Chapter 28 Gastrointestinal Key Terms o Anasarca: Severe generalized edema o Anthelmintics: anti-worm medicine - VERMOX is a single dose chewable

e tablet and is the drug of choice for children over 2 yrs of age. o Colitis: inflammation of the colon o Colonoscopy: visualization of the entire colon to the ileocecal valve. o Currant jelly stools: movement of blood and mucus that contain no feces o Encorpresis: constipation with fecal soiling o Endoscopy: allows direct visualization of the GI tract through a flexible lighted tube. o Entercolitis: inflammation of the small bowel and colon o Guarding: tightening of the abdominal muscles or rigidity of the abdomen on palpation. o Herniorrhaphy: surgical repair of a surgery o Homeastasis: a uniform state o Hypertonic: lost more electrolytes than fluid o Hypotonic: more fluids lost than electrolytes o Incarcerated hernia: a hearnia that can not be put back into place with gentle pressure. o Isotonic: the patient has lost equal amounts of fluids and electrolytes o McBurney's point: characteristic tenderness in the right lower quadrant o Parenteral fluids: are those given by some other route besides the digestive tract o Peritoneal dialysis: "passing of a solute through a membrane" is a therapeutic measure in used in acute renal failure. o Pica: eating nonfood items o Plumbism: lead poisoning o Polyhydramnios: earliest sign of TEF occurs prenatally when this develops. o Projectile vomiting: occurs from pyloric stenosis o Pruritis: (itching) in the absence of allergy may indicate liver dysfunction. o Rebound tenderness: pressing the RLQ with rapid release of pressure causes severe pain. o Reflux: gastroesophageal reflux GER results when the lower sphincter is relaxed or not competent, which allows stomach contents to be easily regurgitated into the esophagus. o Sigmoidoscopy: inspection of the lower colon. o Stenosis: narrowing such as an obstruction at the lower end of the stomach (pylorus) Function of GI tract 647 o Transports & metabolizes nutrients necessary for the life of the cell o Nutrients broken down into absorbable products by enzymes from various digestive organs Imperforate anus: how do you identify 649 o When the tissue of the lower end of the GI tract & anus do not perforate forming blind pouches What is pyloric stenosis, signs & symptoms, how is it corrected 650 o Obstruction at lower end of the stomach (pylorus) caused by an overgrowth (hypertrophy) of circular muscles of the pylorus or by spasms of the spinchter o Classified as a congenital anomaly o S&S Projectile vomiting, occurs immediately after eating Vomitus contains mucus & ingested milk Infant constantly hungry & will eat again immediately after vomiting Dehydration evidenced by sunken fontanelle, inelastic skin, decreased urination o Pyloromyotomy surgery is Tx
1

o Infant is burped before as well as during feedings to remove any gas accumulated in stomach o baby positioned on right side to allow weight of the feeding to stay in the stomach against the pyloric valve Meconium ileus, what is it, what disease process is it associated with, why does it occur 603 o When the intestine of the newborn becomes obstructed w/abnormally thick meconium while in utero o Caused by absence of pancreatic enzymes that normally digest proteins in the meconium o Leads to suspicion of intestinal obstruction What is celiac disease, what are the manifestations, what do you do for it 650 o Aka gluten enteropathy & sprue leading malabsorption problem in children o Symptoms not evident until 6 mos-2 yrs, when foods containing gluten are introduced to infant o Infant presents with failure to thrive o Stools are large, bulky, & frothy b/c of undigested contents o Infant is irritable o Characteristic is abdominal distention w/atrophy of the buttocks o Tx involves lifelong diet restricted in wheat, barley, oats, & rye Hirschsprungs disease (Aganglionic Megacolon): what is it, manifestations, treatment 652 o Occurs when there is an absence of ganglionic innervation to the muscle of a segment of the bowel o Usu happens in the lower portion of the sigmoid colon o Results in chronic constipation o Ribbonlike stools seen as a result of feces passing thru the narrow segment o Portion of the bowel nearest the obstruction dilates, causing abdominal distention o Manifestations Newborn failure to pass meconium stools w/in 24-48hrs may be indicative Infant constipation, ribbonlike stools, abdominal distention, anorexia, vomiting, & failure to thrive may be evident o Tx by surgery impaired part removed & anastomosis is performed o In newborns a temporary colostomy may be necessary What is a hernia 654 o Inguinal protrusion of part of the abdominal contents thru the inguinal canal in the groin o Umbilical protrusion of a portion of intestine thru the umbilical ring o Reducible if it can be put back into place by gentle pressure o Irreducible (incarcerated) if it can not be put back into place by gentle pressure o Strangulated the intestine becomes caught in the passage & the blood supply is diminished Definition, causes, & complications of gastroenteritis 655 o Def inflammation of the stomach & intestines o Colitis involves inflammation of the colon o Enterocolitis involves inflammation of the colon & small intestine o Most common causes of diarrhea involve food intolerance, overfeeding, improper formula prep, or ingestion of high amounts of sorbitol o Priority problem in diarrhea is fluid & electrolyte imbalance & failure to thrive o Priority goal includes preventing fluid & electrolyte imbalance
2

