Finals

• COGNITIVELY- OR PHYSICALLY-CHALLENGED AND CHRONICALLY-ILL INFANTS (1–12 months old)


  • Experience the same health and growth problems as other infants such as colic or diaper rash
• RELUCTANCE OF PARENTS


  • Parents may be reluctant to mention these concerns at healthcare visits because they believe such problems pale in comparison to the child's primary illness or condition
• TAKING THE HEALTH HISTORY


  1. Ask parents about these secondary concerns

  2. "What about everyday things? Any problems there?"

  3. Treat these concerns seriously, so parents can feel confident about bringing them to the healthcare visits

  4. Parents are part of normal infant development so parents can begin to view their child apart from his or her illness
• Intussusception


  The invagination (telescoping) of a section of the intestine into the distal bowel that causes bowel obstruction

  
• INTUSSUSCEPTION IN CHILDREN


  • Most common cause of bowel obstruction in children between 3 months and 6 years old
  • More common in males and children younger than 2 years
• Causes of Intussusception


  • Idiopathic (in infants younger than 1 year)
  • Lead points (in infants older than 1 year): Meckel's diverticulum, Polyp, Hypertrophy of Peyer's patches
• Intussusception


  1. Telescoping of two intestinal sections

  2. Causes irritation, edema, and swelling

  3. A section of terminal ileum telescopes into the ascending colon through the ileocecal valve

  4. Results in obstruction in venous and lymphatic flow

  5. Venous engorgement causes leakage of blood in the stools, which causes damage to the intestine

  6. Ischemia and necrosis may occur and cause death d/t sepsis

  
• Signs and Symptoms of Intussusception


  • Passage of bloody mucus ("red currant jelly" [combination of blood and mucoid fluid]) in stool
  • Severe abdominal pain as evidenced by severe crying
  • Sausage-shaped abdominal mass
• Dance's sign


  Location of the sausage-shaped abdominal mass: right hypochondriac that empties into the right lower quadrant

  
• Other Signs of Intussusception


  • Nausea and vomiting
  • Distention
  • Hypo- or hyperactive bowel sounds (diarrhea)
  • Continuous passage of stool in lumen
  • Symptoms of shock and sepsis

  
• Diagnosis of Intussusception


  • Abdominal radiographs
  • Sonogram
  • Rectal exam
  • History
• Therapeutic Management of Intussusception


  1. IV fluid therapy

  2. Hydrostatic reduction through barium or air enema (pneumatic insufflation)

  3. Ultrasound-guided isotonic saline enema

  4. Surgery (laparoscopy)

  5. Nasogastric tube and IV infusion

  
• Hydrostatic reduction


  A non-surgical treatment and a diagnostic procedure at the same time that attempts to push the intestine back to its place

  
• Laparoscopy


  Surgery to cut and connect or manually place the intestine

  
• Colic


  Paroxysmal abdominal pain that generally occurs in infants under 3 months of age
• Causes of Colic


  • Overfeeding
  • Swallowing too much air or gas while feeding (especially bottle-fed infants)
  • Psychological factors
  • Functional immaturity of CNS and GIT
  • Gastrointestinal hypermotility
• Risk Factors for Colic


  • Formula-fed babies
• Signs and Symptoms of Colic


  • An infant cries loudly and pulls the legs up against the abdomen
  • Infant's face becomes red and flushed, fists clenched and the abdomen becomes tense
  • Infant will suck vigorously for a few minutes if a bottle is offered (as if the infant is not experiencing pain)
• Urge the parents


  To give them assurance that their child is once again well
• Colic


  Also known as kabag
• Causes of colic


  • Overfeeding
  • Swallowing too much air or gas while feeding (especially bottle-fed infants)
  • Psychological factors
  • Functional immaturity of CNS and GIT
  • Gastrointestinal hypermotility
• Risk factors for colic


  Formula-fed babies (milk formula is harder to digest thus they tend to have more symptoms than breastfed infants)
• Signs and symptoms of colic


  • An infant cries loudly and pulls the legs up against the abdomen
  • Infant's face becomes red and flushed, fists clenched and the abdomen becomes tense
  • Infant will suck vigorously for a few minutes if a bottle is offered (as if the infant is not experiencing pain)
  • However, the infant will stop sucking once the spasms of colic returns
• Therapeutic management for colic


