Week 11: GI Dysfunction

Pediatric Exam 4 Week 11: GI Dysfunction Gastrointestinal (GI) System ●​ Anatomy ○​ Extends from mouth to anus ●​ Functions ○​ Nutrition ○​ Fluid balance ■​ Fluids for a patient on NPO ●​ Maintenance fluids→ Anything w/Dextrose ○​ Elimination ■​ Urine, vomit, stools ●​ Development ○​ 4th fetal week of gestation GI System ●​ Review of fluid maintenance calculations ○​ Need for accurate I&O ○​ Neonates and infants very prone to dehydration and fluid and electrolyte imbalances: ■​ larger body surface area ■​ high rate of metabolism ■​ immature kidney function ●​ Review of fluid pressures ○​ Oncotic pressure ○​ Osmotic pressure ○​ Capillary hydraulic pressure (BP and blood ​ flow) ○​ Colloid vs. Crystalloid IVF ■​ Colloid fluids→ ●​ Albumin & Blood ■​ Crystalloid Fluids→ ●​ LR, NS, Dextrose,FFP, IVIG Gastrointestinal System Functions ●​ Swallowing ●​ Digestion ●​ Secretion of digestive enzymes ●​ Absorption of various nutrients ●​ Absorption and secretion of body fluids ●​ Elimination Newborn GI System ●​ Birth to 28 days ○​ Suck reflexively ○​ Swallow ○​ Digest ○​ Absorb and eliminate nutrition and fluids ●​ Vitamin K in newborns ○​ Low levels ○​ Increased risk for vitamin K deficiency bleeding Infant GI System ●​ 1 month to 1 year ○​ Learn to pace feeding and not choke ○​ Eat new foods ■​ Progress from breast milk or formula-exclusive diet ■​ Vegetables ■​ Fruits ■​ Proteins Toddler GI System ●​ Mastering bowel control ●​ Controlling elimination at will ○​ Bowel control required before preschool ●​ Require fewer calories ●​ May appear finicky Preschooler and School-Age GI System ●​ Preschoolers ○​ Mature intestinal tract ○​ Adult-like stools ●​ School age and older ○​ At age 6 stomach has adequate hydrochloric acid ○​ Mature GI tract passes 1 stool a day Assessment of Gut Pain 1.​ Stomachache is the most common complaint heard by parents 2.​ Most abdominal pain resolves on its own 3.​ Review of assessment techniques and findings a.​ Physical assessment b.​ Sequence is important i.​ Inspection ii.​ Auscultation iii.​ Percuss iv.​ Palpate 4.​ Review of pain assessment tools 5.​ Health History Etiology of Gut Pain and Dysfunction ●​ Three most common are: ○​ Salmonella ○​ Rotavirus ○​ Astrovirus ●​ Classic symptoms are abdominal pain, diarrhea, fever and nausea/vomiting ●​ Further symptoms include FTT, regurgitation, constipation, encopresis(fecal incontinent), abdominal distention, GI bleeding, jaundice, dysphagia ●​ A taut and tense abdomen may mean obstruction, peritonitis or perforation Acute Conditions ●​ Incarcerated hernia; infected tissues trapped between or through abdominal wall ○​ Incarcerated due to can’t get it out ●​ Inguinal hernia; common, through lower abdominal wall muscles, may extend to testes ○​ Can be pushed back in ●​ Intussusception; invagination of lower bowel ○​ Folds in to itself, Emergency ●​ Pyloric stenosis; olive shaped mass leading to decreased ability to empty stomach a pyloric sphincter ●​ Viral infections; AGE can cause rapid ECF loss ○​ Puts patient at risk of dehydration due to patient refusal to eat and hydrate ●​ Volvulus with necrosis in 1-2 hrs; twisted or decreased pressure on intestines cutting off blood supply ○​ Risk with low birth weight and very low birth weight, premature infant—DO NOT LEAVE ON STOMACH ●​ Diarrhea ○​ Metabolic Acidosis ●​ Vomiting ○​ Metabolic Alkalosis ●​ Constipation ○​ Mush and push meds Chronic Conditions ●​ Celiac disease; chronic malabsorption disease ○​ Inability to process gluten ●​ ●​ ●​ ●​ ●​ ■​ Wheat ■​ Rye ■​ Barley Hirschsprung’s disease; congenital aganglionic megacolon ○​ Diagnosed during 1st month of life, can’t be discharged until baby passes stool Imperforate anus; requires surgery Lactose intolerance; gas, bloating, pain Toxic megacolon (NEC) GERD ○​ Transfer of stomach content to esophagus with meals ○​ Can cause erosion of esophageal mucosa because of HCL acid ○​ Associated with apnea, bronchospasm, laryngospasm, pneumonia ○​ Surgery→Nissen Fundoplication Structural and Obstructive Disorders ●​ Structural disorders ○​ Affect physical structures of GI system ○​ Interfere with profusion, absorption, and elimination ○​ Hernia ○​ Anorectal Malformations: Imperforate Anus ○​ Gastroesophageal Reflux (GER) ○​ Cleft lip/Cleft Palate ●​ Obstructive disorders ○​ Prevent normal, expected elimination