Dehydration Management and Symptoms Quiz

Child and Adolescent Health Nursing/Theory

• Course: HNR 3123
• Chapter: 22 - Health Problems of the Gastrointestinal System
• Date: July 4, 2024

Learning Objectives

• CLO3: Describe child health conditions, focusing on etiology, clinical presentation, psychosocial/behavioral manifestations, progression, medical management, and associated issues.
• CLO4: Recommend nursing management and support strategies for parents of children with various health issues.

Learning Outcomes

• Identify gastrointestinal system health problems.
• Describe pathophysiology, diagnostic evaluation, and therapeutic management for each gastrointestinal problem.
• Apply nursing management strategies for each gastrointestinal problem.

Distribution of Body Fluids (1 of 5)

• Total body water (TBW) includes intracellular fluid (ICF) and extracellular fluid (ECF).
• Water comprises the majority of body tissues.
• TBW in newborns is typically 75% of total body weight, decreasing to 45% in late adolescence.

Distribution of Body Fluids (2 of 5)

• In newborns, approximately 50% of body fluids are within the extracellular fluid compartment.
• In toddlers, approximately 30% of body fluids are in the extracellular fluid compartment.
• Fluid intake and output are generally equal under normal conditions.
• Maintenance fluid requirements account for obligatory losses (insensible water loss, evaporative water loss, urinary and stool losses).
• Disease conditions (e.g., fever, diarrhea, gastric suction) can alter fluid losses.

Distribution of Body Fluids (3 of 5)

• Increased fluid needs are observed in several situations:
  • Fever (12% increase per 1°C rise)
  • Vomiting
  • Diarrhea
  • High-output kidney failure
  • Diabetic ketoacidosis
  • Burns
  • Shock
• Conditions associated with decreased fluid needs include:
  • Heart failure
  • Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
  • Mechanical ventilation
  • Post-surgery
  • Oliguric renal failure
  • Increased intracranial pressure

Distribution of Body Fluids (4 of 5)

• Basal fluid requirements are calculated based on normometabolism at rest.
• Fluid needs are adjusted according to observed changes in water losses.

Distribution of Body Fluids (5 of 5)

• Fluid requirements must be calculated using body weight and age-specific factors in normometabolism.

Dehydration (1 of 2)

• Types of dehydration (isotonic, hypotonic, hypertonic).
• Degrees of dehydration.
• Diagnostic evaluation.
• Therapeutic management.
• Parenteral fluid therapy.
• Nursing considerations.

Dehydration (2 of 2)

• Causes of dehydration:
  • Impaired oral intake.
  • Abnormal losses (vomiting, diarrhea, diabetic ketoacidosis, extensive burns).

Types of Dehydration (1 of 3)

• Isotonic dehydration: Equal loss of water and electrolytes.
• Hypotonic dehydration: Electrolyte loss exceeds water loss.
• Hypertonic dehydration: Water loss exceeds electrolyte loss.

Types of Dehydration (2 of 3)

• Hypertonic dehydration results primarily from water loss (excessive water loss or increased electrolyte intake), leading to fluid shifts towards the extracellular space.
• Symptoms can include severe neurologic symptoms like seizures.

Types of Dehydration (3 of 3)

• Hypertonic dehydration can manifest with neurological changes: disturbances of consciousness, difficulty concentrating, lethargy, heightened muscle tone with hyperreflexia, and hypersensitivity to stimuli.
• Table 22-4 provides clinical manifestations related to dehydration types (isotonic, hypotonic, hypertonic).

Daily Maintenance Fluid Requirements (1 of 2)

• Table 22-1 outlines daily fluid requirements for children of various weights.

Daily Maintenance Fluid Requirements (2 of 2)

• Calculations for fluid needs include body weight, specific age-dependent parameters, and potential losses based on the various conditions presented in the previous slide sets.

Example 1/2 of Daily Fluid Calculation

• Shows calculations of fluid needs based on different body weights and the application of formulas.

Clinical Manifestations of GI Dysfunction

• Impaired functional integrity (failure to thrive).
• Oral/GI losses (spitting up, regurgitation, constipation).
• Excessive loss of fluid (nausea, vomiting, diarrhea, absorption disorders).
• GI tract anomalies (infectious disease, inflammatory conditions such as Crohn's disease, liver failure, fever).