  • Changing formula bottles (use the ones with disposable bags that collapse as the baby sucks to lessen swallowing of air)
  • Distraction techniques (taking infants for car rides, music boxes that stimulate the sound of a heartbeat)
  • Phenobarbital (used if no pharmacologic solutions are successful, an anti-seizure medication and sedative that would depress the CNS)
• Phenobarbital does NOT address the underlying cause of colic; it only depresses the CNS
• Nursing management for colic


  • Thorough history taking (duration and frequency of the problem, what happens before the attack, description of the attack and its associated symptoms, feeding patterns of the baby, number and type of bowel movements)
  • Health teachings for parents (remind to hold the baby upright and help burp after feeding, recommend small frequent feedings, discourage use of hot water bottle on infant's stomach)

  
• Hirschsprung's disease


  Aganglionic megacolon - absence of ganglionic innervations in a section of the bowel, usually the lower portion of the sigmoid colon just above the anus

  
• What happens when nerve cells are absent in Hirschsprung's disease


  • No peristaltic movements to move the fecal material in this section
  • The bowel would remain constricted, contracted, narrow, and would not relax
  • It will be very difficult for the fecal material to pass through
• Consequences of absent nerve cells in Hirschsprung's disease


  • Chronic constipation
  • Ribbon-like stools (as the fecal material passes through the small, narrow segment)
  • Dilation and distension of the bowel proximal to the obstruction
• Causes of Hirschsprung's disease


  • Abnormal gene on chromosome 10
  • Incidence: 1 in 5,000 live births
• Risk factors for Hirschsprung's disease


  • Higher in the siblings of a child with the disorder than in other children
  • Occurs more often in males than females
• Signs and symptoms of Hirschsprung's disease


  • Infants fail to pass meconium by 24 hours of age
  • Increasing abdominal distention
  • Undernourished infant
  • History of constipation or intermittent constipation and diarrhea
  • Rectum is empty because fecal material cannot pass into the rectum through the obstructed portion
• Diagnostic tests for Hirschsprung's disease


  • Barium enema
  • Biopsy of the affected segment
  • Anorectal manometry
  • Rectal exam

  
• Therapeutic management for Hirschsprung's disease


  • Daily enemas (using normal saline, not tap water)
  • Minimal residue diet, stool softeners, and vitamin supplements
  • Antibiotic solution/saline as prophylaxis
  • Total parenteral nutrition
  • Surgical management (temporary colostomy and bowel repair, or permanent colostomy)
• Nursing diagnoses for Hirschsprung's disease


  • Constipation related to reduced bowel function
  • Imbalanced nutrition less than body requirements related to reduced bowel function
  • Risk for compromised family coping related to chronic illness in child
• Nursing interventions for Hirschsprung's disease


  • Preoperative: Teach parents how to prepare and administer saline enemas, help learn about minimal-residue diet, instruct about stool softener
  • Postoperative: Observe for abdominal distention, assess bowel sounds and passage of flatus/stools, offer small frequent feedings, gradually introduce full fluids, soft diet, minimal-residue diet, and normal diet
• Esophageal atresia


  Condition involving the failure of the esophagus to develop a continuous passage from the throat to the stomach, may also involve an abnormal opening (fistula) into the trachea

  
• Types of esophageal atresia

  • Complete atresia (Type I - 2 blind pouches, no connection to stomach)
  • Atresia with proximal fistula (Type II - upper esophagus connected to trachea)
  • Atresia with distal fistula (Type III - 84% of cases, lower esophagus connected to trachea)
  • Atresia with double fistula (Type IV - both blind pouches open into trachea)
  • Functional atresia (Type V - no atresia, but presence of H-type fistula between esophagus and trachea)

  
• Signs and symptoms of esophageal atresia


  • Oral secretions at birth (appear to be blowing bubbles)
  • Coughing, cyanosis, and choking during feeding (3 Cs)
  • Abdominal distention
  • Abnormal amount of flatus expelled
  • Catheter cannot pass through esophagus to stomach
  • Stomach contents cannot be aspirated

  
• If aspirated stomach contents are acidic, the tube is in the stomach. If alkaline, the tube is in the lungs.