o ORS (Oral Rehydrating Solutions) such as Pedialyte, Lytren, Ricelyte, & Resol are used for infants in small, frequent feedings. o Nursing care includes: Maintain I&O records Providing skin care Provide frequent diaper changes to prevent excoriation from frequent stools What happens with gastroesophageal reflux, manifestations, major complications, treatments 656 o Results when the lower esophageal sphincter is relaxed or not competent, which allows stomach contents to be easily regurgitated into the esophagus o Associated w/neuromuscular delay & is often seen in preterm infants & children w/neuromuscular disorders, such as cerebral palsy & Down syndrome o Symptoms include: Vomiting Weight loss Failure to thrive o Resp. problems can occur when vomiting stimulates closure of the epiglottis & the infant presents w/apnea o Tx

Feed infant no more than age in months + 3, q 3-4hrs (3 mon old gets 6oz max in 1 feeding) medication & surgical intervention may be required in infants w/complicated GERD burp infants frequently upright prone position has been recommended for the infant w/GER when awake & monitored meds that relax pyloric spinchter & promote stomach emptying may be used (Reglanbefore meals) Types of diarrhea and what can cause them, complications, treatments 657 o Acute sudden often caused by an inflammation, infection, or a response to medication, food, or poisoning o Chronic lasts for more than 2 wks & may be indicative of a malabsorption problem, long-term inflammatory disease, or allergic responses o Infectious caused by viral, bacterial, or parasitic infection & usu involves gastroenteritis In infants it is commonly caused by the rotavirus that often occurs in day care centers; by E. coli, which is caused by lack of hygiene or poorly cooked foods; Salmonella; or Shigella o Green, watery stools may indicate diarrhea in infants o Symptoms range from mild to extreme Stools are watery and expelled with force (explosive) May be yellowish green Infant becomes listless, refuses to eat, and loses weight Temperature may be elevated and infant may vomit Dehydration evidenced by sunken eyes and fontanelle, dry skin, tongue, and mucous membranes Urination is less frequent
3

 o Tx:

In severe cases, the excessive loss of bicarbonate from the GI tract results in acidosis