Gastrointestinal (GI) Dysfunctions

• Diarrhea
• Hirschsprung Disease
• Cleft lip and palate
• Esophageal atresia and tracheoesophageal fistula (TEF)
• Anorectal malformations
• Celiac Disease

Diarrhea (1 of 2)

• Diarrhea is a symptom resulting from digestive, absorptive, and secretory issues in the gastrointestinal tract.
• It's often caused by abnormal intestinal water and electrolyte transport.
• Worldwide, there are an estimated 1.7 billion episodes of diarrhea annually.

Diarrhea (2 of 2)

• Diarrhea incidence is higher in lower-income countries and among children less than 5 years old.
• Different forms affect either the stomach and intestines, small intestine, colon or both.

Acute Diarrhea (1 of 3)

• Acute diarrhea is quickly apparent (often due to infectious agents), frequently accompanied by other symptoms (URTI, UTI, antibiotic therapy, or laxative use).
• Viral, bacterial, or parasitic pathogens can initiate acute infectious diarrhea.
• Rotavirus, calicivirus, Escherichia coli, and Salmonella are among the common culprits.

Chronic Diarrhea (2 of 3)

• Chronic diarrhea lasts for longer than 14 days and involves malabsorption, inflammatory bowel disease (IBD), immunodeficiency, food allergies, lactose intolerance, or chronic nonspecific diarrhea (CNSD).
• Occurs as a result of inadequate management of acute diarrhea.

Intractable Diarrhea (3 of 3)

• Intractable diarrhea in infants typically persists for more than 2 weeks and lacks an easily recognizable cause, often stemming from untreated acute infectious diarrhea.

Diarrhea Etiology

• Most diarrhea-causing pathogens are spread through the fecal-oral route.
• Infants experience higher susceptibility to frequent and severe diarrhea than older children because of their immature immune systems and limited exposure to pathogens.
• Rotavirus is a prominent cause of severe gastroenteritis in children.

Diarrhea Diagnostic Evaluation (1 of 2)

• History taking is critical for establishing the cause, severity, and potential complications of diarrhea.
• Questions about recent travel, exposure to contaminated water sources, contacts with animals/birds, daycare attendance, and antibiotic/diet changes are essential.
• Additional symptoms should be noted (fever, vomiting, stool type (watery, bloody), urine output).

Diarrhea Diagnostic Evaluation (2 of 2)

• Stool cultures are recommended when blood, mucus, or leukocytes are evident, or symptoms are severe.
• CBC, serum electrolytes, and creatinine/BUN levels are important indicators in severe cases, especially for children who need hospitalization.

Therapeutic Management of Diarrhea

• Major goals include assessing fluid and electrolyte imbalances, rehydrating, providing maintenance fluid therapy, and, once possible, introducing an adequate diet.

Oral Rehydration Therapy (ORT)

• Effectively restores water and electrolyte balance, enhancing the reabsorption.
• Use alone or with breastfeeding/formula.
• Administer in small, frequent doses (1:1 replacement ratio).
• Give orally or via nasogastric tube.

Prevention of Diarrhea

• Teach hand hygiene.
• Ensure clean and safe water supply.
• Prepare food properly and safely.

Hirschsprung's Disease (1 of 2)

• Congenital aganglionic megacolon.
• Intestinal obstruction from insufficient motility.
• Higher incidence in males.
• Associated with Down syndrome.

Hirschsprung Disease (2 of 2)

• Diagnosis involves X-ray, barium enema, anorectal manometry, and rectal biopsy.
• Clinical manifestations include accumulation of stools, failure of the internal anal sphincter for relaxation, and enterocolitis symptoms.
• Clinical characteristic displays based on age groups (newborn, infancy, childhood)
• Infants may fail to pass meconium, have vomiting and refusal to feed
• Infants may have distended abdomen and explosive, watery diarrhea
• Children will experience constipation, foul-smelling ribbon-like stools, and symptoms of distention

Therapeutic Management of Hirschsprung Disease

• Surgical management is typically required.
  • Preoperative and postoperative care.
  • Two-stage procedure (temporary ostomy, pull-through).

