Total Body Water & Dehydration in Children

Total Body Water (TBW)

• TBW includes intracellular fluid (ICF) and extracellular fluid (ECF).
• ICF refers to fluid inside the cells.
• ECF contains fluid outside the cells, such as intravascular (blood vessels), interstitial (surrounding cells), and transcellular fluids (cerebrospinal, pleural cavity, synovial fluid in joints & lymph system).
• TBW percentages vary: 45% in late adolescence, 75% in term newborns, and 90% in preterm infants.

Dehydration Vulnerability in Infants and Children

• Infants and children face a higher risk of fluid and electrolyte loss due to having an expanded extracellular compartment, making up more than half of their total body water until about 2 years of age.
• They have an elevated basal metabolic rate, body surface area, and insensible fluid loss.
• Immature renal function limits their ability to concentrate urine.
• The risk of both dehydration and overhydration exists.
• Fluids are lost through urine, feces, emesis, and insensible loss (fever, respiratory tract, heat & humidity, respiratory rate, skin).

Predictors of Fluid Loss

• Percentage of weight loss indicates severity.
• Level of consciousness ranges from irritability to lethargy.
• Response to stimuli is a predictor.
• Poor skin turgor, dry mucous membranes, and thirst are indicators.
• Prolonged capillary refill (over 2 seconds) is a sign.
• Vital sign changes include increased heart rate (HR), increased respiratory rate (RR), and decreased blood pressure (BP), which is a late sign of shock.
• Sunken eyes and fontanels, along with absent tears, suggest fluid loss.
• Decreased urinary output (UOP is less than 1 ml/kg/hr, which would normally be WNL) is a sign.
• Input that is greater than output is a predictor.
• Increased hematocrit (H&H), ↑specific gravity, BUN, and creatinine could also point to fluid loss.
• Low serum sodium, potassium, chloride, and magnesium may occur.

Nursing Considerations for Dehydration

• Early recognition is crucial.
• Vomiting, diarrhea, sweating, fever, diabetes, renal disease, cardiac anomalies, diuretics and steroids, burns, and trauma can cause dehydration.
• Monitor vital signs.
• Calculate the balance of intake and output.

Therapeutic Management of Dehydration

• Oral Rehydration Therapy (ORT) uses electrolyte solutions that are more effective, safer, less painful, and less costly than IV rehydration.
• Mild to moderate dehydration is treated with Pedialyte and a regular diet, along with monitoring of intake and output (I&O).
• Severe dehydration requires parenteral fluid therapy, beginning with an initial IV infusion of 20ml/kg of Normal Saline or Lactacted Ringers, followed by reassessment and possible maintenance fluid therapy at 1 ½ times the normal rate .

Common IV Solution List

• Commonly used IV solutions: Lactated Ringers and 5% Dextrose (D5LR), 5% Dextrose and 0.9% Sodium Chloride (D5NS), 5% Dextrose and 0.45% Sodium Chloride (D5 ½ NS), 0.45% Sodium Chloride (½ NS), Lactated Ringers (LR), 0.9% Sodium Chloride (NS), 5% Dextrose (D5W), and 10% Dextrose and 0.45% Sodium Chloride (D10 ½ NS).

Clinical Manifestations of GI Dysfunction

• Failure to thrive (FTT) corresponds to a weight below the 3rd percentile on the growth chart.
• Other symptoms include spitting up/regurgitation, nausea, vomiting, diarrhea, constipation, and encopresis.
• Further signs include abdominal pain, distention, GI bleeding, jaundice, dysphagia, and hypoactive, hyperactive, or absent bowel sounds.

Vomiting Management

• Treatment focuses on addressing the cause and rehydration.
• Aseptic drugs may be needed
• Nursing considerations include assessment such as a head-to-toe exam, characteristics/appearance of vomitus, and accurate I&O.
• Assess for dehydration via electrolyte balance.
• Glucose-electrolyte solutions or IV fluids may be used for rehydration.
• Small feeding of fluids often
• Side positioning is used to prevent aspiration.

Acute Diarrhea Causes

• Infectious gastroenteritis is a cause. Viral pathogens: Rotavirus is the most frequent cause in young children and a significant nosocomial pathogen with infants being most vulnerable; the Rota vaccine is brand-dependent and given at 2 & 4 months or 2, 4 & 6 months; Norwalk virus and cytomegalovirus (CMV) are additional causes.
• Bacterial pathogens: E. coli, Salmonella, shigella, campylobacter, and Clostridium difficile are bacterial pathogens. Antibiotic therapy is a treatment.
• Parasitic and helminthic pathogens also cause diarrheal diseases.

Chronic Diarrhea

• Increases stool frequency & water content.
• Caused by chronic GI conditions: malabsorption syndromes, inflammatory bowel disease, food allergy, and lactose intolerance can cause chronic diarrhea.

Giardia Lamblia

• The most common intestinal parasitic pathogen in the USA.
• It spreads through the fecal-oral route
• Symptoms include foul-smelling stool, abdominal cramps & diarrhea
• Diagnosed via stool specimen
• Treated with metronidazole (Flagyl), tinidazole (Tindamax) & nitazoxanide (Alinia).
• Educate family, daycare providers, and children.

