicken fish

-Avoid food made with aspartane- it releases


aspartane when digested.

*Artificial sweeteners ( NutraSweet, Equal) - Limit consumption of pasta, rice, bread,cookies PREVENTION -low phenylalanine diet before becoming pregnant -women with history of PKU must talk to doctor before trying to conceive ( genetic counseling)

Necrotizing Enterocolitis
Death of intestinal tissue that primarily affects premature infants or sick newborn. CAUSES Decrease blood flow to the bowel Bacteria in the intestine Who is at RISK! - premature infant - infant who are fed concentrated formulas - infant in nursery where outbreak occurs - infant who receive blood exchange transfusion

Signs and Symptoms


Abdominal distention Blood in the stool Diarrhea Feeding intolerance Lethargy Temperature instability Vomiting

Exam and Laboratory Test


Abdominal X-ray Stool for occult blood (Guaiac) CBC (elevated WBC) Thrombocytopenia Lactic acidosis

Treatment
Feeding are stopped Releasing gas from the bowel ( by inserting tube into the
stomach)

Intravenous Therapy Antibiotic therapy Surgery (Peritonitis, hole in the intestines) * colostomy *ileostomy

Complications
Intestinal perforation Intestinal stricture Peritonitis Sepsis

Abdominal wall defect


Omphalocele
Occurs when there is herniation of the abdominal contents through the umbilical ring usually with an intact peritoneal sac The protrusion is covered by a translucent sac that may contain bowel or other abdominal organ Rupture of the sac result in evisceration of the abdominal content

omphalocele

Monitor vital signs every 2-4 hours, particularly temperature because the infant can lose heat through the sac Pre-op care
Maintain NPO status Administer IV Monitor for signs of infection Handle the infant carefully to prevent rupture of the sac

Post op care
Control pain Prevent infection Maintain fluid and electrolytes balance Ensure adequate nutrition

Gastroschisis
Occurs when the herniation of the intestine is lateral to the umbilical ring There is no membrane covering the exposed bowel

gastroschisis

management
The exposed bowel is loosely covered in saline soaked pads and the abdomen is wrapped in a plastic drape Wrapping around the expose bowel is contraindicated because if the exposed bowel expands, wrapping could cause pressure and necrosis

Pre-op care
Care is similar of omphalocele Surgery is performed within several hours after birth because there is no membrane covering the sac

Post op care
Most infant have a prolonged ileus and require mechanical ventilation Parenteral nutrition Control pain Prevent infection

Hernia
A protrusion of the bowel through an abdominal opening in the abdominal wall In children a hernia commonly occurs at the umbilicus through the inguinal canal Hydrocele is the presence of abdominal fluid in the scrotal sac

assessment
Umbilical hernia
Soft swelling or protrusion around the umbilicus that is usually reducible with the finger

Inguinal hernia
Painless inguinal swelling that is reducible Swelling may disappear during the period of rest and is most noticeable when the infant cries or cough

Incarcerated hernia
When the descended portion of bowel becomes tightly caught in the hernial sac, compromising blood supply A medical emergency requiring surgical repair Tenderness at site Patient becomes irritable Anorexia Abdominal distention Difficulty defecating May lead to complete intestinal obstruction and gangrene

Non communicating hydrocele


Occurs when residual peritoneal fluid is trapped with no communication to the peritoneal cavity Usually disappear by age 1 year

Communicating hydrocele
Hernia that remains open from the scrotum to the abdominal cavity Bulge in the inguinal area or the scrotum that increases with crying or straining and decreases when the child is at rest

Umbilical hernia

Inguinal hernia

Incarcerated hernia
Umbilical Inguinal

herniorrhapy

Post op care herniorrhapy


Monitor vital signs Assess for infection Monitor for redness or drainage Monitor I&O and hydration status Advance the diet as tolerated Administer analgesic as prescribed

Post op hydrocele
Provide ice bags and scrotal support to relieve pain and swelling Instruct the child and parents to avoid tub bathing until incision heals Instruct the child and parents to avoid strenuous physical activities

