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Pediatric Nursing Module 3 Caring for Children with Alterations in Nutrition/Elimination Caring for Children with Alterations in Nutrition/Elimination.

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Presentation on theme: "Pediatric Nursing Module 3 Caring for Children with Alterations in Nutrition/Elimination Caring for Children with Alterations in Nutrition/Elimination."— Presentation transcript:

1 Pediatric Nursing Module 3 Caring for Children with Alterations in Nutrition/Elimination Caring for Children with Alterations in Nutrition/Elimination

2 Assessment of GI System History History gathering base line data gathering base line data infant - formula type and tolerance infant - formula type and tolerance children - diet, appetite, preferences meal schedule children - diet, appetite, preferences meal schedule any prior GI problems any prior GI problems elimination patterns elimination patterns stools, characteristic, number per day, toilet habits stools, characteristic, number per day, toilet habits general nutritional appearance general nutritional appearance height and weight height and weight

3 Physical Assessment Inspection Inspection oral cavity oral cavity ability to suck, swallow, chew ability to suck, swallow, chew any ulcers, sores, bleeding, thrush, dental caries,congenital anomalies (cleft lip and palate) sore throat any ulcers, sores, bleeding, thrush, dental caries,congenital anomalies (cleft lip and palate) sore throat Abdomen Abdomen distention, turgor, contour, pain, girth distention, turgor, contour, pain, girth

4 Physical Assessment Stool Stool number, consistency, presence of blood number, consistency, presence of blood Vomitus Vomitus color, amount, blood, projectile color, amount, blood, projectile Urine Urine specific gravity, frequency amount specific gravity, frequency amount Tears Tears Fontanels Fontanels Pf closes at 2-3 months, Af closes 9-18 months Pf closes at 2-3 months, Af closes 9-18 months

5 Assessment - dehydration Children are more susceptible to dehydration due to greater % or portion of their body weight being water Children are more susceptible to dehydration due to greater % or portion of their body weight being water Signs and Symptoms Signs and Symptoms poor skin turgor poor skin turgor sunken fontanel sunken fontanel decreased urine out-put decreased urine out-put (1-2ml/uo/kg/hr) (1-2ml/uo/kg/hr) decreased body weight decreased body weight dry mucous membranes, lips dry mucous membranes, lips no tears no tears

6 Physical Assessment Auscultation Auscultation Abdominal Abdominal peristalsis peristalsis presence/absent presence/absent hypo or hyper hypo or hyper visible - possible pyloric stenosis visible - possible pyloric stenosis

7 Adjunct Assessment Weight Weight Temperature Temperature Labs Labs stool culture, ova & parasite, guiac, roto virus stool culture, ova & parasite, guiac, roto virus electrolytes - Na, K, Cl, HCO3 electrolytes - Na, K, Cl, HCO3 CBC - wbc’s CBC - wbc’s I & O I & O X-ray X-ray barium swallow, barium enema barium swallow, barium enema

8 What questions do you have for the parent, for the child?

9 Signs and Symptoms of Dehydration Neurological Neurological Cardiac Cardiac Respiratory Respiratory Gastrointestinal Gastrointestinal Genitourinary Genitourinary Musculoskeletal Musculoskeletal Integumentary Integumentary

10 Disorders of Motility Gastroenteritis Acute Diarrhea Acute Diarrhea bacterial vs viral bacterial vs viral isolation - good handwashing isolation - good handwashing bloody stools, mucous, cramping bloody stools, mucous, cramping change in the number and consistency of stool, increase in the water margin, usually green in color change in the number and consistency of stool, increase in the water margin, usually green in color

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12 Gastroenteritis Acute vomiting Acute vomiting Differentiate between vomiting vs spitting up Differentiate between vomiting vs spitting up projectile - pyloric stenosis projectile - pyloric stenosis reflux - may lead to respiratory problems reflux - may lead to respiratory problems

13 A 6 month old is admitted with dehydration. Effectiveness of therapy is evaluated by which assessment measures? Choose all that apply assess fontanel assess fontanel measure and document abdominal girth measure and document abdominal girth document mucous membrane moisture document mucous membrane moisture record and analyze I & O record and analyze I & O daily wt., same scale, time, no clothes daily wt., same scale, time, no clothes Analysis question, first recall assessment findings for dehydrated child

14 Hirschsprung’s Disease Congenital absence of the parasympathetic nerve ganglion cells in the mesenteric plexus of the distal bowel 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 area proximal to the aganglionic portion becomes hypertrophied and greatly dilated

15 Hirschsprung’s Disease Signs/Symptoms Signs/Symptoms abdominal distention abdominal distention intermittent intermittent progressively increasing progressively increasing anorexia anorexia malnutrition malnutrition obstruction with diarrhea obstruction with diarrhea dehydration and electrolyte imbalance dehydration and electrolyte imbalance