Intestine is rested by reducing intake of solid foods ORS solutions in liquid or frozen form are preferred Avoid clear fluids, fruit juice w/out pulp, gelatin, carbonated drinks low electrolyte content Avoid BRAT diet not nutritionally sound enough to support growth & development Why does dehydration occur more readily in infants & children 659 o Infants & small children have different proportions of body water & body fat than adults do, & the water needs & water losses of the infant (per unit of body weight) are greater o Surface area is important in fluid & electrolyte balance b/c more water is lost thru the skin than the kidneys o An infants body surface in comparison w/weight is 3x that of the older child; therefore, the infant is subject to greater evaporation of water from the skin o Fluid turnover is rapid, and dehydration occurs more quickly in infants than in adults o Ave daily excretion of urine 1-2ml/kg Know examples of each type of failure to thrive: physical, & non-organic, treatment is going to be based on cause, dont need to know all of them, but know some of the classic manifestations 664 o Types: Physical (organic) OFTT congenital heart disease malabsorption syndromes Nonorganic lack of parent-infant interaction that can result from environmental factors, neglect, or lack of information concerning the nutritional needs of infant o Manifestations: There may be a disturbance in mother-child or caregiver-child relationship Presence of alcohol & drugs Many mothers feel deprived & unloved & have conflicting needs Infants suffer from the inability to establish a sense of trust in their caregivers Coping abilities affected by a lack of nurturing Obvious neglect & physical abuse are not uncommon Presents with weight loss, irritability, disturbances of food intake, vomiting, diarrhea, and general neuromuscular spasticity sometimes accompany the condition Assign same nursing staff to care for child may increase nurturing & interaction w/infant and parent o Treatment: Involves a multidisciplinary approach in accordance w/circumstances If no progress, temp or permanent placement of child(ren) in a foster home may be required Maternal attachment can be facilitated by listening & helping the mother to understand her feelings & frustrations & to explore her choices o some have a rag doll limpness (hypotonia), & often appear wary of caregivers
4

o others appear stiff & unresponsive to cuddling Appendicitis: characteristics, diagnostic testing, treatment, complications if treatment not given 665 o Characteristics: Lumen may become obstructed w/fecal matter or lymphoid tissue after a viral illness or w/parasites There is stasis, increased swelling, edema, & growth of organisms Usu pain perceived is periumbilical & increases w/in a 4hr period When inflammation spreads to peritoneum, the pain localizes in the RLQ of the abdomen o Diagnostic testing & Symptoms McBurneys point rebound tenderness Guarding Pain on lifting thigh while in supine position is caused by muscle irritation Pain in RLQ when palpated & pain on rectal examination often occurs Urinalysis will rule out other a UTI Ultrasound will show a thickened appendix & a soft tissue mass in the RLQ CT w/CTRC is administered via rectum to confirm enlarged appendix Labwork cking increased WBC o Treatment: Surgical intervention typically required Pain management Prevention of infection o Complications: It may become gangrenous or rupture, causing peritonitis & septicemia rupture or perforation can occur w/serious complications w/in 36hrs after onset of abdominal pain Thrush, how to identify, what causes, other disease processes that may be present, how do you treat 666 o Infection of mucous membranes of mouth caused by Candida o White patches resembling milk curds on tongue, inner lips, gums, & oral mucosa o Altered conditions in the vagina produced by pregnancy may lead to development of monilial vaginitis o Mucous membranes of infants mouth may become infected by direct contact w/infection during delivery or by contact w/mothers or nurses contaminated hands o Other disease processes: Can cause inflammation of the esophagus & the stomach Pneumonitis may also develop o Treatments: Responds well to local application of antifungal suspension (Nystatin) Newborns cared for using isolation (standard) precautions Individual sterile feeding equipment is necessary Use disposable bottles, prefilled formula bottles, disposable nipples, & pacifiers Pinworms, What is scotch tape test, name of category of medication used to treat 667

o Diagnostic tape, paddle, or tongue blade covered w/cellophane tape, sticky side out, may be placed against the anl region to obtain pinworm eggs done early in am before child has BM, bathes, or scratches anal area o Med Anthelmintics ie. Mebendazole (Vermox) single-dose, chewable tablet, drug of choice for children >2yrs Pyrantel pamoate (Antiminth) also controls infestation Pyrvinium pamoate (Povan) suspension, 1 dose treatment; stains & turns stool red Methods used to prevent poisonings 667-668 o Remove the poison o Keep all medications, prescription or otherwise, including herbal supplements out of reach of small children o Prevent further absorption o Call the poison control center o Provide supportive careseek medical help Symptoms of lead poisoning, how does infant/child usually get poisoned, what do you use to treat 669 o Results when a child repeatedly ingests or absorbs substances containing lead o The primary source of lead is paint from old, deteriorating buildings o Children who chew on window sills and stair rails ingest flakes of paint, putty, or crumbled plaster o Symptoms occur gradually Beginning stages, signs may be weakness, weight loss, anorexia, pallor, irritability, vomiting, abdominal pain, and constipation Later stages, signs may be anemia and nervous system involvement Can have a lasting effect on the CNS, especially the brain Mental retardation occurs in severe cases of lead poisoning Lead settles in soft tissues and bones Is excreted in urine o Treatment is aimed at reducing concentration of lead in blood Chelating agents are given -- May be taken several months