patterns ○​ Hypertrophic Pyloric Stenosis ○​ Intussusception ○​ Hirschsprung Disease (Congenital Aganglionic Megacolon) Cleft Lip, Cleft Palate ●​ Cleft lip ○​ Incomplete fusion of the oral cavity ●​ Cleft palate ○​ Incomplete fusion of the palates ●​ Post-op care ○​ VS ○​ Pain-free ○​ No pacifier ○​ No prone ○​ Held by mom/dad Pyloric Stenosis ●​ ●​ ●​ ●​ Enlargement of the circular areas of muscle that surround the pyloric valve Presents with projectile vomiting Olive-shaped hypertrophic tissue mass palpable in RUQ Symptoms include: ○​ Fussy/colicky ○​ Hungry after projectile vomiting ○​ Distended ○​ Distressed ○​ Metabolic alkalosis ●​ Surgical intervention to reduce the muscular hypertrophied tissue ●​ Pre-op: correction of fluid deficits and electrolyte imbalance ●​ Post-op: Monitor VS, lab values, respiratory and hydration status; assess wound healing Intussusception ●​ Invagination or telescoping of a segment of the bowel into a section just distal ●​ Abdominal pain causing knee to chest position; pain comes and goes every 15-20 minutes ●​ Classic symptom: ○​ Bloody mucus stool/red “currant jelly” stool ○​ Dehydration ○​ Pain that comes and goes (cyclical pain) →knee to chest is comfortable for patient ○​ Distention→Hard, taught ○​ Vomiting ●​ Treatment→ ○​ Reduce invagination of the bowel with barium enema or hydrostatic enema ●​ Can lead to severe edema and cut off blood supply to intestine, leading to ischemia and tissue death → medical emergency ●​ Assess for→ ○​ dehydration, shock, sepsis (from bowel perforation) ●​ Post-op initiate: ○​ Clear liquids→PO fluids pedialyte, ice, broth, apple juice, jello(not red and sugar free), otter pops, water ○​ Watch for stool Hirschsprung Disease (Congenital Aganglionic Megacolon) ●​ ●​ ●​ ●​ ●​ Lack of ganglion cells in the rectum and lower colon that prevents peristalsis Causes bowel above it to become filled with gas and fecal matter Abdomen distended, gassy, Ribbon-like, foul-smelling stools No stools in newborns within first 2 days (48 hrs) Surgery:(only fix) ○​ Double barrel colostomy ○​ Or rectal pull-through procedure, removes aganglionic segment of bowel ■​ Risk for malnutrition, dehydration→lose the ability to absorb nutrients ●​ Post-op maintain fluid balance, skin integrity, pain management and home care education Pyloric Stenosis, Intussusception, Hirschsprung Disease → Congenital disorders of Infancy Inflammatory Disorders ●​ Inflammation causing tissue damage ●​ Cause significant pain ●​ Associated with serious complications ○​ Infection ○​ Sepsis ●​ Appendicitis ●​ Celiac Disease (Gluten-Sensitivity Enteropathy) ●​ Crohn Disease ●​ Ulcerative Colitis Appendicitis—inflammation of the appendix ●​ Occlusion of lumen of appendix from infection, strictures, or fecal masses ●​ Assessment ○​ RLQ abdominal pain (McBurney’s point) ○​ Anorexia ○​ Nausea & vomiting ○​ Diarrhea or constipation ○​ Rigid abdomen, muscle guarding ○​ Increased temperature→due to infection ○​ Leukocytosis (WBC 15,000-20,000 cells/mm3) ○​ Highest incidence 10-30 years old ●​ Nursing Management ○​ No heating pads(vasodilates) ○​ Enemas & laxatives preop(empty out bowels before surgery) ○​ Maintain NPO status until blood count reports received and in case patient needs to go for surgery ○​ ○​ ○​ ○​ ■​ Maintenance fluids→D5 NS. KCL- hypo No analgesics until cause of pain is determined Ice bag to abdomen to alleviate pain Observe for signs and symptoms of peritonitis Sudden absence of pain can indicate appendix has ruptured→call SURGEON Celiac Disease ●​ Gluten-sensitivity enteropathy that leads to malabsorption due to an immune-mediated enteropathy ●​ Cannot digest: gluten, gliadin, or proteins from wheat, barley, rye, and sometimes oats(from manufacturing process) ●​ Dx→colonoscopy ●​ Symptoms→ ○​ Steatorrhea →fatty stools→due to malabsorption ○​ Distention ○​ Abdominal pain ○​ Anemia→due to malabsorption ○​ Growth delay → from malnutrition ●​ During celiac crisis→ ○​ Severe diarrhea ○​ Dehydration ○​ Metabolic acidosis → from diarrhea (base) ■​ Body compensates by hyperventilating ○​ Electrolyte imbalances Crohn Disease ●​ Inflammation of all layers of the GI mucosa, affecting any portion of the GI tract from mouth to anus ●​ Dx→Colonoscopy ●​ Ulcers form; “skip” lesions ●​ Present with→​ ○​ Diarrhea ○​ Weight loss ○​ Bloody stools→because of ulcers ○​ Abdominal