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17 Hirschsprung’s Disease Treatment Treatment temporary colostomy temporary colostomy Pre-op Pre-op clear liquids clear liquids bowel prep bowel prep enemas/laxatives enemas/laxatives antibiotic therapy - decrease normal bowel flora antibiotic therapy - decrease normal bowel flora

18 Hirschsprung’s Disease Post-op Care Post-op Care pain control pain control hydration hydration assessing stoma assessing stoma bowel elimination bowel elimination teaching teaching

19 Gastric Reflux Gastroesophageal Reflux (GER) Gastroesophageal Reflux (GER) backward flowing of gastric contents into the esophagus backward flowing of gastric contents into the esophagus incompetent lower esophageal sphincter incompetent lower esophageal sphincter increase intra abdominal pressure increase intra abdominal pressure

20 Gastric Reflux Signs and Symptoms Signs and Symptoms Infant Infant spitting up, regurgitation, vomiting spitting up, regurgitation, vomiting crying, irritable crying, irritable wt. loss, FTT wt. loss, FTT Children Children heartburn, chest pain, abd. pain heartburn, chest pain, abd. pain dysphasia, burping, dysphasia, burping, regurgitation, cough, pneumonia regurgitation, cough, pneumonia

21 Gastric Reflux Treatment Treatment small frequent thicken feedings small frequent thicken feedings hypoallergenic formula hypoallergenic formula positioning positioning medications medications H 2 antagonist H 2 antagonist pepcid, tagament, zantac pepcid, tagament, zantac surgical surgical Nissen fundoplication Nissen fundoplication

22 Inflammatory Disorders Appendicitis Inflammation of the appendix resulting from bacterial infection or obstruction Inflammation of the appendix resulting from bacterial infection or obstruction Rupture = peritonitis abscess Rupture = peritonitis abscess

23 Appendicitis Signs and Symptoms Signs and Symptoms G.I. G.I. n/v/a and d/c, rigid abdomen n/v/a and d/c, rigid abdomen Pain Pain peri-umbilical - localizing RLQ peri-umbilical - localizing RLQ re-bound tenderness re-bound tenderness progressive progressive Other Other fever, stooped posture, lethargy fever, stooped posture, lethargy Treatment Treatment appendectomy appendectomy

24 Structural Defects Craniofacial Abnormalities Cleft Lip & Palate May occur separately or together May occur separately or together Unilateral or bilateral Unilateral or bilateral Associated problems Associated problems feeding difficulties feeding difficulties URTI URTI otitis media otitis media speech speech dental formation dental formation self-image self-image

25 Cleft Lip Interference with bonding Interference with bonding Disfigurement Disfigurement Feeding Techniques Feeding Techniques more upright to avoid aspiration more upright to avoid aspiration frequent burping frequent burping lamb’s nipple lamb’s nipple asepto syringe with tubing if infant unable to create closure and suction asepto syringe with tubing if infant unable to create closure and suction

26 Cleft Lip Surgical repair Surgical repair 2-4 months old 2-4 months old Post-op care Post-op care prevent strain on suture line prevent strain on suture line keep infant off their stomach keep infant off their stomach keep suture line clean keep suture line clean Q-tip, NS, antibiotic oint. Q-tip, NS, antibiotic oint.

27 Cleft Palate Feeding Feeding same as cleft lip same as cleft lip solids as soon as possible solids as soon as possible thicken liquids thicken liquids aspiration may be a problem aspiration may be a problem frequent URTI and ear problems frequent URTI and ear problems

28 Cleft Palate Surgical Repair Surgical Repair usually months usually months perform closure prior to speech perform closure prior to speech after weaned to cup after weaned to cup Post-op Care Post-op Care keep on abdomen till fully awake keep on abdomen till fully awake semi-liquid, puree diet semi-liquid, puree diet no sucking no sucking elbow restraints elbow restraints keep suture line clean after feeding with water keep suture line clean after feeding with water

29 Cleft Palate Long term care Long term care speech speech socialization socialization dental problems dental problems psychosocial psychosocial

30 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 HR for impaired parent/infant attachment R/T newborn structural defect Ineffective feeding pattern R/T newborn structural defect Ineffective feeding pattern R/T newborn structural defect HR for aspiration 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. HR for imbalanced nutrition less than body requirements R/T abnormal feeding patterns and structural defect.