Chaper 31 -- Child w/a Metabolic Condition Key Terms o Antidiuretic hormone: lack results in uncontrolled diuresis o Dawn phenomenon: early morning elevations of blood glucose occur without preceding hypoglycemia and may be a response to growth hormone secretion that occurs in the early morning hours. o Gestational diabetes mellitus (GDM): is the appearance of symptoms for the first time during pregnancy o Glucagon: is recommended for the treatment of severe hypoglycemia o Glycosuria: glucose in hunger o Glycosylated hemoglobin test (HgbA1c): reflects glycemic levels over a period of months. o Hormones: chemical substances produced by glands. o Hyperglycemia: excessive glucose in blood o Hypoglycemia: low blood sugar
6

o o o o o o o

Hypotonia: decrease in normal muscle tension. Ketoacidosis: also referred to as a diabetic coma Lipoatrophy: loss of fat at insulin injection site Polydipdia: excessive thirtst Polyphasia: constant hunger Polyuria: excessive urination Somogyi phenomenon: (rebound hyperglycemia) occurs when blood glucose levels are lowered to a point at which a body's counterregulatory hormones (epinephrine, cortisol, glucagon)are released. o Target organ: an organ specifically influenced by a certain hormone. o Vasopressin: the antidiuretic hormone. Methods of early detection - 710 o clinical signs or screening tests that can be performed in utero o Lethargy, poor feeding, failure to thrive, vomiting, and an enlarged liver may be early signs of an inborn error of metabolism in the newborn o If clinical signs are not manifested in the neonatal period, an infection or body stress can precipitate symptoms of a latent defect in the older child o Unexplained mental retardation, developmental delay, convulsions, an odor to the body or urine, or episodes of vomiting may be subtle signs of a metabolic dysfunction Primary responsibilities of endocrine system (ductless) 709 o Regulate the bodys metabolic processes o Primarily responsible for growth, maturation, reproduction, & the response of the body to stress What is a target organ 709 - an organ specifically influenced by a certain hormone. Tay-Sachs disease, metabolic disease affecting digestion of what and ultimately causing problems where 710 o Affects digestion of lipids o Deposits occur on optic nerve, blindness may result o Mental retardation eventually develops b/c brain cells become damaged o Can be passed on from either parent Manifestations of hypothyroidism, is it reversible and what is the treatment, signs of hypo vs hyperthyroidism 711 o An infant is very sluggish and sleeps a lot o Tongue becomes enlarged, causing noisy respiration o Skin is dry, no perspiration o Hands and feet are cold o Infant feels floppy when handled o Chronic constipation o Hair eventually becomes dry and brittle o If left untreated, irreversible mental retardation and physical disabilities result o Treatment involves: administration of synthetic thyroid hormone given at same time each day, preferably in the morning. Do not change brands Serum hormone levels are monitored regularly
7

Therapy reverses symptoms and, in the infant, prevents further mental retardation but does not reverse existing retardation o Signs of Hypo Fatigue Sleepiness Constipation o Signs of Hyper Rapid pulse rate Dyspnea Irritability Weight loss Sweating Differences between Diabetes type I, II, pregnancy induced, causes, treatment, prognosis Triad of symptoms associated with diabetes mellitus 713 o Type I Destruction of beta cells in pancreas results in lack of insulin production Formerly known as insulin-dependent (IDDM) or juvenile-onset DM characterized by an absolute or complete deficiency of insulin. Can occur at anytime in childhood, new cases highest among Symptoms: Insidious onset with lethargy, weakness, and weight loss is also common Skin becomes dry Vaginal yeast infections may be seen in the adolescent girl Glucose in urine (glycosuria) Treatment Ensure normal growth and development through metabolic control Enable child to cope with a chronic illness, have a happy and active childhood and be well integrated into the family Prevent complications through tight blood glucose control o Type II Involves insulin resistance Formerly known as non-insulin-dependent (NIDDM) or adult-onset DM Associated with obesity and elevated blood lipids o GD Transient form of DM that is triggered by pregnancy Resolves after delivery but may reoccur several years later o Triad of Symptoms -- Polydipsia, Polyuria, Polyphagia Differences between types of glucose testing 714 o Random blood glucose Blood is drawn at any time, no preparation; results should be within normal limits for both diabetic and non-diabetic patients o Fasting blood glucose
8