Enterobius Vermicularis

• The most common helminthic infection in the USA.
• Spreads transmission via the fecal-oral route
• Crowded areas and daycare centers are infection locations
• Intense rectal itching is a symptom.
• The "tape test" is a diagnostic test
• Treated using mebendazole (Vermox) and pyrantel (Pin-Rid & Antiminth).
• Education on handwashing is critical.

Diagnostic Laboratoy Values

• In serum, increased H&H, BUN, and creatinine and a decrease in sodium, potassium, chloride, and magnesium may show dehydration.
• In stool, look for neutrophils or RBC for bacteria.
• Eosinophils, gross or occult blood, ELISA, recent antibiotic use, ova, parasites, etc.
• In urine, high specific gravity indicates dehydration.

Acute Diarrhea Management

• Goals include assessing fluid and electrolyte balance, rehydration, maintenance fluid therapy, and reintroduction of an adequate diet.
• Antidiarrheal medications are not recommended because they can slow motility and prolong the illness.

Nursing Considerations for Diarrhea

• Weigh diapers, noting characteristics of stool.
• Voiding is a requirement before potassium administration.
• Monitor intake and output and conduct daily weights.
• Check diaper dermatitis.
• Rectal temps. are contraindicated
• Isolation and contact precautions may be needed.

Diarrhea Prevention

• Most cases spread via fecal-oral route.
• Teach personal hygiene and clean water supply.
• Careful food preparation and handwashing are essential.
• Administer the rotavirus vaccine

Hypertrophic Pyloric Stenosis (HPS)

• There is a constriction of the pyloric sphincter with obstruction of the gastric outlet.

HPS Pathophysiology

• Circular muscle of the pylorus becomes hypertophied, causing thickness in the pyloric canal. It usually occurs between the 3rd and 6th week of life.

HPS Signs and Symptoms

• Begin small vomiting of milk in small amounts
• Progressively gets worse
• No longer keep any milk or formula down
• Forceful projectile vomiting occurs

HPS Assessment

• The HPS history may involve forceful, nonbilious vomiting unrelated to feeding position, hunger soon after vomiting, weight loss, and progressive dehydration.
• Palpation reveals a hard movable "olive" in the right upper quadrant.

HPS Interventions

• Surgery is required.
• Nursing requires fluid management and family anxiety.
• Postoperative care slowly resumes oral feedings after 1-2 days.

HPS Treatment

• Pyloromyotomy treats HPS.

Oral Candidiasis (Thrush)

• Fungal infection of the oral mucosa common in infants, immune disorders, corticosteroid inhalers, immune system suppression, and the antibiotic use.
• Presentation: there are thick white patches on the tongue, mucosa, or palate that resembles curdled milk but are hard to wipe off, oral discomfort, and fungal diaper rash, that can be transmitted during breastfeeding.
• A clinical presentation and a fungal culture are needed for diagnosis.
• In nursing mangement; antifungal agents such as good hand washing, along with assessment of any diaper rash, and proper cleaning of nipples and pacifiers is recommended

Cleft Lip and/or Cleft Palate

• Craniofacial malformations during embryonic development; the most common congenital deformity of the head and neck
• The lip is formed by 5-6 weeks and is closed by 7-9 weeks Sometimes a prenatal dx is made around 20-22 weeks via ultrasound May appear separately or together
• Cleft lip: the maxillary & median nasal processes are not fused and can be unilateral or bilateral
• Cleft palate: there is a fusion failureof both sides of the palate that may involve the hard and soft palates

Cleft Lip and/or Cleft Palate: Etiology and Complications

• May be an isolated anomaly or in conjunction with syndromes with the etiology involving smoking, prenatal infection, advanced maternal age, steroids, or anticonvulsants especially phenytoin..
• Feeding difficulties = FTT are potential complications, altered dentition, speech delay or alteration, otitis media, which may cause OME leading to AOM, a risk of hearing loss, and a risk of aspiration.

Special Feeding Equipment

• Specific equipment is made for babies with cleft lips and/or cleft palates.

Surgical Correction of Cleft Lip

• Deformities of both the lip & palate are both repaired together.
• Lip repair typically occurs between 2-3 months of age For postoperative nursing, you must:
• Clean the suture line and assess for infection
• Protect suture line with a metal appliance and avoid stress
• Put on elbow restraints
• Prevent rolling on abdomen with the upright position Analgesia for pain and stress Clear liquids Encourage bonding

Surgical Correction of Cleft Palate

• Cleft palate to be repaired 9-18 months
• Surgery needed to accomodate growth.
• Depends on surgeon preference

Consider post-surgical nursing:

• Restrain elbows and encourage bonding
• Monitor respiratory status and asses for infection
• Position infant on a side
• Monitor fever and pain with soft food items
• Do not put anything in mouth that can damage surgical repair

Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)

• EA and TEF involves rare malformations where there is a failed separation of the esophagus and trachea.
• Atresia (EA) = the closure of the esophagus like a blind pouch and is a medical emergency. Fistula (TEF) = a passage or connection between the trachea and esophagus.

