On completion of this chapter the reader will be able to: • Describe the characteristics of infants that affect their ability to adapt to fluid loss or gain. • Formulate a care plan for the infant with acute diarrhea. • Compare and contrast the inflammatory diseases of the gastrointestinal tract. • Describe the nursing care of the child with hepatitis. • Formulate a plan for teaching parents preoperative and postoperative care of the child with a cleft lip or palate. • Formulate a care plan for the child with an obstructive disorder. • Identify nutritional therapies for the child with a malabsorption syndrome. evolve.elsevier.com/wong/essentials Animations—Appendicitis; Digestive Tract, Passage of Food; Intestines; Intussusception; Volvulus, Pediatric Case Studies—Acute Diarrhea; Appendicitis; Cleft Lip and Palate; Dehydration; Dehydration and Diarrhea; Gastroenteritis; Gastrointestinal Problems; Hepatitis Nursing Care Plans—The Child with Acute Diarrhea (Gastroenteritis); The Child with Appendicitis; The Child with Cleft Lip and/or Cleft Palate; The Child with Fluid and Electrolyte Disturbances Nurses should be alert for altered fluid requirements in various conditions: TABLE 24-1 DAILY MAINTENANCE FLUID REQUIREMENTS* TABLE 24-2 DISTURBANCES OF SELECT FLUID AND ELECTROLYTE BALANCE Clinical signs provide clues to the extent of dehydration (Table 24-3). The earliest detectable sign is usually tachycardia followed by dry skin and mucous membranes, sunken fontanels, signs of circulatory failure (coolness and mottling of extremities), loss of skin elasticity, and prolonged capillary filling time (Table 24-4). TABLE 24-3 EVALUATING EXTENT OF DEHYDRATION *These signs are less prominent in patients who have hypernatremia. Data from Jospe N, Forbes G: Fluids and electrolytes—clinical aspects, Pediatr Rev 17(11):395–403, 1996 and Steiner MJ, DeWalt DA, Byerly JS: Is this child dehydrated? JAMA 291(22):2746–2754, 2004. TABLE 24-4 CLINICAL MANIFESTATIONS OF DEHYDRATION • The degree of dehydration based on physical assessment • The type of dehydration based on the pathophysiology of the specific illness responsible for the dehydrated state • Specific physical signs other than general signs • Initial plasma sodium concentrations • Serum bicarbonate concentration (CO2) • Any associated electrolyte (especially serum potassium) and acid–base imbalances (as indicated) Laboratory data are said to be useful only when results are significantly abnormal (Emond, 2009). Urine specific gravity, urine ketones, and urinary output during rehydration are reportedly unreliable assessments for determining dehydration in children (Steiner, Nager, and Wang, 2007). Shock, tachycardia, and very low blood pressure are common features of severe depletion of ECF volume (see Shock, Chapter 25). TABLE 24-5 COMPOSITION OF SOME ORAL REHYDRATION SOLUTIONS Cl, Chloride; K, potassium; Na, sodium. *Note that many generic products are available with compositions identical to Pedialyte. Parenteral rehydration therapy has three phases. The initial therapy is used to expand ECF volume quickly and to improve circulatory and renal function. During initial therapy, an isotonic solution is used at a rate of 20 ml/kg, given as an IV bolus over 20 minutes, and repeated as necessary after assessment of the child’s response to therapy (Ford, 2009; Friedman, 2010). Subsequent therapy is used to replace deficits, meet maintenance water and electrolyte requirements, and catch up with ongoing losses. Water and sodium requirements for the deficit, maintenance, and ongoing losses are calculated at 8-hour intervals, taking into consideration the amount of fluids given with the initial boluses and the amount administered during the first 24-hour period. With improved circulation during this phase, water and electrolyte deficits can be evaluated, and acid–base status can be corrected either directly through the administration of fluids or indirectly through improved renal function. Potassium is withheld until kidney function is restored and assessed and circulation has improved (see Evidence-Based Practice box).
The Child with Gastrointestinal Dysfunction
Distribution of Body Fluids
BODY WEIGHT (kg)
AMOUNT OF FLUID PER DAY
1–10
100 ml/kg
11–20
1000 ml plus 50 ml/kg for each kg >10 kg
>20
1500 ml plus 20 ml/kg for each kg >20 kg
Disturbances of Fluid and Electrolyte Balance
Nursing Care Plan—The Child with Fluid and Electrolyte Disturbances
Dehydration
Degree of Dehydration
LEVEL OF DEHYDRATION
CLINICAL SIGNS
MILD
MODERATE
SEVERE
Weight loss—infants
3%–5%
6%–9%
≥10%
Weight loss—children
3%–4%
6%–8%
10%
Pulse
Normal
Slightly increased
Very increased
Respiratory rate
Normal
Slight tachypnea (rapid)
Hyperpnea (deep and rapid)
Blood pressure
Normal
Normal to orthostatic (>10 mm Hg change)
Orthostatic to shock
Behavior
Normal
Irritable, more thirsty
Hyperirritable to lethargic
Thirst
Slight
Moderate
Intense
Mucous membranes*
Normal
Dry
Parched
Tears
Present
Decreased
Absent, sunken eyes
Anterior fontanel
Normal
Normal to sunken
Sunken
External jugular vein
Visible when supine
Not visible except with supraclavicular pressure
Not visible even with supraclavicular pressure
Skin*
Capillary refill >2 sec
Slowed capillary refill (2–4 sec [decreased turgor])
Very delayed capillary refill (>4 sec) and tenting; skin cool, acrocyanotic or mottled
Urine
Decreased
Oliguria
Oliguria or anuria
MANIFESTATION
ISOTONIC (LOSS OF WATER AND SODIUM)
HYPOTONIC (LOSS OF SODIUM IN EXCESS OF WATER)
HYPERTONIC (LOSS OF WATER IN EXCESS OF SODIUM)
Skin
Color
Gray
Gray
Gray
Temperature
Cold
Cold
Cold or hot
Turgor
Poor
Very poor
Fair
Feel
Dry
Clammy
Thickened, doughy
Mucous membranes
Dry
Slightly moist
Parched
Tearing and salivation
Absent
Absent
Absent
Eyeball
Sunken
Sunken
Sunken
Fontanel
Sunken
Sunken
Sunken
Body temperature
Subnormal or elevated
Subnormal or elevated
Subnormal or elevated
Pulse
Rapid
Very rapid
Moderately rapid
Respirations
Rapid
Rapid
Rapid
Behavior
Irritable to lethargic
Lethargic or comatose; seizures
Marked lethargy with extreme hyperirritability on stimulation
Diagnostic Evaluation
To initiate a therapeutic plan, several factors must be determined:
Therapeutic Management
FORMULA
Na (mEq/L)
K (mEq/L)
Cl (mEq/L)
BASE (mEq/L)
GLUCOSE (g/L)
Pedialyte (Abbott)*
45
20
35
30 (citrate)
25
Rehydralyte (Abbott)
75
20
65
30 (citrate)
25
Infalyte (Mead Johnson)
50
25
45
34 (citrate)
30
World Health Organization†
90
20
80
30 (bicarbonate)
20
Parenteral Fluid Therapy.
The Child with Gastrointestinal Dysfunction
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