If greater than 126 mg/dl on two separate occasions, and the history is positive, patient is considered as having DM and requires treatment o Continuous Glucose Measures levels w/in the interstitial tissues & reveals trends in glucose levels o Glucose tolerance test Blood glucose level above 200 mg/dl is considered positive o Glycosylated hemoglobin (HbA1c) Values of 6% to 9% represent very good metabolic control Values above 12% indicate poor control What is ketoacidosis caused by 715 o It is the end result of the effects of insulin deficiency o May result if a pt w/diabetes contracts a secondary infection & does not follow proper self-care o May also occur if the disease proceeds unrecognized When discussing diabetic nutrition/treatment with the family what is the triad of diabetes management o Well-balanced diet o Precise insulin administration o Regular exercise Glucose self-monitoring, good locations, safety practices, eg, wash hands, examine site for signs of infection, sides of fingers that are chosen b/c there are fewer nerve endings & more capillary beds 716 o Best fingers to use are the middle, ring, & little fingers on each hand o Sites of injections are rotated to prevent poor absorption and injury to tissue o Should not inject into areas that would have a temporarily increased circulation, such as in a child pedaling a bike, you would not inject into the leg o Lipoatrophy can occur if sites are not rotated o Insulin cannot be taken orally because it is a protein and would be broken down by the gastric juices What layer of skin is insulin administered, which do you draw up first if you have to give both Regular and NPH insulin, complication of too much insulin, why are children more susceptible to complications with diabetes and insulin administration, signs & symptoms of insulin overdose or hypo/hyperglycemia o Subcutaneous injections o When mixing always draw Regular insulin 1st then add long-acting (NPH No Particular Hurry) o Complications o Symptoms of insulin reaction Irritable May behave poorly Pale May complain of feeling hungry and weak Sweating occurs CNS symptoms arise because glucose is vital to proper functioning of nerves o Child more susceptible: Growth is not steady Occurs in spurts and plateaus that affect treatment Infants and toddlers may have hydration problems
9

Preschool children have irregular activity and eating patterns School-age children may grieve over the diagnosis May use illness to gain attention or to avoid responsibilities Onset of puberty may require insulin adjustments Adolescents often resent this condition and may have more difficulty in resolving conflict between dependence and independence; may lead to rebellion against parents and treatment regimen

Chapter 32 Communicable diseases Key terms o Acquired immunity: gained as a result of having the disease or is artificially acquired by receiving vaccines or immune serums. o Active immunity: when the person produces his or her own immunity o Body substance: refers to moist secretions or parts of the body that can contain microorganisms o Communicable disease: the one that can be transmitted, directly or indirectly, from 1 person to another o Endemic: refers to a continuous incidence of a communicable disease expected in a localized area o Epidemic: a sudden increase of a communicable disease in a localized area o Erythema: diffused reddened area on the skin o Fomite: any inanimate material that absorbs and transmits infection o Health care-associated infection: an infection acquired in a health care facility during hospitalization o Incubation period: the time between the invasion by the pathogen and the onset of clinical symptoms o Macule: circular reddened are on the skin o Natural immunity: resistance is inborn o Nosocomial Infection: o Opportunistic infections: caused by organisms normally found in the environment that the immune-suppressed individual cannot resist or fight). o Pandemic: worldwide high incidence of a communicable disease o Papule: circular reddened area on the skin that is elevated o Passive immunity: provides the antibody. It does not stimulate the system to produce its own antibodies. o Pathogens: organisms that cause disease o Pathognomonic: term used to describe a lesion or symptom that is characteristic of a specific illness o Portal of entry: a route by which the organisms enter the body (e.g., a cut in the skin). o Portal of exit: the route by which the organisms exit the body (e.g., feces or urine) o Prodromal period: refers to the intial stage of a disease: the interval between the earliest symptoms and the appearance of a typical rash or fever o Pustule: circular reddened area on the skin that is elevated and contains pus o Reservoir for infection: a place that supports the growth of organisms (e.g., standing, stagnant water.
10