Cleft Lip and Cleft Palate (1 of 4)

• Embryonic developmental defects.
• Separate aspects or together.
• Etiology and pathophysiology.
• Diagnostic Evaluation.
• Therapeutic management.

Cleft Lip and Cleft Palate (2 of 4)

• Multifactorial inheritance: combination of genetic and environmental factors.
• Unknown genes responsible for clefting.
• Environmental factors impacting development.
• Teratogens (alcohol, cigarettes, anticonvulsants, steroids, retinoids) are associated with higher cleft rates.
• Folate deficiency is also a risk factor

Cleft Lip and Cleft Palate (3 of 4)

• Pathophysiology involves defects in cell migration during embryonic development weeks 4-10 (or later) leading to incomplete fusion of facial structures that will form the lip/palate
• Stages in development
• The process involves both upper lip/alveolus (primary palate) and hard and soft palate (secondary palate) fusion.

Cleft Lip and Cleft Palate (4 of 4)

• Diagnostic evaluation involves assessment of the mouth and palate appearance.
• Prenatal diagnosis through ultrasound is limited.
• Diagnosis usually occurs shortly after birth.

Surgical Correction of Cleft Lip (1 of 4)

• Lip repair precedes palate repair.
• Z-plasty aims to minimize scar retraction.
• Typically performed around 12 to 18 months of age.
• Significant effect on speech development.
• Nursing considerations for preoperative, postoperative, feeding and pain management.

Surgical Correction of Cleft Lip (2 of 4)

• Multidisciplinary team approach (Pediatrics, plastic surgery, orthodontics, otolaryngology, speech/language pathology, audiology, nursing, social work).
• Management is geared towards closure, prevention of complications, and facilitating normal growth and development.

Surgical Correction of Cleft Lip (3 of 4)

• Common procedures: Fisher and Millard techniques
• When assessing for closure of cleft lip , it is likely to be done within 2-3 months of age

Surgical Correction of Cleft Lip (4 of 4)

• Prognosis involves speech therapy and addressing the risk of ear infections, conductive hearing loss, significant orthodontics, prosthodontics, and monitoring of academic performance and behavior.

Feeding Issues (1 of 1)

• Special needs feeders and pigeon bottles with one-way valves aid infants with clefting for successful feeding.
• Valves ensure liquid flows into the oral cavity when the nipple is compressed, avoiding backflow into the feeder.

Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF) (1 of 2)

• Failure of the esophagus to form a continuous passage independent of the trachea.
• Often occurs separately or in combination.
• Etiology, pathophysiology, diagnostic evaluation, therapeutic management, nursing implications, postoperative care considerations.

Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF) (2 of 2)

• Radiopaque catheters are used in diagnostic evaluations.
• Chest X-rays assess the presence of blind pouches and connections between esophagus/trachea.
• An inability to visualize air in the stomach often indicates an incomplete connection to the esophagus, making the presence of the fistula harder to verify.

Therapeutic Management TA and TEF (1 of 2)

• Maintain a patent airway, prevent pneumonia, decompress any existing gastric pouches, and perform surgery as needed for the anomaly.
• If needed, infants are immediately deprived of oral intake, placed on IV fluids and positioned to improve secretions and make aspiration less of a risk.
• Use a double-lumen catheter to facilitate removal of fluids, ideally using intermittent suction.

Therapeutic Management TA and TEF (2 of 2):

• If appropriate, a gastrostomy may be a necessary procedure if an esophageal anastomosis cannot be performed.
• Surgical repair typically involves a thoracotomy, ligating the TEF, an end-to-end or end-to-side anastomosis, and, if needed, placing chest tubes to clear fluids and air.
• Complications (e.g., tracheomalacia) may result from the weakness of the tracheal wall.
• Post-operative care often includes monitoring for complications.

TA and TEF Nursing Care Management

• Nursing responsibilities begin immediately after birth, focusing on identifying classic signs and symptoms.
• Ensuring airway patency, preventing further respiratory compromise, and addressing cyanoses.

TA and TEF Prognosis (1 of 2)

• Survival rate is high (near 100%) among otherwise healthy children.
• Infant mortality is frequently linked to extreme prematurity or associated anomalies.