pain ○​ Anemia→malnutrition ○​ Dehydration ○​ Fever→inflammatory disorder ●​ Treatment→ ○​ Rest ○​ Fluids ○​ ○​ ○​ ○​ Liquid Diet Anti-inflammatory medications(No NSAIDS but corticosteroids OK) Partial colectomy Eliminate foods associated with increasing ulcerations and discomfort (sharp cheeses, highly spiced foods; salted, blackened, or smoked meats; raw fruits, raw vegetables; fried foods Ulcerative Colitis ●​ Localizes to the colon; inflammation of the colonic mucosa ●​ Dx→colonoscopy ●​ Present with→ ○​ Urgent diarrhea ○​ Weight loss ○​ Bloody stools ○​ Abdominal pain ○​ Anemia ○​ Dehydration ○​ Fever ●​ Classic presentation→ ○​ Continuous ulcers, with only innermost layer of the bowel mucosa being affected ●​ Treatment ○​ Rest ○​ Fluids ○​ Liquid Diet ○​ Anti-inflammatory medications ○​ Partial colectomy in severe cases ○​ Eliminate foods associated with increasing ulcerations and discomfort (sharp cheeses, highly spiced foods; salted, blackened, or smoked meats; raw fruits, raw vegetables; fried foods Acute Diarrhea ●​ Signs and symptoms ○​ Increased motility and rapid emptying ○​ Dry, pale skin, poor turgor ○​ Dry membranes ○​ Weakness with electrolyte imbalances ○​ Decreased urine output → (first sign mostly infants/wears diapers) ○​ Change in vital signs → increased HR, low BP (late sign) ○​ Increased thirst ○​ Acid‒base imbalances→ metabolic acidosis(compensate with RR or your kidneys will compensate by urinating) ●​ Risk factors ○​ Travel ○​ Daycare ○​ Improper sanitation ○​ Causative agent ○​ Poor hand hygiene ●​ Treatment ○​ Starts prior to diagnosis ○​ Oral fluids without sugar ○​ IV fluids ■​ NS ■​ 999 ml/hr IV pump or IV push ○​ Foods/drinks to avoid ○​ Fruit juices ○​ Sodas ○​ Gelatin ○​ Caffeine Constipation ●​ ●​ ●​ ●​ ●​ Infrequent passage of stool Difficulty passing a series of small hard stools Abdominal pain Cramping Risk factors ○​ Limited fluid intake ○​ Sedentary lifestyles ○​ Poor fiber intake ○​ Excessive dairy products ○​ Lead poisoning ○​ Underactive thyroid function→hypothyroidism ○​ Celiac disease ○​ Abnormal serum calcium levels ●​ Treatment ○​ Dietary changes to increase fiber ○​ Increase fruits and vegetables ○​ Increase oral fluids ○​ Medications Vomiting (Emesis) → metabolic alkalosis ●​ Expulsion of gastric contents through mouth ●​ Often self-limiting ●​ Rapid resolution ●​ Risk factors→ ○​ Infectious disease ○​ Toxic material ingestion ○​ Allergy ○​ Obstruction ○​ Increased intracranial pressure ●​ Treatment ○​ Not needed unless persists Failure to Thrive ●​ Not an actual diagnosis ●​ Secondary condition ○​ Medical ○​ Emotional/affective disorder ●​ Serious complication of GI disorders and diseases ●​ High morbidity and mortality rates Review of developmental presentation of fluid imbalance ●​ Assessment of dehydration across childhood ●​ Assessment of severity of acidosis ○​ ECF loss leads to decrease in ICF fluid ○​ Poor kidney perfusion → increased carbonic acid build up→ metabolic acidosis ●​ Classic presentation with acute gastroenteritis (AGE) ○​ Copious watery diarrhea, Na loss, K leaves ICF cell to make up ●​ Rehydration with AGE Types of Dehydration ●​ Isotonic ○​ Equal loss of water and sodium occurs ○​ Majority of the fluid lost is extracellular ○​ Hypovolemic shock can occur ○​ LR, NS, Plasma ●​ Hypotonic ○​ Electrolyte loss exceeds water loss ○​ Fluid shifts are extracellular to intracellular ○​ More likely to see physical signs ●​ Hypertonic ○​ Water loss is greater than electrolyte loss ○​ Fluid shifts are intracellular to extracellular ○​ Most dangerous ■​ DKA ■​ DI Dehydration by Weight Comparison → ATI Book S&S ●​ Mild dehydration ○​ 5% or less in infants and 3-4% in children ●​ Moderate dehydration ○​ 10% infant weight loss and 6-8% in children ●​ Severe dehydration ○​ 15% infant weight loss and 10% in children Dehydration Symptoms ●​ Decreased peripheral pulses, weak and thread ●​ Tachycardia/Tachypnea secondary to metabolic acidosis ●​ No tears ●​ Dried mucous membranes ●​ Increased thirst drive ●​ Decreased urine output ●​ Sunken fontanelles ●​ Sunken eyes ●​ Blood ○​ Increased Na ○​ Increased Creatinine ○​ Increased BUN Clinical Presentation of Dehydration ●​ Early is increases in HR, RR and fever, sunken fontanelles and irritability ●​ Late is poor turgor, no tears and dry mucous membranes, ill appearance ●​ Critical is lethargy, decreased