o Scab: dried pustule that is covered w/ a crust o Standard precautions: specific precautions the nurse must understand in order to pretect him/her self and others from a contagious patient o Transmission-based precautions: are designed according to the method of spread of infection, such as airborne infection isolation, contact, and droplet o Vector: an insect or animal that carries and spreads a disease o Vesicle: circular reddened are on the skin that is elevated and contains fluid Terms at beginning of presentation Methods of transmission direct or indirect - 732 o Directtransmitted by contact with an infected person o Indirecttransmitted by contact with objects that have been contaminated by an infected person (fomites) Ie bedrails, IV pumps, overbed tables, door handles, used tissues, countertops, & toys RSV lives on bar of soap for several hrs Best method to prevent spread of infection o Aseptic techniqueused with all patients o Standard precautionsinvolve hand hygiene and use of disposable gloves to protect nurses and others from contamination o Transmission based precautionsdesigned according to the method of spread for a specific organism Contact isolation is used for what type of infections, how is it spread, what precautions do you use o When contamination is likely to occur skin to skin or through contact with a contaminated fomite o Used in conditions such as RSV, MRSA, or VRE infections o Disposable gloves & gowns should be worn in the event that something occurs which causes blood or body fluid exposure Difference between: - 733 o Airborne - airborne particles floating in air can be inhaled any place in the room Used for pts w/conditions such as TB, varicella (chicken pox), rubella (measles) Use of negative pressure rms & N95 masks required upon entering room Particles can remain airborne for several hours o Droplet pt coughs or sneezes, droplets can contaminate area 3 around the pt Used w/diseases such as pertussis & influenza PPE should be worn Droplets do not stay suspended in the air, they immediately fall What is protective isolation and what type of patients would use? - 733 o Used for patients who are not communicable but have high susceptibility to infection, such as a neutropenic patient o NOTE: If a disease has more than one mode of transmission, then more than one precaution technique is used o Definitions of types of rashes - 734 o Erythemadiffuse and reddened o Maculecircular reddened area
11

Papulecircular reddened area that is elevated Vesiclecircular reddened area that is elevated and contains fluid Pustulecircular reddened area that is elevated and contains pus Scabdried pustule that is covered with a crust Pathognomonicterm used to describe a lesion or symptom that is characteristic of a specific illness Differences between: - 734 o Vaccine A suspension of weakened or inactivated (killed) organisms that stimulate immune bodies to form Used to prevent disease, cannot be used to treat disease A form of active immunity Routine vaccinations are not started until 2 mos old, unless high risk of infection exists o Toxoid A modified toxin that stimulates the production of antitoxin A form of active immunity o Immunoglobulin A solution containing antibodies extracted from human blood Shortest acting Provides passive immunity o Types of Immunity They are Natural or Acquired resistance to infection Natural - Resistance is inborn Acquired Not the result of inherited factors but is gained as a result of having the disease or is artificially acquired by receiving vaccines or immune serums Active Person produces his/her own immunity Passive acts immediately but does not last as long as immunity actively produced by the body provides the antibody HIV- methods of contracting, nursing goals, education related to aids o Children usually contract HIV by Contact with infected mother at birth Sexual contact with infected person Contact with infected needles or blood o Nursing Goals Low the growth of the virus Prevent opportunistic infections Provide adequate nutrition Provide supportive therapy Education related to importance of continued drug therapy o Education r/t AIDS Methods of transmission Hazards of IV and illicit drug use o o o o o
12

Safe sex practices Standard precautions when caring for all patients Healthy People 2020 Providing Worldwide immunizations

13