31 Obstructive Disorders Intussusception Telescoping or a portion of the small intestine or colon into a more distal segment Telescoping or a portion of the small intestine or colon into a more distal segment Signs/Symptoms Signs/Symptoms vomiting vomiting pain - paroxysmal colicky abdominal pain - paroxysmal colicky abdominal “current jelly” stools - brown, bloody, mucous mixed “current jelly” stools - brown, bloody, mucous mixed

32 Intussusception Treatment Treatment barium enema to reduce it or surgery barium enema to reduce it or surgery Post-op Post-op gastric decompression gastric decompression IV therapy IV therapy

33 Obstructive Disorders Pyloric Stenosis Narrowing of the pyloric valve Narrowing of the pyloric valve hypertrophic muscle hypertrophic muscle Signs/Symptoms Signs/Symptoms projectile vomiting projectile vomiting left to right peristalsis left to right peristalsis olive sized mass palpated in upper right quadrant olive sized mass palpated in upper right quadrant cries with hunger cries with hunger readily accepts 2nd feeding after vomiting readily accepts 2nd feeding after vomiting

34 Pyloric Stenosis Adjunct Problems Adjunct Problems dehydration dehydration electrolyte imbalance electrolyte imbalance alkalosis alkalosis malnutrition malnutrition Diagnosis Diagnosis confirmed with barium x-ray confirmed with barium x-ray

35 Pyloric Stenosis Surgery Surgery Pyloromyotomy Pyloromyotomy Post-op Feeding Post-op Feeding post-pyloromyotomy feeding schedule post-pyloromyotomy feeding schedule sterile water, small amount, gradually increasing in substance and quantity sterile water, small amount, gradually increasing in substance and quantity

36 Nursing Care - Nutrition and Fluid Balance Needs Nursing Care and Concerns Nursing Care and Concerns Fluid Volume and Electrolyte Imbalance Fluid Volume and Electrolyte Imbalance daily wt. daily wt. I & O I & O assess for s/s of dehydration assess for s/s of dehydration maintain IV therapy maintain IV therapy oral care if NPO oral care if NPO monitor labs - electrolytes monitor labs - electrolytes

37 Nursing Care Nursing Care When introducing fluids When introducing fluids small frequent feedings small frequent feedings clear liquids clear liquids pedialyte pedialyte may dilute formula may dilute formula monitor for monitor for vomiting vomiting diarrhea diarrhea abdominal distention abdominal distention

38 Nursing Care/Concerns Nutrition Nutrition check for vomiting check for vomiting assess tolerance of feedings assess tolerance of feedings weight and graph weight and graph thickened feedings thickened feedings feed slowly feed slowly check suck check suck small amounts small amounts calorie count calorie count upright - infant seat upright - infant seat

39 Nursing Care/Concerns High Risk for Infection High Risk for Infection Cleft Lip/Palate Cleft Lip/Palate URTI or OM URTI or OM diarrhea diarrhea spread of infection spread of infection pyloric stenosis pyloric stenosis body may be debilitated body may be debilitated appendicitis appendicitis peritonitis peritonitis

40 Nursing Care/Concerns Local infection - superficial Local infection - superficial redness, heat, swelling redness, heat, swelling tenderness, pain tenderness, pain Systemic infection - internal Systemic infection - internal abdominal pain, increasing abdominal girth abdominal pain, increasing abdominal girth guarding guarding temperature temperature

41 Nursing Care/Concerns Knowledge Deficit Knowledge Deficit assessing parents understanding of child’s needs and the problem assessing parents understanding of child’s needs and the problem assess parent’s ability to learn assess parent’s ability to learn teach simply, clearly, allowing time for questions and return demonstration teach simply, clearly, allowing time for questions and return demonstration support group support group referrals referrals

42 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. 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. 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. Discuss your impressions of the situation.

43 Questions The US confirms appendicitis. The US confirms appendicitis. Discuss the following orders. Discuss the following orders. NPO NPO B/R B/R D5 1/2 with 10 KCL at 70ml/hr D5 1/2 with 10 KCL at 70ml/hr Gentamycin 45mg IV on call to OR Gentamycin 45mg IV on call to OR MS 1-2mg IVP q2hrs prn pain MS 1-2mg IVP q2hrs prn pain K-pad to abdomen K-pad to abdomen Prepare for OR - lap appendectomy Prepare for OR - lap appendectomy

44 Questions Just prior to OR, Jesus experiences a relief from his pain. What is happening now? What is your nursing action? 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 your nursing priorities in the PACU? What are the pros and cons of letting parents into the PACU? What are the pros and cons of letting parents into the PACU? Post-op orders are as follows: Post-op orders are as follows: routine post op vitals routine post op vitals foley catheter to straight drainage foley catheter to straight drainage D5 1/2 NS with 20KCL 75ml/hr D5 1/2 NS with 20KCL 75ml/hr Gentamycin 45mg IVP q8hr Gentamycin 45mg IVP q8hr Unasyn 900mg IV q 6hr Unasyn 900mg IV q 6hr MS PCA MS PCA Tylenol 240mg q4rhs per N/G tube prn T>100.4 Tylenol 240mg q4rhs per N/G tube prn T>100.4 NGT to continuous drainage NGT to continuous drainage NPO except for meds NPO except for meds IS 10 times each hour while awake IS 10 times each hour while awake


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