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Transcript
Encoporesis/Enuresis Diarrhea and Vomiting Encoporesis Involuntary Passage of Feces Primary Child NEVER achieved bowel control by 4 y/o Secondary Fecal Incontinence occurring after 4 y/o More in Boys than Girls Causes Constipation Stress Myelomeningocele CP Hypothyroidism Encoporesis Treatment Assessment History Doing a Dance Self-Esteem Diagnosis X-ray to r/o Hirschsprung’s Disease Congenital GI anomaly Hi-Fiber Diet Lubricants Behavior Therapy Anticipatory Guidance Normal Patterns Trx Regime Counseling Behavior Modification Enuresis Bedwetting 2x/week; for 3 mos.; at least 5 y/o Primary Never been dry Secondary Incontinent after have established continence Causes Sleep Theory Functional Bladder Capacity Nocturnal Polyuria Theory Assessment Urgency Diagnosis History and Physical Functional Bladder Capacity History of Toilet Training Enuresis--Treatment Conditioning Therapy Retention Control Training Waking Schedule Behavior Modification Therapy Drug Therapy Tricyclic antidepressants Anticholenergics Ditropan Desmopressin (DDAVP) Fluid Imbalance Specific to Peds Greater need for water More vulnerable to alterations in balance Don’t adjust quickly ECF > ICF at birth w/ greater relative content of extracellular Na & Cl Thus, more susceptible to dehydration and fluid overload Metabolic rate 2-3x > adults BSA > adults; neonate 5x greater Immature kidney function;↓ability to conc. or dilute urine Types of dehydration Isotonic – most common in peds H2O Loss = Electrolyte Loss Major loss from ECF→ ↓plasma volume → ↓circulating blood volume → ↓to skin, muscles, kidneys → hypovolemic SHOCK Plasma Na stays bet 137-147 mEq/L (nl) Level & Types of Dehydration Hypotonic = Na+ BELOW normal H2O Loss < Electrolyte Loss Hypertonic = Na+ ABOVE normal H2O Loss > Electrolyte Loss SEE HANDOUTS “A” & “B” See Tables 28-2 & 28-4 on p. 1056-60(9th ed.) Level/Degrees of Dehydration p. 1059 (9th ed.) Mild = Up to 5% of body weight lost Moderate = Between 5-9% of body weight lost Severe = 10-15% of body weight lost Fluid Imbalance Assessment Observation & history of recent symptoms Diarrhea, vomiting, fever, renal disease, medications, trauma, extensive surgery, extensive burns, ketoacidosis Take a good history: drugs, allergy, diet, travel, pet contact, contact w/others who have been sick, etc. Most Important → General Appearance & Behavior! Urinary output Mucus membranes Skin Turgor Infant fontanels Weight change Pale, cool dry skin ↑Pulse, ↑resp, ↓BP, cap refill >2sec → shock Nursing Assessment Degree, type of dehydration Identify causative agent Initial & ongoing evaluations of the following: Na and other electrolytes (K+), pH Weight Same scale, same clothes, same time of day For each 1% wt loss, 10 ml/kg fluids lost Changing sensorium; Response to stimuli Integumentary changes (elasticity & turgor) Heart rate (pulse - weak & rapid) Sunken eyes Sunken fontanels Any 2 of the 4: cap refill of >2 sec, absent tears, dry mucous membranes, ill appearance. Nursing Assessment (cont) Accurate I & O Measure ALL Output Emesis, void (weigh diapers), stool, NG suction drainage Specific Gravity Increase = Concentrated Urine Know Norms for frequency of voiding 1 y/o = every 1-2 hours Toddlers = every 3 hours Older children = 4 – 5 times/day during day Include parents in prescribed plan of care Diarrhea – Medical Management Oral Rehydrating Solutions (ORS) Rehydralyte, Pedialyte, Infalyte, WHO Mild Dehydration 50 ml/kg in 4 hours Moderate Dehydration 100 ml/kg in 4 hours Severe Dehydration IV’s (Ringer’s Lactate/NS) 40 ml/kg/hr until pulse and LOC are normal Then 50-100 ml/kg of ORS Oral Rehydration Therapy Recommended for mild to moderate dehydration Oral Rehydration Solution (ORS): 75-90 mMol Na+, 111139mMol glucose – Pedialyte RS, Rehydralyte for the 1st 4-6 hours. Then – 30-60 mMol Na+, 111-139mMol glucose – Pedialyte,Resol, Lytren, Infalyte – for the next 18-24hrs. @ 1-2 oz/# divided into freq. feedings; Older child: 1-2 oz q hr. It is no longer recommended to withhold food/fluids for 24º after onset of diarrhea or use the BRAT diet!!! Water Intoxication (water overload) Ingest excessive amts of fluids develop concurrent ↓ serum Na+ accompanied by CNS symptoms. CNS irritability, somnolence, HA, vomiting, diarrhea, gen. seizures, may have edema or be dehydrated but looks well hydrated. Causes: acute IV water overload, too rapid dialysis, tap water enemas, feeding incorrectly mixed formulas (diluted to make it last longer), excess water ingestion, too rapid reduction of glucose levels in diabetic ketoacidosis; those with CNS infections may retain excessive amts of H2O if administered hypotonic sol. rapid reduction in Na+H2O