TA and TEF Prognosis (2 of 2)

• Post-operative complications include anastomotic leaks, strictures, motility disorders (dysphagia, GERD), and respiratory distress.
• Routine esophageal dilations are often necessary to treat strictures.
• Careful ongoing monitoring of weight gain, growth, and long-term development.
• The use of gastrostomy/jejunostomy to facilitate provision of adequate caloric content.

Anorectal Malformations

• Defects affecting the rectum, anus, and surrounding areas.
• Diagnostic evaluation focuses on physical findings (absent anal opening, abdominal distention, vomiting, absence of meconium passage, meconium in urine, flat perineum, absence of intergluteal groove).
• The types of anomalies range from those with complete absence of an opening to more complex abnormalities.
• Depending on the type of anomaly, various management strategies may be needed.

Anorectal Malformations Therapeutic Management

• Initial management focuses on stabilization.
• The infant is placed on nothing per-oral, with intravenous fluids to maintain hydration and electrolytes.
• A delay in surgical intervention (at least 24 hours) is advised for better evaluation to identify fistulas and other anomalies.

Anorectal Malformations Types, Treatment & Considerations:

• Variety of anomalies (rectal atresia, rectal stenosis, persistent cloaca, imperforate anus [with/without fistula])
• Surgical approach is tailored to the specific anomaly.
• Pre-operative stabilization, postponement of surgery for 24 hours (to properly assess), and the possible need for colostomy are crucial parts of the management strategy.

Celiac Disease

• Gluten intolerance causing damage to the small intestine.
• Four primary characteristics: steatorrhea, malnutrition, abdominal distention, and secondary vitamin deficiencies.

Celiac Disease Pathophysiology

• Gluten intolerance triggers immune responses involving T cells, antibodies, and complement activation.

Celiac Disease Diagnostic Evaluation

• Tissue transglutaminase and antiendomysial antibodies tests determine the presence of celiac disease, followed by upper endoscopy with biopsy.
• Biopsy identifies mucosal inflammation, crypt hyperplasia, and villous atrophy.
• Important to ensure the patient isn't initially removing gluten and proper diet considerations.

Celiac Disease Therapeutic Management

• Dietary management involves a "gluten-free" diet, effectively removing gluten.
• Four foods that are commonly excluded include wheat, barley and rye.
• Corn, rice, and millet are typically used as substitutes.

Celiac Disease Prognosis

• Celiac disease is considered a chronic disease.
• Its severity varies among children; early childhood and adult life are typically when symptoms peak.
• Successful dietary management frequently leads to a normal, symptom-free life.
• Regular check-ups and routine evaluations are advised in management of this chronic condition.

Celiac Disease Psychosocial/Behavioral Manifestations

• Child anxiety and depression.
• Aggressive behavior.
• Sleep problems.
• Withdrawn behavior.

Case Study: 7-Year-Old with Acute Diarrhea

• Nurse should recommend BRAT diet (banana, rice, apple, toast).

Case Study: 6-Year-Old with Nausea, Vomiting, and Abdominal Pain

• Nursing priorities: hydration, monitoring vital signs, assessing for dehydration, and determining the cause of pain
• Diagnostic tests: likely blood tests, stool cultures, urine analysis, depending on cause.

Case Study: 24kg Child with Acute Appendicitis. Preoperative, Postoperative Nursing Priorities and Minimal Daily Fluid Needs

• Preoperative priorities include maintaining a patent airway, fluid and electrolyte balance, proper pain management, and providing support to the family and the child.
• Important preoperative information includes identifying and addressing any possible issues with hydration or electrolyte imbalance, ensuring the child is properly medicated and calm, and ensuring a calm and supportive environment for the child.
• Postoperative priorities include monitoring for respiratory distress or problems with wound care, pain control, fluid and electrolyte balance, and the encouragement of early feeding and movement.
• The child’s minimal daily fluid needs are based on age and weight factors

Test your knowledge on the consequences and management of dehydration in patients. This quiz covers symptoms indicating a need for care and the relationship between dehydration and pain. Assess your understanding of wound care and monitoring strategies for dehydrated patients.