CRT, poor peripheral pulses and cold, gray skin, severe acidosis, coma and death One-to-One Body Fluid Replacement ●​ Replacement of body fluids lost through NG, J-tube, Bile tube, stool ●​ Replacement amount calculated from previous 4 hours and given in the next 4 hours ●​ Total body fluid lost in 4 hours divided by 4 to give hourly rate for next 4 hours. Oral Rehydration Fluids ●​ Mild to moderate is 60-80 ml/kg over 2 hours ●​ Maintenance with ORF and breast milk or formula ●​ On-going stool loss is 1:1 replacement every four hours ●​ Resume normal feeding habits and breastfeeding ASAP ●​ Move to clears and then BRAT diet ●​ No fruit juices, carbonated soft drinks, gelatin ○​ have low electrolytes and high osmolality From teacher: ●​ Major goals ○​ ○​ ○​ ○​ Assess severity Rehydrate Give maintenance fluid Reintroduce adequate fluid oral first then iv Week 12: GU Dysfunction Function of the Kidney ●​ Production and elimination of body’s wastes ○​ Nutrient and fluid consumption ○​ Absorption ○​ Distribution ○​ Excretion of the end products of metabolism ○​ Elimination of liquid waste products ○​ Production of hormone erythropoietin→produces RBCs ○​ Production of chemical renin→ controls BP ○​ Stimulation of hormone aldosterone ○​ Regulation of fluids and electrolytes ○​ Regulation of acid‒base balance Genitourinary Disorders ●​ Assessment ○​ Fluid status ○​ Skin turgor ○​ Weight and general appearance ○​ Vital signs and peripheral pulses ○​ Acid‒base imbalances ●​ Nursing care ○​ Complications with congenital anomalies ■​ Infection ■​ Inflammation ■​ Obstruction ○​ Calculation of child’s fluid maintenance Alterations in GU System in Childhood ●​ Most common diagnosis is urinary tract infection (UTI) ●​ Bacterial colonization etiologies include E-coli, Staph or Pseudomonas ●​ Structural anomalies: hypospadias ●​ Primary host factors: Short urethra, urinary stasis, diapered baby, uncircumcised, Foley catheter ●​ Teens: improper diaphragm, bubble baths, sex, tampons, menstrual pads ●​ Relationship with acidity: Increase acidity Symptoms of Pediatric UTI→ ●​ Fever and chills ●​ Malodorous urine ●​ Hematuria ●​ Abdominal, pelvic or flank pain ●​ Dysuria ●​ Frequency and urgency ●​ Crying with elimination ●​ Color and clarity of urine ●​ Specific gravity and pH of the urine ●​ Presence of associated symptoms Diagnostic Tools for Pediatric UTI ●​ UA; >100,000 bacteria per 1 ml urine (clean catch, midstream) ●​ Culture and Sensitivity ●​ Serum studies ●​ IVP = intravenous pyelogram ●​ Renal angiogram ●​ KUB =kidney, urethra, bladder ●​ Suprapubic aspiration = done sterile if symptoms persist; needle through pubic region straight to bladder ●​ VUCG = Voiding urethra cystourethrogram; dye in catheter ●​ CT ●​ BUN & Creatinine = between 10:1 and 20:1 ratio; increase in ratio=decrease flow of blood to the kidneys (CHF, dehydration) Antibiotics for UTI: ●​ Penicillins ●​ Sulfonamides (Bactrim, Septra) ○​ Sunscreen for sulfonamides ●​ Cephalosporins ●​ Nitrofurantoin (Macrodantin) ○​ Causes orange urine Nursing Care for UTI ●​ Provide large quantities of child’s favorite oral fluids (clearer the better) ●​ Start and maintain a patent IV ●​ Encourage fluid consumption ●​ Treat fever and discomfort ●​ Reinforce hygiene ○​ Wipe front to back ○​ Change diapers w/stools ASAP ○​ Educate all caregivers Pyelonephritis → Inflammation of the kidneys ●​ Infection and inflammation of the structures of the kidneys ●​ Observed in infants and young children ○​ Acute febrile UTI where bacteria ascended ●​ Upper genitourinary tract infection ○​ Can occur with recurrent UTIs and untreated UTIs ●​ Treated promptly with antibiotics Hemolytic Uremic Disease (HUS) ●​ Intravascular coagulation condition ●​ Etiology is E-coli, Pseudomonas or Shigella ○​ Consumed through food ●​ Pathology follows AGE ●​ Most common 4 months to 4 years of age ○​ Main damage is to kidneys/nervous system/GI tract ●​ Symptoms ○​ Vomiting ○​ Anorexia ○​ Bloody diarrhea- ED ○​ Small bruises on lining of the mouth ○​ Renal failure/thrombocytopenia ○​ Hemolytic anemia w/ fragmented RBC Acute Glomerulonephritis ●​ Minimal to severe ●​ 80% are post strep infections; 1 week to 10 days ●​ Urine is cloudy, smoky, tea colored ●​ Urine output decreased ●​ Pathophysiology → ○​ antigen/antibody complexes trapped in the glomeruli and poly-morphonuclear