overload. Problem: ↓GFR is incapable of compensation to excrete the excesses fast enough, ADH levels are not able to compensate Gastrointestinal Disorders Diarrhea: ↑ in stool frequency and ↑ in water content. Varies by severity, duration, presence of blood or mucous, age of child, & nutritional status. Acute Diarrheal Disease: Leading cause of illness in children < 5yrs; 400 die ea yr; caused by infectious agents including viral, bacterial and parasitic pathogens. Results in dehydration, electrolyte imbalance, hypovolemic shock, & even death Acute Infectious Gastroenteritis 2nd only to URI as cause of childhood illness Self-limiting and benign Bacterial seen in summer and fall Viral (rotovirus) seen in winter After a URI Daycare setting Spread by person-to-person contact and oralfecal route Diarrhea---Causes Acute Table 29-1, p. 1091 Chronic Box 29-4 p.1093 Viral = Rotovirus Malabsorption Bacterial Shigella E-coli Salmonella C. difficile Vibrio cholerae Toxins (bad food) Overfeeding Systemic Infection Irritable Bowel Syndrome Lasts 3 weeks Allergic Reactions Immunodeficiencies Endocrine Parasites (Giardia) Motility disorders Hirschsprung’s Ds. Inflammatory Bowel Crohn’s disease Ulcerative Colitis Differential Diagnosis Sugar intolerance: watery, explosive stools Fat malabsorption: foul-smelling, greasy, bulky stools; stearrhea Enzyme deficiency/protein intolerance: develops after intro of cow’s milk, fruits, cereal Bacterial gastroenteritis/IBS: presence of neutrophils/RBC’s Protein intolerance/parasitic infection: presence of eosinophils Cultures: performed if blood or mucus is present, or Sx’s are severe, travel to developing country and polymorphonuclear leukocytes are found in stool. ELISA: used to confirm presence of rotavirus, Diarrhea—Differential Diagnosis Other Fever and abdominal cramps = Shigella Abrupt onset = Toxins, seen in Food Poisoning > 4 stools/day No vomiting prior to diarrhea onset Hx of antibiotic use: test stool for C. Difficle toxin. Persistent diarrhea: test for ova & parasites when bacterial, viral cultures are negative. Labs Stool Culture, Stool Exam (WBC’s, RBC’s, Fat content) Blood- ↑Hct, ↑BUN + Creatinine if ↓renal circulation, Acid/Base Balance; Electrolytes (NA+ and K+) Clinical Manifestations Labs: ↑Hct, ↑BUN + Creatinine if ↓renal circulation, Acid/Base Balance; Electrolytes Metabolic Acidosis Loss of Na+ and HCO3 in stool Impaired Renal Function ↑ Lactic Acid formation Ketosis from Catabolism Shock---in severe Cases Altered K+ levels, K+ lost is stool Body conserving Na+ and H+I in cells move K out Other Diarrheal Diseases Chronic Diarrheal Disease: caused by malabsorption syndromes, inflammatory bowel disease, immune deficiency, food allergy, lactose intolerance, etc. Chronic Nonspecific Diarrhea: irritable colon of childhood/toddler’s diarrhea; ages 654 mos; loose stools w/undigested food particles. Grows normally w/ no evidence of malnutrition Intractable Diarrhea of Infancy: occurs first few months of life, refractory to treatments. May need cont. tube feedings or parenteral nutrition. Can result in death. Vomiting Forceful ejection of gastric contents thru the mouth. CNS control. Accompanied by nausea and retching. Malrotation: chronic and intermittent episodes Bowel obstruction: green bilious Poor gastric emptying/high obstruction: curdled, mucus, fatty foods several hrs after ingestion GI bleeding: coffee ground appearance Associated symptoms: fever and diarrheainfection; constipationanatomic or functional obstruction; forcefulpyloric stenosis Localized abd. pain→ appendicitis, PUD, pancreatitis Headache and change in LOC→ CNS related Well recognized response to psychological stress; can be a learned behavioral response Assessments Vomiting Diagnosis Color, consistency, odor Amount Frequency Forcefulness Relationship to feeding History Allergy, Illness w/ or w/o diarrhea Child’s behavior in association with vomiting Routine labs Hct/Hgb CBC Electrolytes Na+, K+ BUN Creatinine TCO2 U/A Physical Assessment Vomiting Assess abdomen and hydration status, presence of pain, constipation, diarrhea, or jaundice. Assess relationship of vomiting to meals, specific foods or behavior When cause of vomiting determined then interventions are decided Sm, freq feeding of fluid or food preferable, position to prevent aspiration. Brush or rinse the mouth to remove HCl from the teeth, monitor fluids & electrolyte status Vomiting (cont’d) Complications: dehydration, electrolyte disturbances, malnutrition, aspiration, Mallory-Weiss sydrome Antiemetics: can be given if cause is known and vomiting is anticipated; Motion sickness dimenhydrinate (Dramamine) before a trip Generally vomiting is self limiting requiring no specific tx That’s It