Diagnosis of EA/TEF

• Diagnosed by clinical symptoms of having to much frothy saliva from the nose and mouth.
• 3 C’s = Coughing, Choking, Cyanosis is another dianostic factor
• Apnea may also have
• Increased respiratory distress during feeds
• Abdominal distention
• Can be dianosed on Ultrasound
• Most cases are diagonised soon after birth

EA/TEF Management

• Surgical interventions depends on the anomaly.
• Nursing care for the newborn with S & S of EA or TEF with 1st feed = look for the 3 C’s, use intermittent or continuous suction to blind pouch, NPO, IV fluid, and ↑ HOB.
• Prophylactic broad-spectrum antibiotics are needed to prevent pneumonia.
• Ongoing respiratory assessment, airway management, thermoregulation, fluid & electrolyte management, and nutritional support are neede.
• Associated tracheomalacia: a weakness in the tracheal wall that occurs early in fetal life.

Omphalocele and Gastroschisis

• Omphalocele defined: congenital defect of the umbilical ring involving the anterior abdominal wall where the abdominal contents enter the external peritoneal sac, organs in the sac are usually normal and malrotation is common
• Gastroschisis defined: herniation of abdominal contents through an abdominal wall defect to the side of the umbilicus where: the organs have no protection and are thickened, edematous and inflamed
• For both defects mortality rate is high and it will. be associated with other genetic syndromes: detected via prenatal ultrasound, can have an increased alpha-fetoprotein level.

Umbilical Assessment for Defects

• Get a maternal history
• Encourage bonding and Inspect sac for contents, for the intestines to the level of
• Assess for other congenital anomalies.

Umbilical assessment and Management

• Provide fluid maintenance
• Give antibiotics

Anorectal Malformations

• Absence of Anal
• Opening
• Connection is known as fistula
• Vagina Can join Together

Diagnosing Anorectal Malformations

• Check for patency for newborn and during rectum assessment.
• Positive Sing at birth when not pooping within 24 hours
• Diagnose with Ultrasound

Treating Anorectal Malformations

• Anal Stenosis
• Preanal fistulas are treated by analoplasty.

Umbilical and Inguinal Hernias

• Umbical: the intestine to protrude out
• Inguinal: a small portion of the intestine

Sir Hernia Definitions

• Sir: -Incarerated
• Strangled
• Reducible

Intussusception

• Common cause of bowel obsruction in children
• Small bowel telescopes over itself
• Air or barium enema -Palpated sausage Mass Sometimes cause is unknown or due to intenstinat lesion.

Intussusception symptoms

Main symptoms: belly pain, straining in it,extreme irritation

How Intussusception works

Ileum "telescopes" inside ascending colon, obstructing passage of intestinal contents and Blood vessels become trapped between layers; blood flow decreases, which leads to Edema and Strangulation of bowel, and Gangrene, sepsis, shock and eventually death

How to theraupetically manage Intussusception

Theraupeutic Management Hydrostatic reduction a non surgical procedure, it will suceed nup to80 percent of the time, and to reduce the Intussusception. Sometimes needs to be done but immediate surgrery if persistent. Prepare parents and child before procedure.

Malrotation

• Congenital disorder
• Intestine is abnormally attached and the mesentery narrows
• Volvulus occurs when the intestine twists on itself causing obstruction
• Bilious vomiting, abdominal pain, distention, hypoactive bowels sounds, bloody stools, tachycardia, shock, necrosis

•   DX: KUB, UGI Management: A Ladd surgical procedure
  

Appendicitis

• Peak incidence 10-12 years -Beings as dull to steady pain in perinmical area
• Progresses over hours, causes low grade fever
• Nausea but includes sudden pain relief rebound and tenderness

GERD

• Transfer of gastric contents into the esophagus
• Causes a rise in intra-abdominal pressure very common
• The first year of people's lives. And if you become sick

Diagnostics for GERD

Esophageal PH Probe -Is a Gold standard

• GI upper section of the body, and anemua
• Endoscopy of throat

GERD Risk factors include:

• , infants
• Food for allergy
• Asthma is when you have an infant you
• Need to learn CPR
• Small frequent meals

Therapeutic Management for GERD

• Elevate
• Needs to go in 30, 45 minutes after eating.
• apnea Home. For Infants prone to.
• education for parents.
• Frequent feeing. Thickened feedibng.

.Diet smaller foods PPI Nissen Fundoplication.

Constipation and encopresis

Are alteration and frequent passage of stool mass is fecal

• Psychosocial impact on the child.
• due to painful, a sexual disorder
• Inorganic. There's different types depending hypothyroidism poisoning, or injury may be used.
• May be different, such as diuretics and iron. Les comen in infants and the cause

Management for Chronis IBS

Treat the cause, such as, diet, adding fibre, such as Sugar

Therapeutic Management

• Removal of surgery, bowel
• May need -colostomy or ileostomy -stricture • Dilation of bowel