Celiac Disease( gluten sensitivity enteropathy Intolerance to gluten, the protein component of wheat, barley, rye and oats. It result in the accumulation of the amino acid glutamine, which is toxic to intestinal mucosal cell Intestinal villi atrophy occurs which affect absorption of ingested nutrients

Symptoms occurs most often between ages 1-5 years there is usually an interval of several months between the introduction of gluten in the diet and the onset of symptoms Strict dietary avoidance of gluten minimizes the risk of developing malignant lymphoma of the small intestine and other GI malignancies

Celiac disease

assessment
Acute or insidious diarrhea- stool are watery and pale with an offensive odor Anorexia Abdominal pain and distention Muscle wasting, particularly in buttocks and extremities Vomiting, anemia, irritability

Implementation
Gluten free diet Lifelong elimination of gluten sources Mineral and vitamin supplements including iron, folic acid and fat soluble supplements A,D,E and K Teach the parents about gluten free diet and to read food label carefully Instruct the parents measure to prevent celiac crisis

Celiac crisis
Precipitated by infection, fasting and ingestion of gluten Can lead to electrolytes imbalance, rapid dehydration and severe acidosis Causes profuse watery diarrhea and vomiting

Appendicitis
Inflammation of the appendix When the appendix become inflamed or infected perforation may occurs within a matter of hours leading to peritonitis and sepsis Treatment is surgical removal before perforation occurs

appendicitis

assessment
Pain in peri- umbilical area that descend to Abdominal pain that is intense at Mc Burney`s point Referred pain indicating the presence of peritoneal irritations Rebound tenderness and abdominal rigidity

Cont. assessment Elevated WBC Side lying position with abdominal guarding Difficulty walking and pain in the right hip Low grade fever Anorexia Nausea and vomiting diarrhea

peritonitis Sign of perforated appendix Assessment


Increased fever Sudden relief of pain after the perforation then a subsequent increase in pain accompanied by right guarding of the abdomen Progressive abdominal distention Tachycardia and tachypnea Pallor, chills Restlessness and irritability

appendectomy
Surgical removal of the appendix

constipation
Infrequent and difficult passage of dry, hard stools Encoporesis is fecal incontinence and a result of fecal impaction due to chronic constipation

assessment
Abdominal pain and cramping without distention Palpable movable fecal masses Normal or decreased bowel sound Malaise and headache Anorexia, nausea, and vomiting Evidence of soiling of clothing Scratching or rubbing of anal area Fecal odor Social withdrawal

Implementation
Dietary changes
Increase water and fiber intake Decrease sugar and milk intake Administer fat soluble vitamins during the use of mineral oil

Severe encopresis Overcoming witholding


Administer enemas as prescribed Monitor for hypernatremia Administer stool softener or laxative

Changing the retention habit

Irritable Bowel Syndrome


Occurs as a result of increase motility that can lead to spasm and pain Stress and emotional factors may contribute to its occurrence It is a self limiting problem

assessment
Diffuse abdominal pain unrelated to meals or activity Alternating constipation and diarrhea with the presence of undigested food and mucus in the stool

management
Reassure that problem is self limiting and will be resolve Encourage health, well balanced, moderate fiber diet Encourage health promotion activities Inform the parents of psychosocial resources if required

Inperforate Anus
Incomplete development or absence of the anus in its normal position in the perineum

assessment
Failure to pass meconium stool Absence or stenosis of the anal rectal nanal Anal membrane External fistula to the peritoneum

Pre op management
Determine patency of the anus Monitor for the presence of stool in the urine and vagina and report immediately

Post op management
Monitor for signs of infection Position side lying with legs flexed or in prone (to keep hips elevated to reduce edema and pressure
on the surgical site)

Keep the anal surgical incision clean and dry Maintain NPO and NGT if in place Maintain IVF until GI motility returns

Provide colostomy care if prescribed A fresh colostomy stoma will be red and edematous, but this should decrease with time Instruct the parent to perform anal dilatation if prescribed to achieve and maintain bowel patency Instruct to use dilators supplied by the physician, insert dilators no more than 1-2 cm into the anus to prevent damage to the mucosa