lymphocytes including capillary lumen ●​ Clinical presentation→ ○​ Reduced plasma filtration and water/sodium retention with circulatory congestion, edema and *HTN* ○​ 1st symptoms, puffy eyes in AM, then face then anorexia then dark urine; edema progress in PM to abdomen then to lower extremities ●​ Diagnostics→ ○​ Proteinuria (1-4+), elevated BUN and ESR, antibody titers of anti streptolysin ●​ Laboratory findings ○​ Positive strep cultures, blood cultures, or urine culture ●​ Treatments ○​ Antibiotics ○​ Restore fluid balance ○​ Reduce urea buildup ○​ Restore kidney function ●​ Nursing concerns→ ○​ Renal failure, azotemia ■​ Azotemia=increased nitrogen-containing compounds→urea, cr ○​ Nursing diagnosis: Fluid volume excess ■​ SOB ■​ Orthopnea ■​ Rales ■​ Weight gain from fluid → daily weights at same time, same scale, same clothes for trending purposes. ○​ Monitor for hyperkalemia ■​ Dysrhythmias ■​ Muscle cramping ○​ Promote nutrition ●​ Nursing assessments→ ○​ Hypertension ​ ○​ Fluid status​ ○​ Resuscitation status and overload ○​ Fluid restriction guidelines ○​ Monitor UOP to assess for improvement Nephrotic Syndrome→ ●​ Kidney disorder that causes body to excrete too much protein in urine ●​ Oncotic pressure →excreted by proteins (albumin), plus water into circulatory system; body produces lipids, but they don’t actually help oncotic pressure ○​ **huge pores, protein lost; protein is biggest molecule in blood ●​ Minimal change NS: symptom complex ●​ Four cardinal clinical presentations ○​ Edema (generalized) ○​ Hyperlipidemia ○​ Marked proteinuria ○​ Marked hypoalbuminemia ●​ Pathology ○​ Increased permeability and porous nature of final filtration membrane: unknown repeated etiology** ○​ Up to 2 grams of protein lost per day ○​ Once lost, colloidal osmotic pressure decreases and fluids are lost Nephrotic Syndrome: Clinical Presentation ●​ Hypovolemia leads to edema (periorbital first) ●​ Weight gain with ascites ●​ Pleural effusions ●​ Labia and scrotal swelling ●​ Shiny taut skin ○​ Impaired Skin Integrity ●​ Fatigue and irritability ●​ Urine is frothy and golden; high specific gravity ●​ Anorexia ●​ Normal to slightly decreased BP ●​ Serum sodium slightly low Nephrotic Syndrome Treatments ●​ Diuretics ●​ Angiotensin inhibitors ●​ Convert enzyme ●​ ACE to decrease BP if needed ●​ 25% albumin replacement ●​ Corticosteroids over weeks until proteinuria gone ○​ Infections due to impaired skin integrity ●​ 2mg/kg/day for 21 days then taper ●​ Recurrences common ●​ May need chemo ●​ Cytoxan ●​ Chloorambucil (Leukeran) Nursing Care ●​ High protein, low sodium/salt diet ●​ Strict I&O ●​ Daily weight (or bid) on same scale ●​ Meticulous skin care ○​ Prevent skin breakdown at all cost ●​ Conserve child’s energy ○​ Cluster care ●​ Teach how to assess for protein in urine Enuresis ●​ Assessments ○​ Length of time of the incontinence ○​ Time of day of the incontinence ○​ Presence of trauma ○​ Stressors in child’s life ○​ Conscious holding of urine ○​ Associated medical conditions ●​ Interventions* ○​ Restrict oral fluids after evening meal ○​ Toileting directly before climbing into bed ○​ Emotional support; never scolding, belittling, judging or demonstrating frustration toward child ○​ Motivational rewards for staying dry (controversial) Week 13: Hematologic and Immunologic dysfunction Anemia ●​ Defined as an interruption of the delivery of oxygen ○​ Impaired production of RBCs or hemoglobin ○​ Disturbances in the metabolic pathways ○​ Decreased production or efficacy of erythropoietin(produced in the kidneys) ○​ Bleeding ○​ Conditions of hemolysis or destruction ●​ Other lab values:(other than a H&H) ○​ MCV ○​ Reticulocyte count ○​ Ferritin and Fe ●​ Average life span of RBC→ 120 days ●​ Anemia may be a result of changes in morphology, production or destruction ●​ Role of nutrition/diet Signs and Symptom of Anemia ●​ Classic symptoms ○​ Fatigue ○​ Exercise intolerance ○​ Pallor ○​ Amenorrhea(no menstrual cycle) ○​ Headache ○​ Irritability ○​ Dizziness ○​ Impaired cognition ○​ Clubbed nails(long term effect→more so in congenital heart defects) ○​ Tachycardia ○​ Dyspnea ○​ Tachypnea ○​ Poor sucking(fatigued) ○​ Pica(eating foods that are NOT food) ○​ Anorexia ●​ Medical treatment ○​ Determine severity of presenting anemia ○​ Long course of oral iron supplementation ○​ Additional laboratory evaluations ●​ Transfusion therapy ○​ Donor serum and WBCs are source of transfusion reactions ○​ Transfusions Iron(Fe) Deficiency Anemia ●​ ●​ ●​ ●​ ●​ Most common nutritional disorder in children in the US Mother’s iron store runs out around 6 months. Caused by a decrease in Fe supply, impaired absorption or synthesis, or increased need for Fe Milk Anemia is often culprit: > 32oz per day Highest Risk: ○​ Premature infants (bone marrow dysfunction) ○​ Children of lower socioeconomic status (poor nutrition) ○​ Adolescents (high fat, high carb, low Fe foods) ●​ Administration of Fe supplements ○​ Increased absorption with source of acid ○​ Either give with OJ or on empty stomach ○​ ○​ ○​ ○​ Rinse mouth or brush teeth as iron stains teeth Stool is dark Parental education needed on length of prescription Always refer to dietician for counseling, does not need physician’s order Sickle cell anemia ●​ Autosomal recessive congenital disorder of hemoglobin ●​ Rigid sickle-shaped RBCs→ ○​ Due to the lunar shape the cells clot causing pain ○​ PE ○​ Oxygen does NOT like to attach to the sickle cell→will require oxygen when in a pain crisis ○​ Prone to dehydration ●​ Results from a defective hemoglobin molecule (hemoglobin S) which has poor affinity to O2 ●​ Causes fatigue, ischemia joints, acute chest syndrome ○​ Acute chest syndrome→ ■​ Can cause pneumonia, acid base balance issues, reduced ventilation ●​ Requires narcotic pain control, IVF boluses and high maintenance ●​ At baseline everyday→ ○​ Child needs Fe, folic acid, vitamin C, low O2 ●​ Prognosis infection, Prognosis dehydration, Prognosis oxygen demands ●​ In the presence of a trigger, sickling occurs ●​ Signs and symptoms→ ○​ Pallor ○​ Jaundice(when the sickle cells take over in the liver) ○​ Lethargy, irritability ○​ Anorexia ●​ ●​ ●​ ●​ ●​ ○​ Malaise Treatment→ ○​ Packed RBCs→diluting the sickle cells enough to prevent from clotting ○​ Fluids also help with diluting Sickle cell anemia‒associated crises ○​ Vaso-occlusive crisis ■​ Severe pain ■​ Fever ■​ Joint pain ■​ Lungs ■​ Tissues of the abdomen ■​ Finger and feet ○​ Hyper-hemolytic crisis → rapid destruction of sickle cells (body can’t keep up) ■​ Leads to bilirubin build up and causes jaundice ○​ Aplastic crisis→ ■​ Bone marrow decreases its production ○​ Sequestration crisis→ ■​ EMERGENCY Management ○​ Preventing acute vaso-occlusive episodes ○​ Hydration ○​ Reducing life-threatening complications ○​ Decreasing transfusions complications→ ■​ They are at higher risk for blood transfusion reactions due to having recurring blood transfusions ○​ Increasing hemoglobin F ○​ Premedicate before transfusions→like benadryl or hydralazine ■​ Epipen at bedside and hydrocortisone ○​ Current type and screen before administering a blood transfusion Nursing care ○​ Providing rapid interventions ■​ Secure IV access ■​ If IV access is compromised due to being poked too much patient may likely have a port ○​ Monitoring for signs of complications r/t multiple blood transfusions ○​ Teens may need Child Life to provide contract for pain control, ambulation, chest physiotherapy Splenic Sequestration→ ○​ Life threatening crisis; ■​ Sickled blood clots become sequestered in the spleen ■​ Sudden trapping of blood within the spleen ■​ Precipitous decrease in BP ■​ Tachycardia, shock, dizziness, CO is diminished, hypotension, tachypnea, cool extremities, thready pulse, and decreased UOP ○​ Treatment→ ■​ Splenectomy(spleen helps with immune system ABX is needed) ●​ Will need to be on ABX for life →Penicillin Hemophilia ●​ X-linked, recessive bleeding disorder ●​ Affects coagulation processes and clot formation ○​ More common in MALES ●​ Determination of which clotting factor is deficient and to what extent for diagnosis and treatment ●​ Hemophilia A accounts for 75% of all cases→missing factor 8 ●​ Hemophilia B → missing factor is 9 ●​ 60-70% of cases are quite severe ●​ Classic presentation→ ○​ Bruising(more bruising than usual and in random spots) ○​ Bleeding gums ■​ When teething, it can cause hematomas ○​ Significant bleeding with injury ○​ Hematuria ○​ Epistaxis (nosebleeds) ○​ Joint pain ●​ Labs ○​ PTT ○​ Factor Specific Assays ●​ Treatment ○​ Administration of clotting factors→daily or weekly doses of SubQ injections ○​ DDAVP ■​ Vasopressin(increases plasma factor 8) ○​ Antifibrinolytic agents ○​ PRBC transfusions ●​ Nursing care:Hemophilia→ ○​ Safe home environment ○​ Education of all caregivers ○​ No IV, SQ or IM(UNLESS you are ready to give the factor so no unnecessary pokes happen) ○​ 5 minutes of direct pressure ○​ Apply ice for injuries(NEVER HEAT FOR PAIN) ○​ Soft toothbrush ○​ Medical alert bracelets ○​ Electric shaving only ○​ Acute situation: rapid administration of factor ○​ Control pain with acetaminophen(NOT NSAIDS) ○​ NO contact sports ■​ Sports Safe→ ●​ Swimming ●​ Golf ●​ Tennis ●​ Track ●​ Hiking ●​ Solo Dancing ***Blood Transfusion*** ●​ Pre Transfusion ○​ Consent ○​ Lab check ○​ Pre-meds(Benadryl, Hydralazine, or EPI @ bedside) ○​ Filters(filter out any dead cells) ○​ All components are fresh and present, HLA? ■​ You have 4 hours until blood expires ■​ Blood is only compatible with normal saline ○​ Double check with a second RN at BEDSIDE!, Two IDs ○​ Identify religious or cultural barriers to administration ●​ Intro Transfusion ○​ Pre-VS, 15 minutes, Q30 x 4, Q1 x 4 ■​ Stop infusion if reaction occurs(reaction usually occurs within the first 15 mins) ●​ Rash, fever, flank pain, bloody urine, itching ○​ Save tubing and bag if reaction suspected ●​ Post Transfusion ○​ Monitor for late symptoms of hemolysis, reactions ○​ Don't let Hgb rise more than 1 per hour ●​ You CAN bolus blood in trauma or emergency situations Cancer ●​ Cancer Dx, Staging, and Tx ○​ Presentation in ER for fevers, pain or fatigue ○​ Staging includes TNM system ○​ Risk factors are age related ○​ Treatments→ ■​ Chemo ●​ (2 nurses double check) ■​ Radiation ■​ Immunotherapy ■​ Biotherapy ■​ Surgery (7 indications) ■​ Gene therapy Leukemia-Hematologic Cancer ●​ A malignant proliferation of WBC precursors triggered by an unknown cause and affecting all blood-forming organs and systems in the body ●​ Presence of blasts on CBC ●​ Most common form of childhood cancer ●​ WBC consists of → ○​ Monocytes ○​ Eosinophils ○​ Neutrophils ○​ Basophils ○​ Lymphocytes ●​ Acute lymphoblastic leukemia (ALL) ○​ Begins in bone marrow(blasting out immature WBC) ○​ Found throughout blood ○​ Treated with chemotherapy ●​ Acute myeloid leukemia(AML) ○​ Less common; more difficult to treat ○​ Older male patients→19-21 years of age ●​ Signs and Symptoms of Leukemia ○​ Decreased functional WBC, increased blasts(Immature cells) ○​ Bone marrow dysfunction results in: ■​ Neutropenia(no immune system) ■​ Anemia(no RBC or HGB) ■​ Thrombocytopenia(Low platelet count) ■​ Petechiae, bone pain, fatigue ●​ Post Neutropenic Precaution on child’s hospital door→ ○​ Post handwashing signage on the child’s hospital door ○​ Place the child in double door isolation ○​ Positive pressure room ○​ Screen all visitors for infectious diseases, including a child’s visitor’s temporal temperature ○​ Refrains from including fresh fruits or fresh vegetables on food trays due to potential for microbial contamination ○​ Refrains from placing fresh flowers due to potential for Aspergillus contamination ○​ Decontaminate child’s full skin surface daily with skin cleanser ○​ No tap water on bottle water ○​ VS equipment stays in the room ○​ Bathe with chlorhexidine daily ○​ No tylenol and NSAID for pain→will mask if the patient has an infection (fever) ■​ ABX ASAP(within 60 mins) and blood cultures ●​ Diagnosis and Treatment ○​ Diagnose ■​ Tissue biopsy ■​ Bone marrow aspiration ●​ From iliac crest→ side lying position ○​ Treatment ■​ Combination of therapies ■​ Pain management ■​ Infection control and prevention ○​ Prognosis ■​ Realistic, based on specific presentation of blasts, based on type of leukemia Neuroblastoma ●​ Arises from nerve branches exiting the cord ○​ Common site is on the adrenal glands ●​ Often presents as abdominal cavity tumors ●​ Typically found before age 5 ●​ Present with→ ○​ Distended belly(OK to palpate; ONLY if no suspicion of Wilms Tumor) ○​ Bone pain ○​ Difficulty walking(refusal to walk) ○​ Loss of appetite ○​ Bowel and bladder problems→secondary enuresis ●​ Treatment ○​ Surgery to remove the tumor ○​ Chemotherapy, radiation, and retinoic acid Ewing Sarcoma ●​ Types ○​ Undifferentiated Ewing sarcoma ○​ Peripheral primitive neuroectodermal ○​ Extraosseous ●​ Typically occur in adolescence BEFORE the age of 20 , common on thigh bone ●​ Osteosarcoma is also a bone cancer and also happens/peaks during adolescence ●​ Treatment factors ○​ Location and size ○​ Metastasis Wilms Tumor ●​ Mostly on kidney ○​ Encapsulated tumor can rupture if palpated ●​ Occurs in children age 15 or younger ●​ Associated congenital defects ●​ Symptoms ○​ May be asymptomatic ○​ If symptomatic, abdominal pain common ○​ Pink-tinged urine ●​ Referral to pediatric oncology specialists ●​ DO not palpate the abdomen if a tumor is suspected! Retinoblastoma ●​ ●​ ●​ ●​ DX → glare on one eye like a little cat, two eyes is okay thoughTumor on or within the retina Leukocoria - cat eye’s pupil Treatment ○​ Enucleation of affected eye ○​ Introduction of custom-made prosthesis ○​ Cryotherapy Chemotherapy Phases ●​ Induction ○​ Given to induce a remission ●​ Consolidation ●​ Intensification ●​ Maintenance ○​ Includes chemotherapy to maintain a remission Chemotherapy Management ●​ Pre→ ○​ UOP and urine PH, bicarb infusions → checking urine specific gravity & UA function ■​ Hyper Hydrate patients to help filtering process in the kidney ●​ ●​ ●​ ●​ ○​ CL(central line) care →check for blood return ○​ Lab, audiology, pulmonary functions test, calculate BSA(Body Surface Area) ○​ Consent ○​ Double check with a 2nd RN at bedside, independent calculations Intro→ ○​ Fluids, UOP ○​ ATC(Around the clock) anti-nausea(zofran, ativan, scopolamine, benadryl) ○​ Safe handling and disposal(yellow bins→are for bodily fluids) ○​ Blood return for vesicants(for central lines) ■​ Making sure there is good blood return because if no blood return then not in a good line ○​ Prevent extravasations ○​ Chemoprotectant meds→ ■​ Mesna with Ifos, leucovorin with MTX Post→ ○​ Nadir teaching→ worse than neutropenic precautions(no immune system at ALL) ○​ Long term effects ○​ Late onset nausea ○​ Drug specific side effects→ ■​ Bleo, Adira, cisplatin, and cytoxan Consent, health assessment VS, labs, SG or urine(lower better), evaluate plan of care and understanding, safety check and appropriate bins are in the room, legal guardian is present, wear proper PPE, assess CL, make sure patient is getting correct fluids, check electrolytes pre and post, checking and treating for symptoms, side effects, UOP, care and meds at home Side effects ○​ Neutropenia→ ■​ Should be 40-60% of total WBC, lives 6-8 hours ■​ Calculations of ANC→how neutropenic a patient is ■​ Neutropenic precautions ■​ Neupogen→grow cells you need given once a week ■​ Fevers immediately reported: BC q24 hours, triple ABX ■​ Play and normalcy ○​ Thrombocytopenia→ ■​ Decreased platelet production ■​ Should be 150,000 to 500,000, lives 8-11 days ■​ Daily assessment for petechiae→will tell you how bad the thrombocytopenia is ■​ Anemia ●​ Should be 3.4 or 5.4, lives 120 days, follow H&H ●​ Treatment ●​ EPOGEN (epoetin alfa) Nursing care of Pediatric Cancer Patient ●​ Nursing certifications ○​ Chemotherapy ○​ Biotherapy ●​ Nursing skills ○​ Identify a child in trouble ○​ Identify potential for serious side effects ○​ Identify child who needs care of central line or implanted port Nursing Education ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ ●​ Prognosis of infections Vaccine guidelines: post treatment Prognosis of injury and trauma Neutropenic precautions** Central line care and instruction Pain relief Conservation of energy Play and independence Symptoms of complications and side effects of chemo ○​ Stomatitis→mouth is so painful prevents the child from eating ●​ Prediction of Nadir ●​ Post Neutropenic Precaution on child’s hospital door→ ○​ Post handwashing signage on the child’s hospital door ○​ Place the child in double door isolation ○​ Positive pressure room ○​ Screen all visitors for infectious diseases, including a child’s visitor’s temporal temperature ○​ Refrains from including fresh fruits or fresh vegetables on food trays due to potential for microbial contamination ○​ Refrains from placing fresh flowers due to potential for Aspergillus contamination ○​ Decontaminate child’s full skin surface daily with skin cleanser ○​ No tap water on bottle water ○​ VS equipment stays in the room ○​ Bathe with chlorhexidine daily ○​ No tylenol and NSAID for pain→will mask if the patient has an infection (fever) ■​ ABX ASAP(within 60 mins) and blood cultures Family Education: Cancer ●​ ●​ ●​ ●​ ●​ Side effects of treatment How to calculate neutrophil count Neutropenic precautions Actions to take if neutropenia occurs Management of symptoms and central lines